It's not perfect, but our health system is one of the best

When it comes to self-belief, Australians are funny. We have no doubt that Australia punches well above its weight in almost every sport. And our Diggers are braver and more dependable than the rest. In other departments, however, we don’t rate ourselves highly.

Australians pay among the lowest taxes of all developed nations, but the belief that we’re among the highest taxed is so widely believed it’s impervious to facts.

Take the latest headline that we’ve been “flattened by the biggest tax increase in the world”. “There, I knew it,” I hear you mutter. Well, not quite.

It’s true, as the story said, that in 2023 working Australians suffered the biggest increase in their average tax rates in the developed world, according to figures issued by the Organisation for Economic Co-operation and Development.

The increase was caused by bracket creep and the Morrison government’s sneaky decision to end the “low- and middle-income tax offset” (a move that never made it to a press release, meaning most of the media didn’t notice and didn’t tell their audience about).

But that doesn’t in any way confirm our belief that we’re highly taxed. It may have been true last year, but it will be far from true this year as the huge stage 3 tax cuts take effect in July.

Nor is it confirmed by the repeated assertion that we are more dependent on income tax than any of the other OECD countries. This is literally true, but only because, unlike almost all the others, we don’t impose separate social security contribution taxes on the incomes of workers and employers.

The more important point, however, is that so far we’ve been talking only about the biggest and most noticeable of our taxes, personal income tax. Surely you don’t think that’s the only tax we pay?

What about a little thing called the goods and services tax? (Or, to other rich countries bar the United States, value-added tax.) Our tax rate of 10 per cent is way lower than even the Kiwis’, let alone all the Europeans’. They’re up in the 20s.

No, all told, we pay less tax than almost all the others. But how would you rate us on, say, healthcare? My guess is most people’s answer would be, at best, nothing to write home about.

Wrong. We keep hearing about problems with Medicare, but every country’s healthcare system has its shortcomings. New research by the Productivity Commission – hardly known for its boosterism – has found that our health system “delivers some of the best value for money of any in the world”.

The commission has been measuring the productivity of our healthcare system – roughly, what we get for what we pay – and, for the first time, taking account of changes in the quality of that care.

In principle, the system covers all our spending on healthcare: public and private; hospitals, GPs and specialists, whether paid for by taxpayers, health insurance or directly out of our pockets.

Over this century, our total spending on healthcare has risen from 8 per cent of national income to about 10 per cent – meaning it’s grown much faster than the economy has, including the growth in our population.

The continued rise in the average age of our population, the growing burden of chronic diseases and our expectations that governments will keep spending more to improve our health means our spending on healthcare will continue to grow faster than on most other things.

This being so, it’s important to check that the increased spending is leading to better health. The researchers were able to check the performance of only part of the system: the treatment of cancers, cardiovascular diseases, blood and metabolic disorders, endocrine (organs and glands) disorders, and kidney and urinary diseases.

These account for about a third of healthcare spending. The study found that, after allowing for changes in quality, the “multifactor” (that is, combining labour and physical capital) productivity of this care improved by about 3 per cent a year over the six years to 2017-18.

If that doesn’t impress you, it should. It compares with productivity improvement of just 0.8 per cent a year in the whole market sector of the economy.

Importantly, all the healthcare improvement came from improved quality in the treatment of ailments. This arose from technological advances in how they are treated, rather than from simply doing more with less. And the gain was in lives saved rather than the reduced illness of people living with those diseases.

But here’s the kicker. When the commission compared the level of our productivity with that of 27 other rich countries (after allowing for differences in risk factors, such as obesity – the big one – smoking, diet, alcohol and age) it found we came third, beaten only by Iceland and Spain.

Coming a distant last was the United States. The Yanks win two prizes: one for the most expensive system, the other for coming last on value for money. Why? Because their system is designed to maximise medicos’ incomes. At which they take away another prize.

Read more >>

When funding healthcare, don't forget the caring bit

 It’s Easter, and we’ve got the day off. So let’s think about something different. As a community, we spend a fortune each year on health, mainly through governments. What has economics got to tell us about healthcare? And, since it’s Easter, what light has Christianity got to shed on how we fund healthcare?

One man who’s thought deeply on these questions is Dr Stephen Duckett, Australia’s leading health economist, whose career has included academia, running government health departments, and the Grattan Institute think tank. He’s now back in academia, at the University of Melbourne.

Duckett has long been a lay reader in the Anglican Church. He’s recently completed a doctorate in theology, awarded by the Archbishop of Canterbury. He’s turned his thesis into a book, Healthcare Funding and Christian Ethics, published by Cambridge University Press.

One way to run a hospital is to let the doctors and nurses do as they see fit until the money runs out but, for several decades, health economists’ advice has reshaped the health system, helping to ensure that the money available is spent in ways that do the most good to patients.

One definition of economics is that it’s the study of scarcity. We have infinite wants, but limited resources of land, labour and physical capital to achieve those wants. So we must carefully weigh the costs and benefits of the many things we’d like, so we end up choosing the particular combination of things that yields us the greatest “utility” (benefit) available.

Since there’s never enough money to spend on healthcare, hard decisions have to be made about what can be done and what can’t, what drugs should be subsidised and what can’t, who should be helped and who turned away.

Health economists analyse the cost-effectiveness of the various options to help governments and hospitals make their choices, working out the number of “quality-adjusted life years” each option would add.

The Scotsman called the father of modern economics, Adam Smith, saw it as a moral science but, as economists have striven to be more “rigorous” (which mainly means more mathematical) this touchy-feely stuff has fallen away.

Most economists see economics as amoral, that is, neither moral nor immoral; having nothing to say about moral issues. When it comes to means and ends, economists see themselves as sticking to means.

They’re saying: tell me what you want to do, and I’ll tell you the best way to achieve it. That’s what they say; it’s not always what they do.

Economics is based on utilitarianism: seeking the greatest good for the greatest number. But this ignores the question of “equity”: how fairly the benefits are shared. Are some getting a lot while others miss out?

Duckett says: “Economics’ assumption that humans are simply individual units, de-emphasising community, and [economics’] ubiquitous use in policymaking, comes at a cost, as Homo economicus [the self-interested, rational calculator that economists assume us to be] crowds out other manifestations of what it is to be human.”

Economists often say they have no expertise on equity and the community, so they leave that to others – such as the politicians. Economists often claim that economics is “objective” and “value-free”.

But Duckett says it’s not simple. By ignoring issues you’re implying that they don’t matter. And you’re making implicit assumptions that are value-laden.

For instance, if a cost-effectiveness study does not explicitly highlight the distribution of costs and benefits [how unequally they are shared between people], it is implicitly conveying the message that the distribution is not a relevant issue.

If nursing home funding allows money ostensibly allocated for care to be leached out as extra returns to the owners, then quality is assumed to be not a concern of those doing the funding.

If a system design places a higher monetary reward on cosmetic surgery intended solely to improve appearance compared to the monetary reward for caring for older patients and people with mental illness, this sends a signal about the value placed on care for the marginalised.

Duckett says that, because decisions about public policy inherently involve value choices, health economics becomes a “moral science” whether economists like it or not. What’s true, however, is that economics is not well-equipped to determine issues such as what should be society’s priorities, what value should be place on unfettered choice, and the value to place on ensuring no one is left behind.

This is where Christian ethics has a contribution to make, a contribution that, except on matters of sexual morality, doesn’t differ much from the views of the aggressively secular philosopher Professor Peter Singer and, no doubt, many other Western ethicists.

Duckett offers a “theology of healthcare funding” based on Christ’s parable of the Good Samaritan. As I hope you remember, a man was travelling to Jericho when he was set upon by robbers, who left him naked and bleeding by the road.

Two separate religious figures passed by him on the road without stopping to help. But a Samaritan saw him and “was moved with pity”. He bandaged his wounds, put him on his donkey and took him to an inn, where he paid the innkeeper in advance to look after him, promising to come back and pay for any extra expense.

From this parable Duckett derives three principles that should guide health economists in the advice they give on healthcare funding.

The three are: compassion (shown by the behaviour of the Samaritan), social justice (everyone included and treated equally; shown by the identity of the Samaritan, a race despised by the Jews) and stewardship (shown by the innkeeper, who was trusted to care for the traveller and to spend the Samaritan’s money wisely).

Compassion must involve feeling leading to doing. It must involve helping people other than yourself. So health economics must be less impersonal, remembering the flesh and blood behind the statistics and calculations. Any funding arrangement must allow time for workers to care for patients in a compassionate way.

The Christian ethic is that social justice is not simply about fairness for atomised individuals, but also the person as part of a community, something economists tend to forget. Archbishop Desmond Tutu has said “a person is a person through other people . . . I am human because I belong. I participate, I share.”

“Christian contributions to the public square need to challenge policy ‘solutions’ that rely on individuals pulling themselves up by their own bootstraps, victim-blaming approaches, and a narrow definition of [who is my] ‘neighbour’,” Duckett says.

As for stewardship, it’s the easy bit. It’s the Christian word for what economists already know about: making sure that other people’s money is spent carefully, and their property is looked after. It’s being efficient.

But the Christian contribution to what health economists do is to make sure stewardship is kept in tension with the other two principles. “Austerity does not mean that compassion and social justice can be ignored, or distributional consequences [for the rich and the poor] can be erased from consideration.

Read more >>

Voting No? You may have this key assumption wrong

If you’re thinking of voting No in the Voice referendum because governments have been spending so much taxpayers’ money trying to “close the gap” without much sign of success, perhaps you need to reconsider. If the Voice to parliament of Aboriginal and Torres Strait Islander people is enshrined in the Constitution, obliging our politicians and bureaucrats to listen, chances are that money will be better spent.

But I can tell you now the message First Nations people will be trying to get across: we want the local spending on health and education and the rest to be administered by Indigenous-led local organisations.

Why? Because when you do it that way, the money’s spent by people with a much better understanding of what the problems are, and the best ways to go about fixing them. Because when the government’s being represented by Indigenous-run outfits, they get much more trust and co-operation.

I’ve realised this mainly by reading a report, Better Outcomes and Value for Money with a Seat at the Table, issued by the Lowitja Institute, a largely government-funded, Indigenous-controlled health research organisation, based in Melbourne.

Let’s start with some facts about government spending on Indigenous people.

According to the Productivity Commission’s most recent estimates, for the 2015-16 year, spending by all levels of government on Indigenous people totalled $33 billion, representing 6 per cent of those governments’ total spending of $556 billion.

Some mates of mine believe Aboriginal people get a lot of government money the rest of us don’t. Only $6 billion of that $33 billion was specifically targeted to Indigenous people. The remaining $27 billion was the share of ordinary spending on hospitals, education, aged care and, importantly, the justice system, used by Indigenous people.

Even so, that $33 billion represents average annual spending of $44,900 per Indigenous person, compared with $22,400 per non-Indigenous person.

Why are Indigenous people getting twice as much? Because they have more disadvantage than the rest of us, and so need more help. For instance, their burden of disease is 2.3 times that of non-Indigenous people, the report says.

Indigenous people “have survived centuries of systemic racism, economic and social exclusion, and intergenerational trauma. As a result, our peoples now die far earlier and experience a higher burden of disease, disability, poverty, and criminalisation than other Australians,” it says.

But here’s the upside. Because governments are spending so much, “slight improvements in the efficiency of the existing spend would generate substantial savings, both directly and through flow-on impacts to other policy areas,” we’re told. For a case study, read to the end.

The federal government first signed a statement of intent to work in partnership with Aboriginal and Torres Strait Islander peoples in 2008, to “achieve equality in health status and life expectancy … by 2030”.

This partnership was refreshed and strengthened in 2020 by a National Agreement on Closing the Gap, made between peak Indigenous community organisations and all federal, state, territory and local governments.

The agreement accepted four priority reforms: formal partnerships and shared decision-making, building and strengthening the community-controlled sector, transforming government mainstream organisations, and shared access to data and information at a regional level.

Are you getting the message? In practice, however, the report says, “these changes have been patchy and incremental despite increased investment from government”.

“An Aboriginal and Torres Strait Islander Voice could support more effective public investment in our wellbeing because our communities know what they need and how to deliver outcomes with the right support,” we’re told.

The report argues that government-run, top-down programs to close the gap haven’t worked as well as community-controlled initiatives.

Research indicates that Indigenous-controlled community health organisations “attract and retain more Aboriginal and Torres Strait Islander patients than mainstream providers, are more effective at improving our health, and see more significant health benefits per dollar of expenditure,” the report says.

It was Indigenous community health organisations that had the knowledge and expertise to rapidly respond to the especially great threat presented to their people by COVID-19.

Throughout the first year of the pandemic, just 147 cases of the virus were reported among Indigenous people, out of 28,000 total cases in Australia. There were no Indigenous deaths and no identified cases in remote Aboriginal communities.

In the second year, Indigenous community health organisations worked tirelessly to ensure their communities were vaccinated.

Turning to education, the report says the federal government’s “remote school attendance strategy”, begun in 2013, with total spending of more than $200 million over eight years, had seen falling attendance rates.

By contrast, the report argues, in 2017, the community-led Maranguka justice reinvestment project in Bourke achieved a 31 per cent increase in year 12 retention, a 23 per cent reduction in recorded rates of family violence incidents, and a 42 per cent reduction in adult days spent incarcerated.

These improvements were calculated to have saved the NSW economy $3 million that year – five times the project’s operating costs.

I’ve drawn my own conclusions from all this. So close to the vote, I leave you to draw yours.

Read more >>

If GPs want more money, they'll have to be less alergic to change

Who’d be Anthony Albanese? Everywhere he looks, another problem. Now it’s the GPs. They’ve become a lot harder to get to see, and more expensive. Even getting them to return your call can take days.

It’s become so bad even the premiers are complaining. What’s it got to do with them? When some people find it too hard or costly to see a GP, they take their problem to a public hospital’s emergency department, where waiting times are long, but there’s no charge.

Even the ambos are complaining that too many of their call-outs are to take someone with a minor problem to the emergency department.

The GP “crisis” was discussed at the national cabinet meeting on Friday, which received the final report of the Strengthening Medicare Taskforce. You can find the report on the internet but, although it’s mercifully short at 12 pages – with lots of lovely glossy photos of happy, good-looking Aussies, I doubt you’d find it very informative.

Remember the joke that a camel is a horse designed by a committee? The pictures suggest it’s intended for ordinary readers, but it’s written in bureaucratic code that would be crystal clear to any expert who already knew what it was saying.

You wade through guff about “access to equitable, affordable, person-centred primary care services” and “co-ordinated multidisciplinary teams” to find the odd bit you understand.

See if I do better. According to the doctors’ union, the AMA, the reason GPs have become so hard to find is that the federal government isn’t paying them enough. Whereas in the old days half of all medical graduates became GPs, now it’s down to about 15 per cent.

So, pay them more. Problem solved.

What the report’s saying is: sorry, not that simple. It’s true the Coalition government inherited a temporary freeze in Medicare rebates – the amount of a doctor’s bill that’s paid by the feds – in 2013, and continued it until 2018. And although the schedule of rebate payments has been increased annually since then, the increases have been much smaller than inflation.

Why? Partly because the Liberals were trying to prove they could cut taxes without damaging “essential services” such as Medicare.

But also because they knew something was wrong with the way general practice works. They needed to pay GPs differently to do different things. Rather than pay more and more the old way, they’d hold back until they – or some future government – worked up the courage to make changes.

Over the almost 40 years of Medicare, there’s been a big change in the problems people bring to their GPs. Because we’re living longer, healthier lives, much more of our problems are chronic – someone with heart trouble or diabetes has to wrestle with it for the rest of their lives – rather than acute: something that’s easily and quickly fixed.

But the present (subsidised) fee-for-service way of remunerating doctors is designed to suit acute problems, not chronic conditions. It involves waiting for problems to arise, not early diagnosis or stopping chronic conditions getting worse.

It encourages GPs to keep consultations short, avoiding long discussions of multiple problems.

A change no one wants to talk about is the way sole practitioners or partnerships of doctors are giving way to companies owning chains of practices staffed by doctors they employ.

When you separate the person delivering the care from the person watching the bottom line, you increase the likelihood doctors are pressured to keep consultations short and order many tests – a further reason to be cautious about reinforcing GPs’ dependence on fee-for-service.

The report wants to move to “blended” funding, with acute consultations continuing to be fee-for-service, but GPs paid lump sums for developing and managing “care plans” for particular patients with chronic conditions.

While it’s true fewer medical graduates are becoming GPs, it’s not the whole truth. As the Grattan Institute reveals, “Australia has more GPs per person than ever before, more GPs than most wealthy countries, and record numbers of GPs in training.”

How do other countries with good healthcare get by with fewer GPs? By making sure their GPs can’t insist on doing things that could be done by other health workers – nurses, nurse practitioners (nurses trained to do some of the more routine things doctors do), pharmacists and physios.

This is what “co-ordinated, multidisciplinary team-based care” means. Changing GPs’ surgeries into more wide-ranging “primary care clinics” is also about making it easier for patients to move between different kinds of care, with GPs taking more responsibility for the total package, and all the various doctors and paraprofessionals having access to a patient’s medical history.

There’s nothing new about this. Federal governments have been trying to improve the performance of primary care for decades – with little success. Why? Because they’ve had so little co-operation from the premiers and the GPs themselves.

The true message of the latest report is: Medicare reform must not just be about more money to do the same things the same way.

Read more >>

Why prime ministers do have to hold a hose (and much else)

If we don’t have another setback on the COVID front between now and May, it seems likely Scott Morrison will escape having his various fumbles in handling the pandemic loom large in the federal election campaign. Even so, the coronavirus was a stark reminder of how much the running of this nation is down to the premiers, not the Prime Minister.

The premiers took full advantage of this opportunity to raise their political profiles. And they’re likely to stay more assertive for years to come.

We’ve all lived all our lives with Australia’s federal system of government. We all know it doesn’t work so well. We long ago tired of the eternal bickering, buck-passing, duck-shoving and cost-shifting between the two levels of government. But just as we’re “learning to live with COVID”, so we long ago got used to living with a dysfunctional federation.

Does a nation of 25 million people really need one federal, six state and two territory governments? Well, if you were starting with a clean sheet of paper, you wouldn’t design it that way.

But we’ve never had a clean sheet. Back in the 1890s, we began with six self-governing colonies. They would never have agreed to dissolve themselves in to one national government. And, today, it’s not just that all those premiers and state parliamentarians wouldn’t want to give up their well-paid jobs.

The Australian mainland is such a big island, and its people are so widely spread around its coastal edge, I doubt if voters in any state would choose to be ruled henceforth solely from distant Canberra.

But the states being immovable, efforts by various prime ministers to make the system work better have had little success.

The pandemic has reminded us that our constitution grants to the states, not the feds, ultimate responsibility for most of the things we expect governments to do for us: healthcare, education, transport, law and order, housing, community services and the environment. Only the states and territories had the constitutional power to order lockdowns or close state borders.

But the problem isn’t just constitutional. It’s also economic. It’s what economists call “vertical fiscal imbalance”. Over the years – and with much help from rulings of the High Court – the feds have accreted to themselves most of the power to levy taxes.

See the problem? The feds raise most of the tax revenue, whereas the states have most of the responsibility for spending it.

Economists think the federation would work better if there was a closer alignment between each level’s spending responsibilities and its tax-raising capacity. But prime ministers haven’t been keen to hand over their taxing powers.

The bigger problem with VFI, as the aficionados call it, isn’t economic, it’s political: the feds cop the blame for levying nasty taxes; the states get the credit for lots of lovely spending. The states love it, the feds hate it.

Related to this is a truth that seems to come as a shock to prime ministers. The feds run defence and foreign affairs and customs and trade. Apart from that, they raise taxes and write cheques – to the premiers, universities, chemists and bulk-billing doctors, pensioners and people on unemployment benefits.

What the feds don’t do much of is deliver programs on the ground, whereas that’s the main thing the states do. Run hospitals and schools, build highways, fight bushfires and clean up after floods.

Turns out that when the feds do try to deliver programs on the ground – put pink batts in ceilings; roll out vaccines across the land – they stuff it up.

In all this you have the hidden explanation for some of Morrison’s coronafumbles.

Despite him setting up the national cabinet – and doing most of the on-camera talking after each meeting – it turned out that most of the credit for our success in handling the pandemic went to the premiers, not him. “What? Even though the feds were picking up almost all the tab?”

Apart from the feds’ failure to order enough vaccines early enough, it seems clear Morrison decided to deliver them through an essentially federal distribution chain of GPs and pharmacists, in the hope this would yield him more of the credit.

That’s how the rollout became a stroll out. It was slow and unfamiliar. Only when the feds admitted defeat and started distributing vaccines through the experts – the states’ public hospitals and mass-vaccination hubs – did things speed up.

I suspect other hold-ups – in replacing JobKeeper; in distributing rapid antigen test kits – came because the feds and states fell to arguing over how the bill should be divvied up. “Why am I paying when you’ll be getting all the credit?”

Morrison said what he did about hoses because bushfires are a state responsibility. Constitutionally, correct; politically, incorrect. He’s had to learn the hard way that if a state problem affects more than one state – or just gets too big for the state to cope with – it becomes a federal problem in the minds of voters.

If you can’t hold a hose, just bring your chequebook.

Read more >>

Timing the economy to fit a pandemic election is a tricky business

So, with Scott Morrison pulling the new AUKUS pact out of his hat, will we be off to a khaki election? It would hardly be the first election conservative governments have won by promising to save us from the threat to our north.

But that’s why I doubt it. For an issue to dominate an election campaign, it has to be in contention. National security is an issue that always favours the conservatives, so Labor won’t be offering any objection to AUKUS or nuclear subs.

Similarly, an issue that should figure large in the campaign is whether the Coalition is too conflicted over climate change to be worthy of re-election. But that issue naturally favours Labor, so Morrison won’t want to take up that fight.

Which leaves? The economy, stupid. Until the end of June, the economy was looking in great shape, better than it had been even before the pandemic. But the arrival of the Delta variant means that, right now, more than half the national economy is back in lockdown, and looking mighty sick.

Does it surprise you that Morrison’s so keen to see the south-eastern mainland states out of lockdown and the others opening their borders, and is pressing the premiers accordingly? He desperately needs the economy back looking trim and terrific by March – May at the latest.

Add to this the business community’s pressure to get back to business – “don’t bother me with all the COVID details” – and the public’s impatience to get life back to normal. Sydneysiders have had enough of lockdowns; Melburnians have had more than enough – something even “Dictator” Dan Andrews can see.

So Gladys Berejiklian and Andrews have added their separate modelling by the Burnet Institute to Morrison’s National Plan modelling by the Doherty Institute – not to mention the independent modelling by the Kirby Institute – and announced their “road maps” for opening up their economies progressively once vaccination rates have reached 70 per cent and 80 per cent of the eligible population, expected in mid-to-late October and early November.

NSW is projected to be only about a week ahead of Victoria, and the gap between 70 and 80 per cent only about two weeks.

Everyone’s so pleased to be getting on with it that we risk losing sight of the high risks the two premiers are running. If all goes to plan, we’ll be back to a new (still-masked) normal by early next year, and the economy will be humming in time for a March election.

But models, based on a host of unmentioned explicit and implicit assumptions, inevitably give politicians and punters a false sense of certainty. No model can accurately predict something as mercurial as human behaviour. And, as we’ve learnt, a new coronavirus knows nothing of models and is a law unto itself.

The risk Andrews and Berejiklian face is that so many unvaccinated people contract the virus that our hospital system is overwhelmed, with people dying because they were turned away, leading to a number of deaths the public finds unacceptable. Whether they press on or turn back, the premiers would be in deep trouble.

The first risk comes from an ambulance and hospital system that, 18 months after the crisis began, is already at full stretch. The premiers tell us our wonderful health workers are coping; the message from ambos, doctors and nurses on the ground says they’re close to collapse.

The next risk comes from the inconvenient truth that our vaccination targets of 70 and 80 per cent of people 16 and older turn out to be just 56 and 64 per cent of the full population. That’s a huge proportion of unvaccinated friends and relations.

Remember, too, that these are statewide averages. They conceal less-vaccinated pockets of particularly vulnerable groups – the disabled, the Indigenous, for instance – and a city-country gap that leaves many rural towns hugely exposed, together with their limited hospital capacity.

Even the decision to move as soon as the 70 and 80 per cent targets are reached, rather than wait another fortnight for vaccines to become fully effective, carries a risk of higher infection.

Both the Burnet and revised Doherty modelling say starting to open up at 70 per cent rather than 80 per cent is likely to involve significantly higher infections, hospitalisations and deaths. Why take that risk just to avoid waiting another fortnight or so?

Morrison’s national plan called for all states to open up together once all had reached the 70 and 80 per cent targets, but now NSW and Victoria are going first. This increases the risk that, despite the other states’ closed borders, the virus will spread to them – where the lesser threat of catching the virus has caused vaccination rates to be much lower.

The risk for Berejiklian and Andrews is that they could be moving the Delta outbreak from the city to the country. The risk for Morrison is that, by pressing those two to open up early, he could be moving the outbreak from one half of the economy to the other.

Read more >>

Smaller Government push explains much of our pandemic fumbling

It’s right for our elected leaders to be held responsible for the failures that have led to the loss of lives and livelihoods in our struggle against the coronavirus. But let’s not fail to see the systemic failures that have led our governments – federal and state; Liberal and Labor – to fall short.

If you’re not looking for it – or don’t want to find it – it’s easy to overlook the inconvenient truth that decades of pursuit of Smaller Government have contributed greatly to the difficulty we’ve had controlling the spread of the virus and hastening the rollout of the vaccine.

Earlier this month, two economics professors, Steven Hamilton and Richard Holden, used two articles in the Australian Financial Review to lay much of the blame for delay in the rollout and in rapid COVID testing at the feet of the “medical regulatory complex”.

They criticised our TGA - Therapeutic Goods Administration – for being “persistently behind the curve – lagging months behind foreign regulators” in approving the various vaccines. The medicos should hardly need economists to remind them of the point they themselves dinned into the rest of us: the spread of pandemics is exponential, so a delay of just six weeks really matters.

So, if medical bureaucracies overseas can approve new drugs with expedition, why can’t we? And they can approve in-home rapid tests, but we can’t?

Because our standards are so much higher than theirs? Doubt it. More likely because we weren’t trying hard enough. Maybe the TGA was short-staffed or the government hadn’t approved enough overtime. As for the reservations about rapid testing, you wonder if it wasn’t a case of doctors trying to make work for doctors, not nurses or pharmacists.

Then there was all the chopping and changing over who should get the AstraZenica vaccine by ATAGI – the Australian Technical Advisory Group. It was narrow, inappropriate advice that failed to take account all the relevant considerations and did much damage to the rollout.

Maybe the government asked the wrong bunch of specialists, or gave them the wrong terms of reference. I’ve seen it suggested that a more appropriate committee had been abolished in cost-cutting by the Abbott government.

The Morrison government’s delay in acquiring sufficient vaccines seems to have arisen from a desire to limit the cost of the exercise, combined with an ill-fated preference for having the vaccine manufactured locally.

Much of our difficulty preventing leakages from hotel quarantine has arisen from cost saving: using ill-suited empty hotels would be much cheaper than purpose-building out-of-town cabin-style facilities, especially when you remember we won’t get another pandemic for decades. Maybe.

Similarly, outsourcing quarantine security to private contractors using casual, low-paid and untrained workers, who probably work at several facilities to make ends meet, saves money. The same way we use outsourcing to cut the cost (and quality) of so many public services these days.

At state level, stockpiles of personal protective equipment recommended by a committee charged with getting us ready for a pandemic were cut as a cost-cutting measure.

Wherever responsibility is shared between federal and state – which is most areas - you get cost-cutting, cost-shifting, game-playing and duck-shoving. The feds had huge success at shifting the blame for Victoria’s second lockdown to Dictator Dan, even though the great majority of deaths occurred in federally regulated aged-care homes.

As the royal commission found, the unending string of scandals in aged care arises from decades of trying to hold down the cost of care to the federal government. Knowing they’re not spending enough to fund decent care, the feds don’t dare to properly regulate the sector’s mainly for-profit providers.

But, since businesses are entitled to a reasonable return on their capital, turning the sector over to private providers adds another layer of cost. There’s little reason to hope their profit margins are covered by their greater efficiency in running institutions. They make room for their profit by cutting other costs.

Cost cutting is just one aspect in which the Smaller Government push has hindered our efforts to respond to the pandemic. Another is the longstanding rundown in the capability of the public service, especially its ability to give policy advice.

Who needs advice from public servants when, if the minister doesn’t know what to do, the politically ambitious young punks in the minister’s office will have plenty of ideas? Failing that, you can always commission a report from one of the big four accounting firms which, you can be sure, will tell you only what you want to hear. I doubt the health departments are immune from these weaknesses.

Of course, our pandemic problems are just the latest, most acute demonstration of the failure of the Smaller Government project, but that wider story’s a topic for another day.

Read more >>

Our leaders would do better if their followers were thinking harder

Much has been said about the failures of Scott Morrison, Daniel Andrews and Gladys Berejiklian in our never-ending struggle to keep on top of the coronavirus. But just this once, let’s shift the spotlight from our fallible leaders to the performance of those they lead. I think we ourselves could be doing a better job of it.

There is, after all, much truth in the saying that we get the politicians we deserve. When we think we’re entitled to have good government served up to us on a plate, we’ve lost sight of the truth that well-functioning democracies require diligent citizens, not just honest and smart politicians.

Perhaps our biggest complaint has been that our leaders and experts keep changing their tune. Why can’t we be told simply and clearly what’s required of us? Why can’t the pollies decide what they want and stick to it?

It’s as though they’re making it up as they go along, chopping and changing when they realise they’ve taken another wrong turn. Hopeless.

Let me tell you the shocking truth: they are making it up. But if you were thinking harder you’d realise that’s all they can do. As Morrison rightly says, a new virus doesn’t come with an instruction manual.

Our political leaders are relying heavily on epidemiologists and other medical experts because pollies have so little knowledge and experience of pandemics. The medicos know a lot about viruses, epidemics, vaccination and immunology, but at the start they knew little about the characteristics of this particular virus.

They were forced to make assumptions about those characteristics but, as they’ve realised those assumptions were wrong, they’ve changed them.

At the start they thought the virus was spread in big droplets landing on surfaces within one or two metres, whereas now they think it’s more like smoke. Without strong ventilation, it builds up in the air. This explains much of the early uncertainty about whether masks were a good idea.

The medicos have relied on the findings of the limited studies available, but when bigger and better studies have come along with different findings, they’ve updated their views.

As I don’t think Keynes actually said, “When the facts change, I change my mind. What do you do, sir?” Or, as he did say, “It is better to be roughly right than precisely wrong.”

Those people carrying on about how confusing it all is and how incompetent our leaders are reveal their own intellectual laziness: their reluctance to think through complex, nuanced, ever-changing problems when they’d prefer to be back watching carefully choreographed “reality” television. And their ignorance of how science works, slowly groping towards an ever-changing best guess at the truth.

The media’s new-found interest in public health means formerly obscure academics have become TV stars and any boffin who disagrees with what the government’s doing about X gets an op-ed article to air their dissent.

You could say this is adding to the confusion, but it’s science proceeding the way science does. It’s academics doing what academics do – eternally arguing among themselves.

It’s tempting to tell them “not in front of the children”, but when you remember how lacking our leaders are in competence, openness and accountability, the last thing our democracy needs is for experts to keep their critique of government policies to themselves.

You might have thought that a bunch of media-innocent scientists and a news media devoted to highlighting the exceptional over the typical, seeking out controversy and not always untempted by the sensational, would make an explosive combination.

But for the most part, the media have been on their best behaviour, favouring their audience’s need for accurate, trustworthy information. That brings us to the Australian Technical Advisory Group on Immunisation, and its ever-changing recommendation on who should be receiving the AstraZeneca vaccine now it’s been found to carry a very rare risk of blood clotting.

The advice has changed partly because circumstances have changed, but mainly because the original advice led to considerable vaccine hesitancy at a time when the vaccine rollout is way behind, we have Greater Sydney in lockdown and loads of AstraZeneca is going begging while little of the alternative Pfizer vaccine is available.

The advisory group has been criticised, but I think it was a narrowly constituted group, which gave narrow advice when what the government needed – and should have sought from elsewhere – was advice taking account of a broader range of factors.

The public’s huge reaction against the vaccine is unwarranted and unfortunate at such a time. AstraZeneca is less risky than taking aspirin. But when the media gave such attention to the clotting risk, the overreaction wasn’t surprising.

Responsible reporters can say “very rare” as many times as they like but, as our science reporter Liam Mannix has explained, humans are notoriously bad at giving minuscule probabilities the weight they deserve.

The saver may be that, as highly social animals, when people see so many of their friends lining up to “bare their arms”, their hesitancy may evaporate. It’s a strange, messy world we live in.

Read more >>

The economy’s job is to serve our good health

What a tough, tricky world we live in. There we were, starting to think the pandemic – for us, at least – was pretty much over bar the jabbing, when along came a new and more contagious variant and knocked our confident complacency for six. It’s now clearer that getting free of the virus will be messier, more expensive and take longer than we’d hoped.

It’s natural to be impatient to see the end of this terrible episode in the nation’s life, but no one’s been more impatient to see the end of restrictions than Scott Morrison and the business lobby groups.

We should worry less about any continuing small risks and more about getting the economy working normally again, we were told. Why do those appalling premiers keep closing state borders? Don’t they understand how it disrupts businesses?

One theory that’s been blown away is the tribal notion that continuing problems keeping a lid on the virus were limited to dictatorial Labor states, not “gold standard” Liberal states. We’ve been reminded of what pride so often causes us to forget: success is invariably a combination of competence and luck.

Luck was running against Victoria, now it’s NSW’s turn. NSW did do better on contact tracing, but along came a variant that could spread faster than the best contact-tracing system could keep up with.

The nation’s macro-economists learnt some years ago that the best response to a recession is to “go early, go hard”. That’s something the exponential spread of viruses means epidemiologists have long understood.

The sad truth is, no matter how long NSW’s present lockdown needs to last before the virus is back under control, Premier Gladys Berejiklian’s critics are certain to say she waited too long and didn’t go hard enough.

And they’ll be right. If there’s ever a possibility of starting even a day earlier, it’s always right.

Is it a bad thing to want to limit the economic disruption caused by our fight against the virus? Of course not. But it’s a tricky choice. You don’t want to act unnecessarily, but the longer you take to realise you must act, the more disruption you end up causing.

Berejiklian’s problem is that she was being held up as the national pin-up girl of governments’ ability to cope with the crisis while minimising economic disruption.

The economy is merely a means – a vital means – to the end of human wellbeing. Health is also a means to achieving human wellbeing. But good health is so big a part of wellbeing it’s almost an end in itself. And prosperity isn’t much good to you if you’re dead.

So, as surveys show, most economists get what it seems many business people (and certainly, their lobby groups and media cheer squad) don’t get: in any seeming conflict, health trumps economics.

It’s also a matter of solving problems in the best order. Just as a war takes priority over material living standards, so does a major threat to our health. Fix the health problem, then get back to worrying about the economy.

To put it yet another way, “the economy” exists to serve the interests of the people who make it up; we don’t exist to serve the economy.

The people who want to exalt “the economy” tend to be those using “the economy” to disguise their pursuit of their own immediate interests, not the interests of everyone. “Keep my business going; if that means a few people die, well, I’m pretty sure I won’t be among ’em.”

Some economists estimate that the NSW lockdown will cost the economy (gross domestic product) about $1 billion a week. But don’t take that back-of-an-envelope figure too seriously. For a start, it’s not huge in a national economy producing goods and services worth about $2000 billion a year.

In any case, it’s misleading for two reasons. First, can you imagine what would be happening in the economy had St Gladys (or, before her, Dictator Dan) done nothing while the virus raged about us, getting ever worse?

Most of us would be in what Professor Richard Holden of the University of NSW calls “self-lockdown”. Which would itself be a great cost to the economy – not to mention the angst over the lack of leadership.

So don’t confuse the cost of the virus with the cost of the government’s efforts to limit its spread by doing the lockdown properly.

Second, remember that the economy rebounded remarkably quickly and strongly after the earlier lockdowns, making up much of the lost ground. Of course, the exceptional degree of income support for workers and businesses provided by the federal government does much to account for the strength of the rebound.

Which is why it’s good to see the federal-state assistance package announced on Tuesday, even though its cut-price version of JobKeeper, while being better than was provided to Victoria recently, isn’t as generous as it should have been.

Like Berejiklian, Morrison is still adjusting to his newly reduced circumstances.

Read more >>

The real reason the budget may stay in deficit for the next 40 years

If you follow a rule that when a politician cries “look over there!” you make sure you stay looking over here, there’s much to be deduced from Treasurer Josh Frydenberg’s Intergenerational Report, before we put it up on the shelf with its four predecessors.

That’s especially so with a federal election coming by May next year. Elections are times when politicians try to convince us they can do the arithmetically impossible: cut taxes while guaranteeing adequate spending on “essential services” and getting on top of “debt and deficit”.

Intergenerational reports always involve sleight of hand. They’re always about getting us to focus on a certain aspect of the problem and ignore other aspects.

As Frydenberg admits, the five-yearly intergenerational reports “always deliver sobering news. That’s their role. It is up to governments to respond.”

He’s given us little idea of what that response will involve. But there’s little doubt about his sobering news: the budget is projected to stay in deficit in each of the 40 years to 2060-61.

And we’re left in no doubt about the stated cause of those deficits and growing government debt: excessive growth in government spending.

As the report’s authors confess in an unguarded moment, “the emphasis of the [successive intergenerational] reports rested on pressures that demographic change [that is, the ageing of the population] was likely to impose on future government spending”.

We’re told that, even after you remove the effect of inflation, government spending per person is projected to “almost double”. (And I thought only journalists were prone to exaggeration. “Almost double” turns out to be an increase of 73 per cent.)

Why the huge growth in real terms? Mainly because of huge growth in spending on healthcare, but also because of big growth in spending on aged care and interest payments.

Get it? Government spending will grow like steam because of the ageing of the population. Except that when you read the report’s fine print you find that’s not the main reason. Only about half the projected growth in health spending is explained by population growth and ageing.

The other half is explained by advances in medical “technology, changing consumer preferences and rising incomes”. That is, as Australians’ real incomes rise over time, they want to spend a higher proportion of that income on preserving their good health and living longer.

And improved medicines and procedures almost always cost more than those they replace. But voters won’t tolerate government delay in making the latest drugs and operations available under Medicare.

As for the projected greatly increased spending on aged care, only part of it’s due to the Baby Boomers eventually reaching their 80s. The rest is explained by “changing community expectations”.

That’s a bureaucrat’s way of saying that “after the royal commission confirmed all we’ve been told about widespread mistreatment of people in aged care, governments will have no choice but to stop doing aged care on the cheap”. That is, it’s the higher cost of better-quality care.

Expressed as a percentage of national income, spending on the age pension is expected to fall as bigger superannuation payouts put more people on part-pensions. And, even though this saving is projected to be more than offset by the increased cost to revenue of super tax concessions, the combined effect is that the retired will have a lot more money to spend than their parents did.

Now get this: whereas total government spending is projected to grow, in real terms, at an average rate of 2.5 per cent a year in the coming 40 years, this compares with growth of 3.4 per cent a year over the past 40 years.

So it’s not just that ageing doesn’t adequately explain the expected growth in government spending, it’s also that the projected 40 years of budget deficits can’t be adequately explained by excessive spending.

The real reason the spending horse is expected to outrun the taxing horse is that the taxing horse has been nobbled. At a time when the coronacession led to a huge blowout in the budget deficit, the government used this year’s budget to bring forward the second stage of its tax cuts, and will proceed with the third-stage tax cut in July 2024 despite the continuing deficits and rising debt.

Worse, the projections assume that, because projected tax collections would otherwise exceed the government’s self-imposed limit on taxation as a proportion of national income after 2035-36, we’ll be getting new tax cuts in each of the last 15 years up to 2061. Yes, really.

No wonder interest payments are projected to account for three-quarters of the budget deficit in 2060-61.

We can be sure Scott Morrison will go into the election campaign claiming the Liberals are the party of lower taxes. But what voters will have to decide is whether a re-elected Morrison government would “respond” to the Intergenerational Report’s projection of its existing policies by letting taxes grow, slashing spending on “essential services” or letting debt and deficit just keep keeping on.

Read more >>

Deeper causes of America's troubles are economic and social

The older I get the more I prefer movies where nothing much happens. I’m increasingly impatient with car chases, gunfights and sword fights. I like movies that look at people’s lives and the way their relationships develop. Truth be told, I prefer escapist movies, but make an exception for those that help me better understand the difficulties encountered by people living in circumstances very different to mine. They may not be much fun, but they are character-building.

I put Frances McDormand’s memorable Nomadland in that category. If you want to understand how the richest, smartest, most “advanced” civilisation in the world could be tearing itself apart before our very eyes, Nomadland is an easy place to start.

McDormand plays an older woman who, having recently lost her husband, finds the global financial crisis and its Great Recession have caused her to lose her job, her home and even the small company town she’s lived in for years.

She fits out a second-hand campervan and takes off on the roads of middle America in search of somewhere to earn a bit of money and somewhere to camp for a few weeks that doesn’t cost too much.

It’s a solitary life, but slowly she makes casual friendships with a whole tribe of other older nomads moving around in search of unskilled casual work. The climax comes when her van breaks down and she must return to suburbia to beg her sister for a loan so she can keep on the move.

It’s a fictionalised version of a non-fiction book, Nomadland: Surviving America in the Twenty-First Century. In the hands of the film’s director, it becomes a story of human resilience, how McDormand’s character and the other nomads learn to adapt and survive. According to the reviews, the movie glosses over the book’s criticism of the poor treatment and payment of people working at a huge Amazon warehouse.

For a harder-nosed expose of life on the margins of America’s mighty economy, I recommend the recent work of the Nobel prize-winning Scottish American economist, Sir Angus Deaton. With his wife Anne Case, another distinguished economics professor from Princeton University, Deaton has obliged Americans to acknowledge an epidemic that’s been blighting their society for two decades, the ever-rising “deaths of despair” among working-class white men.

These are deaths by suicide, alcohol-related liver disease and accidental drug overdose. Much of the problem is the opioid crisis, in which increased prescription of opioid medications – which the pharmaceutical companies had assured doctors were not addictive – led to widespread misuse of both prescription and non-prescription opioids and many fatal overdoses.

Deaton and Case found that these deaths of despair had risen from about 65,000 a year in 1995 to 158,000 in 2018 and 164,000 in 2019. This increase is almost entirely confined to Americans – particularly white males – without a university degree.

While overall death rates have fallen for those with full degrees, they’ve risen for less-educated Americans. Amazingly, life expectancy at birth for all Americans fell between 2014 and 2017 – the first three-year drop since the Spanish flu pandemic. It rose a fraction in 2018, as the authorities finally responded to the opioid crisis.

Deaton and Case have found that, after allowing for inflation, the wages of US men without college degrees have fallen for 50 years, while college graduates’ earnings premium over those without a degree has risen by an “astonishing” 80 per cent.

With the decline in employment in manufacturing caused by globalisation and, more particularly, automation, less-educated Americans have become increasingly less likely to have jobs. The share of prime-age men in the labour force has trended downwards for decades.

Despite losing the popular vote to Hillary Clinton in 2016, Donald Trump won more votes in the Electoral College partly because most Republicans held their nose and voted for him, but mainly because three or four smaller midwest “rust bucket” states – still suffering from the loss of less-skilled jobs in the Great Recession – switched from the Democrats to the man who promised to give the establishment a big kick up the bum. (Instead, he gave it big tax cuts and more deregulation.)

So Trump is more a symptom than a cause of America’s long-running economic and social decay. Which doesn’t change the likelihood that his woeful mismanagement of the coronavirus pandemic will add to the economic and social causes of deaths of despair.

Deaton and Case say the pandemic has exposed and accelerated the long-term trends that will render the US economy even more unequal and dysfunctional than it already was, further undermining the lives and livelihoods of less-educated people in the years ahead.

In the pandemic, many educated professionals have been able to work from home – protecting themselves and their salaries – while many of those who work in services and retail have lost their jobs or face a higher risk of infection doing them.

“When the final tallies are in, there is little doubt that the overall losses in life and money will divide along the same educational fault line,” they conclude.

Read more >>

Doing health admin on the cheap may mean things go wrong

In my game, where you spend years watching the antics of politicians and bureaucrats from a ringside seat – say, watching the inquiry into Victoria's tragic hotel quarantine debacle – you tend to become cynical. But not as cynical as a gym buddy of mine, who's had much experience of such inquisitions.

He says that when everyone's denying having made the fateful decision, but saying they don't know who did make it, it's usually a sign they're trying not to dob in the boss.

It's possible the boss in question was now-departed health minister Jenny Mikakos, but I doubt it. Bureaucrats from one department don't usually cover for some other department's minister.

One thing I've noticed over the years is that when the hue and cry is closing in on the really big political boss, it's not surprising to see someone else take the dive on their behalf. If it's a public servant writing the so-sorry-I-misled-you-prime-minister letter, they can expect to be looked after in their next appointment. When it's another minister, it's usually less congenial.

The inquiry revealed various instances of ministers claiming not to have been briefed by their departments. So, the Sir Humphreys work it out themselves and let their ministers know later? Don't believe it. The days of Yes, Minister are long gone.

These days, department heads – federal and state – are sacked so often that senior public servants live in fear of displeasing their minister. How might that happen? If you told them something they'd prefer to be able to say they hadn't been told. Or even if you gave them advice that really annoyed them.

As so often happens, what was missing from the quarantine inquiry's proceedings was acknowledgment of the role of ministerial staffers. They're invisible, apparently. These days, much communication between a department and its minister goes via the staffers. They decide what's too trivial, inconvenient or potentially embarrassing to be passed on.

In all the toing and froing before the inquiry, you may have noticed a lot of witnesses declining to accept responsibility for "collective decision-making" decisions. Such evasion of responsibility is one of the besetting sins of public servants. Their political masters ought to put a stop to it. Which they would – were they not too busy playing the same game.

Back to the search for a guilty party. In Canberra lore, conspiracies are always trumped by stuff-ups. So I don't find it hard to believe that no one in particular made the decision to outsource the running of hotel quarantine to private contractors. It really was a decision that, in Scott Morrison's memorable phrase, "made itself".

It was taken without much thought or discussion because "that's what we always do". Outsourcing the provision of public services has become so ubiquitous no one thought of doing it any other way.

You may think that outsourcing the delivery of public services to for-profit providers – a form of privatisation – must be the bright idea of some naive economist, and you'd be right. Actually, half right.

An economist who's put much thought into government "contracting out", Oliver Hart, of Harvard, demonstrated that it was a good idea if your goal is to cut costs, but a bad idea if you care about maintaining the quality of the service.

This is because of a problem economists call "incomplete contracts". It's humanly impossible to write a contract that covers every problem that could arise and every way the contractor could game the contract at your expense. When you deliver the service yourself, you retain control over quality. Hart was awarded the Nobel prize for his sagacity.

Outsourcing is hugely fashionable in business as well as government. In my experience, it's always about saving money in the fond hope any loss of quality won't be noticed.

Often, the saving comes from ending the good wages and conditions you pay your own workers by sacking them and sending them down the road to work for some contractor on lower pay and worse conditions. It's a way of side-stepping successful unions.

In the public sector, however, another attraction of outsourcing is that it blurs lines of responsibility. "The contractors are giving you a hard time? Blame them, not me." "You'd like to see the contract I've made with the supplier? Sorry, commercial in confidence."

Truth is, governments at both levels and of both colours have gone for years saving money by contracting out wherever possible and imposing annual "efficiency dividends" (an Orwellian term for public service redundancies).

They've given us government on the cheap because they believed we'd prefer a tax cut to decent service. They could have striven to give us better government – including government that was big on accountability and where lines of responsibility were clear – but they settled for cheaper government.

They've spent decades cutting corners in a hundred ways, hoping we wouldn't notice (or do no more than grumble about) the slow decline in quality. Now the pandemic has caught them out. Pity so many lives were lost in getting the message through.

Read more >>

Morrison and the medicos must also avoid complacency

They say Australians always respond well to a crisis, and it seems it's true. Even in these days of disposable leaders, Kevin Rudd deftly stopped the global financial crisis from sucking us into the Great Recession, and now Scott Morrison has got on top of the corona crisis in a way few would have expected. His approval rating has soared. But I still wouldn't want to be in his shoes.

Why not? Because, as an old econocrat explained to me long ago, if you dispose of a crisis with too much ease – without a titanic struggle – you get precious little gratitude from the voters. If it was that easy to fix, it can't have been much of a crisis in the first place. Indeed, all that money you spent – well, most of it must have been a waste. That's the very way his political opponents have sought unceasingly to denigrate Rudd's unbelievably skilled performance in 2009.

And now Morrison faces the same risk. Everyone's saying he – along with the premier cats he's been herding – has done surprisingly well in controlling the outbreak. But that's not true. The unvarnished truth is that – if you'll forgive the expression – he hasn't just done well, he's killed it. He set out merely to "flatten the curve" but in fact has driven it down almost to zero. And done so with just 80 or so people losing their lives so far.

In the jargon of the epidemiologists, he and the premiers have succeeded in getting "R" – the average number of other people infected by someone who's contracted it - below 1, meaning it's dying out.

Utterly uncharacteristically for a politician of any stripe, Morrison has sought to play down this achievement. Why? Because the whole world has a year or years to go before the virus is tamed and, in the interim, some mishap on our part could cause the virus inside our borders to become undead.

That's why Morrison and his medico advisers live in fear that any loosening of the lockdown could lead us to become "complacent" and flip to the opposite extreme, stopping all social distancing.

But keeping us locked down as tight as possible for as long as possible offers no solution to Morrison's challenge as our leader. That's because, though we care deeply about saving lives, we also care about saving our livelihoods. Our success in getting on top of the virus has been bought at the cost of shutting down most of the economy, with hundreds of thousands of workers losing their jobs.

Morrison's problem is that, because it was so relatively painless, his remarkable success in driving out the virus will soon be forgotten, whereas the continued dysfunctional state of the economy – the way-high unemployment – will be upmost in people's minds come the election in 2022.

And, even now, his critics – mostly from his own side – are concluding that his measures to deal with the virus grossly overestimated the size of the problem and have decimated the economy for no good reason.

For instance, we were terribly worried about the risk of hospitals being overwhelmed by patients who couldn't get proper treatment to prevent them from dying. We had to delay the virus' spread while we more than doubled the existing number of 2200 intensive care beds. Fine. Last time I looked, there were 43 virus victims in ICU.

But such criticism is just being wise after the event. It forgets that we had to respond quickly and forcefully to a new virus, the characteristics of which we knew next to nothing about. The best we had to go on were numbers from China, which proved much worse than our own experience.

The medicos' original modelling assumed Wuhan's R – reproduction number – of 2.68, whereas their more recent modelling using Australian numbers shows we started with Rs above 1 only in Victoria and NSW, before falling below 1 in all states bar Tasmania.

Morrison's deeper problem is that the longer he keeps the economy locked down, the less there will be left to reopen. So avoiding complacency cuts both ways. You and I must not become complacent about hygiene and social distancing, but Morrison and his medicos must not be complacent about the enormous economic (and social) cost that our success in getting on top of the virus is inflicting on all of us.

The solution is to take advantage of our success in taming the virus by moving quickly to replace the sledgehammer measure of closing down most of the economy with the less economically damaging measures of much more testing, better tracing of people exposed to the virus, and jumping on any local outbreaks ASAP. The new app is a big part of this shift to less invasive cures for the disease.

These are the three things Morrison has been quietly saying we need to get organised before we consider easing the lockdown. But now he needs to move strongly in dismantling much of it while, naturally, retaining our closed borders.

Read more >>

It will take time to get used to living with the new virus

The coronavirus is deadly – it will end up killing quite a few oldies – but we (and the rest of the world) are making so much fuss about it mainly because it’s new. Thanks to that fuss, it’s likely to do more damage to the economy than it does to life and limb.

How much damage we do to the economy – and whether it lasts a few months or a few years – will be determined largely by the way Scott Morrison and his ministers manage all the fuss: on the medical side and the economic side.

There’s one sound medical reason for being concerned about the newness of this particular virus: as yet, we have no natural immunity to it. But don’t worry, we’ll get it in due course – although we’ll have calmed down long before that. The “novel coronavirus”, as the medicos call it, will have lost its novelty in a different sense.

The news media are making a great fuss for no reason other than the virus’ newness. New is what news is about. What’s new is unknown and what’s unknown is frightening.

You may think we’re making all this fuss not because the virus is new, but because it’s deadly. But we have daily contact with a lot of deadly things we don’t make a fuss about because we’re used to them.

It could be that road accidents cause more deaths – and certainly more injury – than the virus does this year. And seasonal flu carries off a lot of oldies every year without much fuss. In the end, Sydneysiders decided that the death and injury caused by late-night drinking wasn’t a good enough reason to limit the fun.

One key group who are understandably worried about the virus because of its newness are doctors and other health and aged-care workers. It does matter more if someone in such intense contact with the elderly and the ill gets the virus than if I get it.

But what’s worrying the doctors is how little we yet know about the characteristics of the virus and, more particularly, how little they’ve been told about what to do. Where are the protocols on how to handle patients who present with symptoms? What about face masks and testing kits?

Our surgery or hospital or old people’s home is already stretched, how will we cope with the influx? What will we do if we have to send key workers home for a fortnight because they’ve caught it or may have caught it?

I’m sorry to disillusion you if you haven’t worked it out yet, but the health authorities aren’t trying to stop the spread of the virus. They’re not trying to nip it in bud or stop it in its tracks. The cat’s out of the bag and it’s too late for that.

So what are they trying to do? Just slow down its spread. Why? To give the medical and aged care system time to prepare for the onslaught – including the time to set up separate “fever assessment clinics” where the “worried well” are kept away from those likely to have caught the virus, and away from those known to have.

As the disease spreads to many more people, it won’t be possible to put lots of medical time into tracing the contacts of every particular carrier – nor close a school for a few days while you do it. That is, in the best sense, a delaying tactic.

As Dr Katherine Gibney, of Melbourne’s Peter Doherty Institute for Infection and Immunity, and others, explain on the universities’ The Conversation website, as case numbers rise, case management will need to be streamlined. “While many mild cases have been admitted to hospital during the containment phase, community-based care [that is, staying at home] will be the reality for most people,” they say.

Australia’s Chief Medical Officer, Professor Brendan Murphy, says travel bans are only a way to slow down the spread of the virus. “It is no longer possible” to prevent new cases entering Australia, he says. This suggests that, before long, the border measures will be relaxed.

Last week the NSW Chief Health Officer, Dr Kerry Chant, was blunt: “We are not going to be able to contain this virus.”

Gibney and colleagues say “it’s likely, but not certain, that COVID-19 will remain in circulation beyond 2020 and become ‘endemic’ in Australia – that is, here for good” – like many viruses before it, including seasonal flu. Last season almost 300,000 cases of flu were reported, with 810 deaths – a fatality rate of about 0.27 per cent.

As yet, figures for the coronavirus are preliminary but it’s thought to be much more deadly than the flu, with a fatality rate of 1 or 2 per cent. It’s also more contagious than the flu, though much less so than measles. Its incubation period of two to 14 days is three times longer.

Even so, about 80 per cent of those who get it have a mild to moderate illness and only 20 per cent have a severe to critical illness. Most people who aren’t elderly and don’t have underlying health conditions won’t become critically ill.

Disruption to the economy is unavoidable, but the danger is that hour-by-hour reporting of efforts to slow the spread is frightening a lot of people and will lead them to overreact to the risk of infection, closing businesses and purses and making everything worse than it needs to be.

Read more >>

Eat, drink and be merry, for tomorrow the virus won't get you

The coronavirus will harm the economy – ours and the world's – but how much damage it does will be determined not just by how far and how fast the virus spreads, but by what the government does to protect us from that spread and what people take it into their heads to do to protect themselves.

There's a good chance the reaction to the threat of the virus will do far more damage to the economy – and the livelihoods of the people who constitute it – than the damage it does to life and limb.

If the reports we hear of people stripping supermarket shelves and deserting cafes, bars and other places of recreation are a guide, the main consequence so far is an outbreak of national hypochondria. Crazed by an overexcited world media, Aussies have gone into panic mode well before the threat has materialised.

I suspect part of the problem is that word "pandemic" – the thing Scott Morrison last week acted on ahead of the World Health Organisation having declared. To many of us it's a highly emotive word, raising images of people dropping like flies as the disease spreads.

In the minds of epidemiologists, however, it just means the virus has popped up in quite a number of countries, without saying anything about how far and fast it's spreading in those countries.

According to Professor Ilan Noy, a specialist in the economics of disasters at New Zealand's Victoria University, "All signs point to a global overreaction to this crisis, and therefore to an amplified economic impact."

According to Professor Cass Sunstein, of Harvard Law School, "A lot of people are more scared than they have any reason to be. They have an exaggerated sense of their own personal risk."

That's because humans are notoriously bad at assessing the risks they face. Studies by psychologists and behavioural economists show individuals typically overestimate risks that are memorable, vivid or generate fear, while underestimating more common risks.

Noy says that, in a survey of 700 people in Hong Kong at the height of the SARS epidemic in 2002, 23 per cent of respondents feared they were likely to become infected. In the US, 16 per cent of respondents to a survey felt they or their family were likely to be infected. The actual US infection rate was 0.0026 per cent.

Sunstein says it's likely that, for residents of a particular city, "The risk of infection is really low and much lower than risks to which they are accustomed in ordinary life – say, the risk of getting the flu, pneumonia or strep throat."

One implication of this, he says, is that, "Unless the disease is contained in the near future, it will induce much more fear, and much more in the way of economic and social dislocation, than is warranted by the actual risk.

"Many people will take precautionary steps - cancelling holidays, refusing to fly, avoiding whole nations - even if there is no adequate reason to do that. Those steps can, in turn, increase economic dislocations, including plummeting stock prices."

But let's say you defy the odds and actually get infected. What are your chances then? Last week WHO said that, using the figures for China, for every 100 cases of coronavirus, about 80 people get better unassisted, 15 have serious but manageable problems, five are very serious and about three die. But that's for China. For the rest of the world it's more like 1 per cent who die.

So, like the flu, the coronavirus is usually something you get over fairly quickly. The people who don't recover quickly tend to be the elderly, and the few who die are usually those with another complication, such as asthma, cancer, cardiac disease or diabetes. (Oh no, that's me! I'm done for.)

But while you await your certain demise, remember something Scott Morrison said last week that didn't hit the headlines: "You can still go to the football, you can still go to the cricket, you can still go and play with your friends down the street, you can go off to the concert, and you can go out for a Chinese meal."

When it comes to the economy, remember that the share market is the drama queen of the financial world. It tends to overreact to bad news – but it does so knowing that later in the week it will be overreacting to good news. A cut in interest rates? God be praised.

Even so, the coronavirus and the efforts to contain it – official and amateur - have had adverse effects on the Chinese economy, with flow-on effects to our economy among others. The Chinese are already getting back to business, but it will be slow and economic activity – producing and consuming – has been seriously disrupted in the present quarter and probably the next. The world economy isn't strong and this will make it weaker.

Our border controls are hitting our tourist industry and universities. How much the overreaction of individuals adds to that we'll soon start seeing in economic indicators rather than anecdotes. In principle, we're experiencing a temporary adverse shock to the economy extending over a quarter or three, followed by a partial bounce back as consumers release pent-up demand and firms rush to fill back orders and re-stock.

Coming on top of all our other economic woes, however, it won't be fun.

Read more >>

Mental health: the smart way to increase happiness

You have to hand it to Scott Morrison. He is, without doubt, the most skillful politician we’ve seen since John Howard. He runs rings around his opponents. It’s just a pity he puts so much time into strengthening his own position by making his opponents look bad and so little into strengthening our position by working on some of our many problems.

Speaking of problems, on the very day the Royal Commission into Aged Care was revealing how appallingly we treat so many of our parents and grandparents, the Productivity Commission released a draft report on how much our treatment of the mentally ill leaves to be desired.

Sometimes I think that if hastening the economy’s growth is intended to increase our happiness, why don’t we do more to increase it directly by reducing the unhappiness of, for instance, those in old people’s homes and those suffering mental illness, not to mention their families?

Why do you and I somehow imagine it won’t be us being mistreated in some institution in a few years’ time? Why could mental ill-health never reach us or our family and friends?

The commission’s report found that almost half of Australian adults will meet the diagnosis for a mental illness at some point in their lives. In any given year, however, one person in five will meet the criteria. And, although it can affect people of any age, three-quarters of those who develop mental illness first experience problems before they’re 25.

And yet we’ve gone for years providing quite inadequate help to the mentally troubled. Why? Because physical problems are more visible and less debatable. But also because the stigma that continues to attach to mental problems makes sufferers reluctant to admit to them, and the rest of us reluctant to dwell on it.

Mental illness includes more common conditions such as anxiety, substance use and depression, plus less common conditions such as eating disorders, attention-deficit/hyperactivity disorder, bipolar disorder and schizophrenia. And suicide, of course.

The report says that many who seek treatment for mental problems aren’t receiving the level of care necessary. As a result, too many people suffer additional and preventable physical and mental distress, relationship breakdown, stigma, and loss of life satisfaction (the $10 words for happiness) and opportunities.

A big part of the problem is that the treatment of mental illness has been tacked on to a health system designed around the characteristics of physical illness, especially acute rather than chronic illnesses.

Five long-standing and much-reported-on problems causing the mental health system to deliver poor results are, the report says, first, the underinvestment in prevention and early intervention. This is what makes the fact that mental problems tend to start early and get worse good news, in a sense. It means that, if you get in early, you can stop people experiencing years of unhappiness (not to mention cost to the taxpayer).

Second, the focus on clinical services – things done by doctors and nurses – often means overlooking other things and other people contributing to mental health, including the important role played by carers and family, as well as the providers of social support services.

Third, the frequent difficulties finding suitable social supports, sometimes because they just don’t exist in regional areas. This is despite suicide rates, for example, being much higher outside the capital cities.

Fourth, the social support people do receive is often well below best-practice, isn’t sustained as their condition evolves or their circumstances change, and is often unconnected with the clinical services they get.

Fifth, the “lack of clarity” about roles, responsibility and funding between the federal and state governments. This means persistent wasteful overlaps existing side by side with yawning gaps in the services provided. And it means no level of government accepts responsibility for “the system’s” poor performance.

It’s clear we’re not spending enough on mental healthcare. But this is where we get into an old argument. Ask the people running the system and their answer is always “just give us a shedload more money and we’ll decide how best to spend it”. But ask the Smaller Government brigade and they’ll say “we’re already spending far more than we did and spending even more would improve nothing”.

As usual, the truth’s in the middle. It’s true we’re spending a lot more without much evidence of improved results, but equally true we need to spend more – particularly on social support, such as suitable housing. Fix people, throw them onto the street, and see how well they do.

Sorry, but the days of “trust me, I’m a doctor/teacher/public servant/whatever” are gone. Too many occupations have abused our trust. We need to spend what we’re already spending a lot more effectively – particularly on prevention and early detection, on the non-clinical aspects of the problem, and on better coordination of federal and state roles – as a condition of spending more.

And that will mean paying a bit more tax. After all, if we’re so willing to spend on a big-screen TV or overseas holiday or new car to make us happier, what’s the hang-up with spending via taxes to improve our treatment in old age or should we or a rello strike mental problems?

Read more >>

Health insurance: paying to boost specialists' incomes

I think I could probably get to the end of the year just writing once a week about the many problems Scott Morrison faces, but doesn’t seem to be making any progress on. And that’s before you get to climate change.

Take private health insurance. The public is terribly dissatisfied with it because it gets so much more expensive every year and because, when you make a claim, you’re often faced with huge out-of-pocket costs you weren't expecting.

The scheme has such internal contradictions it’s in terminal decline, getting weaker every year. Neither side of politics is game to put it out of its misery for fear of the powerful interests that would lose income – the health funds, the owners of private hospitals and myriad surgeons and other medical specialists – not to mention the anger of the better-off elderly who have convinced themselves they couldn’t live without it.

But neither is either side able to come up with any way of giving private health insurance a new lease on life. Anything governments could do – and probably will do – to keep the scheme going a bit longer involves slugging the taxpayer or forcing more people to pay the premiums.

I’ll be taking most of my information from the latest report on the subject by the nation’s leading health economist, Dr Stephen Duckett, of the Grattan Institute, but drawing my own conclusions.

Private health insurance is caught in a “death spiral” for two reasons. First, because the cost of the hospital stays and procedures it covers is rising much faster than wages are. Duckett calculates that, since 2011, average weekly wages have risen 8 per cent faster than general inflation, whereas health insurance premiums have rise 30 per cent faster.

Why? At bottom, because the health funds have done so little to prevent specialists raising their fees by a lot more than is reasonable. Federal governments have gone for years meekly approving excessive annual price increases.

Second, as with all insurance schemes, those policy holders who don’t claim cover the cost of those who do. The government’s long-standing policy of “community rating” means all singles pay the same premium, and all couples pay about twice that, regardless of their likelihood of making a claim.

This means the young and healthy subsidise the old and ill. Which would work if health insurance was compulsory, but to a large extent it’s voluntary. So the old and ill stay insured if they can possibly afford to, while the young and healthy are increasingly giving up their insurance.

The Howard government spent the whole of its 11 years trying to prop up health insurance with carrots and sticks. These measures stopped coverage from falling for a while but, with premiums continuing to soar, have lost their effectiveness.

Over the year to last December, the number of people under 65 with insurance fell by 125,000 (particularly those aged 25 to 34), while the number with insurance who were over 65 increased by 63,000.

So here’s the bind the funds are in: the more healthy young people drop out, the greater the increase in premiums for those remaining. But the more premiums increase, the more youngsters drop out.

The funds’ talk of being in a death spiral is intend to alarm the public into insisting the government bail them out by imposing more of the cost on taxpayers or, ideally, on young people. But before we panic, we should ask why we need the continued existence of private insurance.

After all, our real insurance is Medicare and being treated without direct charge in any public hospital. If the taxpayer-funded public system is less than ideal, it could be a lot better if the $9 billion a year the federal government tips into private insurance and private hospitals was redirected.

To some people, the big attraction of private insurance is “choice of doctor”. But this can be illusory. It’s usually your GP who does the choosing – to send you to one of their mates or their old professor. In any case, if people want choice, why shouldn’t they be asked to pay for it without a subsidy from the rest of us?

Ah, but the real reason I must have private insurance, many oldies say, is to avoid the public hospitals’ terrible waiting lists for elective surgery. That’s a reasonable argument for an individual, who can do nothing to change the system.

But it’s not a logical argument for politicians, who do have the power to change the system. And when the health funds claim that, without them, the waiting lists would be far longer, they’re trying to hoodwink us.

Most specialists work in both the public and private systems, but do all they can to direct their patients to private, where their piece rate is much higher. Were the health funds allowed to die, many fewer patients would be able to afford private operations and would join the public hospital waiting list.

But what would the specialists do to counter the huge drop in their incomes? They’d do far more of their operations in the public system, probably doing more operations in total than they did before. It’s even possible the queues would end up shorter than they are now.

Read more >>

Governments are learning to nudge us down better paths

The world is a complicated place – partly because humans are complicated animals. One of the many things this means is that when governments try to influence our behaviour, their chances of stuffing up are surprisingly high.

Consider this. Say I’m an investment adviser telling you (or your parents or grandparents) where to invest your retirement savings. I warn you that, should you take my advice, I’ll be paid a commission by the managers of the investments I put you into.

How do you react?

Well, you should react by becoming a lot more cautious about following my advice. It’s clear I have a conflict of interest. Is my advice aimed at doing the best I can for you, or at maximising the commissions I earn?

When governments require investment advisers to disclose any conflict of interest to their clients, that’s how the pollies expect you’ll react. They also expect that this requirement will prompt advisers to eliminate or reduce any conflict so their advice is more likely to be trusted.

But research by Dr Sunita Sah, a psychologist at Cornell University in upstate New York, has found it often doesn’t work like that. Although such disclosures do indeed cause clients to have less trust, they can often lead people to feel social pressure to act on the advice anyway.

Clients may be concerned that refusing to follow the advice would be a signal of their distrust in the adviser, with whom they’ve often formed a personal bond. They may even interpret the disclosure as a request that the advice be taken, as a favour to the adviser who, after all, needs to earn a living like the rest of us.

Sah found that clients given advice they knew to be conflicted were twice as likely to follow that advice as were clients where no disclosure was made.

The lesson is not that we should stop requiring advisers to disclose their conflicts, but that government policymakers need to think carefully about the specific design of their policies.

It turns out you can reduce the undesirable effects of disclosure if they come from a third party – that is, someone other than the adviser. It also helps if clients’ decisions are made in private, or if there’s a cooling-off period before the decision is finalised.

Have you guessed where this is leading? It’s a plug for a relatively new tool that’s been added to the bureaucrats’ policy toolkit – “behavioural insights”.

In a speech he gave in Canada last week, Dr David Gruen, a deputy secretary in our Department of Prime Minister and Cabinet, explained that behavioural insights is an approach to policymaking that draws from psychology, cognitive sciences and economics to better understand human behaviour, help people make good choices more easily, and help improve the effectiveness of public policy interventions.

As the case of conflict-of-interest disclosures illustrates, people’s responses to government policy measures can be surprising. Politicians and bureaucrats need to be more conscious of the insights of behavioural insights when designing policies to fix problems.

And the behavioural insights tool can also be used for real-world testing of how policy measures are working – or not working – in practice.

The first government to establish a behavioural insights team was Britain in 2010, at the initiative of prime minister David Cameron, Gruen says. It’s since become a partly privatised joint venture.

By now, according to the Organisation for Economic Co-operation and Development, there are more than 200 public sector organisations around the world that have applied behavioural insights to their work.

In Australia, the federal government’s behavioural economics team – BETA – was set up to apply behavioural insights to public policy and to build behavioural-insights capability across the public service. It’s at the centre of a network of 10 behavioural insight teams across the federal government and alongside several state government teams.

These teams are also known as “nudge” units because they’re often trying to give individuals a nudge in the direction of making more sensible decisions, while leaving them free to do something else should they choose. You’re not forced, just nudged.

Gruen offered several examples of what the feds have been doing. BERT, the behavioural economics research team in the Department of Health, looked at the ballooning cost of reimbursements to doctors for providing after-hours care.

After-hours care considered urgent was remunerated at about twice the rate of that judged a non-urgent visit. Who judged whether the care was urgent? The doctor.

The department identified the 1200 doctors with the highest urgent after-hours claims, and ran a randomised control trial, sending each of them one of three alternative letters, with the letter a doctor received chosen at random.

One letter compared the doctor’s billing practices with their peers, showing they were claiming the urgent category far more often than others were. This drew on the behavioural insight that individuals are often motivated to change their behaviour when they are out of step with their peers.

The second letter emphasised the consequences of non-compliance, including the penalties and legal action. This letter drew on the behavioural insight that people tend to avoid losses more than they seek the equivalent gains.

The third letter was the control – the standard bureaucratic compliance letter, running to three pages.

All three letters were successful in reducing claims, but the peer-comparison one was far more effective than either the standard compliance letter or the loss-framing letter. The peer-comparison letter reduced claims by 24 per cent.

And it was just a nudge, not a threat of punishment for dishonestly claiming cases to be urgent when they weren’t.

In the six months after the letters were sent, the 1200 high-claiming doctors reduced their claims by more than $11 million (across all three letters), and 18 doctors voluntarily owned up to more than $1 million in previous incorrect claims.

So, as Gruen concludes, a simple and cheap nudge can yield big dividends.

Read more >>

Why government-controlled prices are soaring

As if Scott Morrison didn’t have enough problems on his plate, we learnt last week that government-administered prices are rising much faster than prices charged by the private sector.

Last week my colleague Shane Wright dug out figures from the bowels of the consumer price index showing that, over the almost six years since the election of the Abbott government in September 2013, the prices of all the goods and services in the CPI basket have risen by just 10.4 per cent, whereas the government-administered prices in the basket rose by 26 per cent.

Some of those "administered" prices actually fell and others rose by less than prices overall. But let’s do what everyone does and focus on the really big increases.

Behavioural economics tell us that people’s perceptions of the cost of living are exaggerated by a ubiquitous mental shortcut psychologists call "salience". We tend to remember the things that leapt out at us at the time and forget all the things that didn’t.

So, for instance, we vividly remember the shock we got when we opened our electricity bill and saw how huge it was and how much it had increased.

In round figures, the cost of secondary education rose by 30 per cent over the period, childcare by 27 per cent, postal costs by 27 per cent, hospital and medical services by 36 per cent, council rates by 21 per cent, cigarettes by 109 per cent, gas prices by 16 per cent and electricity by 12 per cent (most of the bigger increase came during the term of the previous Labor government).

Not hard to see that the government has a huge salience problem. Plenty of scope there for the punters to convince themselves the cost of living is soaring.

But what should Morrison do? At a glance, the problem's obvious: government prices rising much faster than market prices say governments are hopelessly wasteful and inefficient. So expose the government to competition and the waste will be competed away, to the benefit of all.

Sorry, the true story’s much more complicated. Indeed, part of the problem is the backfiring of governments’ earlier attempts to make the provision of government services "contestable".

Let’s look deeper. For a start, some of the increase in administered "prices" is actually increases in taxation. The doubling in cigarette prices is the result of the phased massive increase in tobacco excise begun by Malcolm Turnbull.

Local council rates work by applying a certain rate of tax to the unimproved land value of properties. State governments usually cap the extent to which the tax rate can be increased, but the base to which it’s applied soars every time there’s a housing boom.

Postal costs rise because we want to continue being able to post letters to anywhere in Australia at a uniform price, even though we're actually doing it less and less, thus sending economies of scale into reverse. Australia Post would have been privatised long ago if any business thought it could make a profit from the business without scrapping the letter service.

The doubling in the retail prices of the now largely privatised (but still heavily regulated) electricity industry over the past decade is the classic demonstration that attempts to introduce competition to monopoly industries are no simple matter and can easily backfire.

The cost of childcare has been rising over the years because governments have been raising quality standards – staff-child ratios, better educated and paid workers. Is that bad? This formerly community-owned sector has long been open to competition from for-profit providers without this showing any sign of helping to limit price increases.

Even so, childcare is heavily subsidised by the federal government. This government’s more generous subsidy scheme caused the net out-of-pocket cost to parents (which is what the CPI measures) to fall a little last financial year.

The modest suggested fees in government schools wouldn't have risen much over the past six years. If private school fees have risen strongly despite the heavy taxpayer subsidies going to Catholic and independent schools, it’s because the number of parents willing to pay them shows little sign of diminishing. Hardly the government’s problem.

Detailed figures show that the out-of-pocket costs for pharmaceuticals rose by less than 6 per cent (thanks to reforms in the pharmaceutical benefits scheme) and for therapeutic goods fell a few per cent, while for dental services they kept pace with the overall CPI, leaving the out-of-pocket costs of hospital and medical services up by a cool 36 per cent.

That tells you private health insurance is falling apart. Add the continuing problems with needs-based funding of schools, and electricity and gas prices, and the scope for further efficiency improvements in healthcare, and you see the Morrison government has plenty to be going on with.

Read more >>