Albanese's bulk billing pledge renews the promise at the heart of Medicare

The Guardian

23-02-2025

When the Hawke Labor government implemented Medicare in 1984, it established a new foundational principle for the Australian health system – that access to health services for all is a right, not a privilege.
Since then, successive Labor governments have sought to deliver the simple proposition that all Australians, regardless of where they live, should have timely access to the highest quality medical services and advice based solely on clinical need, rather than on their financial capacity to pay.
In 1984 Bob Hawke claimed that, compared with the succession of postwar private health schemes adopted by conservative governments, Labor's Medicare would be fairer, simpler and cheaper.
Four decades later, Hawke's promises have been more than fulfilled.
The principle of access to services based on need, not wealth, is the very definition of fairness.
Provision of, and payment for, medical services through a single, state-owned payer, and hospital services through a tightly regulated hybrid public-private hospital system is relatively simple and efficient.
And in terms of the national health budget, Medicare provides comprehensive health services, steady increases in life expectancy and quality health outcomes for about 10% of GDP compared to, for example, the disastrous health outcomes of the largely privatised United States healthcare system which consumes almost 20% of the American GDP.
But over four decades the continuing public policy challenge has been to deliver access to medical services at no or very little cost at the point of delivery.
Bulk billing is the mechanism through which Medicare delivers this equitable access.
In 1984, the first iteration of Medicare provided generous funding to general practitioners to bulk bill and thereby reduce or remove financial barriers to patients seeking medical advice and treatment.
Since then, in poll after poll and election after election, the Australian people have overwhelmingly supported the core principles of Medicare, including bulk billing.
Remarkably, however, Medicare's success never stopped ideological and political attempts to undermine its universality and equity.
In 1993, the Liberals' 'Fightback' manifesto launched a frontal demolition attack on Medicare and envisaged replacing it with a privatised system based on the American model.
This foolishness contributed to the conservatives' resounding defeat at that election.
Chastened by the consequences of their zealotry, since 1996 conservative governments in office have opted for a more subtle and crabwise undermining of Medicare.
The political calculus was simple – if bulk billing could be steadily eroded by reducing nominal and real reimbursements to general practitioners, over time doctors would be forced to levy co-payments, consumer and voter dissatisfaction with 'Medicare' would increase, and political support for an alternative, privatised medical system might emerge.
Influenced by American private equity interests, local neoliberal thinktank economists attempted to redefine Medicare as a 'safety net' rather than as a universal scheme.
No form of privatised health provision could ever be fairer, simpler or cheaper to individuals and health budgets than Medicare – but this did not deter Liberal governments from undermining bulk billing by continuing significant freezes in the level of rebates paid to general practitioners, as well as increasing and largely unnecessary overregulation of general practice.
The deep ideological commitment to the destruction of Medicare was apparent in the Abbott government's 2014 proposal to introduce a high co-payment for doctors' consultations.
While the co-payment proposal collapsed, along with Abbott's prime ministership, the ideological assault on Medicare continued unabated until the election of the Albanese government in 2022.
When he came to office, the health minister, Mark Butler, was faced with the consequences of more than a decade of relentless and effective conservative depredations on the core principles of Medicare.
But since 2022, Butler has restored and strengthened Medicare step by step.
More than 80 Medicare urgent care clinics – all bulk-billed – have been established, with more to come to meet demand, especially in the outer suburbs and rural and regional Australia.
The critical importance of general practice has been recognised by funding significantly increased numbers of general practitioners through the training system.
A series of primary care reviews have delivered achievable reforms aimed at enhancing all aspects of primary care and the rapid adoption of emerging new technologies to improve patient and professional outcomes.
The government tripled the bulk-billing incentive for those who needed to see their GP most often – pensioners, concession cardholders and families with children.
But the decision to introduce the new bulk billing practice incentive program to cover all Australians and to introduce a 12.5% loading patents for fully bulk-billing practices, are the reforms that shatter for good the idea that a safety-net Medicare could ever be acceptable to modern Australia.
Butler's reforms finally put Medicare back on track to meet and exceed the promises made to the Australian people by Hawke's government 40 years ago – an effective and efficient health system designed by, and for, Australian people, that reflects the core values of fairness and equity and rewards those who dedicate their lives to deliver such excellent health outcomes.
Bill Bowtell AO is an adjunct professor at UNSW and a strategic health policy consultant. He was senior private secretary and chief of staff to Neal Blewett, the health minister in the Hawke Labor government responsible for the introduction of Medicare