COAG healthcare reform: A perspective from WA

This week the Gillard Government finally reached an in-principle agreement with state Governments about reforms to the Australian heath care system. In this piece WA health economist Luke Slawomirski consisers the implications of the in-principle agreement. This piece first appeared in Online Opinion (here).

Health (Care) Reform

by Luke Slawomirski

The in-principle agreement struck between the Commonwealth and the States at COAG on Sunday is good. It is not great. While Australians have reason to be cautiously optimistic that health care reform is back on, it is also disappointing that it doesn’t go far enough.

More transparency

Firstly the positives. These revolve around the emphasis on transparency, accountability and efficiency. The key drivers will be

(a)    introduction of Activity Based Funding (ABF) for hospital services - paying public providers an agreed fee per care episodes such as a knee replacement,

(b)   the development of ‘efficient prices’ for episodes - a difficult, but not impossible task as some commentators have indicated

(c)    a more transparent, pooled federal funding mechanism.

Health care is one of the most opaque industries around and reforming the ‘blank cheque’ block funding approach, at least for hospitals, has to be a good thing. Increased scrutiny brought about by these measures can help reduce pernicious aspects of health care such as unwarranted variation in clinical practice and over treatment. 

Efficiency

The creation of Local Hospital Networks (LHNs) also has the potential to translate into better, more efficient services. In metropolitan and semi-rural regions, hospitals will be able to establish partnerships with nearby peers, and consolidate and rationalise services. This can not only enable economies of scale but also improve quality and safety because increases in the volume of cases for procedures and treatments increases are often accompanied by improvements in quality and decreased complications. 

Also encouraging are the provisions built in to ensure smaller, rural hospitals are not swept away by the utilitarian calculus and rationalisations of ABF.

Lack of integration

Now to the not so good parts. Setting aside the likely mess of establishing Medicare Locals and GP Super Clinics, a key problem is the non-integration of primary and tertiary care. The health care system could operate much more efficiently if there was more clinical and administrative coordination between primary providers such as GPs, pharmacist etc, and hospitals. LHNs would be much more effective if the network included at least some local primary care providers.

Much of this is a result of the funding split between the Commonwealth and state budget – and this is, unfortunately not rectified in this agreement, counter to a key recommendation of the National Health and Hospitals Reform Commission’s 2009 Report.

No prevention or promotion

It is all very hospital-centric, much to the disappointment of those who know that in the long run, the most value for money in health is in prevention and promotion. This makes all the talk of ‘efficiency’ ring a little hollow.

Implied in the agreement is the misconception that the principal driver of health, and preventer of ill-health, is health care. It is now accepted that this is not the case at all. Health care (especially tertiary care) is, at best, only a modest contributor while the dominant factors are structural and societal. Even in developed nations such as Australia, health and disease rates are predominantly influenced by things like education, literacy, income equality, social mobility and cultural factors.

There is also not much mention of mental health and nothing on addressing Indigenous health status. Both are essentially a prevention problem, whose long-term solutions reside within the sphere of the cultural, social and economic determinants, well outside the health care sector and

Of course, selling prevention is politically extremely difficult as it lays outside the reach bio-medical technology. However, Julia Gillard explained parts of the deal very well on the 7.30 Report on Monday night (14.2.2010). There is no reason why she and other political leaders cannot begin to communicate with the community the real need for and benefits of prevention.

Cost escalation and lost opportunities

Health care is extremely expensive. Its costs, as a percentage of GDP, are rising. The reasons for the escalating cost are erroneously attributed to demand side drivers including demographic change and an ageing population. This is largely incorrect. The main driver of escalating cost is actually on the supply side - the constant development of new medical and pharmaceutical technology. The rising expectations these foster in the community then serve to amplify an already rising demand.

There is no mention of addressing these in the part of the agreement on efficient cost growth. One hopes that this will be adequately tackled in the setting of efficient prices outlined in the agreement. However in its negotiations with this (admittedly pre-Gillard) government does not have a solid track record in tackling vested interests within the medical industry.

The other problem is opportunity cost – each public dollar spent on a hospital bed or PBS prescription is a dollar unspent on schools, playgrounds or other preventive expenditure.

Likewise, each interview minute spent by the PM talking about hospital beds and Super Clinics is a minute not spent communicating the value of programs and initiatives that keep people out of hospitals.

Prevention, of course, requires expenditure of financial and political capital. In a world of scarce resources (and three year electoral cycles) it is often more expedient to talk about ‘more beds and more GPs’ than tackling the root causes of disease, which are notoriously difficult to explain to the public.

In summary, the agreement reached at COAG was definitely a win for the Prime Minister. However, it is very pragmatic and there is a lot of detail left to sort out. Most importantly, it could have been a lot better. If Julia Gillard wishes to be remembered as a reformist like her political hero Nye Bevan and mentor Bob Hawke, some of the shortcomings briefly outlined above may need to be addressed before the next election.

Luke Slawomirski is a Health Economist and has worked as a clinician in Australia and overseas. The views expressed here are his own.

Phillip Pullman and the greedy ghost of market madness

"there are things above profit, things that profit knows nothing about.. things that stand for civic decency and public respect for imagination and knowledge and the value of simple delight"  Phillip Pullman

Fantastic speech here by British author Phillip Pullman on what he calls "the greedy ghost of market madness" and the social, cultural, and democratic dislocation that it causes. 

In this speech Pulman attacks the British Government for its austerity cuts which are resulting in the closure of hundreds of libraries throughout the UK and are hitting the most marginalized and disadvantaged the hardest, whilst delivering tax cuts and more public funds to the wealthy, the corporate elite and business and corporate interests.

Pulman points the finger directly at all those who advocate for the unfettered freedom of the market  and who measure the success of an endeavor or a public responsibility by the metric of profit .

"...........And it always results in victory for one side and defeat for the other. It’s set up to do that. It’s imported the worst excesses of market fundamentalism into the one arena that used to be safe from them, the one part of our public and social life that used to be free of the commercial pressure to win or to lose, to survive or to die, which is the very essence of the religion of the market. Like all fundamentalists who get their clammy hands on the levers of political power, the market fanatics are going to kill off every humane, life-enhancing, generous, imaginative and decent corner of our public life. I think that little by little we’re waking up to the truth about the market fanatics and their creed. We’re coming to see that old Karl Marx had his finger on the heart of the matter when he pointed out that the market in the end will destroy everything we know, everything we thought was safe and solid. It is the most powerful solvent known to history. “Everything solid melts into air,” he said. “All that is holy is profaned.”

Market fundamentalism, this madness that’s infected the human race, is like a greedy ghost that haunts the boardrooms and council chambers and committee rooms from which the world is run these days.

So decisions are made for the wrong reasons. The human joy and pleasure goes out of it; books are published not because they’re good books but because they’re just like the books that are in the bestseller lists now, because the only measure is profit.

The greedy ghost is everywhere. That office block isn’t making enough money: tear it down and put up a block of flats. The flats aren’t making enough money: rip them apart and put up a hotel. The hotel isn’t making enough money: smash it to the ground and put up a multiplex cinema. The cinema isn’t making enough money: demolish it and put up a shopping mall.

"...............The greedy ghost understands profit all right. But that’s all he understands. What he doesn’t understand is enterprises that don’t make a profit, because they’re not set up to do that but to do something different. He doesn’t understand libraries at all, for instance. That branch – how much money did it make last year? Why aren’t you charging higher fines? Why don’t you charge for library cards? Why don’t you charge for every catalogue search? Reserving books – you should charge a lot more for that. Those bookshelves over there – what’s on them? Philosophy? And how many people looked at them last week? Three? Empty those shelves and fill them up with celebrity memoirs.

That’s all the greedy ghost thinks libraries are for.

Now of course I’m not blaming Oxfordshire County Council for the entire collapse of social decency throughout the western world. Its powers are large, its authority is awe-inspiring, but not that awe-inspiring. The blame for our current situation goes further back and higher up even than the majestic office currently held by Mr Keith Mitchell. It even goes higher up and further back than the substantial, not to say monumental, figure of Eric Pickles. To find the true origin you’d have to go on a long journey back in time, and you might do worse than to make your first stop in Chicago, the home of the famous Chicago School of Economics, which argued for the unfettered freedom of the market and as little government as possible.

Gavin Mooney on the difference between compassionate acts and a compassionate society

photo courtesy of the Age and Getty

This piece first appeared in Crikey.

Floods aside just how compassionate is Australia
by Gavin Mooney, Health Economist and co convener WA Social Justice Network

The recent devastating floods have brought out all sorts of emotions. We have seen expressions of great compassion and generosity. And these are emotions that we seem genuinely to treasure when we see them, whether these be in our fellow citizens or in our leaders. In all the heart-wrenching devastation of lives and property, it is heart-warming to see so many showing their compassion for those who have lost so very much.

The question of compassion is one in which as a health economist I have a particular interest. I have recently sought to make a case that strong, compassionate communities are good for people’s health.
I also argued a few years ago, for example, that countries that were more compassionate treated drug addiction and drug addicts better and, while it was difficult to "prove", some leading drug experts expressed the view that I was on to something.

One of the difficulties here is how to quantify compassion. Can we find a measure that will allow us to see how compassionate we are as a society compared say to the Swedes or the Americans or the Brits?

Earlier I used just public expenditure as a proportion of total national income and Australia didn’t come out of that well. Across 33 OECD countries, for example in 2008, we came fifth from the bottom on 27.1%. On this indicator, the countries that came out well -- perhaps predictably -- were the Scandinavians with Denmark at the top with 48.2%.

Another possible measure is public social expenditure and here we do rather badly again.
These are somewhat crude but not silly measures of social compassion. In this context, public expenditure matters. It is difficult to see how we can build a caring society if we rely too heavily on the market. That may be OK for Tim Tams and TVs but for addressing poverty, inequality, Aboriginal disadvantage, mental illness and flood protection, we need public monies.

But I have just come across a paper that has some really worrying stats on Australian compassion. Well not strictly compassion but what is called "generosity" but it is pretty much the same thing. It examines what it calls "the generosity of social insurance".

What it does is rather neat. It argues that we can use certain public-sector programs to get an estimate of how generous (or in my language compassionate) a country’s welfare state is.

So, for example, we can take unemployment insurance. One measure of that program’s generosity is what proportion of income that replaces. Added to that is the "coverage ratio" i.e. the proportion of the population covered. Multiplying these together gives an index of "generosity" for that program. Clearly the higher the index, the greater the generosity.

The paper then does the same for sick pay and for state pensions. It adds the three indices together and comes up with an overall generosity index.

Not perfect but an interesting exercise.

Now the scary bit. Australia comes bottom of 18 OECD countries! Oh dear, we are the least generous of them all. Even the US, which is often seen as being the land of free enterprise, individualistic and unwilling to provide decent health care for its people (especially its poor), comes out quite a bit above us. According to this index, in comparison, countries such as Sweden and Norway are dripping with compassion.

I think we are a compassionate people -- if we are given the chance and all sorts of private acts in the past few days and weeks show that. But we need our governments to recognise that. We need leaders prepared to lead. Many -- most? -- of us who are well off would be willing to pay more taxes to help the less fortunate.

We do want a compassionate society. We do believe in the fair go.

Julia: stop messing about. Recognise that we Aussies really do have a decent streak in us -- we have just shown it. We want a caring community. We cannot get it -- and you will not get it -- if you continue to pander to our baser selfish interests and instincts.

Tax us more. Build a caring public sector. We want to be the custodians of a decent society. We want to be led to that compassionate society. It will also make us a healthier society. Let’s get on with it.

Andrew Thackrah on a mining boom built on myth

In the piece below Andrew Thackrah shows how much of the political and economic logic that underpins Western Australia's so called "mining led economic boom is built upon a series of myths.

In particular, the wealth generated by the mining industry, which enriches some at the expense of many, is built on the back of massive public investment and active intervention by the State Government to advance the interests of mining corporations and WA's business and corporate elite.

This piece first appeared in the online publication Australian Policy and History.

Mining, Myths and making it up in Western Australia

by Andrew Thackrah,
Postgraduate candidate, School of Humanities, University of Western Australia

Following then prime minister Kevin Rudd's announcement in May that the Commonwealth Government would introduce a new 40% 'super-profits' tax on the profits of some mining companies, a wave of hysteria swept through sections of the political class of Western Australia. In its Foundation Day editorial the state's main newspaper, The West Australian, said its inhabitants could be forgiven for feeling like 'they are living in a state under siege'. Prominent Western Australian identity and boss of Fortescue Metals, Andrew Forrest, has predicted the new tax could result in 30,000 job losses.

Julia Gillard's ascension saw a new deal negotiated with the mining companies. The rate of taxation was reduced to 30% and the number of companies affected by the new arrangements was drastically cut. The hyperbole, however, has not subsided. Fresh mining industry-funded ads have claimed that electricity prices will rise and the value of superannuation funds fall if the new arrangements are introduced. With Tony Abbott promising to oppose Labor's 'big new tax', the proposed changes have become a red-hot election issue - nowhere more so than in the mining-centric state of Western Australia.

Western Australia is a mining state whose citizens' obsession with resources has shaped almost every facet of their lives. A degree of parochialism commonly creeps into political debates in the West. Ironically, however, in their strident defence of the significant role played by resource companies in maintaining Australia's prosperity, mining tax opponents have clearly highlighted just how much the dominant framework of political economy in Western Australia draws upon globally ascendant free-market ideology. In short, the history of mining in Western Australia bears striking parallels to the wider history of contemporary free-market capitalism. 

This reality becomes clear when one considers two of the key arguments deployed against the mining tax. First, it is suggested that the mining industry is a 'golden goose' that spreads prosperity throughout society and that government regulation will only succeed in 'killing off' the good times. The 'golden goose' defence of the mining industry was quickly deployed following the announcement of the super-profits tax. Shadow Treasurer Joe Hockey, for example, declared that Kevin Rudd was 'about to take money off the golden goose that's delivering Australia an age of prosperity'. 

Globally, this line of argument commonly has been used to defend the interests of domestically dominant industries. Yet, as British geographer Doreen Massey highlights in World City, her book on the City of London, the golden goose analogy serves to conceal more than it reveals. Massey notes that instead of the concentration of economic activity in London's finance sector over the last two to three decades being seen as '…an element in the production and reproduction of inter-regional inequality… it is taken as given and then interpreted as a source of London's largesse to the nation as a whole'.

The point here is not to deny that the finance and mining sectors have produced substantial wealth. Rather, the golden goose analogy serves to promote the notion that minimal government regulation actually spreads that wealth throughout society, obscuring the creation of inequalities (both local and global) upon which economic growth may actually rely. One only has to think of the economic stagnation in areas of northern England and Scotland and the continuing poverty of some indigenous Australians to be reminded of the losers in periods of rapid growth. 

The second key argument deployed by mining tax opponents is that mining fosters an entrepreneurial spirit that is entirely independent of government involvement in the economy. West Australian newspaper columnist Paul Murray, for example, recently made the extraordinarily simplistic assertion that 'mining has always met its own risk - and provided its own infrastructure. It doesn't want, or need, the Government as a "silent partner" in its business'.

The notion that mining has thrived when government has left the industry to its own devices simply flies in the face of history. As academic (and now Vice-Chancellor of Victoria University) Elizabeth Harman noted in the early 1980s, a paradigm has reigned in Western Australia where state and capital have worked together to ensure that the need for development is prioritised over other interests. Premier Charles Court was particularly pro-active in attracting mining investors to the state. 

A more recent analysis of WA economy by Peter McMahon of Murdoch University reveals that, while private enterprise has played a vital role in the state's history, it has not done so as a solo operator. McMahon notes that 'successive governments…were absolutely critical in developing W.A.' Recently the Barnett Government committed $3.5 million for the development of plans to build a new port in the Pilbara and boasted that the Government's decision to construct new power lines had ensured that a large resource project went ahead. Just as the finance industry was lured to London by conscious government regulatory and tax changes, so, too, the Western Australian mining industry is aided and abetted by the state. 

The 'golden goose' and 'entrepreneurial spirit' arguments outlined above follow from a specific aspect of free market thought - the notion that commercial enterprise guided only by a minimal state sees wealth 'trickle down' to almost all in society. Ideas like these have not emerged in a vacuum. David Harvey in his Brief History of Neo-liberalism explains how such free market notions have become dominant since the Western economic crises of the 1970s. They were championed by leaders such as Ronald Reagan and Margaret Thatcher as part of a conscious political strategy. The continuing reality of inequality reminds us that, rather than being grounded in common sense, free market ideas are a product of a historically specific context that leaves them open to revision and debate. Voters in Western Australia and beyond should look carefully at the rhetoric used by anti-mining tax campaigners. It says much about how the political and economic logic of the present is grounded in myth-making about the past.

Australians thinking and writing about Markets and Society

Damien Cahill  is an Australian academic who has written extensively about the influence of neoliberalism and the use of market solutions to an increasing number of social issues. Some of his writings can read here and here.

Damien is also the co-convenor of the Markets and Society Research Network at the University of Sydney, which  brings together social scientists concerned about markets and society to discuss the social foundations of markets; the regulation of markets; the social effects of markets; and the shifting boundaries between the state, private sector, and civil society.

Like this blog, the Market and Society Research Network aims to challenge orthodox conceptions of markets at a time of increasing ‘marketisation’. This  includes critical examination of the role and nature of markets, the legitimate scope of markets as well as investigations of markets as sites of contestation.

The Network recently ran a 2 day conference to critically analyze the increasing reliance on market-based solutions in Australia  in areas such as  climate change, provision of human services, childcare services, health, education, superannuation and housing. The program and the papers can be read here.

The crisis in the Murray Darling and the failure of market mechanisms

Bruce Haigh on the madness of using market mechanisms to manage water in the Murray Darling Basin and the need for a radically different approach to the management of Australia's water resources:

"The management of water should not be left to markets where the pursuit of profit has water abused, devalued and often powerless with respect to sustainability. Water needs a voice and a value beyond the market. At the moment it comes a very poor second in calculations relating its use - agriculture and industry have the upper hand and water is required to comply".


"The National and Liberal Parties presided over the slow decline of rural Australia. They had the opportunity to reverse this during almost 12 years of government. They declined to do so and as a result many jobs were lost and economic opportunities that may have come through the provision of better services and infrastructure were not created, but were lost. This neglect saw the rise of rural Independents who now hold the balance of power". 

The ideological straitjacket of economics

"We need to develop a new way of conceiving the economic process. In calling for an end to economics, I am not suggesting that we should dismiss everything that economists have learned about the economy. Some economic insights are useful. Our goal should be to build up an understanding of the economy in a context that transcends the narrow context of economic theory that characterizes modern economic theory. In doing so, we may lay the groundwork for an economy that transcends our outmoded capitalist way of life." 
Michael Perelman Railroading Economics

Stephen Marglin calls it the "dismal science". Michael Perelman writes about the ideological straitjacket of modern economics. James Galbraith describes contemporary economics in terms of a god that failed, a governing creed whose fallacies have been exposed by events of recent years.  In his book Economia Australian Geoff Davies writes that we have all become so accustomed to the current economic regime that we fail to see how absurd it is. He is right.

I am currently reading the books pictured and all present a radical and sustained critique of contemporary economics. They challenge the idea that market and market forces are a solution to our social, environmental and economic problems.  

These books don't just expose discredited contemporary economic orthodoxies, they also document the destructive effects of those orthodoxies in the real world (rather than the theories of economists and business leaders). These authors more importantly set an  alternative and radical economic agenda for the future.

The books pictured include:

  

Stephen Margeli (2008) The Dismal Science

Michael Perelman (2006) Railroading Economics

James Galbraith (2008)  The Predator State: How Conservatives Abandoned the Free Market and why Liberals Should to

Geoff Davies (2004) Economia: New Economic systems to empower people and support the living world

James Gustav Speth (2008) The Bridge at the End of the World

Barry Lynn (2009) Cornered:The New Monopoly Capitalism and the Dynamics of Destruction