Vision for Australia's Health. Transcript of journalist questions to AMA President Dr Omar Khorshid at National Press Club

9 Jun 2021

DAVID CROWE: Thank you very much, Dr Khorshid. There was plenty there in that speech. We'll go to questions in a moment. In fact, I'm going to skip a question, so whoever wants to, get ready to ask. But I am going to say something before we go to questions, which is an oversight on my part. At the very beginning, I forgot to mention some of the people that we've got in the audience including the Chief Medical Officer, Professor Paul Kelly, the Deputy Chief Medical Officer, Dr Michael Kidd. We've also got the vice president of the AMA, Chris Moy. Thank you for being here. And thank you to other medical experts I can see in the audience that I won't name because I don't want to miss anybody out. But there's never been a time when it's been so important to have medical commentary on what Australia and the world is going through, and I thank every medical expert who's in the room today.

And after that, I will now go to our first question, which is from Paul Karp of Guardian Australia.

QUESTION: Paul Karp from Guardian Australia. Thanks very much for your speech. Yesterday Greg Hunt put out a joint statement with the AMA about future consultation on Medicare Benefit Schedule changes. Does this address your concerns about the current round of changes to start on 1 July? And what do you make of Labor's claims about out-of-pocket cost hikes in recent days? Have the seeds been planted for a Mediscare-style campaign?

OMAR KHORSHID: Thanks, Paul. I certainly hope we're not going see a Mediscare campaign. The sad reality of Medicare is that successive governments over the entire life of Medicare have failed to index it properly and have therefore effectively cut Medicare for 30 years. Now this review that the AMA has supported was designed at modernising the MBS, and it has taken five years to do. We have a few quibbles and issues with how it was done, but at the end of the day, the AMA is supportive of the review process and of most of the outcomes.

 What we were not happy with was the process of implementation - something that we had brought up repeatedly with government, to make sure that both patients, doctors, and of course, our health insurers as well have the information they need so when a patient sits with a doctor to book an operation, that they know what the rebate will be, what the doctor's fee will be, and that is not the reality right now because of the speed with which these changes have come in since they were announced. So that message has been heard by government, and the agreement with the Minister was that for future rounds, there will be more time given so that every patient is ensured a full, informed financial consent. And also and very importantly, the Minister has agreed to a rapid process for us to review some of the oversights and errors or unintended consequences that are there buried within the review recommendations.

QUESTION: So you think there will be changes to the current round mopped up through that review process?

OMAR KHORSHID: There are certainly issues that our profession has with numbers in orthopaedics and cardiology that have what we believe are unintended consequences. They have been already pointed out to the Health Department, and we look forward to resolving those in coming weeks and months.

DAVID CROWE: Thank you. Okay, our next question is from Krishani Dhanji from SBS.

QUESTION: Krishani Dhanji, SBS World News. Dr Khorshid, last week Prime Minister Scott Morrison announced Lieutenant General Frewen would lead a new COVID vaccination task force. He follows Commodore Eric Young's appointment as head of the Vaccine Operation Centre. What does this change with the involvement of the military mean for the rollout? What impact could this have? And do you think it should have been done earlier?

OMAR KHORSHID: Thank you for that question. I think the appointment of these senior military leaders to critical positions in the vaccine rollout is a sign of the Government's need to make sure we are doing everything we can to make the rollout smooth, to make it efficient, to get the vaccine into the arms of Australians. There's no point having it in warehouses around our cities. It needs to get out into the community, and there's a huge logistic task around doing that. So I think it's a recognition of where we've been and where we need to go. I think the military are probably a lot better at logistics than the Health Department is, and that assistance, I'm sure, is being gratefully received.

DAVID CROWE: Thank you. Our next question is from Greg Brown of The Australian.

QUESTION: Greg Brown from The Australian. I just wanted your view on the Victorian Government's handling of the latest COVID outbreak. regional Victoria had a week of a hard lockdown without any new cases. Melbourne had two weeks of a hard lockdown. And after only one new case today, there are still pretty heavy restrictions on people. No visitors, no gyms. Melbourne and regional Victoria are divided. Do you think the response in this particular outbreak was proportionate or draconian?

OMAR KHORSHID: We are learning along the way with this pandemic. And what Victoria has seen is our first significant outbreak of the Kappa variant and, of course, now the Delta variant - things that we haven't seen in Australia before - and they have to take precautionary measures. Having watched what was happening overseas, having learnt from that, they have to do what they have to do to protect Victorians and, of course, the rest of the country as well.

So the AMA has been supportive of the actions of the Victorian Government. I think the public expects to be kept safe, and this is what is necessary to be kept safe when we're in an evolving situation. Now, of course, as information comes in, things become clearer, decisions become easier to make. And I think the best thing for us all to do is support the advice that's been given by the chief health officers around the country. They're doing their best to protect us all. And what every Australian can do, what they have in their own power, is to go and get vaccinated. That is the thing that will- if you don't like lockdowns, go and get vaccinated. If you don't like border closures, go and get vaccinated. If you want to travel internationally, go and get vaccinated.

DAVID CROWE: Our next question is from Andrew Tillett.

QUESTION: Andrew Tillett from the Financial Review and also board member here at the Press Club. You mentioned obviously private health insurance during your speech, and the need for some reforms there. We saw in the Budget the Government announced that they were going to do a review of the Medicare levy surcharge. I guess the issue there has been the fact that it's cheaper to pay the tax than actually to get an insurance policy so you've sort of got a perverse incentive sort of thing there to take out health insurance. And the other part they said they were going to review is the private health insurance rebate, which was once was 30 per cent but I think is down to twenty-something or other. What exactly is the AMA's stance on those issues? Have we got to look at the whole system of carrots and sticks for it? And you talk about providing value for private health insurance. Does part of that include looking at the sort of the current ban on private health insurers paying for GP services and specialist consultations and things like that? Has that got to be part of the mix as well?

OMAR KHORSHID: Complex question, Andrew. I'll answer the first part first, which is really around the AMA's prescription for private health insurance. We've analysed all of those carrots and sticks, and we do agree that change is needed. They've been quite effective in the past. We've seen our health insurance rates really go up in Australia when some of those measures were brought in under successive governments. But they've been left alone for too long, and as you mentioned, the rebate has gone down over time since it's been linked to income. So, we need to look at everything, and the take home message is to make the insurance product attractive and sustainable, particularly for young people. If young people don't perceive value, then they're not going to take out the product. And the way it's structured, we rely on the premiums of young people to help support the health care needs of older people. That's the best thing and worst thing about our private health insurance model. But it's here to stay. It's one that Australians and the AMA fully support. And we just need to look at all of those things: the Medicare levy surcharge, where it kicks in, the lifetime health cover penalties and when they kick in, how big they are, as well as the rebate itself and its spot.

Now, when we talk about broader issues, yes, we do need further reform, and you suggested one potential reform, but there's a whole lot of options that are available to us in changing our private health system. But one thing I think we need to really stick with is this mix. We are almost unique in the world with our mix of private and public in our hospital sector. And if we can keep that, that will be great, but in order to make both those systems sustainable, we've actually got to do those investments that I mentioned before in prevention. We've got to invest in primary care because otherwise both the health insurance and the public hospitals will become unaffordable for Australia.

QUESTION: Thank you.

DAVID CROWE: Thank you. The next question is from Rachel Clun from the Sydney Morning Herald and The Age.

QUESTION: Thanks. Rachel Clun from The Age and the Sydney Morning Herald. You've outlined a large number of reforms you'd like to see to the health system and you've also said that governments in the past have been quite unwilling to make some really big changes. We've got an election looming either the end of this year or early next year. So what sort of things will you be pushing for? Will it be things like the sugar tax that you've mentioned and how willing do you think either side of the political spectrum are to make some of these really big changes?

OMAR KHORSHID: Unfortunately, the reality of our political system is that if you take a big reform agenda to an election, you don't tend to win. So we're well aware of that, as are political parties. And we need to be careful how much we make major reform an election issue rather than something that has to be done for the Australians. So we'd like, if possible, to keep some of the politics out of it, for the industry to come up with solutions and take them to government. And hopefully, that will help there. In respect to the AMA's position for an upcoming election, we will be outlining the areas where we think change is needed, where spending is needed. And they are around primary care, around prevention, around hospitals. But we would like also to be able to have this longer term conversation about health reform around the five pillars that we've set up here with the principles that we mentioned in the paper, because if we can do that as a society, we will actually have a chance of having a health system still delivering the quality of health care we have now in 20 years' time. If we don't do something, we're not going to be able to afford the health care that we all take for granted right now.

QUESTION: What about things like the sugar tax? Would you like to see that brought in before an election or as part of that?

OMAR KHORSHID: The sugar tax has been thought about for a number of years in Australia, and both political parties haven't taken it on board so far. We've now put together an economic argument, so it's not just the AMA saying this is what you need to do for health but here's the economic realities of this sort of tax. And we'll be taking it to anybody who will listen. And if one of the parties would like to pick it up for their election platform, we'd be very pleased to support them.

DAVID CROWE: Can I ask a follow-up on the sugar tax. What's your sense of whether the Australian community is ready for that yet or how much work is going to be needed to be done to make that acceptable? Your mention of it raises for me a question about whether you think taxes on alcohol and tobacco are adequate at the moment or whether they should be increased as well? How far do you think tax can go and how big does the tax need to be achieve the public health outcome?

OMAR KHORSHID: In the sugar paper, we propose actually a pretty modest tax. It's nothing like the level of taxation that is present on tobacco products, and it's really a signal. A signal to the society from government to say this product is actually not helpful. This product has no nutritional value. This product is harming your health and the health of others in the community. So let's drive a change in society. And in fact, we know we can drive a change within industry. We're already seeing reformulation of sugary drink products in Australia and overseas as a result of community needs.

We also know a sugar tax is popular within the community. There have been surveys showing the community does support the concept. And similarly, overseas experience has shown that sugar taxes reduce consumption of these sugary drinks, which are at the very far end of harm versus no benefit. The other issue, I think, is around the sugar industry, and that's an issue that's been brought up in the past. And our analysis shows that the impact on the sugar industry will be tiny. We're talking about 5 per cent of domestic production being in sugary drinks. And if you look at a modelled reduction in consumption, less than 1 per cent of production, it will have a zero impact on the farmers, sugarcane farmers, and that's not a reason to take on this policy going forward.

Just on alcohol and other things, tobacco has shown us it's not just tax, it's actually a broad range of initiatives that you need to improve health and change people's behaviours. Tax is part of it, but so are campaigns, so are rules and regulations around where you can and can't use those products. Tobacco took decades to do, but we've done well. We haven't finished the job. There's still 11 per cent of Australians who are smoking. On alcohol, the AMA is supportive of either increased volumetric taxes on alcohol or a floor price, because we recognise that a lot of the harm of alcohol is actually caused at the very bottom of the price pyramid of alcohol, where the quantity of alcohol you get for the lowest price is at most risk of harming people. And either of those policy decision, if you went down either path, we would see a reduction of harmful alcohol consumption in our community.

DAVID CROWE: Our next question is from Lanai Scarr from The West Australian.

QUESTION: Lanai Scarr from The West Australian. Thank you so much for your address. From Thursday, WA will open its vaccines to over 30s. Should other states and territories be looking to do that? And what are your thoughts around the level of vaccine hesitancy still in the community? How do we combat that? Would one way be opening up vaccines to anyone who wants to get it so that we do have a higher rate of people being vaccinated in Australia?

OMAR KHORSHID: Thanks for the question, Lanai. It is a complex area, because we have this constraint on supply. And right from the start, our experts, the ATAGI committee, and our National Cabinet agreed to priorities for the vaccine rollout, focusing the rollout on those at highest risk of contracting COVID, or those at highest risk of harm if they get COVID. So your front-line workers, people living in residential aged care, disability care, et cetera. Now that job is not yet done. We still have significantly number of elderly Australians in residential aged care who are not vaccinated. We still have enormous numbers of aged care workers who are not vaccinated. And a lot of Australians over the age of 70 who are not yet vaccinated. So that has to be our priority group if we are to limit the impact any outbreak of COVID in the community. Now to your question around if we open it up, will it improve public confidence? It probably will, and I think that's the decision that WA government have taken apparently on their own in the last couple of days, and it'll be interesting to see what the impact is in Western Australia. But our call is for all states and governments to finish their high priority people, because they are those at most risk. They must be our priority. Those between the ages of 30 and 39 are not a high risk group, and if we did get an outbreak in Australia the chance of someone in that group ending up in hospital, on a ventilator with COVID is actually very low.

DAVID CROWE: There are estimates that in order to protect the population, we're going to need a vaccination- or to get more than 80% of the population vaccinated. Do you see that as a realistic target? And do you think that in order for the community to benefit as a whole, that vaccination is going to have to be mandatory, compulsory, for many people in the community, depending on perhaps their work?

OMAR KHORSHID: We don't know enough about the vaccines, enough about the various types, variants of this virus, to know what proportion of the population needs to be vaccinated with which vaccine to achieve true herd immunity. But that's not really the aim here. The aim here is to protect Australians from ending up in hospital with COVID. That's been very clearly enunciated by the Chief Health Officer, by our governments around the country. And that should be, still, our primary aim.

DAVID CROWE: Thanks. Our next question is from Cameron Gooley of the ABC.

QUESTION: Cameron Gooley, ABC News. Thank you for your speech. I just have two questions for you. The first one's regarding- we've seen a couple in quarantine in Queensland unable to see their newborn child physically for about a week while they've undergone quarantine. Understanding the difficulties with letting people in quarantine into a neonatal ICU ward, this couple had been fully vaccinated and they had both tested negative to COVID-19. Do situations like this show a need for a discussion over whether fully vaccinated Australians should be able to have separate quarantine arrangements to other people coming back into the country? And just on your comments about Aboriginal and Torres Strait Islander health professionals and the lack- well, the low number of them, we actually have in the sector, what can we do to make sure that the health sector is both culturally safe and welcoming of First Nations staff?

OMAR KHORSHID: Thank you. So, on the first question, the AMA is certainly supportive and I am supportive of there being a tangible benefit for Australians who have been vaccinated. That's been a difficult thing for our Chief Health Officers to discuss because they haven't been absolutely certain as to how much vaccination reduces transmission but it's a lot. They are very effective with the variants that we know of, and I think for some Australians who are hesitant, who are not sure or who are just waiting, having a direct benefit such as greater freedoms, whether it be to travel, whether it be crossing state borders, whether it be, as you described, a different quarantine arrangement, those are things that should be considered by our government as we go forward in this pandemic and as more and more of our population are vaccinated.

We need to be a little bit careful we don't provide freedoms to people who have had access to vaccine, that are not available to those who haven't yet had access. So there's an equity issue there. But I think at the heart, there is a significant conversation needed about what a vaccinated population means. Where we should take that further, though, is what does the health system look like once we're fully vaccinated? Once we open international borders. And that goes back to some of our pillars. Because although we may have a vaccinated population, the moment those borders go down, and people start travelling, we're going to get not just COVID coming into Australia, which we have to learn how to manage, but also influenza again. And when you've got public hospitals that are bursting at the seams with ambulance ramping, it's hard to see how there's any capacity to deal with the surge that we know happens, normally, every winter. We haven't been getting them at the moment because we're not travelling. We're reasonably well vaccinated against the flu, but probably not this year as much as last year. And we are sitting ducks for, not just COVID, but for the flu when those borders open. So that's a broader conversation that we'd like to see happening very openly in society.

On your second question, the AMA is committed to improving cultural safety for Aboriginal and Torres Strait Islander people who go into hospitals. That includes our own profession. So I am pleased to say that the AMA's Federal council is actually due to spend a whole day doing the Australian Indigenous Doctor's Association's cultural safety program, that's schedule for later this year, COVID willing. Because it is- it does have to be a face-to-face commitment. And that has been tricky due to COVID restrictions. And we're looking to support rolling out that kind of program right across the medical profession in coming week, months and years.

                                                

DAVID CROWE: Thanks. Our next question is from Simon Grose.

QUESTION: Simon Grose, Canberra IQ. Excuse me. Health insurance regulation. You put out a press release a couple of weeks ago having a go at the ACCC about their draft decision about Honeysuckle and NIB forming a buying group and calling for a new regulator of health insurance. What's the detail of your complaint about the Honeysuckle-NIB arrangement? And when it comes to regulation, is it sensible to bring in- to create a new regulator or could you just change the remit for the ACCC?

OMAR KHORSHID: Thanks for that. So, Honeysuckle Health, for those who don't know, and NIB have put in a request for authorisation by the ACCC to create a buying group for the purposes of procuring services for their members and for the- potentially for the members of other health funds. This is health funds coming together. And the ACCC in its draft determination has pointed to some potential competition issues there. The issues the doctors are concerned about and the issues that, in fact, multiple medical groups, almost all of the medical groups, wrote to the ACCC about, is the potential for Honeysuckle, through its collaboration with an American-managed care organisation, to apply those managed care principles to the contracts that it uses to procure services here in Australia. Now we hear from NIB that they're not going to do that. But that's not enough nor us. We want to see much more concrete barriers against managed care so that the best bits of our private health system are preserved. And one of which is the independence of the patient and the doctor at the core of all the decision making. Now, we recognise that we need to- we need some change to make our system more sustainable, but this is not the way to take it. There are other options and we'd like to continue that conversation. We have already started it. But continue that conversation with insurers and hospitals and other players in the market, so we've got an attractive private health insurance product going forward.

In terms of the regulator, there's a whole series of issues around private health care that are not currently specifically regulated. Some are under the Department of Health, obviously ACCC is involved in the competition aspects. And we've got a prudential regulator looking at the insurance aspects. What there isn't, in our view, is enough looking at the health outcomes, the quality, the impacts on patients and on our industry. There's a whole series of tasks that are done at the moment by various groups, by government, and others, and these can be all brought together and certainly that's our view. And if you have a regulator, it allows the government of the day to decide what our health system looks like. Is it reasonable to have an insurer own a hospital, employing the doctors and it's all packaged into one like you might see in some parts of the world, or do we like a system where you've got independent players making independent decisions? It does reduce control, but it's delivered us one of the best health care systems in the world.

QUESTION: Thank you.

DAVID CROWE: Thanks. The next question is from Nic Stuart of the Canberra Times.

QUESTION: [Talks over] Thanks for a specific speech. As a Canberran I heard five brilliant policy pillars. As a tabloid journalist, however, I only heard the words sugar tax. And as a result of that immediately being politically attuned I began bargaining with myself. 20%? Does he really mean- would he accept 5%? And what is the answer? I mean, obviously we need it. We need it urgently. Should it be 20%? Is that an ambit claim? Do we say 5%? What's the break-even point here?

OMAR KHORSHID: So, that's the whole point of the paper if you get a chance to read it fully you'll see the justifications there. It looks at the international experience and it looks at the economics of the cycle of production from the sugar cane farm through to the consumer. What we're talking about is a 40 cent tax per 100 grams of sugar. It's not actually fixed at 20% but that turns into around about 20% at a supermarket retailer. Now, the reality overseas has been not all of that increase in price has been passed on to consumers. It gets diluted a bit by the retailers and by the manufacturers, the wholesalers. But if we look at the UK, if we look at Mexico, if we look at other places that have done this, we believe this rate of 40 cents per hundred grams or about 20% is a pretty good spot to be aiming at. It's not enough to put sugar drinks out of the reach of Australian consumers, nowhere near, but it's enough to send the signal and start to change behaviour. Because it's not just around sugary drinks where we need to change behaviour - it's sugar full stop. It's carbohydrates, full stop. For which there is an emerging body of evidence that in fact our struggles with diabetes, our skyrocketing levels of diabetes, which then causes all sorts of other health problems, are largely due to our excessive consumption of sugar and other simple carbohydrates. And we need to start changing that trajectory right now.

DAVID CROWE: You're not going to try and tax chocolate, too, are you?

                                                [Laughter]

OMAR KHORSHID: Only those drinks with absolutely no nutritional value. There is a lot of nutritional value in chocolate.

                                                [Laughter]

DAVID CROWE: Our next question is from Astrid Watts from the University of Canberra Press Club.

QUESTION: Hi there. My question - I actually have two questions as well. My first question is due to the mass increase of demand for mental health supports, and, of course the increased rate of suicide due to COVID, how do you feel the AMA could work with state and federal governments to increase facilities and funding to reduce the mental health impact of social isolation?

                                                

OMAR KHORSHID: Yeah, a really important question and it's one that's close to the AMA's heart, and one that we advocate on all the time. In this policy document we're making the clear view that mental health is not separate. It's not a siloed thing that's over there. It's actually part of every Australian's experience and it's extremely common in our community, even without COVID. The starting point for all health care is in general practice, and that's where we believe investment needs to be made to up skill GPs to give them the time, the resources they need, the coordination they need, to help their patients navigate their mental health journey. They can procure resources, they can be the gatekeeper and the navigator for their patient in our complex system. What we don't want to see is separate silos and the danger of the Government's very welcome over $2 billion investment in mental health in the budget is that it becomes another silo. And we're really keen to work with government to ensure that doesn't happen. That any new service that is created is integrated in a general practice and it's also integrated on the other end with our acute mental health system, with our hospitals and so on. And talking about hospitals, that's another place where mental health crises are occurring. We don't prevent illness the way we want. We have issues in our hospitals right now today in EDs all around the country and mental health is a huge part of the pressure that is experienced in our emergency departments. So we do also need investment in those large hospitals unfortunately, in order to deal with the acute mental health needs of people who've, I guess, where our system has failed and they've gotten right to the very pointy end which can result in serious health outcomes.

QUESTION:  Sure. Okay my second question is about the addressing of diabetes in the media. One thing I have noticed is that they never clarify the difference between type 1 and type 2. This actually creates a very unfair stigma to type 1s because they actually can't fix their diabetes with diet or reduction of sugar tax. How do you feel the AMA could use their power to influence the media a bit more, as a member of the media I try to do it all the time, but to clarify the actual difference?

OMAR KHORSHID:  That's actually a really good point you've made there, and perhaps we need a new word. The danger, though, about I guess labelling type 2 diabetes, or what we've traditionally called type 2 diabetes as a lifestyle disease too much is that you then stigmatise that condition as well. And what we're really about is helping Australians make healthy decisions through public policy initiatives. So the sugar tax is one, there are other things that we can do through our society to assist in making- helping Australians to make good decisions, which will have the impact of changing culture, changing people's usual behaviours when they come to what foods they're choosing. And there are specific things that we can do to make sure, for instance, in remote communities that we actually provide access, access that we all take for granted, to fresh fruit and vegetables, to healthy foods, to make it the easy thing to do and the cheap thing to do, rather than to reach for convenience foods which unfortunately underpin the horrific rates of type 2 diabetes in our remote communities.

QUESTION: Thank you very much.

DAVID CROWE: And we have a last question from Greg Brown.

QUESTION: I saw today you backed a vaccine certificate, but the more substantive vaccine passport has come up against a lot of opposition. What is your message to state and territory leaders who have rejected the notion of a vaccine passport, and is there any medical reason why fully vaccinated people should not be given exemptions from restrictions and border closures during breakouts?

OMAR KHORSHID: So, on your first question, we are certainly supportive of Australians being able to demonstrate their vaccination status. That is going to be required in our future. We're not entirely sure how and when, just yet, but for you to get on an international flight, it's pretty hard to imagine you'll be able to do that without being able to demonstrate your status. So the information is available right now on the Australian Immunisation Register, it's linked to your My Health record, and it's easy to create a specific app that allows access to that and we'd certainly encourage governments to do that, and then encourage state governments to use that information in whatever ways they're going to be setting up their societies post COVID, or once we're actually fully vaccinated. The second question, I've forgotten?

QUESTION:  Well, it's this idea, I suppose, there's opposition to a vaccine passport, and is there any medical reason why people with these vaccine certificates should not be exempt from a state border closure or restrictions?

OMAR KHORSHID: So there are some concerns around the potential that you can be vaccinated and still contract COVID and that's been shown with a number of the variants. In fact, we have some cases in Victoria right now in people who have contracted COVID who have been vaccinated. However, these people to my knowledge have not gotten sick. What we don't know is can they transmit it to someone else? So if you travel to another state and catch the virus, despite you being vaccinated there is that chance you could still bring it back to your state and that's, I think, what state and territory leaders are grappling with at the moment. However, our view is that in Australia right now, with our very limited outbreaks, the chances of you even being exposed, let alone actually contracting it and bringing it back, if you are vaccinated, are extremely small, and we believe it is a positive policy direction that all states and territories should be considering at this stage, to help Australians make that important decision to get themselves vaccinated.

DAVID CROWE:  Thank you, and on that note, ladies and gentlemen, let's conclude. Please thank Dr Omar Khorshid.

                                                [Applause]

Thank you for being here and for your speech and taking questions and answers. I'd like to present you with gold membership of the National Press Club. Please come back often. Thank you.