NT GP Dr Jessie Johnston says the proposed GP co-payment is very likely to result, in more disease and death among remote Australians — especially First Australians.
Having worked as a doctor in the Northern Territory for the last 25 years, I am under no illusions regarding the precarious nature of life in this culturally diverse part of Australia. For some, the GP co-payment may literally be a matter of life and death.
Two per cent of Indigenous Australians in the Northern Territory have rheumatic heart disease (RHD), a condition caused by acute rheumatic fever (ARF), which in turn is caused by a streptococcus infection.
ARF predominantly affects children and young people. A significant number of those affected require repeated hospitalisation and heart surgery. The average life expectancy for children with RHD following heart valve replacement is less than 15 years.
RHD is the most common cause of childhood cardiovascular death worldwide and results in 300,000 deaths each year. It is a disease of poverty and social disadvantage — the worst affected areas being sub-Saharan Africa, south-central Asia, the Pacific and indigenous populations of Australia and New Zealand.
In 2002, the Northern Territory had the highest reported incidence of ARF and RHD in the world.
The following two clinical cases are representative of many occurring across the Northern Territory.
A 17-year-old girl, whom I will call Naomi, is brought to the clinic having experienced lethargy and joint pains. An electrocardiogram (ECG) of her heart and blood tests show characteristic abnormalities and ARF is diagnosed. Heart ultrasound shows structurally normal heart valves.
Naomi gradually returns to good health but, having had one episode of ARF, she is at increased risk of another. One or two further episodes are likely to result in permanent valve damage. To prevent this, Naomi must have RHD prophylaxis, which involves a painful intramuscular injection of penicillin every 3-4 weeks for the next 10 years. Not only that, but under the proposed changes to Medicare, Naomi will have to pay for GP consultations, medication, pathology tests and radiological imaging.
Nine-year-old Winston is less fortunate.
He has an episode of ARF but his heart ultrasound shows a moderately to severely damaged mitral valve. Within 18 months, his heart is failing and he is taking six cardiac medications every day. His medication list resembles that of an 80-year-old man. Two years later, he has a mitral valve replacement. He will be a regular attender at the clinic for the rest of his life.
The GP co-payment applies to all Australians. Children under 16 years and concessions card holders will only be exempt after 10 visits to the GP in one year. The GP can bulk bill at their discretion, but their rebate will be reduced by $5, so they will be $12 out of pocket for the consultation. This serves as a disincentive to bulk bill.
Treasurer Joe Hockey stated on ABC 7.30 on 13 May that patients with a chronic disease would not be charged the GP co-payment.
In fact, he was referring to the Chronic Disease Management Medicare items such as a GP Management Plan, where the patient and the GP together map out clinical goals and objectives for the year. The GP co-payment will not be charged for these items. However, all regular consultations with the GP (for example for a prescription or a specialist referral) will attract the usual GP co-payment, regardless of whether the patient has a chronic disease or not.
Aboriginal people in remote and very remote Australia cannot afford the GP co-payment. Gross income for this population is less than half the Australian average and unemployment is four times the national average (ABS, 2008).
The cost of food in remote stores is a staggering 49% higher than in a Darwin supermarket (NT Market Basket Survey, 2013).
The GST is seen as a ‘fair tax’, but it discriminates against those living remotely. The more it costs to bring food and goods to remote areas, the more expensive they will be and the greater the GST mark-up will be.
It is not unusual for families to run out of money before payday and food may be scarce. Having money to pay for medical expenses under these circumstances is clearly out of the question.
No child, Indigenous or otherwise, chooses to be born into conditions of poverty and social disadvantage. That families should be asked to pay for medical services which reduce the rates of serious complications is anathema. We might ask ourselves for whom exactly have we had an ‘Age of Entitlement’?
Dr Jessie Johnston is a GP and medical educator.
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