Monday, 17 September 2007
Health Insurance Amendment (Medicare Dental Services) Bill 2007
The purpose of the Health Insurance Amendment (Medicare Dental Services) Bill 2007 is to amend the Health Insurance Act 1973 in order to provide for the expansion of the government’s failing Medicare dental program for people with chronic conditions and complex care needs. Labor will be opposing this legislation. Labor has consistently and loudly highlighted not only the weaknesses of this particular policy but also the Howard government’s negligent approach to the dental health needs of Australians over the last 11 years. A decade of Howard government neglect cannot be fixed by throwing millions of dollars at this failing policy.
There is little doubt that Australia is in the midst of a potentially catastrophic dental care crisis. Currently, there are 650,000 Australians on public dental waiting lists around the country, many waiting years for treatment. Thirty per cent of Australians reported avoiding dental care due to the cost. Dental workforce shortages mean that Australians simply cannot get in to the dentist when their teeth need attention. In the public sector it means long waiting lists; in the private sector it means not being able to get in to see a local dentist at short notice. These dental workforce shortages are particularly felt in outer metropolitan, regional and rural areas, where there are very few dental professionals.
These problems with accessing affordable dental care are contributing to Australia’s deteriorating dental health. The deterioration of the oral health of Australians is the most worrying factor in this debate today. Tooth decay ranks as Australia’s most prevalent health problem, while gum disease ranks as the fifth highest. Untreated dental decay in the Australian adult population stands at over 25 per cent—that is, more than a quarter of Australians are not getting the dental care that they require. A recent study found that one in six Australians had avoided certain foods during the last 12 months because of problems with their teeth. About 50,000 Australians a year are being hospitalised for preventable dental conditions which have escalated into more serious problems because they have not been able to access treatment when needed.
Perhaps the biggest indictment of all is that, while Australian kids had world’s best teeth during the mid-1990s, there are now pockets of real concern. For example, between 1996 and 1999, five-year-olds experienced a 21.7 per cent increase in deciduous decay. This was matched by soaring hospitalisation figures for the removal or restoration of teeth. According to statistics of the New South Wales Chief Health Officer, between 1994 and 2004, hospitalisation rates for children under five have increased by a staggering 91 per cent. Think about that for a moment: over a decade there has been a 91 per cent increase of hospitalisation rates for our children with dental health problems. This finding was confirmed by disturbing claims information, recently released by the health insurer MBF, which showed a 42 per cent increase in children being treated in private hospitals for dental cavities.
It is clear that Australians need action on dental health. But, rather than addressing this range of issues to improve accessibility to affordable dental care and therefore improving the oral health of Australians, the Howard government have instead spent much of the past decade cynically playing the blame game on dental health. Time and again, Prime Minister Howard and Health Minister Abbott have deflected criticism onto the states and territories, reiterating that Australia’s public dental crisis and deteriorating oral health standards are entirely a state and territory problem.
In seeking to blame the states and territories, the Prime Minister and the Minister for Health and Ageing have conveniently ignored two key facts. Firstly, it was the Howard government which scrapped Labor’s Commonwealth Dental Health Program in 1996, ripping $100 million a year from Australia’s public dental system. While state and territory governments have more than doubled their investment in public dental care over the past decade, the impact of the Howard government’s decision in 1996 is still reverberating today, not least on the hundreds of thousands of Australians languishing on public dental waiting lists. But let us be clear about this: dental care in Australia is in crisis because of the underfunding that I have mentioned and the workforce shortages. I emphasise these twin issues, because our current dental crisis is far more complex than the all too familiar Howard government one-liner, ‘It’s all the states’ fault.’
The Howard government seems to have forgotten that the training of dental professionals is uniquely a Commonwealth government responsibility. The Howard government’s neglect in this area is longstanding, and it is not as though it has not had sufficient warning of what was coming. A national oral health training strategy for oral healthcare providers and other health professionals was recommended by the Senate Community Affairs References Committee as long ago as 1998, but the Howard government has failed to act.
In 2003, researchers highlighted that there would be a shortage of 1,500 dental professionals by 2010 unless action was taken. In 2004, dental graduation levels were found to be at their lowest level for over 50 years. Belatedly, the government recently increased dental training places at Australia’s universities, and Labor welcomes the recent budget announcement of a new dental school at Charles Sturt University. But comprehensive and strategic national policies are required to ensure a long-term solution to this crisis. Not enough has been done to address in particular public sector shortages and regional and rural demand for dental professionals.
To give the House an example, I recently visited Bathurst, where I heard from locals how hard it was to get in to see a dentist, with many clinics having closed their books to new patients altogether. Meanwhile, those who relied on public services faced long waiting lists for attention from the dental clinic run by the Greater Western Area Health Service. More than 5,700 people were waiting for a public dental assessment, with another 2,200 people on treatment waiting lists, despite having been clinically assessed with a range of oral health problems. The public dentists were doing their best within their resources, but they were simply run off their feet. In Cairns it was a similar story, where the Edmonton clinic in the southern part of Cairns had 4,000 people on their waiting list. When you consider that the Cairns region has a population of around 130,000, and there are nine public dental clinics in the broader region, that waiting list of 4,000 at just one service really hits home. Everyone I spoke to in Cairns about the dental crisis pointed to workforce shortages as the key issue: the region simply cannot attract the dental professionals they need. The story was the same again in Burnie in Tasmania, where I visited in April. A fully equipped public dental clinic was there, in good condition, to be used, but there was insufficient staff to run the place. As a result, there were almost 4,000 people on the general waiting list in Northern Tasmania.
I give these examples to show that there are two reasons for the crisis in dental care in Australia. It is an underfunding and resourcing issue which is severely exacerbated by the actions of the Howard government, and it is a workforce shortage issue, which is entirely the responsibility of the Howard government. It would be reasonable to expect that in these circumstances the Howard government might be looking to develop effective policy solutions to address these areas and to tackle the dental health needs of Australians. But, alas, we do not see solutions to any of those problems in the bill that is before us today.
After all, when we are discussing these facts and figures about waiting lists and preventable hospitalisation, workforce shortages and clinics that are closing their lists to people who need to see a dentist, we must always remember we are talking about people. We are talking about Australians who sometimes have such severe dental problems that not only their health but also their entire work and social lives are affected. These are people who may be having trouble eating, who will not go to visit friends, who will not socialise, who cannot apply for a job or who cannot get a job—simply because they cannot get the dental treatment that they need.
Unfortunately, the Howard government is far more interested in playing the blame game than it is in providing solutions for this dental crisis. The Howard government’s dental health initiatives have been limited to the subsidies of 30 per cent or more for those with private dental health insurance—rebates that Labor supports—and this ineffective Medicare dental program for people with chronic conditions and complex care needs.
This program was initially announced in March 2004 and commenced in July that year. According to the minister’s media release of 10 March 2004, which announced the inclusion of dental services in the government’s enhanced primary care program, this was ‘a health care measure, not a dental care scheme and will only be available where dental treatment is required to treat a chronic medical condition’. Under this policy, Australians were eligible for assistance with their dental care if they had a chronic medical condition, like valvular heart disease, diabetes or malignancies of the head and neck, and they had poor oral health or a dental condition which was exacerbating their chronic and complex disease, and they were being treated under a multidisciplinary care plan. These complex and restrictive eligibility criteria, which limited the program to people with chronic conditions and complex care needs, have severely limited the uptake of the program in the three years it has been operating.
Extremely high out-of-pocket expenses have also proven to be a significant barrier to uptake. Under the original policy, patients could claim up to three items in one calendar year, at a cost of $220 per year, for a program of treatment. But, according to 2005-06 data released earlier this year, the average out-of-pocket expenses for assessment or treatment by a dental specialist under Medicare item 10977 was a whopping $692. It is hardly surprising that this has adversely affected the program’s take-up.
Complex referral processes between GPs and dentists have also been cited as a significant problem. In evidence to the Senate Standing Committee on Community Affairs, which examined this bill, the Australian Dental Association stated that the paperwork in the initial system was ‘a bit cumbersome’—a significant understatement—and that the administration of the scheme, most particularly practitioners’ unfamiliarity with Medicare, continues to cause concern. The AMA noted in their submission to the committee that there was ‘some ongoing concern that GPs have difficulty locating a dentist who will accept the rebates as full payment when referring patients’.
To get an idea of just how poorly this program has been executed, I refer again to the minister’s media release of 10 March 2004, when the program originally commenced. It stated that the new dental services would provide ‘for up to 23,000 people under multidisciplinary care plans’. In fact, in the three years between its introduction in July 2004 and June 2007, the program provided for around 7,000 patients at a cost of $1.8 million—well, well under estimates and certainly seriously underspent for the allocation that the government had made.
As I said earlier, Labor has consistently and loudly highlighted the weaknesses of this policy: its restrictive nature and the small number of people it is able to help. The government explicitly introduced this measure three years ago as a healthcare measure, not a dental care measure. But, on any assessment, this program has failed spectacularly as either. Although the health minister has on occasions openly acknowledged this failure, the government announced in this year’s budget not that it would look at addressing the restrictive eligibility criteria of the program, not that it would replace this failing program with something more effective and not that it would look more broadly at how to tackle Australia’s dental crisis. No, the government announced that it would pour an additional $377 million into an expansion of this failing and flawed program—and that amount has subsequently been increased to $384.6 million. A program that is so flawed that it has managed to spend only $1.8million in three years has now been allocated $385 million over four years. It almost defies belief that, without changing the criteria or a range of other problems with this program, it would be possible for the government to spend this sort of money in the program the way it is currently designed.
The budget announcement included a change in the benefits available under this program, but this was also subsequently adjusted. If this bill passes through the parliament, from 1 November eligible patients will be able to access up to $4,250 worth of Medicare funded dental treatment over two consecutive calendar years. I admit that this might sound good to a casual passer-by, and the change might go some way to addressing the out-of-pocket expenses incurred by eligible patients, but the key problem of how few people are eligible remains well and truly in place. Given the extremely poor take-up to date, the bad design of this program and the lack of its utilisation to date, Labor has no confidence that the extended program will be any better, particularly because the government has failed to address the range of other problems besetting this Medicare chronic disease dental program. Most importantly, the eligibility criteria remain totally unchanged by this legislation.
Further, the government has failed to address the complex and restrictive referral processes identified as cumbersome by dentists and doctors alike. In fact, the department revealed to the recent Senate committee examining this legislation that the current three Medicare items will be expanded to more than 450 Medicare items under the extended programs. It hardly sounds to me that that is actually simplifying the process for doctors and dentists. Labor is not convinced that moving from three Medicare items to 450 Medicare items can possibly simplify this program or encourage greater take-up by patients or practitioners.
Mr Deputy Speaker Barresi, we know what this means. It means that people in your electorate, people in my electorate and people in the electorates of everybody who sits in this House will not be able to be assisted by this program. Throwing hundreds of millions of dollars at this failing program is not just an appalling piece of public policy. Labor objects to the continuation of a policy that not only is failing on its own narrow objectives but also will do very little to address Australia’s public dental waiting lists, will do nothing to make dental care more affordable and accessible to Australian families and fails to even contemplate Australia’s dental workforce crisis.
What do this bill and this policy do for our children? What do they do for older Australians in aged-care facilities? What do they do for those on really low incomes or working families with not a lot of extra cash to spare? What does this policy do for most Australians? The answer to all of those questions is: absolutely nothing. Labor considers that it is plainly inadequate to provide funding for acute dental services after the government has removed its contribution to general and preventative dental care, as was provided through the Commonwealth dental program previously.
The Prime Minister says that Australians have never been better off—but tell that to the Australians who cannot chew their food. Tell that to the people in Bathurst, in Cairns, in Burnie or in any of our seats around the country who have been waiting for years to access basic dental care. A decade of Howard government neglect cannot be fixed by throwing millions of dollars at this failing policy. It is Labor’s view that an investment of the magnitude proposed by the government should be directed towards a broad based Commonwealth scheme that better addresses the priority oral health needs of those groups in the community most in need of assistance. For these reasons, Labor will be opposing this bill.
The bill itself is actually very brief. The provisions simply provide the legislative framework for the policy detail still to be fully revealed by the government. The bill makes amendments to the Health Insurance Act to, firstly, enable a monetary limit on Medicare benefits for dental services to be introduced for eligible patients. The limit of $4,250 over two consecutive calendar years will be set out in a ministerial determination made under subsection 3C(1) of the Health Insurance Act. Secondly, the amendments provide for Medicare benefits to be paid for the supply of dental prostheses, such as dentures, under the new dental items.
According to the explanatory memorandum, details such as the Medicare dental items, including the schedule fees, the eligibility requirements for dental providers and patients, and other administrative requirements will all be set out in a ministerial determination under subsection 3C(1) of the HIA. Perhaps when we see the rest of that detail we will be surprised by the policy developments outlined by the government, but for now Labor is not convinced that this policy is worthy of our support. Pouring hundreds of millions of dollars into a failing program which has not even been able to spend $2 million over the last three years of operation is not good policy and will not help the hundreds of thousands of Australians in need of dental care.
Rather than support a failing policy, Labor will instead draw on these funds to support Labor’s own dental policy. Rather than focus on a policy with such restricted eligibility, a Rudd Labor government will re-establish a Commonwealth dental program and ease the cost pressures on working families by contributing to the cost of dental care. Rather than constantly blaming the states for the crisis in Australia’s dental health, a Rudd Labor government will end the blame game and work with the states and territories to fix Australia’s dental care system, to provide services for those people in our communities who are desperately in need of dental care and to ensure that working families who are currently under pressure to choose whether they get the dental care that they need, whether they pay their childcare costs or whether they pay for their groceries or their petrol will not be put in the position where their children cannot get the basic dental care that they need. It is for these reasons that we oppose the bill and think that the money could be much better spent on a program that supports working families.