Doctor and activist


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Category: Market Failure

‘Health Policy’

Chesterfield-Evans, A. (2024)

Journal of Australian Political Economy  No. 92, pp. 98-105.

HEALTH POLICY

Arthur Chesterfield-Evans

Just before the 2022 federal election, Mark Butler, now the Minister for
Health in the Albanese government, spoke to the National Press Club,
praising the courage of the Hawke government in creating Medicare in
1984. His speech also set modest priorities for a prospective Labor
government, committing to (1) improve the digital health record and make
the MyHealth record actually useful; (2) develop multidisciplinary care;
(3) establish a new funding model for ‘MyMedicare’; and (4) grow the
medical workforce, with special mention of nurses and pharmacists (Butler
2022). Significantly, Butler did not commit afresh to Medicare as a
universal health scheme free at the point of delivery, the key element of
the original 1984 scheme that he praised. In an environment where,
politically, it seems that taxes cannot be increased, perhaps this ideal may
be an impossibility, but it is surely significant that it is no longer stated as
an aspiration.

Currently, Medicare is quietly dying as the low rebates cause doctors to
abandon it. Australia is moving to a US-type private system by
default. This has resulted in large amounts of hand-wringing rhetoric, but
so far little action. This short article comments on the changes initiated by
the current Labor government during its first year and a half, contrasting
these with the deep-seated problems needing to be addressed if better
health outcomes are to be achieved.

Labor’s reforms

The government has made some minor changes to Medicare which came
in with great fanfare on November 1, 2023. There were new item numbers

for new specialist technologies or treatments and an increased Medicare
rebate for GPs, up to $41.40 for a standard visit for a RACGP member,
which is 40.6% of the AMA fee. Doctors without the RACGP qualification
still get $21, which is 20.6% of the $102 AMA fee.

When Medicare was born, the Medicare rebate was 85% of the AMA fee.
The rebate has risen at half the inflation rate for 39 years, so doctors now
feel ripped off every time they see a Medicare patient. Labor blames the
disparity on the rebate freezes of the previous LNP Coalition governments,
but its own record is poor. Successive governments of all types have
deferred to the private health lobby and are starving Medicare, slowly
defaulting towards a principally private system, as in the USA. This is a
deeply-troubling prospect because the US health system has been
recurrently criticised (Commonwealth Fund 2021) – and rightly so –
because it makes access to health care dependent on ability to pay. Notably,
however, it is the world’s best system at turning sickness into money.

The other recent Labor ‘reform’ was to allow pharmacists to process
prescribed medications to cover patients’ requirements for 60 days, rather
than 30 days, thereby halving the costs of prescribing and dispensing.
While this may seem helpful, patients are often confused by complicated
generic names and generic brands; and compliance or discontinuation of
medicines is a largely unquantified problem. These are existing problems
with the current arrangements for dispensing medications: the recent
policy change, while well-intentioned, does not redress them. It transfers
resources from professional staff to the pharmaceutical industry.

The ‘Strengthening Medicare Taskforce’ had good medical and allied
health representatives and support. Its December 2022 report defined the
problems but, trying to avoid controversy, positive suggestions were thin
on the ground. A deeper analysis and more comprehensive approach to the
redress of health issues is needed.

Basic problems in the health system

Diverse funding sources causes cost-shifting

Fundamentally, no-one is in overall control of the health system. It has a
number of different funding sources: the Federal and State governments,
the Private Health Insurance industry (PHI), Medicare and individuals

themselves. Workers Compensation (WC) and Compulsory Third Party
(CTP) insurers also put in a bit. These arrangements lead to a situation
where each funding entity attempts to shift costs without any real care for
the overall cost of the system. Private entities such as pathology and
radiology also have an interest in providing more services, whether they
are needed or not.

The broad division of the health system is that public hospitals and
emergency departments (EDs) are State-funded, and non-hospital services
are Federally, PHI or self (patient) funded. There is some overlap,
however, because the State’s provision of some community-based services
allows them to save on hospital-bed days; and private funds paid to State
hospital in-patients are eagerly sought. The starvation of Medicare (which
reduces the Federal government’s spending) has resulted in more patients
going to EDs at higher (State) cost, as well as increasing PHI and patient
costs.

This cost-shifting has evident implications for the affordability of health
care: notably, a recent study showed that Australia, when compared to 10
other countries, scored poorly on its measure of affordability
(Commonwealth Fund 2021).


A new health paradigm is needed

Yet more fundamentally, there is a huge problem with the conceptual
model of the health system. In common parlance, the ‘health system’ is the
‘paying to treat illness’ system. Paying doctors to see and treat patients is
seen as the major cost and is the most politically fraught element in the
system.

Historically, everyone was assumed to be healthy and had episodes of
either infectious diseases or surgical problems. They went into a hospital
for a brief period and either recovered or died. The legacy of this is that
heroic interventions are over-resourced and the more cost-effective early
interventions are under-resourced.

Infectious disease is now relatively uncommon, notwithstanding the recent
and ongoing coronavirus concerns. Most disease is chronic; and the
objective is to maintain health for as long as possible and to support those
who need support in the community rather than in institutions. ‘Health’
must be re-defined as a state of physical and mental wellbeing; and
maintaining it as ‘demand management’ for the treatment system.

Life-style diseases of diet, obesity, smoking, vaping, alcohol, drug-use and
lack of exercise need attention. It might be commented that these habits
are more determined by the political economy of the products than by any
health considerations; and the government should intervene to re-balance
this market failure.


Hierarchies, cartels and corporatisation

The medical system is hierarchical with specialists at the top and GPs at
the bottom. The specialist colleges have produced less practitioners than
would have been optimal. The starvation of General Practice has led to
increasing specialist referrals for simple procedures. Most patients are
happy to go along with this, though often much less happy about the rising
costs. Practitioners tend to work down to their station rather than up to
their capacity. GPs, if given the appropriate additional education and
empowered to act, could do what quite a lot of specialists do now, while
nurses could take the load from GPs; and, in terms of home support, a more
comprehensive and flexible workforce needs to be developed.

Private medical insurance systems are a further source of problems. They
have marketing, churn, profits, liability and fraud issues; and they make it
necessary to account for every item of every procedure. While the
corporations watch every cost, the regulator cannot. Corporations buy
medical practices and take up to 55% of the gross revenue. Smaller
radiology practices are being gobbled up as investments (Cranston 2020).
If overheads are defined as the amount of money put in compared to the
amount paid for treatments, Medicare costs about 5% and PHIs, as they
are regulated in Australia, about 12%. In the USA, the private health funds
take up to 35%, and Australia’s CTP system got close to 50%. A universal
health insurance system could avoid many of these costs and would be far
superior from a social equity point of view.

Similar problems are evident in the provision of care for people with
disabilities. Labor pioneered the NDIS when last in office a decade ago,
and rightly claims this as evidence of its commitment to redress the
previous neglect. However, the NDIS can be considered as a privatisation
of the welfare system. It overlaps medical system functions and is poorly
regulated. If its efficiency is judged by the percentage of money put in that
is paid to the actual workers delivering the service, care is not very

efficient. There have also been significant criminal rip-offs (Galloway
2023).

Retirement care arrangements have major flaws too. Aged-care
accommodation is largely driven by the real estate industry; and access to
continuing care is an add-on of often dubious quality.

What should the government do?

The problems described above are diverse, deep-seated and not easily
rectified. However, a government intent on staying in office for a series of
terms could heed the call for some big thinking, drawing on the experience
of health practitioners themselves. Here is a list of what might be done,
becoming more medical and more politically difficult as it progresses:

Keep people healthy with education, clean water, sanitation, housing,
good food, regular exercise, high vaccination rates, road safety,
universal swimming lessons, CPR and first aid training and the active
discouragement of smoking, vaping, alcohol and drug use, junk food
and gambling.

Provide housing with graded community support options for those
people with disadvantage or impairment. Create a registration and
insurance system for home and community support services, so that
individuals can buy standardised services from other individuals.

Maintain fixed staff-patient ratios related to the disability
classification of residents in institutional care.

Make maximum use of community and school interventions and
support services such as District and Community nurses and School
nurses, mental health support networks, Aged Care Assessment
Teams, Hospitals in the Home etc.

Address health problems as early and as low down the support and
treatment hierarchy as possible, by empowering those who provide
the services.

Create a meaningful regulatory, inspection and enforcement system
for support services, both community and residential, and for
workplaces and recreational facilities.

Use the medical information system to research drug and treatment
effectiveness.
Support General Practitioners and try to increase their ability to solve
problems without referral. Have GPs work in Health Centres with
community support workers as far as possible; and improve
communication with data collection a by-product of normal work, not
an additional imposition.

Have independent evaluation of the numbers needed in the specialties
and pressure the colleges to provide these numbers. Use waiting times
as an initial index.

Initiate either university-based or college-based continuing medical or
professional education, with mandatory refresher exams every
decade.

Have universal professional indemnity insurance, with doctors and
other health professionals unable to be sued if they report all incidents
of sub-optimal outcomes within 48 hours of becoming aware of them,
and participate in regular quality control meetings.

Publicise and promote organ donation, end of life plans, wills and
enduring powers of attorney as sensible steps in life-management.

Evaluate Intensive Care interventions in QALY (Quality-Adjusted
Life Years) terms, researching their outcomes and comparing them to
earlier intervention initiatives.

Change the composition of the Pharmaceutical Benefits Advisory
Committee so that it has no pharmaceutical industry representative on
it; and remove ministerial discretion from its decisions. The previous
system evaluated new drug listing approvals with a cost-benefit
analysis (Doran et al. 2008), but the Howard reforms of 2007,
following the Australia-US Free Trade Agreement and lobbying by
Pfizer, put a drug industry representative on this committee, making
its negotiations more transparent and thus more difficult for the PBS
to negotiate prices (Access to Medicine Working Group 2007).

Work towards replacing Workers Compensation and CTP insurance
schemes with income guarantee schemes (this will only be possible
when Medicare allows timely treatment).

Create a credible and indexed scheme for paying medical
professionals which does not have KPIs that distort performance.
Make Medicare a universal taxpayer funded health system that is free
at the point of delivery and stop subsidising PHI. It might be noted
that the Government currently quotes Medicare and PHI costs
together as a sum rather than itemising the two, which serves to
disguise the subsidy to PHI (Parliament of Australia 2022).

Conclusion
The current federal Labor government has made statements about health
policy reform and done minor tinkering during the first year and a half in
office. Based on this start, it is doubtful that it will have the courage to
make the necessary major changes, addressing the systemic problems.
Fine rhetoric is unlikely to achieve much. That makes it doubly important
to develop proposals for more fundamental reform. Written with this
intention, the suggestions made in this article could be the basis for
tackling the fundamental institutional and political economic issues
problems associated with personal and societal ill-health.

Dr Arthur Chesterfield-Evans trained as a surgeon in Sydney and the UK
and is a Fellow of the Royal College of Surgeons. He currently works as a
GP with interests in workers’ compensation and third-party injury. He has
been a tobacco activist and an elected member of the upper house of the
NSW Parliament. He has Master’s degrees in Occupational Health and in
Political Economy.

chesterfieldevans@gmail.com

References

Butler, M. (2022) ‘Address to National Press Club, 2 May,’ available:

www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-
care-speech-national-press-club-2-may-2023.

Commonwealth Fund (2021) US Report, available:
www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-
reflecting-poorly.

Cranston, M. (2020) ‘Radiology enjoys a post-virus buying boom’, Australian Financial
Review, available: www.afr.com/policy/economy/radiology-enjoys-a-post-virus-buying-
boom-20201106-p56c7k.
Doran, E., Henry, D., Faunce, T.A. and Searles, A. (2008) ‘Australian pharmaceuticals policy
and the idea of innovation’, Journal of Australian Political Economy, 62, pp. 39-60.
Galloway, A. (2023) ‘Federal crime syndicates using cash vouchers and gifts to steal NDIS
funds’, The Sydney Morning Herald, available: www.smh.com.au/politics/federal/criminal-
syndicates-using-cash-vouchers-and-gifts-to-steal-ndis-funds-20230414-p5d0ma.html.
Parliamentary Library (2022) Health overview, available:
www.aph.gov.au/About_Parliament/Parliamentary_departments/Parliamentary_Library/p
ubs/rp/BudgetReview202223/HealthOverview.
PBS (2007) ‘Access to medicines working group’, available: www.pbs.gov.au/info Access to
Medicines /general/working-groups/amwg/amwg-jul-2007.
Sax, S. (1984) A Strife of Interests: Politics and Policies in Australian Health Services,
Sydney: George Allen and Unwin.
Searles, A., Jefferys, S., Doran, E. and Henry D.A. (2007) ‘Reference pricing, generic drugs
and proposed changes to the Pharmaceutical Benefits Scheme’, Medical Journal of Australia,
187(4), pp. 236-39.
Strengthening Medicare Taskforce (2022) Taskforce Report, Commonwealth Department of
Health, available: www.health.gov.au/sites/default/files/2023-02/strengthening-medicare-taskforce-report_0.pdf.
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Hospital Crisis is just part of the story.

6 November 2023


The hospital crisis is partly because General Practice has been so downgraded that more cases go to hospital than need to. The Federal government starving Medicare has a number of consequences:
Many GPs are simply retiring and there are no enough new ones taking their place, so we are getting towards a serious shortage
GPs cannot survive on the Medicare rebate, so now charge a co-payment.
Since Emergency departments are free, people wait until the situation gets worse then go there.
Emergency Depts are about 6 times the cost of GP visits, so the total cost of the Health Care system rises.
The other part of the Federal government starving Medicare is that the State governments pay for the emergency departments, so it is a case of the Federal government saving money by making it a lot more difficult for the States.
But an overriding fact is that Australia has been convinced by the neo-liberals that tax is a bad thing and government spending must be a small percentage of GDP. Currently this is about 38.4% of GDP, slightly less than the USA, which has very poor welfare and health systems. This means that the governments cannot actually afford to do anything, and behave like a corporation, cutting employee wages and making cuts wherever it thinks no one will notice, or it has the power to do so. Now if Labor ever tries to raise taxes, the Liberals, who are great exponents of small government accuse Labor of being ‘tax and spend’, and Labor, rather than have a serious debate merely retreats. The fact that he Scandinavian countries have government as close to half of GDP and have their citizens much better off never gets mentioned. Denmark is at 49.9%, Germany 49%, Finland 54% and France at 54%. The UK is at 45%.
We now have a failing GP sector, a problem in aged care, a shortage of nurses, paramedics on strike, a hollowed out public service that merely awards its former tasks to private sector operators that it cannot even monitor and Australia falling down the World educational standards table is not a coincidence. The governments have a virtual monopoly of these jobs. They have deliberately let wages fall, so that now people simply will not do them.
We need to stop privatising, rebuild that public sector so that it can deliver services that we need. Profit is merely another unnecessary overhead. We need to decide what needs to be done, and raise enough tax to pay the people to stay in their public service jobs. Education, health and aged care do not need a ‘market’ to function/. If one exists for comparison purposes, that is fine, but there is no actual virtue in having most of the services delivered by corporations that have the choice of good service or good profits. It is a con, and it is time we forced the government to give us Medicare and a health system that actually works for all, and education for all.
Here is a letter from my Medical partner in today’s Sydney Morning Herald.

The horror stories now emerging about overloaded public hospitals, ambulances and emergency departments comes as no surprise to anyone following the downgrading of Medicare to a ‘‘mixed billing’’ system. This has made it unaffordable for many people to see a GP. But the real cost of turning Medicare into a two-tier system has been to the public hospital system. The only winners are private corporations, private hospitals, private health insurance funds and their many lobbyists in Canberra. We are going the way of the US, and if people don’t fight for Medicare, we are all doomed.
Con Costa, Hurlstone Park:


Here is today’s Herald Editorial

Health system needs its own emergency care
The state of health of the health system has dominated the lives of Australians for four years, but it has never been in such need of urgent care. Indicative of how working conditions for frontline healthcare workers have deteriorated, people now spend a median of three hours and 36 minutes in NSW hospital emergency departments, the longest wait ever. It’s little wonder that health workers are suffering burnout, stress and bullying and are leaving the industry in record numbers.
The COVID-19 pandemic sharpened awareness of our vulnerabilities and forced extra spending on hospitals, clinical responses, vaccinations and prevention measures.
And when we emerged from the pandemic’s worst days it became evident the health system too was experiencing difficulty recovering from years of stress. It had been deteriorating for a long time already, but post-pandemic we became uncomfortably aware that ambulances were queueing for hours to offload emergency patients and hospitals were under enormous pressure with lengthy wait times in emergency and admission.
GPs bumped up fees, forcing people who could not afford the $11-a-visit hike into hospital emergency departments. The industry is being further destabilised by the exodus of 6500 nurses and midwives a year.
If anything, the situation is worse outside the big cities. Last year, for instance, five deaths in regional hospitals could potentially have been prevented, but not in an overworked hospital system with staff shortages that make mistakes even more likely. The NSW parliament’s health portfolio committee report on rural, regional and remote health 18 months ago found a ‘‘culture of fear’’ which did not encourage or value feedback and complaints. Some workers say they were even punished for making complaints.
Now an investigation by the Herald has revealed a health system sinking further into crisis. Eight nurses and midwives have taken their lives in the past three years, while nearly 2000 NSW Health workers have lodged compensation claims for psychological injuries over the past two years. More than 33,500 NSW Health employees have also claimed they are burnt out, while 21,000 workers say they have witnessed bullying in the workplace. One in 12 ambulance employees hold a compensation claim for a psychological injury.
Experts and unions warn that the data, drawn from documents obtained exclusively under freedom of information laws and the state government’s recently released annual employee survey, People Matter, shows a workplace struggling with staff mental health concerns.
Further illustrating the stress, NSW Ambulance fielded a record 363,251 calls and fired up the lights and sirens for more than 181,000 emergency call-outs between July and September, the most of any three-month period since the Bureau of Health Information began taking records in 2010.
Money seems to be the root cause of health’s problems. Today’s national cabinet meeting will address the rampant cost blowouts in the NDIS and Canberra wants the states to take responsibility for funding treatments. On Friday, Premier Chris Minns and Treasurer Daniel Mookhey meet the Health Services Union over a protracted pay dispute threatening to collapse the NSW triple zero call system on New Year’s Eve. Minns said the money is not available.
The future funding and structure of our health systems concerns us all. It is an area where the federal and state governments share responsibility. The solution to the healthcare crisis is complex and will take time, but it is an area where increased funding must be found.
That clearly calls for a better national approach and the states responding with an end to parochial wheelbarrowpushing and finger-pointing.

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Apartheid Education Buses

23 November 2023

I live near a turning circle in a good area of Sydney.  There is a Bus Stop there and the government bus there has an ad with a picture of a forlorn looking schoolgirl saying that she cannot have a decent education, so would I donate to The Smith Family so she can.

As the ad displays there, 8 shiny new buses take private school children from the turning circle to 8 different private schools.

It seems that our governments are happy to subsidise ‘choice’ so that they do not have to fund a fair go and we are happy to tolerate an apartheid education system.

 

www.theguardian.com/australia-news/2023/nov/23/australia-100-wealthiest-schools-earnings-income-data-education-department?utm_term=655e79e42ab1fedfc11542549409ff2e&utm_campaign=AustralianPolitics&utm_source=esp&utm_medium=Email&CMP=aupolitics_email

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Climate Change- a Depressing Update

23 November 2023

In Australia the Labor government struggles mightily to get legislation through to allow Woodside to pipe carbon dioxide to East Timor’s territorial waters for supposed CCS (Carbon Capture and Storage) to allow them to develop a new gas field. East Timor is not a signatory to the Paris Accord- convenient eh?  Supposedly the carbon dioxide will be pumped into a reservoir that used to have gas, but Woodside has a track record of not meeting its CCS targets; if you think CCS is a real thing and not a cop-out farce.

 

Evidence suggests that the world is on target for a 3 degrees temperature rise, which may make human life unsustainable in its present form.  Petrostates are installing lights at beaches so that people can go for a night swim to cool off because it is too hot in the daytime!

 

The graphs below show world energy consumption tripling since 2000 and continuing that upward trajectory.  If one considers that the production of energy by a human is about a kilowatt a day, one realises that the amount of energy consumed now per person is many times that, and far higher in developed countries, the situation is unsustainable. The invention of the steam engine in 1690 and the internal combustion engine in 1872 and the use of fossil fuels, which has resulted in the energy and carbon dioxide stored as carbon over tens of thousands of years being released in a century.  It is ridiculous to think that reforestation can capture this amount of carbon as the total area of forests in the world is still declining.

 

COP28 (the 28th Conference of the Parties) of the UN Framework Convention on Climate Change (UNFCCC), will start on 30 November in the United Arab Emirates (UAE), chaired by Sultan Al Jaber, the CEO of the UAE state oil company ADNOC. How much good is this likely to do?

 

COP-out: Why the petrostate-hosted climate talkfest will fail

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Advocacy to Delay the Silica Benchtops Ban

18 October 2023

I wondered why the NSW Government was delaying the ban on silica-containing benchtops until July 2024.  Infectious diseases have no political friends, but industrial diseases do. Below is a full page ad in today’s Sydney Morning Herald advocating a delay on the ban and some regulations about how to cut the benchtops with no dust.  They also point out correctly that other benchtop materials have some hazards, and there are a lot of other products that produce silica dust when cut or dug. And they point out that a lot of people are involved in installing benchtops.

 

It is true about other products being harmful. But it is also true that there are readily available non-toxic alternatives that could be used. It is a bit rich for an industry that did precious little to stop the development of silicosis now to ask to be regulated.  The obvious solution is to minimise the harm from all sources of silica including cutting concrete and digging sandstone foundations.  That requires regulations that often actually exist, but Safework does few site inspections and relies on ‘self regulation’ and a ‘notify us’ system of light regulation, based on a fundamental contempt for OHS as soon as it inconveniences business.

 

The government must be forced by publix pressure to ban silica benchtops, which are basically all silica except for a bit of binder chemical, and to enforce other regulations with filtered air and barriers with PPE (personal protective equipment) as a last resort. Concrete or sandstone must be cut with water on the saw so that there is minimal dust.

 

It is depressing, but not surprising that those who have created so much of a problem by setting up an import system for this toxic product now have the gall to lobby against effective government action.

C:\Users\chest\OneDrive\Pictures\SMH Silicosis Ad 231018.jpg

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The IR Bill- two problems and a suggestion

25 November 2022

When I buy petrol, I sometimes ask the attendant how much he or she is paid.  Often they glance at the CCTV camera and say that they cannot answer that.  But the other morning early I asked an attendant who looked like a very tired student from the Indian subcontinent.  Yes, she had worked all night, a 12 hour shift for $10/hour cash.  I asked her how she thought she might get a decent wage.  She replied, ‘Well, an Australian boss might help’.  I took this to mean someone who paid an award wage.

As small business tries hard to exempt itself from ‘sector-wide’ bargaining, I wondered how she will fare if there is still no industry-wide award or no enforcement.  What will change?

I have a friend who runs a small business and he says that although wages have not risen, neither have small business profits.  I asked why?  He said that the supply chain had ‘consolidated’ and took a larger share of the final price. One might note that Deliveroo just left food delivery, Amazon is taking an increased percentage of online retail sales, Airbnb takes an increasing percentage of accommodation spending, Uber has increased its percentage take from its rides, and Spotify pays very little to those who make their music.  It is the Monopoly game in real life, the big get bigger and the frail are pressed to the rail. The view that the biggest problem small business has is big business seems a neglected truism.    The question is whether this will or indeed can be addressed by Federal Parliament.   The point is that competition drives down prices, but cartels and oligopolies develop if not stopped. A new book looks at this problem, Chokepoint Capitalism www.thesaturdaypaper.com.au/culture/books/2022/11/30/chokepoint-capitalism#mtr

Another aspect is that the system seems totally unable to restrain is the salaries of top executives.  One person I know advised, ‘I always vote against the management salary increases at the AGM’.  There is legislation that salary rises have to be approved by the shareholders, but it seems that the top executives always have enough proxies to ensure that they salary rises come despite the efforts of small shareholders like my friend.  So I suggest legislation that stipulates that no executive may get more money than, say, 20 times the full time equivalent hourly rate of the lowest paid person in the organisation.  It seems that a few hundred thousand at the top does not matter, but a few dollars at the bottom do. This needs to brought into perspective.

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iCare- a letter to the Editor of the Sydney Morning Herald

24 November 2022

Dear Editor,
iCare was set up by private insurers on their model with the NSW government keen to minimise costs, take profits and distribute them (just before the last election). So iCare delays or refuses treatments to the needy, and was very careless about what their Pre-Accident Average Weekly Earnings (PIAWE) were. Many accident victims complained that they were underpaid, and that was before their compensation was stopped or cut because they were certified partially fit to do jobs that could not be found.

The overheads of Medicare are about 5%, iCare about 38%, so it is totally inefficient as well as incompetent with bloated salaries for the top executives who think it is a financial problem rather than a medical one and hence are unable to solve it. The real solution would be to fund Medicare as the only medical system and let the insurers have widespread income-guarantee insurance.
Sincerely
Dr Chesterfield-Evans- works as a GP specialising in Workers Comp and CTP injuries.

Here is an article from today’s SMH

EXCLUSIVE
Injured workers to lose benefits
Adele Ferguson

Greg Dayman is one of almost 400 workers who will get a Christmas ‘‘present’’ they will never forget.

The Sydney construction worker was badly injured on a building site in 2013, which left him unable to work with chronic pain in his neck, the side of his head, down his arm, torso and leg.

In 2017 he was among thousands of employees whose compensation payments to cover wages were cut as part of controversial reforms to the state’s scandal-ridden icare organisation. Changes to the legislation terminated injured workers receiving weekly wage benefits after five years unless they met a whole body impairment assessment of more than 20 per cent.
However, he still received medical or health benefits. Now he has found out even these will be cut from December 25.

‘‘It’s another upper-cut,’’ he said. ‘‘And to do it on Christmas Day, that’s just cruel.’’

Dayman is one of 395 workers facing a grim future as a crisis at icare deepens, with a document prepared by the State Insurance Regulatory Authority (SIRA) revealing the workers’ compensation scheme ‘‘has deteriorated to the point the longer-term sustainability of the scheme is under threat’’.

NSW Auditor-General Margaret Crawford will hold a performance audit into icare next year that will examine how effectively key risks are managed, including the rising cost of workers’ compensation claims and its payment processes. Dayman said he lost everything after his injury.

‘‘I lost my health, my career, and financially I’m in a position that if my specs break I can’t afford to buy them. The system dehumanises you, so you give up.’’

He does now qualify for a disability pension but will have to rely on Medicare for future medical treatment. ‘‘I have been suicidal at times because of the system and the way it treats you,’’ he said. ‘‘My time is spent trying to survive.’’

In the executive summary of SIRA’s review into icare’s Nominal Insurer Improvement Plan, dated September 26, the authority said it had a ‘‘low level’’ of confidence icare’s strategy would improve return to work rates and overall performance.

In 2015-16, 93 per cent of injured workers were back at work 26 weeks after their injury, compared with 84 per cent in August 2022.
SIRA said it believed icare’s strategy ‘‘encompasses an increase in work capacity decisions to cease worker benefits instead of focusing on improving health and recovery through return to work’’.
Richard Harding, icare’s managing director and CEO, said it was the insurer’s role to implement the law, and legislation ‘‘does not give icare any discretion to act outside that’’. ‘‘Tailored and individualised support is provided to workers transitioning from the workers’ compensation scheme,’’ he said. ‘‘This may include support from NDIS, Community Support Services and Medicare in conjunction with their GP.’’

This masthead this week revealed a third underpayment scandal of injured workers and concerns raised by NSW Treasury in August that a deterioration in icare’s finances would require insurance premiums to rise 33 per cent by 2025, or $1 billion a year, to cover the shortfall.

Against this backdrop, the icare board granted pay increases to 116 of its executives, including Harding, making him one of the state’s top-paid public servants, earning more than $1 million a year.
Shadow Treasurer Daniel Mookhey said icare’s finances were in a catastrophic condition.

‘‘They’ve lost billions. They are planning massive premium hikes. And their next step is to expel even more injured workers from the system,’’ he said.

‘‘It is a ruthless tactic stemming from their financial desperation.’’
In a statement, SIRA chief executive Adam Dent said its views on the Nominal Insurer Improvement Plan in September were made with limited detail on how the plan would be executed.

‘‘Over recent weeks, SIRA has continued to engage with icare to address information gaps, including detailed briefings on managing IT and transition risks associated with the onboarding of new claims services providers.’’

But SIRA said poor return to work performance continued to be an issue of concern.

‘‘Icare’s targets for 2023 are lower than current return to work rates, and they are projecting a further decline of 2.5 per cent on 26-week return to work rates through 2023 and 2024 as the scheme transitions to new claims providers,’’ Dent said.

Icare said its focus was building injured workers’ capacity for employment using rehabilitation providers and associated vocational placement interventions. ‘‘This includes assistance with job seeking and vocational retraining. Work capacity decision-making is applied when the worker has a demonstrated capacity for work and has been provided the right support.’’
Lifeline: 13 11 14

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Australia’s Role in the COP 27 Farce in Egypt.

24 November 2022

It seems that there is a growing view that gas is part of decarbonising the world to save it from Climate Change.  The term ‘Climate Change’ is itself a euphemism for ‘Global Warming’ as the latter is a bit more threatening, like we have ‘new prices’ rather than ‘price rises’.

Natural gas is largely methane, which is carbon and hydrogen and burns to carbon dioxide and water. But methane is itself also a greenhouse gas, far more potent than carbon dioxide in terms of its warming effects, and quite a lot of it escapes into the atmosphere unburnt, especially if it is released by fracking.  One may remember Jeremy Buckingham’s videos of him lighting the gas coming out of the river in Grafton. Carbon Capture and Storage or CCS is a bad joke, with the fossil fuel industry getting grants to research this.  My view it is merely a tactic to play for time, like the search for the ‘safe cigarette’. It allows them to keep doing what they are doing, as regulators hope for a technofix.

The fossil fuel industry was in Egypt and seems did quite well, getting agreements to cut down on coal, but not gas and oil.  And Australia’s approval for more gas was not criticised here, presumably because Europe is in such a mess with no Russian gas that they had become dependent on.

The cost of extracting gas has not changed, but Australia’s gas companies can just charge the world’s prices and can pocket the extra margin, known in economics as ‘super normal profits’.  It might be noted that silly Liz Truss in the UK was going to subsidise gas for the people, i.e. simply give the extra profits to the gas companies by creating a taxpayer debt; a Tory idea of ‘welfare’.  In Australia we just let the money go from consumers to the companies with few royalties. Norway and Qatar benefit from their resources- we don’t.

It seems that the COP meeting in Egypt was overshadowed by the G20 and the ASEAN meetings, but it is also likely that Egypt was leaned on by its affluent neighbours, the Middle East fossil fuel producers. 

Here is a summary- it is not encouraging. The much-praised Albanese government has not done enough!

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BUGA UP –  the issues keep resurfacing

19 November 2022

BUGA UP originated in 1979, when its 3 founders were prevented from a regular evening out to re-face tobacco billboards by pouring rain.  As it they sat and waited, they thought about how to publicise their work so that it did not appear as random anti-tobacco graffiti. They wanted a word that would be irreverent and would embody the concept of hitting back against the unhealthy promotions. After some discussion, the word BUGA UP was developed, an acronym for Billboard Utilising Graffitists Against Unhealthy Promotions. From that night they signed all the re-faced billboards with BUGA UP.

The major problem at that time was tobacco promotion, which accounted for over half outdoor advertising, with alcohol second. The concept was self-regulatory in that anyone taking up a spray can had to make their own decision about what they wanted to say, i.e. what they were willing to be arrested for. 

A relatively large number of graffitists, especially from the medical fraternity, were inspired by what appeared to be a large campaign and were willing to be arrested for spraying on tobacco billboards. Other activists were concerned about alcohol promotion and some were concerned about sexism in advertising.  A relatively small percentage were willing to be arrested for junk food or drink ads. (There were no ads for gambling at that time).

BUGA UP, however, looked at the whole issue of the regulation of advertising, asking that it not be one-way communication with no input from consumers or regulators as to the content or consequences of the promotions.  The advertisers’ position was that it was their money, they could  say what they liked, as this was ‘freedom of commercial speech’. Note the extra word in the cliche ‘freedom of speech’.

The advertisers set up a farcical ‘Advertising Standards Council’ which had very loose ‘codes of practice’ and an industry dominated judicial system, which took so long to work that the ad campaign was invariably over even if they banned an ad, which very rarely happened as they had the numbers in the kangaroo courts.  One hapless paediatrician was recruited onto one of these committees, had his name used to champion the quality of its membership, and of course was outvoted in every deliberation.  He eventually acknowledged sadly that he had been ‘used’ and he resigned.

But BUGA UP was active, producing a publication, ‘Billboard’, which was sent to all the major players in the advertising industry to emphasise to them that their regulatory systems were recognised as farcical.  BUGA UP invented the ‘Advertising Double Standards Council’ to satirise the ‘Advertising Standards Council’.  Its slogan was ‘If advertising standards are good, double standards are twice as good’.

One of BUGA UP’s members, Peter Vogel, wrote over 400 complaints about many ads. He was labelled a ‘serial complainer’ and they wanted not to respond to his complaints. He insisted that by their own charter they had to. They rejected all 400+!

Eventually there had been so much publicity about advertising regulation that the advertising industry wanted the Trade Practices Commission to re-legitimise its self-regulatory system, presumably as they thought government regulation was possible in the future.  The Fairfax newspapers fronted this action, and it was opposed by ACA, The Australian Consumers’ Association. The advertisers said that their codes and practices were working well.  At this stage Peter Vogel of BUGA UP came out of the woodwork, with his huge file of denied complaints. He had systematically made complaints using every item of the advertisers codes of practice and had a farcical response to every item, which the Commission could judge for itself.

Two academics, Shenagh Barnes and Michael Blakeney  wrote a book called ‘Advertising Regulation’ (Law Book Co 1982) which concluded that the self regulatory system manifestly lacked credibility’. But despite the moral victory, the consequences of the trial were not good. The Trade Practices Tribunal concluded that it was not able to set up a regulatory structure, but could only either approve or reject what was put in front of it, so in the absence of any alternative it approved the self-regulatory system as it might have a bit of benefit over nothing at all. ACA, the Consumers’ organisation, was almost sent bankrupt by the legal fees involved, and overall the Industry had got what it wanted.  A few years later when the issue had faded from the public eye, the Advertising Standards Council faded too.

The original BUGA UP guide, ‘Ad Expo- a self-defence course for children’ from 1983 is still available  online, but of course its ads are now dated. (ww.bugaup.org/publications/Ad_Expo.pdf

But now, as gambling wreaks havoc with families, and childhood obesity skyrockets, the issue of irresponsible advertising is back in the spotlight. Let us hope that there is more success this time, but a lot of work will be needed even to get up the momentum that BUGA UP had in 1983.

Here is an article on sugar and obesity: 

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The Myth of Liberal Competence-1

19 November 2022

One of the enduring myths of politics is that conservatives are better money managers.  This is the case in the US, where the Republicans, who enthusiastically dismantle government programs that help poor people and the UK Conservatries who do the same.  And it is the case here with the Liberals.

Perhaps the logic is that since they are rich, they must be better with money.  But I wonder at the influence of Christianity. The key message is that you must suffer to be redeemed.  Suffering is worthy and will later be rewarded.  This seems to play into notions that the country will benefit if we all suffer now, ‘we’ in this case being those more dependent on welfare, or those at the bottom of the heap.

The other overarching fact in a market economy the more wealthy people can set the prices, which effectively means they set their incomes. At the bottom of the social pyramid, those at the bottom compete for the jobs and wages set by others.  In short, the rich get richer and the poor get poorer.  The game ‘Monopoly’ was designed to illustrate this.  People play Monopoly, and when they win or lose, they stop the game and go on with life. But what is the game were real and never ended?  The losers would get poorer and poorer until they had nothing else to give. That arguably is what a market economy will do without some intervention from an outside force, like a government, to intervene in the cause of those going backward.

Arguably the world’s leading economist is Thomas Piketty.  He is a Frenchman who, as he rose, was offered a post in Harvard.  He did not take it, opining that economics in the US was theoretical and not based on hard data, as a science should be.  Records of national income and death duties going back for 400 years in 4 countries had been put together and he analysed it.  His book, ‘Capitalism in the 21st Century’ is a towering work.   It is long, but it is very well-structured with concise conclusions at the beginning and the proof in the later chapters for those who want to read more.  He observed that  the wages of the population go up at the inflation rate, and the income of the rich who loaned money go up at the interest rate, but the interest rate was always higher than the inflation rate, otherwise there would be no profit in lending.  So the income of the rich would always go up faster than the rest of the population, so social inequality would increase in the absence of other interference.

It has always been known that money goes round, and to stimulate the economy people have to spend more.  But Piketty points out that poor people spend a greater percentage of their money than rich people. Very poor people spend all the money they have, rich people save about a third. So if you want to stimulate an economy, you should give money to poor people.  This is of course not what conservative governments do.  They give money to infrastructure, which these days means big private contractors or have industry assistance packages. But these initiatives are giving money to the rich, on the assumption that it will generate more jobs in the long term than the extra consumption would have generated.

(You might ask why Piketty has not got a Nobel Prize for being the first economist to use real data over centuries and come to such a profound conclusion.  If you did ask that you might wonder if the Nobel prize economics  committee are all neo-liberal economists and you might be right).

The point is without government intervention, the rich will get richer and the poor will get poorer. The best way to minimise this is to have as much shared wealth as possible in the form of park and public facilities, such as transport, health, education and essential services that blunt the significance of income disparities, as a base-line is set without it having the stigma of charity. 

But conservative governments, like the Nobel committee want to ignore Piketty and the obvious facts as they do not suit their ideological agenda.  A cynic would say that the ideological agenda from right wing ‘think tanks is merely an endless list of convenient reasons to keep the money flowing to the top end of town, to lessen government ‘interference’ which might act for fairness, and to commodify everything such as housing, transport and education so they can become profitable, increase inequality and profit those at the top.  How can this agenda ever be considered the foundation of good financial management?

But as Treasurer, Morrison was not even clever in his management of his own revenue.  Here is a tale of how his GST deal with Western Australia was out by a factor of almost 10 times over 3 years.  Yet the legacy of this shambles is contracts and deal that other have to grapple with.

One of the modest contributions that I am seeking to make to political discourse is to sheet home the blame for failures to the people responsible for them.  Here is a start, from the SMH:

Cost of Morrison’s WA GST deal blows out by $20 billion as debt hits record high

By Shane Wright  SMH November 14, 2022 — 5.00am

A deal put in place to placate Western Australia when its share of GST revenue was tumbling is on track to cost the nation’s taxpayers 10 times more than originally forecast, helping drive up federal government debt and interest payments to record levels.

Pulled together by then-treasurer Scott Morrison in 2018 before being put through parliament by his successor, Josh Frydenberg, the deal that was originally expected to cost $2.3 billion is now on track to cost more than $24 billion.

WA, which delivered four seats to Labor at the May election on the back of a 10.6 per cent swing, is vowing to fight to keep the arrangement, due to expire in 2026-27.

Morrison struck the deal at a time WA’s share of the tax pool had fallen to an all-time low of 30 cents for every dollar of GST raised within the state. Its iron ore royalties were effectively being redistributed among the other states and territories based on a Commonwealth Grants Commission formula that takes into account each state’s revenue sources and expenses.

Under Morrison’s deal, from 2022-23 WA must receive a minimum of 70 cents in the dollar before increasing to 75 cents in 2024-25. When the policy was put in place, it was expected iron ore prices would fall and WA’s share of the GST pool would therefore rise. Instead, prices have soared.

The Morrison government ensured other states and territories wouldn’t be worse off, which requires the top-up funding for the deal to come from outside the $82.5 billion GST pool.

It was originally forecast to cost federal taxpayers $2.3 billion over three years, including just $293 million in 2021-22, but the surge in iron ore prices has meant more top-ups and for longer.

The October budget revealed that last year, the deal cost $2.1 billion and is forecast to jump to $4.2 billion this financial year. By 2025-26, the cost of the entire deal is on track to reach $22.5 billion, with another $2-3 billion likely the year after that.

Throughout the entire period, the budget is expected to be in deficit, forcing the extra cash to be borrowed. In percentage terms, the blowout in cost is larger than the NDIS, aged care, health or defence.

Independent economist Chris Richardson said the deal had been ill-conceived from the beginning with the cost to be borne by future taxpayers.

He said all significant spending programs needed to be properly assessed, including the GST deal.

“Yes, the politics of it are difficult. But we have a whole host of other issues, like the NDIS, and the economics of them have to be dealt with,” he said.

Any change to the GST deal would create enormous political problems in WA which is likely to gain more political power with an additional seat in a looming federal electorate redistribution.

WA Premier and Treasurer Mark McGowan, who reported a $5.6 billion budget surplus for the 2021-22 financial year, told this masthead he expected the GST deal to remain.

“I have made it very clear that West Australians will not accept any changes to the GST distribution,” he said.

“Those on the east coast who are demanding WA lose out still do not realise that under the reforms, WA will receive 70 per cent of its population share of the GST next financial year. In complete contrast, no other state has ever received a share of the GST lower than 83 per cent.

“WA will continue to subsidise all the other states into the future under this arrangement. No state has lost a dollar under these reforms.”

The extra borrowing for the GST deal has contributed to the lift in gross debt, which on Friday reached a record $909.4 billion.

Ahead of the COVID-pandemic, gross debt was expected to reach $576 billion this financial year. Instead, it is now forecast to reach $927 billion before reaching $1 trillion in 2023-24.

Treasurer Jim Chalmers said the cost of servicing the debt was getting more expensive and was now the budget’s fastest-growing expense.

“We’ve made good progress in a very short space of time. We’ve found $22 billion in savings and kept real spending growth flat across the forward estimates,” he said.

“[But] it will take more than one budget and more than one term of government to make up for a decade of missed opportunities and messed-up priorities.”

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