Ageing: will the real culprit please stand up?

THE Intergenerational Report, released in the 2002-03 Federal Budget, is another sleight of hand. It claims to be about ageing and a blow out in health costs. But a closer look reveals that it identifies only a blow out in pharmaceutical costs. Moreover, the report itself reiterates the views that moderate and respected commentators have been arguing for a long time - ageing contributes in only a small way to rising health costs. According to the Intergenerational Report spending on aged care is likely to rise, but compared to the rise in general health costs, aged care will be a pretty modest burden. Moreover, the real drivers of health costs are things like ‘the growing cost of new health care technology, increasing use of services and strong consumer demand and expectations’. And one main component of future health expenditure - pharmaceuticals - outflanks all the rest, projected to increase five-fold between now and 2042. Is the report inferring that the Pharmaceutical Benefits Scheme will blow out because of ageing, that more older people will mean more and more expensive medicines? If so, it produces no evidence, and neither does any other literature. Possible reasons, although much debated, include the distorting influence of a small number of new and very expensive drugs, aggressive marketing of drug companies and the problem of ‘leakage’ (that is, when drugs achieve a higher usage level than was initially anticipated by the PBS). But the main reasons vying for pole position do not include population ageing. Indeed, it seems safe to conclude that if it wasn’t for the blow out in pharmaceuticals subsidies (because of reasons unrelated to ageing) the future would not look nearly so miserable. Population ageing has been ‘framed’ and its contribution to future health costs wildly exaggerated in popular and political rhetoric. To the extent that ageing will pose fiscal difficulties in the future, according to the Intergenerational Report, it will be because we cannot expect extra revenue to meet extra costs. Most of our revenue is raised through incomes tax and income tax revenue declines with age. (Maybe this is softening us up for a rise in the GST?) On this basis, the Treasurer suggests that we have a simple and stark choice: we can cut funding now or we can raise taxes to pay for it. A truly forward-thinking view of the future, however, would not be so limited. The report attempts, and fails, to project important trends into the future. Trend lines for factors such as the ‘unemployment rate’, ‘average hours worked’, ‘labour productivity growth’ fluctuate according to actual variation until about 2006, but then the projection turns into a single, straight line. But we know that variations in these trends could have a profound impact on future revenue, and all are highly amenable to policy resolution. In fact, there are many alternatives to simply cutting funds or raising taxes. The first task is to change our thinking and our questions. We need to start thinking of health expenditure as an investment not a cost. Rather than asking ‘how will we cope with the demographic timebomb’, we need to ask ‘what can we do to minimise the costs of medicines and health costs in the future without reducing population health’? We can increase the emphasis on public health and health promotion. It is true that older people have a range of health problems requiring medication. But the vast majority of these conditions are lifestyle-related. The Australian Institute of Health and Welfare estimates that 80 per cent of health related conditions in old age are preventable or postponable if corrected in time. If dietary changes and an increase in physical exercise can replace the need for expensive medications and at the same time extend productive and non-dependent life, this seems a highly efficient strategy with returns far exceeding outlay. Despite this, according to the Australian Institute of Health and Welfare, spending on public health initiatives currently amounts to around 2 per cent of total government health expenditure. Over the past few years, government funding for public health research has declined by around 21 per cent. We should also realise that cutting funding to essential services may only exacerbate the problem in the long run. If we want the majority of people to enter old age as healthy as possible, then making it harder and more expensive to gain access to quality health care - especially for low income earners who are most vulnerable to poor health - is hardly going to achieve that end. Increasing co-payments for drugs may mean that those on low incomes will be the least likely to take advantage of whatever benefits may be available from medication. They may choose not to visit the doctor or fill their prescriptions. A recent cross-national study found that almost one in five Australians reported not filling a prescription in the past year due to cost. But this is the group who need it most because the other circumstances of their lives increase the risk of poor health in old age. The biggest lesson from the Intergenerational Report, however, is that we should stop trying to hide serious governmental mismanagement and lack of vision behind scare-mongering about a crisis - ageing - that isn’t really there. Instead, we should begin with an accurate and forward thinking analysis of the real problems that we will face in the future. •Pamela Kinnear is a Research Fellow at the Australia Institute. Her report Population Ageing - Crisis or Transition? was released in December last year