Australia needs to rethink private health system

By Leith van Onselen

As reported over the weekend, almost 70% of Aussies with private health insurance have considered dumping or downgrading their cover over the past year due to escalating premiums and the perception that they are being ripped-off:

Close to 80 per cent of people believe health insurance companies put profits before patients and more than 90 per cent are concerned they’re trying to “Americanise” the health system to boost their bottom line.

The new ReachTEL polling shows just how displeased and distrustful Australians have become of their health insurance providers.

The average cost of premiums has gone up by about 35 per cent since 2010, well outpacing inflation. This is believed to be a key reason why people are starting to abandon private cover…

Commissioned by the Medical Technology Association of Australia, the polling of more than 1100 people found 69.2 per cent have considered dropping or reducing their coverage. The numbers are largely in line with a recent government survey of 40,000 people.

Perhaps it is time for Australia to rethink the role of private health insurance and private health care?

Every year, the Australian Competition and Consumer Commission (ACCC) releases its report to the Australian Senate on competition and consumer issues in the private health insurance industry. And every year, the ACCC finds that Australia’s private health insurance industry is characterised by market failures due to asymmetric and imperfect information, as well as significant complexity.

Since 1999 a raft of government initiatives – essentially financial carrots and sticks – have forced Australians into purchasing private health insurance.

And yet successive governments – both Coalition and Labor – have failed to articulate why Australians need a duplicate health care system, or why the federal Government subsidies to private health insurance should be so substantial.

It’s not as if private health insurance buys patients extra quality and safety. The Productivity Commission (PC) found that the larger, most comparable public and private hospitals had similar adjusted premature death ratios. Further, the PC found that the team-based care in large public hospitals also leads itself to better coordination of care.

International evidence also does not support the contention that private health insurance keeps medical costs down:

ScreenHunter_1766 Mar. 20 14.45

In fact, in Australia’s case, private health insurance is likely raising overall health costs. This is because the high financial overhead of private insurance means that only 84 cents in every dollar collected by private insurers is returned as benefits, with the rest going to administrative costs and corporate profits. By contrast Medicare returns 94 cents in the dollar, even after the cost of tax collection is taken into account.

A single national insurer, like Medicare, also has the monopsony buying power to control prices demanded by powerful service providers.

The 2015-16 Budget Papers showed that the cost of the private health insurance rebate will rise from $6,228 billion in 2013-14 to $7,061 billion by 2019-20 – an increase of 13%.

Where is the evidence to show that spending taxpayer money in this way is superior to expanding funding to the public system?

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Unconventional Economist
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  1. “Where is the evidence to show that spending taxpayer money in this way is superior to expanding funding to the public system?”

    Because incentives say so. Running a public system that does not have management incentives to minimise costs won’t perform as well as private organisations with these incentives (all else being equal).

    If you read the reports of the private health insurers, the rising premiums are the result of increased amount of medical care, not increased cost of the same services (NHF FY16 annual report comes to mind). Furthermore, the ‘risk equalisation’ system is once again forcing the young to subsidise the old. Not that this is directly related to the debate above, but just pointing out that it’s goverment regulation that is bastardising the private system (in some cases justified, in this case, it’s not).

    • “Because incentives say so. Running a public system that does not have management incentives to minimise costs won’t perform as well as private organisations with these incentives (all else being equal).”

      Where is your evidence? The chart in my article suggests otherwise.

      Single national insurers keep costs down because:
      1) there are less financial overheads (they return more in benefits per dollar of revenue collected); and
      2) they have monopsony buying power. Competing private insurers have little ability to control prices demanded by powerful service providers. If one insurer tries to bargain hard with hospitals to keep prices down, the hospitals simply choose to do business with another insurer. By contrast a single national insurer, usually a government agency, has the market power to put some discipline into prices and utilisation.

      Using your logic, the US should have the most efficient health system in the world. Whoops!

      • @UE – both a single national insurer and the US system belong in #4 below which is the most corrupted medical health system with respect to oversight for monies spent.

        Levels of oversight where monies are spent
        Most oversight = #1 You spend Your money
        #2 = Someone else spends your money
        #3 = You spend someone else’s money
        Least oversight = #4 Someone else spends someone else’s money

        Time to flip this thing on it’s head and move back to #1. Give us all an annual amount of crypto health dollars that expire at the end of the tax year. This will create a genuine market and put the decision of spend back in the individual’s hands.
        Current medical insurance of no blame corrupts the system with respect to oversight

      • Travis,

        Your list of principles don’t apply here because not everyone is a doctor. So how are people going to make informed choices about what to ‘buy’?

      • “Where is your evidence?”
        Capitalism. Telstra privatisation, Vic Power generation privatisation. Shall I go on?

        “The chart in my article suggests otherwise.”
        Your chart simplifies the situation far too much. Those on Private Health Insurance generally pay more for extras that aren’t necessary (room to themselves, extra time in hospital (e.g. pregnancy), choice of doctor, skipping queues, etc.). The level of care provided is not the same, so you’re essentially comparing apples and organges.

        “there are less financial overheads”
        Economies of scale generally hold true. But when the system isn’t efficient, growing in scale just makes it worse. I would rather many smaller groups operating with less scale, knowing they’re incentivised to operate efficiently.
        A little reading of Berkshire Hathaway annual reports (written by one of the best businessmen of our time) reveals that allowing entities to operate in a de-centralised manner is more efficient. The idea that one group of management knows what’s best for each operation is ridiculous.
        I don’t know the divisions within Medicare, so I can’t go further than a general principle here.

        “Competing private insurers have little ability to control prices demanded by powerful service providers”
        Really? NIB and Medibank are rather large insurers… I would suggest they have just as much pricing power as the government (unless the govt introduces pricing caps). You’ll also find that they deal with a large portion of the private health insurance market.

        As for the US health care system – I really can’t comment. I’m not familiar with the specifics.

      • @[email protected]
        of course what I said applies, hands down. Its a vast improvement on the current system. People aren’t informed now and there is no price point. How does a patient find a orthopedic surgeon right now? They blindly accept the recommendation of their GP. As such there is zero incentive to move incrementally from their position of absolute ignorance on what to “buy”.
        At the very least what I suggested encourages them to get off that zero bound on knowledge by creating a price point ie. I’ve only got $4k health dollars left this year, what surgeon can you recommend that is both good and can do it for that price? Inherent in your point is the base assumption that a $15k knee replacement is always better than a $4k one. I’d disagree on that point. Clearly being a market place you can always top up any shortfall you have, especially if they expire each year.
        Introducing some competition amongst service providers is the only way to ensure universal health coverage for all, otherwise this thing goes bust after becoming unfundable.

    • @Hoborg

      Actually, I think you will find that the public system is far more efficient in terms of cost than private health providers. This is actually one of the complaints of the private health insurance providers. The public systems run cross public/private clinics in which they get more funding from private arrangements, so they, arguably, point patients to private options. The issue is that the public system drive down costs on things like prosthesis and then charge the private health insurer at the private rates. This makes a windfall gain for public hospitals and gets right up the nose of the private insurers. Here is a report setting out some of these issues:

      Effectively, Private Health Insurers are arguing that the massive efficiency benefits from the public system need to be passed through to the private insurers or else the premiums need to keep going up.

    • Since when in history has “management incentives to minimise costs ” ever resulted in better outcomes for the consumers. Its there to incentivize the reduction of the company’s costs to increase profits. Thats it. Insurance companies dont give a flying rats ass about you or your problems. They just want to make money and they will go out of their way to extraordinary lengths to avoid paying you. Insurance company staff get bonuses if they can get you to settle quickly at what they want to pay you.Not what you think you should get.

      • “Since when in history has “management incentives to minimise costs ” ever resulted in better outcomes for the consumers”

        Well if you count access as a benefit to consumers ?!?!?

        Air travel used to be an expensive luxury. Now, not so much.

        You think the consumer has benefited there?

      • How is that the result of management incentives ? As opposed to say deregulation of a rent seeker industry to provide some competition. Exactly the same in telecommunications. So really thats the reason its cheaper. All management incentives do is result in cost cutting and make the service they provide shittier for the consumer.

    • “Actually, I think you will find that the public system is far more efficient in terms of cost than private health providers.”

      That’s not the sole measure of ‘efficiency’.

      Form a fiscal perspective, I reckon my background has more insight on the fiscal aspects that nearly everyone here.

      Private practice is churn and burn. Well developed, well rehearsed procedures enacted like a conveyor belt. it allows peoplpe to jump the queue, get procedures down at their desired time and allowances to pay for more rehabilitation.

      They all incur a premium, but much of the market is willing to pay. The doctors themselves say it’s about the money too.

      I know of many private practitioners who maintain a public presence to ensure they are kept up to scratch with research developments. Less money focus, less deadline driven and many administrators with their finger in the pie along the way.

      Many doctors are frustrated by the bureaucracy making many things less efficient. I know one highly skilled private practitioners about to leave the public system because of this.

    • You’ll find that the public health system is the ‘price maker’ in Australia, and they’re the one keeping the cost down. If it’s all left to the private insurers, the price will skill rocket like in the US, and they’ll just push up premium.

    • I actually agree with you Hoborg. The reason the public system keeps costs down is that people can’t access the medical or surgical care it provides.

      I also agree that “Australia needs to re-think its private health system”, as there are major problems with it. It has all changed now that 60% of the insured population is insured by shareholder-owned companies rather than not-for-profit mutuals. It is true that they are so complex and opaque that it stifles competition, as they are so difficult to compare.

      I don’t agree that the private health insurance rebate money would be better spent in the public system. Firstly because the extra money would only get half of the work done that it gets done in the private system (I can here the cries of “show me the evidence” already), and secondly because the subsidy gives the government power. Unfortunately the government does not wield this power, but they should. They should say “we are only going to subsidise simple policies that cover this, this, and this” and they should not rebate the policies with massive excesses or exclusions.

      True for the rising costs too. 20 years ago there might have been 100 over-70s for every 1000 members, and now there might be 200. There are other issues, but this is the main one.

    • That is not what the evidence shows. Private organisations can be bureaucratic and costly if they are able to pass their costs on as a result of a limited/dysfunctional market or poor regulatory oversight. The private health insurance companies add very limited value in terms of the delivery of national health objectives. You cannot create a market in health – read Kenneth J Arrow’s 1963 paper the conclusions which still hold today.

      Private companies can add value in other ways. The neoliberal nuttery permeates the LNP they want to sign the Trade in Services Agreement which would wreck our public services.

    • Hoborg, with all my respect, please read the works of Nobel prize winner J.Stieglitz to learn why the public health system is more efficient and should be public, not private. Not all goods and services are equal and tradable on the market by private companies. This is the first difference one has to learn in Public Finance (public economics). If you ignore those differences, the system does not work well, the private companies in this area are highly inefficient and the goods or services very expensive and lowering people’s well-being, not the other way.

  2. The private health insurance rebate was all about ensuring that those that could afford could jump waiting lists and receive a subsidy for doing so. Another of Howard’s election bribes.

  3. Beyond the price increase, there is also a huge problem in regard to what is being covered by your health insurance. The ‘basic cover’ is just a way to avoid pay the extra Medicare levy, and people are encouraged to go onto it since it’s a “junk insurance”. The rebate should only apply to full hospital cover.

    • It’s worse than that. In the 80’s when I first took out cover, my top cover and extras policy provided for (for example) 20-30 visits to a psychologist or months and months of inpatient psychiatric treatment in a private hospital, should that be necessary. Now the same top cover and extras policy would cover two visits to a psychologist and charge Yuuuuge excesses and daily co-payments for private hospital treatment. The policy is massively more expensive and the coverage is tremendously less.

    • +1. The govt. should be using they power that they have by providing the rebate to enforce this.

      Re. “full hospital cover” – I agree with this too – I’m not sure that the PHI rebate should be provided on extras cover. Yes it’s honourable to be insured for dental, optical, physio etc, but if there is not a direct payoff for the government (ie, avoiding public hospital costs instead) then I’m not sure the taxpayer should be subsidising it.

      They might as well also subsidise house, car & contents insurance – all sensible and honourable things to have, but not really the government’s role to subsidise.

  4. armchair economist

    What is misunderstood is that heathcare is not an industry … its a collection of separate industries all with a profit motive…the more links in the chain, the more ppl, the more intermediaries, the more expensive it will be… cant have a cheaper system by cutting pay to doctors, the nurses, the dentists, to pharma, to medical devices, to insurers, to IT companies, etc….if you want a cheap healthcare system it’s easy…..dont use modern technology, dont use new drugs dont train doctors and import them from the 3rd world on minimum pay and substitute nurses for family members, replace hospitals with just an open space where everything gets done…like good ol MASH, the television series!!!
    But no one wants that…so suck it up and pay for it, if you cant afford it too bad, there is no reason why someone else should pay for you!!!

  5. Does someone wish to join these dots and dashes?

    Longevity: Right now, the average life span increases by 3 months per year.
    Four years ago, the life span was 79 years, now it is 80 years.
    The increase itself is increasing and by 2036, there will be more than a one-year increase per year. So we all might live for a long, long time, probably way beyond 100.

    Diagnoses:‘Watson’ helps nurses diagnose cancer, 4 times more accurately than doctors.
    Facebook now has pattern recognition software that can recognize faces better than humans.
    In 15 years time. computers will have become ‘more intelligent’ than humans.

    Health: The Tricorder X price will be announced this year – a medical device (called the “Tricorder” from Star Trek) that works with your phone, which takes your retina scan, your blood sample and your breath.
    It then analyses 54 biomarkers that will identify nearly any diseases.
    It will be cheap, so in a few years, everyone on this planet will have access to world class, low cost, medicine.

    Employment : 70-80% of jobs will disappear in the next 20 years.
    There will be a lot of new jobs, but it is not clear that there will be enough new jobs in such a short time.

    • I hope it works out because at the moment the Australian medical system is geared towards maximising doctors visits, e.g. they get people to go to the doctor every 6 months for repeat prescriptions for cholesterol lowering drugs when even if the drugs are actually needed, the repeats don’t need to be reviewed any more often than once a year.

      And that’s assuming the cholesterol lowering drugs actually help anyone live longer in the first place which itself is often dubious.

  6. adelaide_economist

    It’s been clear that private health insurance in this country was headed for an epic fall for some time. It doesn’t take a genius to work out that sustained 5 to 10% per annum increases over decades (and that’s what we’re trending on) will force most people out sooner or later. Given low and falling wages, I’d suggest sooner more than later as well.

    All the ‘measures’ designed to keep it afloat, such as continuously freezing income levels for the medicare surcharge and increasing the rate the surcharge can only buy a little more time. I’m not against the concept of a parallel private health system but as with many things in Australia what we really have is a massive boondoggle set up to funnel profits to the select few under cover of it being about ‘a market system’ or ‘choice’.

    • armchair economist

      Thats what all businesses & industries do….straight out of highschool economics books…SELF INTEREST….who cares about the greater good? do you in your day job?

      • Actually people do and they are predisposed to support the ‘public good’. The current neoliberal nuttery treats everything a market and we are only dumb consumer drones is alien and imposed. Community based structures work better and deliver better outcomes (validated by a number of MIT studies into human behaviour). You can never have a market in health due to the supporting ‘social structures’ that will always be required. Pretending you can simply drives up non value add costs via pointless subsidies like in the US. It serves one purpose though which is the transfer public funds to the ‘mates’ of the LNP for delivering not a lot.

    • sustained 5 to 10% per annum increases over decades (and that’s what we’re trending on) will force most people out sooner or later

      If you can’t manage to keep up your health insurance until your old age, which is when you need it far more than when you’re younger, then paying for it is a complete failure.

  7. Geez the American system was ready to implode so they had to cram ACA through, as a back door bailout, which was written by the industry its self and now they don’t even like the damn thing…. all whilst health care cost sky rocket and health outcomes plummet.

    Disheveled Marsupial…. Hoborg aside from the imagined reality you might consider that EMH is not a description of reality…. insurance and health providers constantly screw each other over profit and market share and their customers…

  8. I cancelled my coverage. After two hospitalisations in one year and my little boy breaking his leg badly. I found my top private cover to be essentially useless.

    The best we got was $25 back out of a $100 weekly physio bill for my boy. For that I paid $380pm. Trips to dentist for both kids about the same, Annual bills around $500, and rebate bugger all.

    I prefer to self insure.

    Even with the high income earner medicare hit, I would still be better off without it and I would rather support the public system.

    • armchair economist

      yeh for minor stuff you can comfortably self insure..afterall paying 3-4000 for theatre, 4-5 nurses, a surgeon, an anaesthetist, all the emergency drugs & equipment that must be available and maintained in case something goes wrong, etc….is a bargain….what do you suppose 3-4000 buys you in legal services?
      Remember you insure against large expenses (cardiac, joints, major neuro, major bowl, thoracics) not for rubbish like kids dentistry and a minor op or two here and there

    • I wouldn’t say it’s useless. My wife underwent a minor but necessary surgery recently, had to pay $500 in excess, but the cost of operation and the room would have cost far, far more than premium for a few years. That is what you’re really insuring for, not the rebate for minor things.

  9. It’s not as if private health insurance buys patients extra quality and safety.

    None of this would matter if the government did not force people, on pain of tax fines, to take out private health insurance. This force was set up by a so-called “Liberal” party, supposedly a freedom-loving party. “Freedom-loving”, what a sick joke from a party of psychopaths.

  10. It’s great that this is finally getting some air.

    We already have a two tier system with private “insurers” dictating who gets attention and by which providers. Those who rely wholly on the public system get shoved to the back of the queue.

    Private “insurers” who exist solely to make a profit are definitely pushing the Australian system (if you can call it that) towards an American way of providing health care and making it more expensive.
    I think Leith is right.
    Let’s start a mature conversation.

    • armchair economist

      Free market healthcare is the way to go….why should those who work in healthcare be denied access to a free market for their services and labour? what you are all complaining about here is that we dont have healthcare slaves who can be forced to deliver healthcare for which we can pay as little as we would like….sorry..folks…thats not the way it works!!!

  11. FiftiesFibroShack

    “…crony capitalism is driven by a grand coalition between the pragmatic centre-left and the pragmatic centre-right. Crony capitalist policies are always justified as the pragmatic solution. The range of policy options is narrowed down to a pragmatic compromise that maximises the rent that can be extracted by special interests. Instead of the government providing essential services such as healthcare and law and order, we get oligopolistic private healthcare and privatised prisons. Instead of a vibrant and competitive private sector with free entry and exit of firms we get heavily regulated and licensed industries, too-big-to-fail banks and corporate bailouts.”

  12. @FiftiesFibroShack

    “competitive private sector with free entry and exit of firms we get heavily regulated and licensed industries”

    Firstly there is no such animal as a free market or that markets self regulate, now if you think currant regulations sux… ask the people that wrote them where they got their perspective from and if said industries had anything to do with writing them.

    Disheveled Marsupial…. neoliberalism…. the best governance money can buy….

  13. I am a Doctor in the public system (Emergency medicine) and here is my 5c worth. Apologies for the length.

    From a financial perspective there is a very poor fit between the absolute inevitability that someone will need health services in their lifetime and the risk based insurance model that is being used to address it. Insurance only works if the risk insured is relatively uncommon i.e. will materialise for only a minority of the pool of insureds. Once you try to insure for a ‘risk’ that is likely to materialise for the vast bulk of your insured population you are really just running a prepaid coupon scheme where your profits come from the few customers who couldn’t be bothered to redeem their coupon (q.v. the prepaid gift card industry). Now, it is perfectly understandable that people could not be arsed to go down to a crowded shopping centre on a Sunday to try to find some way to spend the odd $7.24 left on a gift card (we have all done it), but when you break a bone or need to have a baby etc you are not really going to sit there and say “it is too much hassle I will just stay home”. Yes, people do that for niggling health things they should see the GP for, but not for the stuff that private health insurance is meant to cover.

    We need to cut out the insurance model (and industry) from the equation or at least dump the legislated compulsion to buy insurance. Having it as an optional thing is fine, and I would advocate completely deregulating pricing (but not disclosure / consumer law requirements) and let the market establish a price that is responsive to demand for the product (the current version of which IMHO is a piece of shit and would be priced down accordingly were it optional to buy it).

    The private hospital sector should be allowed to tender to the public system for selected defined services that would be demonstrably required to be performed urgently / non electively in the public system in any event if not done elsewhere and be paid for those from public revenue. This will mean increasing the medicare levy and there is just no getting around that. I would refer to these as ‘replaceable public services’. Waiting lists established in the public system would be used to allow this to occur and with appropriate technology (hopefully not designed by the baboons who make the other applications that we are forced to use in the public system), tendering could be requested on a case by case basis by bed managers / patient flow units in the public hospitals in real time. All geographically relevant private providers (say within 50KM) would be allowed to bid and transfers could be made direct from public emergency departments and wards. This goes on a little bit now, but is slow and sporadic. It needs to be case by case, in real time and properly systematized with a Wotif / ebay type approach and dimension.

    If the private hospital wanted to offer purely non clinically related extras (flowers in the room, or a single room, or Wifi or gourmet meanls etc etc) for a charge and make extra profits in the way airlines / petrol stations / cinemas and other service industries do on those things, that would be fine. There would need to be strict rules about no charging for extra clinical care e.g. stronger painkillers etc etc, but these could be easily worked out.

    Now obviously a patient who is getting CPR in an ED on a Sunday night is not going to be tendered out, but a young fit male with an appendix due to come out the next day who is stable and sitting in an ED bed at 700pm on a Sunday and who will be there until he gets his op about 19 hours later would be a prime candidate to go to a private facility, if there were a free bed and a space on an OT list. If the private facility was not interested, or a price could not be agreed then he would stay in the public system (as he does now) and the private facility could go without the extra revenue.

    If the private hospital sector wanted to do other non essential stuff e.g. cosmetic surgery, they could negotiate with consumers and work out a price. If a private health insurance industry could figure out a way to offer value to consumers for these types of services (without telling lies about what their products cover) then they could be allowed to find a market, so long as this were purely voluntary. If the private hospital sector didn’t want to bid for any ‘replaceable public services’ and could survive on liposuction etc alone, then that would be fine also.

    • “Insurance only works if the risk insured is relatively uncommon i.e. will materialise for only a minority of the pool of insureds. Once you try to insure for a ‘risk’ that is likely to materialise for the vast bulk of your insured population you are really just running a prepaid coupon scheme where your profits come from the few customers who couldn’t be bothered to redeem their coupon”

      Excellent point. I guess the risk is likely to materialise in a similar way to the risk of getting old and retiring, hence everyone needing superannuation.

      So why can’t people instead choose to put their money into a savings scheme? Perhaps a savings scheme/fund where dividends/interest is tax free, and withdrawals can only be made for medical purposes. People could choose to use that fund for medical/dental/optical as they see fit, or use it to pay for family members medical expenses. This of course would be on top of the public system.

      The insurance model seems ridiculous, what other insurance:
      – is heavily subsidised by the government, and punishes those who do not partake in it? house insurance? car insurance?
      – puts all the financial risk on policy holder? At least with car insurance you know what you will be out of pocket.

      And the sales pitches are bogus.

      – “You can choose your own doctor!” How does one do that? Conduct interviews? What criteria should one use to determine a good doctor?
      – “You get your own room!” Only if one is available, otherwise you’re stuck with everyone else on the public system except you end up with large bills from your insurer.

      There doesn’t seem to be a lot of benefit to health insurance, only risk.

      If insurance is such a good model, let’s go free market where there is no coercion from the government. The young and healthy will opt-out and the old and sick will be the only ones who buy, pushing prices to the point where you might as well pay for everything out of your own pocket.

      • you might as well pay for everything out of your own pocket

        That is the objective I think. “Look, it’s broken. What a shame. Oh well you can’t deny we tried”

    • “Insurance only works if the risk insured is relatively uncommon i.e. will materialise for only a minority of the pool of insureds. Once you try to insure for a ‘risk’ that is likely to materialise for the vast bulk of your insured population you are really just running a prepaid coupon scheme where your profits come from the few customers who couldn’t be bothered to redeem their coupon”

      This is a good point, and it is one of my problems with “extras” cover.

      I have hospital cover only, and I hope that I never need to use it. The same way that I hope that I never need to use my car insurance, house insurance, or income protection insurance. I hope that what I pay each year is dead money never to be redeemed.

      However, how many times do you hear “I’ve been paying into it for years, it’s about time I get something back from it” with health insurance. The population’s attitude is also that it is like a pre-paid coupon.

      I think that extras cover has a lot to blame for this. People love extras cover because they “get something back” from it, even though if you do the sums you really have to “max out” at least two of the categories (for example, dental and physio) each and every year to actually “be ahead”. Not many people actually do this, and even if they do they’re not “up” by much. Not like the $100,000 that the insurers rebate for a multiple level spine fusion. The insurers make heaps of money from extras cover because of this weird double-think that the population has.

      I think that extras cover should not be subsidised – partly because there is no direct government saving by subsidising it (ie removing patients from the government hospital system), and partly because lumping it in with hospital cover perpetuates the pre-paid coupon attitude.