Poorer and rural Australians are sicker, yet they get less healthcare. It's a broken system
When it comes to health, Australia is an unfair country.
Poorer Australians die about 7.5 years earlier than the wealthiest, and spend more years living with chronic disease. People from some communities, such as Aboriginal and Torres Strait Islander people, face an even higher risk of illness.
This injustice has deep, gnarled roots, from disadvantage and discrimination to poor air quality and unhealthy diets. But there's one cause that's more visible, and should be easier to fix: people missing out on healthcare they need.
A recent comparison of 10 wealthy countries found Australia's healthcare system rates highly overall, but ranks second-last on access to care, beating only the notoriously inequitable US system.
Poorer and rural Australians are sicker, yet they get less care. It's a perverse pattern that applies to most types of healthcare, including dentists, medicines, mental health care and allied health.
And a Grattan Institute report released this week compiles new data showing that access to specialist doctors, such as psychiatrists and cardiologists, is also highly unequal.
We mapped access to public and private specialist care and found that people in the poorest areas receive about a quarter fewer services than those in the wealthiest areas. That means poorer communities are missing out on tens of thousands of appointments every year, despite being sicker than average.
Rural Australians get about half as much care as people living in major cities. In many rural areas, specialist care is extremely scarce. Half of remote and very remote areas receive fewer than one specialist service per person each year, something not seen anywhere in Australia's major cities.
Why does this happen?
First, specialist fees are high, and there's not much relief for poorer people. Unlike at the GP, disadvantaged people are rarely bulk billed when they see a specialist.
Three-quarters of people earning less than $500 a week paid a bill for at least one specialist visit in 2023. That's not much less than for people on the median household income, who paid a bill 84% of the time.
And when the bills come, they're high and rising. The average fee charged has risen by nearly three-quarters since 2010. Again, poorer people aren't getting much of a discount: the median cost for the poorest people who pay fees is $170. That's not much lower than the $220 figure for people on an average income.
Second, there aren't enough public appointments where they're needed most. Free clinics in public hospitals deliver just one-third of all specialist appointments. And as private services decline, public services don't fill the gap.
Compared with the average, the communities in the bottom fifth of the nation get 26 fewer private services per 100 people. But they only get an extra three public services per 100 people. As a result, waiting lists for public clinics can be very long – often many months longer than clinically recommended.
Put these two problems together and you get a broken system. In much of Australia, private care costs are high, and there's no good alternative if you can't pay. The result is missed or delayed diagnoses, preventable illness and avoidable hospital visits.
To reduce fees and wait times, Australia needs to reform specialist training, reduce unnecessary referrals, and crack down on excessive fees. But an essential part of the solution is much more investment in specialist clinics in underserved areas.
Governments must invest for impact by targeting need. They should combine data on public services, private services, and community needs, then rebalance our skewed service system and put care where it's needed most.
To make it happen, health ministers should commit to a guaranteed minimum level of specialist care in the national health funding deal currently being negotiated between federal and state governments. It would cost about $500m to fill the worst gaps in the country.
To maximise the impact, public clinics should change the way they operate. There are many opportunities to improve their efficiency, but too often, they aren't the focus of hospital investment and improvement plans.
State governments should give public clinics more funding and support to adopt best practices. To make sure that expansion and improvement efforts are working, all governments should publicly report waiting times, as some states already do.
The unfair gaps in access to healthcare in Australia are deep and longstanding, but they're not inevitable. Without real change, we can expect fees and wait times to rise further as Australians get older and sicker. But with targeted public investment, we can make sure that specialist care doesn't become a special privilege.
Peter Breadon is the health program director at Grattan Institute
Elizabeth Baldwin is a Senior Associate in Grattan Institute's Health Program
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