The Politics of Health Care and Population Health Dr Buddhima Lokuge Regulatory Institutions Network, ANU

Overview Political analysis of health system Case studies Medical indemnity & tort law reform Aboriginal health Private Health Insurance and Medicare Population health and health care

Relevant concepts and theories Discounting The statistical life vs identified life Public versus private goods Concentrated versus diffuse interests Exit voice and loyalty Politics of mainstream vs minority health

Health Experts and Health Politics Bridge The Gap Between Health Experts and Health Politics

Core Beliefs of Health Experts Health is Most Important Goal Children Come First Decisions Should be Based on Studies of What Improves Health (EBM, statistics) Reducing health inequities is a top priority

Core Beliefs of Healthcare Experts (Continued) Government Should Do More, Not Less Taxes Must be Raised to Meet Key Health Needs Prevention is important

Goals of Political Experts: Win Elections and Govern Effectively Means to Goal Gain Majority Support of Voters and Favorable Public Opinion Gain Support of Major Interest Groups Gain Favorable Press Coverage By the Media Gain Support of Key Political Institutions and Actors

Core Beliefs of Political Experts Health is a Second Level Goal The Needs of The Middle Class Are The Top Priority The Elderly Come First Decisions Should be Based on Studies of Preferences of Voters and Key Interest Groups SENIORS COME FIRST 16% of the Population 22% of Voters Most Likely to Vote on Health Care Issues Twice as Politically Active as Low Income Families Well Organized and Informed

Core Beliefs of Political Experts (Continued) Government Should Do Less, Not More Taxes Are Too High, And Need to be Lowered Projects with quick, visible results are best

Most important issues in 2004   Which Party is Better For Issues Three most important issues L-NP ALP Improving health services and hospitals 63 29 57 Improving education 34 30 56 Reducing crime and maintaining law and order 33 42 41 Reducing the taxes you and your family pay 35 50 Open and honest government 28 43 Managing the economy 26 Defence and national security 21 55 31

Taxation 32% dominated the list Defence 19% Health issues 16% However, when electors were asked what the Federal Government could do that would most benefit them and their families: Taxation 32% dominated the list Defence 19% Health issues 16% Private versus Public Goods

1. Political Cycle Tort Law Reform: Broken System? Compensation Protect patients, protect patients interests. Alternatives exist Politics of reform: Benefit > Cost to Government Concentrate interests Clearly articulated alternative Window of opportunity

Probability of Reform Government If Costs>Benefit Political, Economic Benefit >Costs Window of opportunity (media, mass public) Alternative exists, easily articulated Personal interest If Costs>Benefit Do and inquiry Symbolic changes Short term fix Force for change α Concentration of interests (Money, Jobs at stake) Ability to interest mass publics Height α Concentration of interests (Money, Jobs at stake) Cost to Government Tort Law No Fault

2. Aboriginal and Torres Strait Islander Health E.g. of Mainstream versus minority politics Health status, expenditure Right to healthcare versus charity Charity model: money for health versus health care Corruption, waste and political correctness

Indigenous PHC expenditure: in the Australian Context Commonwealth expenditure on Indigenous specific PHC: $260 million in 2002-03 Commonwealth expenditure on 3 drugs for indigestion/peptic ulcer disease: $314 million in 2002-03 *(OMEPRAZOLE $187 mil, PANTOPRAZOLE $78 mil, ESOMEPRAZOLE $49 mil) Source: Department of Health and Ageing, PBS, June 2003

3. Medicare versus PHI E.g. of Exit, voice and loyalty Expand PHI? (supplement to complement) - see ANU’s Gwen Gray) Long opposition to UHI by organised medicine Governments want to pull out of UHI Weak PH system strengthens bargaining power of PHI For Doctors: Fee for service versus capitation, managed care For Patients: costs, selective cover

4. Medicine and Population Health Symbiotic relationship

Relative Risks of Stroke. By Level of Diastolic Blood Pressure. % Population Relative Risk of Stoke Diastolic Blood Pressure (mm Hg)

The Prevention Paradox A large number of people at small risk may give rise to more cases of disease than a small number of people at big risk

Political Policy Trade-off Population strategy (good policy, bad politics) Big population benefit Small individual benefit Statistical versus identified pt Discounting High risk (healthcare) approach Big individual benefit Modest population benefit

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