All patients merit home nursing

The Federal Government is proposing that private health insurance should be expanded to cover elements of care in the community for people with serious and continuing illness. This cover would supplement that already available through general practitioners, community health centres, aged care and rehabilitation services and many non-government agencies.

The need for more investment in community services accords with increasing numbers of older people among whom these conditions are prevalent. Current estimates, calculated by Dr Deborah Schofield, suggest that, while the demand on hospital beds by those aged 75 or more is currently running at about 5.5 million bed days a year, this is set to almost double by 2025 and triple by 2030.

At present the majority of patients with chronic lung and heart problems do not receive formal rehabilitation and community-based care following an admission to hospital. Finding ways of better assisting these people in the community makes great sense, especially because the evidence is clear that it helps. After an eight-week rehabilitation program, people with chronic lung problems have better quality of life and fewer admissions to hospital in the year following.

But the idea that additional public resources for community support for these patients should be channelled through private insurance raises serious questions about equity. By equity I mean equal access to equal care for equal medical need irrespective of financial status, or any other social discriminator.

It was not reassuring to read the recently reported comments of Dr Michael Armitage, the Australian Health Insurance Association's chief executive, who said that the aim of the new private health insurance was to reduce hospital use, therefore those dependent on public hospitals should benefit. "If there is a privately insured patient in a public hospital and the patient can be discharged sooner and be treated in their own home, what we are doing is opening up a bed for a public patient," he said.

There are two problems. First, it is possible to hear these comments as an endorsement of the idea that those with private insurance should receive preferential treatment - that is more and better care - than those without it. If that is true, then the claim that the Australian health care system remains fair is false.

Second, there is no evidence, yet, that expanding the private sector has reduced the pressure on the public system. In his research on the impact of the 30 per cent private health insurance rebate, Professor Denzil Fiebig, from the University of New South Wales, found that there was no simple relationship between the uptake of private health insurance and pressure on the public system.

Because the reasons why people take out private insurance vary, it cannot be assumed that they will cease to be treated in public hospitals. Although this recent policy decision may encourage privately insured patients to leave hospital sooner and continue treatment at home, claiming it will benefit patients in the public system is an unfounded assumption at this stage.

One of the most interesting, and as yet unclear, implications of this recent decision is its effect on private hospital admission policies for patients with chronic diseases. When these patients deteriorate, after years or more of care provided by private health insurance, can they reasonably expect treatment in a private hospital? Or is it the case that they will be expected to spend the unprofitable (hospital) part of their medical care back in the public system?

It is, of course, a matter for the voting community to decide how much Australia should privatise health care. But if proposals are put forward for extending the reach of private care, without making similar improvements in the public sector, the voting public should be clear about the implications.