In this latest edition of The Health Wrap, Associate Professor Lesley Russell examines bold ideas emerging from Ireland on private hospital care, the need for care in responding to links between menopausal hormone therapy and breast cancer, overincarceration of Aboriginal and Torres Strait Islander people, and a project that provides menstrual cups to school girls in parts of Africa.
Lesley Russell writes:
The Health Wrap is back after a brief hiatus while I walked part of the Larapinta Trail, on the traditional lands of the Arrernte people in the Northern Territory.
An amazing experience, the exhausting, crowning moment of which was climbing Mt Sonder in the dark to watch the sun rise.
But now the red dust has been washed away and it’s back to work. Here’s my take on recent health and healthcare news.
Bold ideas on public vs private hospital care from Ireland
As the debate on private health insurance (PHI) continues with no signs of meaningful action to address consumer concerns, the Morrison Government would do well to read a recent report to the Republic of Ireland Government that looks to address state-sponsored inequalities in access, funding and provision of hospital care.
This report was written last year but has only just been released, without fanfare (does this signal its fate?).
The healthcare system in Ireland is strikingly similar to that in Australia, as are the issues that this report is trying to address. While state-subsidised healthcare is universal, it is subsidised in two tiers.
Waged citizens earning below a certain threshold, currently about 200 euros (AU$325) a week (about 37 percent of the population), are entitled to a medical card that allows the holder to receive many health services free of charge.
For everyone else there are co-payments for doctors’ visits and prescriptions with safety net provisions. Hospital stays are capped at 1,000 euros each year, and Emergency Department visits cost 100 to 120 euros, although GP referrals to EDs are normally given rebates.
There is a booming private healthcare market with a number of private hospitals. About 40 percent of the population have PHI although numbers have fallen somewhat in recent years as insurance prices have increased. You can read more here.
In 2017, the Oireachtas Committee on the Future of Health Care published the Sláintecare Report with proposals for a ten year strategy for health care reform. The agreed vision was for a universal single-tier health and social care system with equitable access to services based on need rather than ability to pay. This includes the phased elimination of private care from public hospitals, although those who have PHI will still be able to purchase care from private providers in private hospitals.
The Oirreachtas Committee recommended an independent impact analysis of the separation of private practice from the public system in order to identify adverse and unintended consequences.
It states that “the Government should send a clear signal through legislation that, from a specific date in the future, no private activity in public hospitals will be permitted” and calls on the Government to legislate “so that public resources are used only for purposes of providing public services in our public hospitals.”
This move will require an additional 1,000 doctors in public hospitals in order to provide to care on the basis of need and increased salaries for these doctors. And the report also calls for better resourcing of and access to diagnostics and an increased range of primary care services as an effective way to help reduce demand for acute care.
The report details the cost of removing private activity from public hospitals at 650 million euros over ten years. In effect, this is a transfer payment from what is currently paid through PHI to the public purse.
The expectation is that removing private practice from public hospitals will reduce insurance costs initially and then costs would rise as fewer people will feel the need to have an insurance policy. The report concludes that “successful Sláintecare reforms would reduce the size of the market and ultimately lead to a change in the nature of health insurance to a more supplementary role over time”.
You can read the response from the Irish Medical Organisation here. It’s far from enthusiastic (surprise!) and seems mainly focused on current salary discrepancies between public and private (no surprise!).
Despite similarities, the Australian and Irish healthcare systems are not the same, so you have to be careful about how far you draw the analogies here. But you must admire the scope and bravery of the proposed reforms and wish we could see something similar here.
And in case you missed it – I did – there was an OECD report on Assessing Private Practice in Public Hospitals produced in 2018 to assist the Republic of Ireland in this work that refers to Australia, France, Israel and the United Kingdom.
It provides an overview of the costs and benefits of private practice in public hospitals and highlights potential consequences of a ban on this practice. It does not give a definitive recommendation, rather weighs the pros and cons of such a ban and issues to be considered either way, to help inform policy decisions.
The links between health insurance coverage and prevention activities
I recently came across an interesting paper published earlier this year that looks at the impacts of Obamacare (the Affordable Care Act) – which substantially increased health insurance coverage through a variety of mechanisms – on behaviours relating to future health risks.
It showed that the ACA increased preventive care utilisation in a number of ways, but also increased risky drinking.
The aim of the paper was to look at the relative roles of out-of-pocket prices, ex ante moral hazard (the phenomenon in which the reduction in financial risk associated with unhealthy behaviours incentivises such behaviour), and income effects – all of which are changed by the increased availability and affordability of health insurance – on preventive care utilisation and risky health behaviours such as drinking, smoking and ignoring vaccination schedules.
It used data from the 2011–2016 Behavioral Risk Factor Surveillance System. The estimated gain in insurance coverage from the ACA was eleven percentage points over that time.
The study found that the ACA increased several aspects of preventive care utilisation (well-patient check-ups, pap and HIV tests, and mammograms) with these gains largely concentrated among those in the lower half of the income distribution. The increases in pap and HIV tests are concentrated among those below the sample median age, while the rise in mammograms is driven by those above the median age.
No statistically significant results emerge for flu shots, body mass index (BMI), smoking, or exercising.
An increase in risky drinking in non-Medicaid-expansion states was seen, more so for those in the upper half of income distribution.
Interestingly, the observed effects are attributable to the “private portion” of the ACA—the package of national reforms including regulations in the non-group insurance market, mandates, and subsidized health insurance exchanges—as opposed to Medicaid expansion.
The reason for this is not clear, but there is no evidence that it is linked to payment rates for healthcare services (Medicaid rates are generally lower than those paid by insurance funds); it might relate to access.
The failure to see changes in risk factors like obesity and smoking can be attributable to the fact that the affordability of food, gym memberships, and cigarettes are not directly influenced by health insurance.
However, this does not explain why risky drinking increases when insurance coverage is made affordable but smoking does not. Perhaps it has to do with public perceptions of risk?
This work builds on that undertaken in the RAND Health Insurance Experiment of the 1970s–1980s which provided some of the first causally interpretable evidence on the impacts of health insurance coverage on health behaviours.
There is also a large literature focusing on the impact of Medicaid expansions prior to the ACA.
Medicaid expansions for children and pregnant women in the 1980s and 1990s reduced low birthweight but increased smoking among pregnant women.
Studies of the more recent randomized 2008 Oregon Medicaid lottery found that Medicaid coverage increased use of preventive services but did not have statistically significant effects on smoking or obesity.
Among seniors who become eligible for Medicare at aged 65, slightly worsening smoking and drinking habits and preventive health behaviours have been documented as a result of gaining Medicare coverage. However these can be offset by health promotion information and physician counselling.
It’s interesting to speculate whether and how having PHI affects the preventive health behaviours of Australians. I could find no references to this, so interested to hear of any sources.
New news on the link between menopausal hormone therapy and breast cancer
Last week The Lancet published two major papers from the international Collaborative Group on Hormonal Factors in Breast Cancer.
The first paper brought together the international evidence on menopausal hormone therapy (MHT) and the incidence of invasive breast cancer. All types of MHT examined, except vaginal oestrogens, were associated with a significant excess incidence of breast cancer.
Both among current users and among past users, the risks increased steadily with duration of MHT use. Risks were greater for oestrogen-progestagen than for oestrogen-only preparations, and some excess risk persisted for more than a decade after cessation of use.
The second paper looked at the epidemiological evidence, published and unpublished, of the associations between MHT and breast cancer and reviewed the relevant randomised evidence.
It concluded that for women of average weight in developed countries, five years of MHT, starting at age 50 years, would increase breast cancer incidence at ages 50–69 years by about one in every 50 users of oestrogen plus daily progestagen preparations; by one in every 70 users of oestrogen plus intermittent progestagen preparations; and by one in every 200 users of oestrogen-only preparations.
This is an issue where the knowledge and evidence has changed over time as more and more data have become available.
It’s confusing for people who work in health policy and it must be even more so for the average woman who gets her information from simplistic reporting in mainstream and/or social media.
One commentary accompanying this paper provided this advice:
Clinicians must heed the message of this study but also to take a rational and comprehensive approach to the management of menopausal symptoms, with careful consideration of the risks and benefits of initiating MHT for each woman.
This might be dependent on severity of the symptoms, contraindications for MHT (ie, breast cancer, cardiovascular disease, and stroke), and BMI, and could take into account patient preference.”
Bob Debus on Indigenous incarceration
In a speech to the Law Society of NSW last month, Bob Debus, a former Attorney General and Minister for Corrective Services in NSW, spoke out about the failure to deal with the tragedy of over-imprisonment of Indigenous Australians, calling it a scandal.
Here are some shocking facts from his speech, which was published on John Menadue’s blog.
- The national rate of imprisonment in Australia is currently 220 per 100,000 of the population, but the rate for the two percent of the Australian population who are Indigenous is 2,480 per 100,000.
- Despite numerous high-profile inquiries and interventions, the national rate of Indigenous imprisonment has increased from 19 percent of the prison population in 2000 to 28 percent in 2018, with rates of imprisonment largely unrelated to the rates of crime.
- More shamefully, in the absence of rehabilitative services, the rates of recidivism are up to 75 percent for Indigenous prisoners.
Debus spoke at length about what could and should be done to address these issues. He made the point that internationally validated data shows that tailored, culturally sensitive through-care and programs to help prisoners to re-join the community are effective in reducing recidivism. But these require the appropriate investment of resources and can’t be run properly if prisons are over-crowded.
Even better are substitutes for prison such as community supervision combined with well-designed treatment. Yet national provision for diversion remains intermittent, underfunded and uneven.
The recommendations in the 2017 Australian Law Reform Commission report Pathways to Justice – An Inquiry into the Incarceration Rate of Aboriginal and Torres Strait Islander Peoples consolidates and refines decades of research and official inquiries.
It recommends the promotion of substantive equality before the law, for instance by the institution of provisions that consistently take account of systemic background factors affecting Indigenous people as well as the circumstances of an individual offender.
It asserts the fundamental importance of Indigenous leadership and participation in the delivery of programs for Indigenous people in contact with the legal system.
And it recommends a reduction in the number of people coming into the prison in the first place through an approach known as “justice reinvestment”. (You can read Professor Tom Calma, former Aboriginal and Torres Strait Islander Social Justice Commissioner and Race Discrimination Commissioner, and a Champion of Just Reinvest NSW, on justice reinvestment here. See also a series of articles at Croakey).
Debus makes the point that we know what to do – what is needed is the political will and resources to do it.
This is not an area where I can claim any expertise, but it is so important if there is to be success in Closing the Gap.
The Change the Record alliance of Aboriginal and Torres Strait Islander health, social and justice groups has long advocated for justice targets.
The Closing the Gap Refresh is looking at targets of reducing the rate of Aboriginal and Torres Strait Islander young people in detention by 11-19 percent and adults held in incarceration by at least 5 percent by 2028. But these are not ambitious and would be state-led, with no commonwealth involvement.
The Joint Council on Closing the Gap that was set up in response to big concerns that Aboriginal and Torres Strait Islander people were being left out of the Refresh process last month reported it was making good progress towards new National Agreement on Closing the Gap
Other resources you might find interesting and useful include:
- The Law Council of Australia’s submission to COAG which outlined the need for justice targets and accurate reporting.
- Croakey has some excellent resources on this issue collated under #JustJustice. A number of articles have been included in a free e-book which can be downloaded here.
- Racial and gender justice for Aboriginal women in prison on the Power to Persuade blog.
- The Guardian Australia compilation of articles on Indigenous incarceration here.
- The Conversation compilation of articles on Indigenous incarceration here.
The good news story
I’m shamelessly plugging a project that has been developed by the daughter of a close friend.
The Cova Project provides menstrual cups to school girls in s ub Saharan and West Africa. It’s a cost effective, hygienic way to help girls escape the financial and physical burden and shame of menstruation and to attend school.
Here’s a recent piece from the BBC on the effectiveness of menstrual cups.
And here’s a video of Cova Project founder Geena in Liberia and Malawi.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. You can follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.