No more shortcuts to budget surplus

Maybe we're getting somewhere. The nation's almost unanimous rejection of the proposed Medicare co-payment has proved to be a blessing. It's obliged the replacement Health Minister, Sussan Ley, to go back to basics and find genuine savings.

It won't be long before we find out what effect the failure of last year's budget has had on this year's. Judging by most accounts, it won't a favourable one.

Badly burnt by the monumental misjudgments in his first attempt, Tony Abbott seems to have swung to the opposite extreme of doing little or nothing to tackle our medium-term budget deficit problem.

But Ley's more positive response – initiating a review of the Medicare benefits schedule, a review of primary health care, a focus on Medicare compliance and a tougher renegotiation of the government's contract with the chemists' union – is a more hopeful sign.

The nationwide rejection of last year's budget is a seminal event, not just in the potentially brief life of the Abbott government, but in the history of budget-making. The present generation of politicians will be making judgments and drawing conclusions that will affect their behaviour for years to come.

But there's just as much cause for the econocrats, economists and business lobby groups to be learning from this historic stuff-up.

The rule that bureaucrats' advice to their political masters remains confidential means we can never know how much that advice contributed to the budget's failure. It's possible all the dumb ideas and misjudgments came from the pollies and their private-office advisers – not forgetting the totally over-the-top advice from a commission of audit subcontracted to the Business Council – but I find it hard to believe the econocrats contributed nothing to the disaster.

With Abbott copying John Howard in making his first act the sacking of a range of department heads "to encourage the others", it's possible the econocrats' advice wasn't as fearless as it should have been.

If so, let's hope Coalition politicians have learnt their lesson. If you frighten the econocrats to the point where they say Yes, Minister then stand well back while you do yourself an injury, your bullyboy tactics have robbed you of the protection the public servants could have provided.

But I suspect part of the problem is that year upon year of departmental staff cuts perversely known as "efficiency dividends" have, in fact, rendered the public service less efficient by robbing it of the expertise needed to propose sensible, targeted, efficiency-enhancing cost savings.

Finance and Treasury no longer have the ability to identify those areas in a particular portfolio where savings could be made without loss of quality or unintended consequences, and nor does the department itself.

If so, governments and their advisers have got themselves into a vicious circle: successive efficiency dividends have removed their ability to come up with well-considered savings, so they're compelled to fall back on another round of efficiency-sapping efficiency dividends.

The most obvious lesson – one to be learnt not just by politicians but by all those who care about fiscal responsibility – is that if you manage to con the pollies into proposing blatantly unfair "reforms" you run a high risk of actually setting back the cause of reform.

If, for instance, you tell the punters a Medicare co-payment is unavoidable because health spending is growing "unsustainably", while forgetting to mention that you're paying too much for generic drugs and chemists' dispensing, as well as paying for medical procedures that are known not to work.

A corollary is that slugging the punters so as to avoid fights with powerful drug companies, chemists' unions and doctors' unions is dumb politics.

The less obvious lesson is that the 2014 budget failed partly because the savings measures it proposed were such poor quality. So primitive, short-sighted and otherwise ill-considered. They were kneejerk cuts to which little thought had been given or expertise applied.

Don't try to reduce the element of waste and rent-seeking in health spending, just shift some of the cost onto patients, rich and poor alike, using some pseudo-economic excuse about the need for a "price signal".

Don't ask how many of the patients you deter from visiting doctors should have sought early advice or whether they'll end up costing taxpayers more than they would have. Worry about that in another budget – and fix it by increasing the co-payment.

Too many of the measures in last year's budget seem to have been proposed by accountants who understood nothing but the budget arithmetic and didn't care what crazy things were done to get back to surplus.

Let's hope Ley's more intelligent approach is a sign these lessons are being learnt.

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Budget needs more efficiency, less deficit repression

Joe Hockey's intergenerational report says something I really agree with: "to ensure government expenditure is sustainable and better targeted . . . governments need to focus their efforts on achieving the efficient provision of services".

At last, Hockey is acknowledging that we need to reduce the rate of growth in government spending in ways that increase the efficiency of the government's delivery of services.

To me – but no one else, it seems – the pet shop galahs' call for "more micro reform" points directly at two of our biggest industries, healthcare and education, which happen to be mainly in the public sector.

The intergenerational report projects that federal healthcare spending will rise only modestly over the next 40 years from 4.2 per cent of gross domestic product to 5.5 per cent, while federal education spending actually falls from 1.7 per cent to 1 per cent.

Believe that and you'll believe anything. These implausible projections rest on assumptions that the unsustainable cuts in the indexation of federal grants for state hospitals and schools plus the deregulation of uni fees proposed in last year's budget will roll on untouched for four decades.

Truth is, both healthcare and education are "superior goods", meaning they make up an ever growing proportion of consumption as real incomes rise over time. They account for such a large proportion of federal and state government spending that they expose the fiscal monoculists' goal of cutting spending to the point where taxation stops increasing and even falls, for the pipe dream it is.

Fiscal monoculists are those who take a one-eyed view of the budget. If it's in deficit, this can only be caused by excessive spending, never by inadequate taxation, even when the lack of revenue arises from choice-distorting sectional tax breaks, blatant multinational tax avoidance or irresponsible Reagan-style tax cuts.

Brushing aside the more obvious objections to last year's budget, another was its dearth of what Paul Keating called "quality cuts". These are cuts that aim to improve the efficiency of the provision of services.

By contrast, most of the savings came from nothing more virtuous than cost-shifting – to the young unemployed, university graduates, the aged, the sick and, above all, the state governments. This is why so many of the measures, even if they'd got through the Senate, were unsustainable.

You could argue that the GP co-payment, with its introduction of a price signal, and the deregulation of uni fees were genuine, cost-saving reforms, aimed at increasing efficiency in healthcare and higher education.

But such an argument stands up only if you make the most cursory examination of the economics involved. A co-payment price signal improves efficiency only if it deters unnecessary consultations, not if it deters low-income patients from reporting serious problems to their GP before they get worse. Too many of the latter and your "reform" becomes a false economy, storing up higher costs for later.

Deregulating uni fees and expecting market forces to prevent over-charging is a case of magical thinking when you remember the unis remain government-owned and highly regulated, are possessors of market power, and would be selling a service still heavily subsidised by taxpayers via HECS's income-contingent, real-interest-free loans.

There are ways to cut costs in healthcare and education – or, at least, slow their rate of growth – without reducing quality, but they require a lot more thought and effort than was put into last year's GP co-payment and uni fee deregulation proposals.

If you accept that governments ought to be assisting the victims of homelessness, domestic violence, people who can't possibly afford legal representation, dispossessed Indigenous people, the working poor and so forth, it's not efficient to make savings by cutting grants to charities, whose non-profit benevolence is a free good being offered to the taxpayer.

Echoing economists' strictures against "repressed inflation" in days past, the prominent American economist Lawrence Summers is warning against the prevalence of "repressed deficits", where governments engage in accounting tricks and false economies to hide the true costs and make budget deficits and debt look better than they really are.

Such as? Failing to properly maintain public assets, deferring the replacement of infrastructure beyond the end of its useful life, effectively paying higher interest rates to persuade private firms to hide government-initiated debt on their own balance sheets or, with similar effect, engaging in the sale and leaseback of government offices.

On the latter, the Howard government wasted millions of taxpayers' dollars doing that in its first budget. And now, I hear, Hockey is planning the same thing for the Treasury building. Not smart, Joe.

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Materialist era a qualified success

Tired of obsessing over what happened in the economy yesterday? Let's go to the other extreme and look at what's been happening in the past 200 years, and broaden the focus from poor, ailing Australia to the world.

In October, the Organisation for Economic Co-operation and Development published a report, How Was Life? Global Well-Being Since 1820. It's an extension of the work of great economic historian Angus Maddison.

His life work was to piece together estimates of real gross domestic product for all the big countries and regions of the world between 1820, which he took to be the end of the (first) industrial revolution, and 2000.

This latest study has extended the GDP figures to 2010, but also tried to estimate measures of various other socio-economic indicators of well-being.

It paints a picture of the way economic development has spread throughout the world, raising living standards, widening but then narrowing the gap between incomes, fostering population growth and, when you combine the two, causing great damage to the globe's natural environment.

The world's population was about 1 billion at the start of the 19th century, but has grown to more than 7 billion today. That growth was both a cause and a consequence of economic development and the technological advance it promotes.

Advances in public health, particularly sewerage and clean water, led to falling death rates, which slowly encouraged people to have fewer children. Then advances in medical science took over, eventually including more effective means of contraception.

However, these improvements took a long time to spread from Western Europe and the "Western Offshoots" (Maddison's name for the United States, Canada, Australia and New Zealand) to the rest of the world.

This is the story of the huge challenge the world economy has faced in the past 200 years: how to feed, clothe and house this growing population. Overall, we've done it.

Between 1820 and 2010, the world's average real GDP per person increased by a factor of 10. Multiply that by the sevenfold increase in population and world real GDP rose by a factor of 70.

The first weakness in this materialist success story is obvious: this economic growth was spread very unevenly. In 1820, the richest country, Britain, was at most five times as wealthy as the poorest countries. By 1950, the richest countries were more than 30 times as well off.

Only recently has the spread of industrialisation to China and India, which between them contain about one-third of the world's population, caused global income inequality to begin to decline.

Another indicator the study examines is the movement in the real wages of unskilled labourers. They rise more or less in line with real GDP, suggesting that some income does indeed trickle down, even if it has to be helped along by government interventions such as minimum wages.

During the first half of the 19th century, unskilled wages were above subsistence level only in Europe and the Western Offshoots. Now, however, world unskilled real wages are about eight times what they were then.

They were always highest in the Western Offshoots, with Western Europe catching up only since World War II, and they are still low in south-east Asia and Africa.

Turning to education, in 1820 less than 20 per cent of the world's population was literate, and most of these were in Europe and its offshoots. Today, literacy is nearly 100 per cent almost everywhere, although in south-east Asia, the Middle East and North Africa, it's about 75 per cent, and in the rest of Africa it's only 64 per cent.

Much of the increase in literacy has been achieved since the war and decolonisation. It has been accompanied by rising average years of education in all parts of the world. Levels of global inequality are much lower for education than for income.

At the start of the industrial period, average life expectancy was about 40 years in Europe and its offshoots, and 25 to 30 in most of the rest of the world. Only after the late 1890s did life expectancy start to rise significantly. Now, it's about 80 in the rich countries. Elsewhere, the catch-up started after the war, with most of the other world regions now up to about 60 to 70, and only Africa lagging significantly behind.

Income inequality within particular European and offshoot countries has followed a U shape, declining between the end of the 19th century and about 1970, since when it has risen sharply. In other parts of the world, particularly in China, recent trends have led to greater income inequality.

However, when we look at global income inequality, it was driven largely by increasing inequality between countries, as opposed to within them. It worsened until the 1950s, but has since stabilised.

The other big weakness in the success story is, of course, what we have done to the quality of the environment. There has been a long-term decline in biodiversity worldwide. Emissions of carbon dioxide have been rising since the industrial revolution, with its shift to fossil fuels such as coal and oil.

Although almost all the greenhouse gases that have built up in the atmosphere since the early 19th century are the result of economic activity in the developed countries, China's huge population and remarkably rapid industrialisation mean that it has now taken over from the US as the world's largest emitter.

Something tells me that, from here on, climate change and other environmental damage will be the main factor limiting the spread of industrialisation and prosperity to the remaining less-developed parts of the world.

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Greenery has magic properties

I've just got to get through extended Christmas festivities - and subsequent mopping up - and I'll be off on my hols. What am I doing this year? Same as most years: heading for the bush. This time, we're going to the mountains.

As a denizen of the inner city, I've long had a great desire to get out into the country whenever possible. Get into the grass and trees, where the air is clean and the sleeping seems better.

There's a place we rent not far up the coast that backs on to a national park. I call it Lyrebird Lodge. And even when we go overseas, I often find the country towns beat the big cities.

In recent times, I've been singing the praises of big cities: how efficient they are and how they promote creativity and productivity, particularly in the era of the information economy.

But cities have their dark side and insufficient grass and trees is it. That's more than just a personal preference. Environmental psychologists and others have been gathering impressive evidence of the health-giving properties of greenery.

It's evidence to support the US biologist E. O. Wilson's "biophilia" hypothesis: because humans evolved in natural environments and have lived separate from nature only relatively recently in their evolutionary history, people possess an innate need to affiliate with other living things.

Research published last year found that people who live in urban areas with more green space tend to report greater well-being - less mental distress and higher life satisfaction - than city dwellers who do not have parks, gardens or other green space nearby.

Mathew White and colleagues at the University of Exeter Medical School used a national longitudinal survey of households in Britain to track the experience of more than 10,000 people for 17 years to 2008.

They found that, on average, the positive effect on well-being was equivalent to about one-third of the difference between being married rather than unmarried and a 10th of the effect of being employed rather than unemployed.

A different study followed the experience of more than 1000 people over five years, in which time some moved to greener urban areas and some to less green areas. The results showed that, on average, people who moved to greener areas felt an immediate improvement in their mental health. This boost could still be measured three years later.

"These findings are important for urban planners thinking about introducing new green spaces to towns and cities, suggesting they could provide long term and sustained benefits for local communities," the lead author of the study said.

A study from Canada began by summarising all the various benefits from contact with nature that other research had found: it can restore people's ability to pay attention, improve concentration in children with attention-deficit hyperactivity disorder, and speed recovery from illness. It might even reduce the risk of dying.

Yet another study notes that the first hospitals in Europe were infirmaries in monastic communities where a garden was considered an essential part of the environment in that it supported the healing process.

This study of studies, from Norway, says: "In most cultures, both present and past, one can observe behaviour reflecting a fondness for nature. For example, tomb painting from ancient Egypt, as well as remains found in the ruins of Pompeii, substantiate that people brought plants into their houses and gardens more than 2000 years ago."

Many studies find health benefits from contact with nature. The Norwegian paper says a key element in this may be nature's stress-reducing effect. Stress plays a role in the causes and development of cardiovascular diseases, anxiety disorders and depression.

Contact with nature may help "simply by being consciously or unconsciously pleasing to the eye".

Office employees seem to compensate for lack of a window view by introducing indoor plants or even just pictures of nature. One study found that having a view to plants from the work station decreased the amount of self-reported sick leave.

One of my favourite blog sites, PsyBlog, conducted by the British psychologist Dr Jeremy Dean, notes research estimating that people now spend 25 per cent less time in nature than they did 20 years ago. Instead, recreational time is often spent surfing the internet, playing video games and watching movies.

But this is more up my line: Dean reports a study finding that taking group walks in nature is associated with better mental well-being and lower stress and depression.

The study evaluated a British program called Walking for Health, and involved nearly 2000 participants, divided into two matched groups of those who took part in the walks and those who did not.

The walks, which extended over three months, combined three elements, each of which you'd expect to make people feel better: walking, being in nature and being with other people.

Those who seemed to benefit most were those who had been through a recent stressful life event, such as divorce, bereavement or a serious illness.

"Our findings suggest that something as simple as joining an outdoor walking group may not only improve someone's daily positive emotions, but may also contribute a non-pharmacological approach to serious conditions like depression," one of the study's authors said.

You beaut. When I get to the mountains, I'm hoping to do a lot of bush walking.

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How the medical research fund is a trick

As an accountant turned journo, I try to ensure the creative accounting used to make the budget figures look better than they really are doesn't go unexposed. But I've never seen a con as audacious as the proposed medical research future fund.

I wrote at length about all the accounting tricks perpetrated by the Gillard government, but now it's the Abbott government's turn.

In their budget update during last year's election campaign, the heads of Treasury and Finance signed off on a deficit estimate for 2013-14 of $30 billion. But four months later Joe Hockey and Mathias Cormann popped up with their own mid-year review claiming the deficit they'd inherited would be closer to $47 billion.

Today you'll hear Hockey repeat that claim. But that higher number was largely the result of our heroes indulging in a little creative accounting of their own.

About $7 billion of the $17 billion increase since the election was explained by Treasury revising down its forecasts for employment and wage growth and, hence, tax collections. Fair enough. But most of the remaining $10 billion involved dubious transactions our heroes claimed to have been forced to make because Labor had left them hanging.

The biggest was a transfer of $8.8 billion to the Reserve Bank - an amount the Reserve hadn't asked for and Treasury had recommended against. Its effect was to make Labor's last deficit look bigger and to make it easier for the Reserve to pay higher dividends into Hockey's subsequent budgets.

When in this year's budget Hockey announced the GP co-payment and various other cuts in health spending, he explained that these savings would be put in a new medical research future fund.

Once the money in the fund had built up $20 billion, the annual interest on the money in the fund would be used to pay for medical research. But under the changes announced last week, these payments from the net interest earned would instead begin in 2015-16.

This is an accounting trick, but it seems only students of government accounting rules can see it. People think that since the savings are being spent building up the fund, there won't be any net saving to the budget until after the $20 billion target has been reached.

Not so. The saving to the budget bottom line is immediate, though the change means this saving will be reduced a fraction by the increased spending on research.

Like many budget fiddles, this one relies on exploiting loopholes in the definition of the bottom line, the "underlying cash deficit".

The best way of thinking of it is that transactions recorded "above the line" affect the size of the deficit, whereas those recorded "below the line" don't. Below-the-line transactions are regarded as affecting only the way the deficit is financed.

The Medicare spending cuts are recorded above the line, but the decision to put an amount of money equivalent to those savings into a special fund goes below the line. It is, after all, only a decision to move money around the government's balance sheet. It doesn't involve the government spending a cent, just moving money between its accounts.

Of course, since the government is in deficit, it doesn't actually have any money to put into its medical research future fund account. So to its normal borrowing to cover the deficit it will have to add borrowing to finance the money it puts into the research fund.

This extra will add to the size of its gross public debt, but not to its net debt, since the latter is the gross debt (everything the government owes other people) minus all the money in the various parts of the future fund, which has been used to buy shares and bonds, and so represents all the money other people owe the government.

However, when the government spends the interest on the medical fund on medical research, this spending will be recorded above the line and so will add to the deficit.

Once the dust has settled, however, I expect to see a second leg of the trick brought to fruition. In a subsequent budget the government may decide that, now it's spending more on medical research via the future fund, it's able to spend less on medical research via the National Health and Medical Research Council. This brilliant con job will be complete.

What's the point of it all? Partly it's an attempt to bamboozle doctors, but mainly it's designed to allow the government to break its election promise not to cut health spending while claiming it hasn't broken it, just "reprioritised" health spending.

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Health spending is quite sustainable

Oh dear, what an embarrassment. Thank heavens so few journalists noticed. Last month, one of the federal government's official bean-counters, the Australian Institute of Health and Welfare, issued its report on total spending on health in 2012-13. It didn't exactly fit with what the government has been telling us.

As you recall, Health Minister Peter Dutton got an early start this year, warning that health spending was growing "unsustainably". (Blame it all on Gough Whitlam, whose supposedly too-expensive Medibank Malcolm Fraser dismantled, only to have Bob Hawke restore it as Medicare.)

The report of the Commission of Audit soon confirmed that health was prominent among the various classes of government spending growing - and projected to continue growing - "unsustainably".

Something would have to be done.

In the budget, we found out what the something was. A new "co-payment" of $7 a pop on visits to the GP and on each test the GP orders. The general co-payment on prescriptions to rise by $5 to $42.70 each.

And the previous government's funding agreement with the states to be torn up, with grants for public hospitals to rise only in line with inflation and population growth.

Sorry, but it was all growing "unsustainably".

So how unsustainable was growth in 2012-13? Total spending on health goods and services was $147 billion, up a frightening 1.5 per cent on the previous year, after allowing for inflation.

This was the lowest growth since the institute's records began in the mid-1980s, and less than a third of the average annual growth in the past decade.

Allow for growth in the population, and average annual health spending of $6430 per person was actually down a touch in real terms.

It gets better (or worse if you've been one of the panic merchants).

That $147 billion is the combined spending on health by the federal government, state governments, private health funds and other insurers, plus you and me in direct, out-of-pocket payments on co-payments and such like.

So, total spending may not have grown much, but the federal government's share of the tab rose faster than the rest, right? Err ... no. The opposite, actually.

The feds' health spending in 2012-13 actually fell by 2.4 per cent in real terms. The states' spending rose by 1.5 per cent, but that left the combined government spend falling by 0.9 per cent.

So it was actually the private sector (including you and me) that accounted for more than all of the overall increase in spending. This is a big problem for the government?

By my reckoning, out-of-pocket payments by individuals rose by 6.9 per cent in real terms. The pollies seem to have been doing a good job of shunting health costs off onto us even before the latest onslaught.

So, all very embarrassing for the three-word-slogan brigade. Or would have been had the government's spin doctors not had the media off chasing foreign will-o-the-wisps at the time. Easily diverted, the media.

But let's be reasonable about this. One year of surprisingly weak growth in total health spending - and falling federal spending - doesn't prove there isn't longer-term problem.

Government health spending has grown pretty strongly in previous years, and the latest year's moderation may be the product of one-off factors rather than the start of a new moderate trend.

Actually, the real fall in federal spending seems to be largely the product of savings measures taken by the previous government, particularly its tightening of rules for the private health insurance rebate - which the Coalition fought so hard to stop happening.

Even so, when you look at the trend of spending in recent years revealed by the institute's figures, it does suggest that health spending may not grow as strongly in coming years as we've long been told to expect.

The spectre of ever more rapid growth in public spending on healthcare - to the point where health spending comes to dominate the federal budget - is one the federal Treasury has been warning of in each of its three "intergenerational reports" since 2002.

The state treasury versions of this exercise portray health spending positively overrunning state budgets, crowding out all other spending.

Federal Treasury has explained its dramatic projections in terms of the ageing of the population, developments in medical technology that invariably are much more expensive than the technology they replace, and the public's insatiable demand for immediate access to whatever advances medical science has come up with.

But Treasury's figures are essentially mechanical projections of past growth trends over the coming 40 years, meaning just a small reduction in the assumed annual rate of growth can make a big difference.

The institute's latest figures show the federal government's real spending on health grew at an annual rate of 4.8 per cent over the five years to 2007-08, but by just 4.1 per cent over the five years to 2012-13.

Perhaps more significantly, they show that whereas the prices of health goods and services rose faster than the prices of all domestic goods and services by 0.7 per cent a year during the first five-year period, during the second period they rose by 0.2 per cent a year more slowly than other prices.

In other words, the long-feared problem of "excess health inflation" seems to be going away.

It will be interesting to see Treasury's latest prognostications in next year's intergenerational report.

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Econocrats advise false economy

Joe Hockey and Tony Abbott shouldn't take all the blame for the low quality of the measures in the budget. I suspect they're victims of poor advice from the econocrats of Treasury and Finance.

Gary Banks, former boss of the Productivity Commission, says the public service's role is to inform policy choices. If so, it did an unimpressive job of informing an inexperienced government on the best way to exploit the unique political opportunity offered by the Coalition's very first budget.

We can never know exactly what advice passed between the bureaucrats and their masters, but it would be an unusual budget whose measures didn't arise from options provided by the presumed experts.

And a comment by Laura Tingle of The Australian Financial Review offers a clue: "Former Labor ministers were genuinely surprised after the May 13 budget that the new government had simply picked up the same raw policy proposals the public service had been serving up for years and included them in the budget ... It seemed no one in the new government ... recognised these as policy chestnuts from the bureaucracy's bottom drawer."

If that's right, it's an indictment of the bureaucrats' intellectual laziness and lack of expertise. It's the 21st century, but these people have sat for decades learning nothing but "here's where you could cut, minister".

A huge proportion of the spending on two of the nation's biggest and fastest-growing industries, education and health - industries whose performance has major implications for productivity and social wellbeing - passes through the federal budget, but all the budget bureaucrats have to offer is a list of things you could chop.

Since the budget measures focused almost exclusively on the spending side, and since those measures had the smell of the bookkeeper rather than the economist (economists are trained to think about subsequent, not just immediate, effects), I suspect it's Finance more than Treasury that's responsible for such a dismal performance.

What we needed were sophisticated initiatives aimed at raising the efficiency with which public services are delivered to the public.

What does the empirical literature and the experience of other governments tell us about what works and what doesn't? If Finance and Treasury aren't expert on this, why aren't they?

What we got instead were crude spending cuts - or, more often, cost-shifting. A high proportion of the savings will come merely from shunting more of the cost of education and health onto graduates, patients and the states. How much thought went into cooking that up?

The right answer to the growing cost of the Pharmaceutical Benefits Scheme, for instance, is to drive harder bargains on generics with the big foreign drug companies (which pose as Medicines Australia) and the chemists, and to force harder choices on the medicos who advise on which new drugs should be listed by giving them an annual spending cap.

So what did we get? A $5-a-pop increase in the already high general patient co-payment which, in any case, is indexed, with a smaller rise for pensioners. Could laying it on so thick discourage people from filling their prescriptions, thus worsening their health and eventually adding to public spending on healthcare?

Who knows? Who cares? No one in the budget bureaucracy, it seems. If the measure makes things worse rather than better, worry about that in a later budget. "I know, minister, let's whack up patient co-payments again. Tell 'em health costs are unsustainable."

It's a similar story with Medicare. Health economists have devised various ways of achieving greater efficiency, particularly in hospitals, but who's bothered about that? Why tax your brains when you could just chop spending on preventive health programs, slash grants to the states and introduce a $7 co-payment for GP visits and tests?

The co-payment will shift costs to the states and add to ill health and costs down the track, but who's worried? It will be costly to administer, but less so when we advise ministers to whack it up again in a few years' time because health costs are still rising "unsustainably".

But the most mindless false economy is surely the now 2.5 per cent annual "efficiency dividend" cut imposed on the budgets of government departments. Treasury complains it's had to cut staff numbers by one-third just since 2011. Finance must be suffering, too.

Wouldn't it be ironic if the budget bureaucrats were among the chief victims of their failure to give the pollies better advice on spending control? By now, of course, this would be their chief excuse for continuing bad advice. "We don't have the resources, minister."

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The news on our health is good

It's good news week. There are lots of bad things happening in the world and journalists regard it as their job to dig them out and wave them in front of your face. No piece of disheartening news should go unreported.

But good things are happening, too. And I often think people would enjoy reading the news more if we didn't ignore so many of them.

One of the main jobs of the federal government's Australian Institute of Health and Welfare is to produce a report card on the state of Australia's Health every two years. The latest edition is just out and it's crammed with good news.

Perhaps our most basic desire is to delay our death, and on this score we're doing particularly well. "Australians have one of the highest life expectancies in the world and can expect to live about 25 years longer, on average, than a century ago," the institute says.

In 1910, a baby boy could expect to live for 55 years and a baby girl 59 years. Today it's 80 and 84. That puts us sixth highest on the world league table for boys and seventh for girls, but the countries coming top - Iceland and Japan - beat us by less than two years. And we leave the Yanks for dust.

Of course, that's just for babies. Those of us who survive beyond our youth can expect to live longer again. A man turning 65, for instance, can expect to live another 19 years to 84. Women can expect another 22 years to reach 87.
All that's on average, of course. It happens because, by the time you reach 65, you've successfully avoided having your life cut short by accidents or other causes of premature death. You've become one of those who'll exceed the at-birth average.

But even if we are living longer, is that so wonderful if it means we're spending more years living with some kind of disability? Well, some disabilities are worse than others. And my guess is most people would tell you that, though their particular disability isn't fun, it beats the alternative.

The news is better than that, however. The institute's figuring shows that as our years of life are lengthening, our years of living with disability aren't increasing commensurately. And though they're increasing slowly for women - to almost 20 years for a newly born girl - they're falling slowly for men, to less than 18 years for baby boys.

The rate of daily smoking has been falling for 50 years, from 43 per cent of adults in 1964 to 16 per cent today. Quitting smoking can increase your life expectancy by up to 10 years if you do it early enough.

The institute says vaccination is one of the most successful and cost-effective health interventions. And the proportion of five-year-olds who've been vaccinated rose from 79 per cent to 92 per cent over the four years to 2012. Thank God for the nanny state.

The proportion of new cases of cancer each year is steady - kept up by the ageing of our population - but rates of death from cancer are continuing to fall. Over the 20 years to 2011, the mortality rate for all cancers fell by 17 per cent to 172 deaths per 100,000 people.

This is because of reduced exposure to the risk of cancer (such as fewer smokers), improved prevention (such as better sun protection), advances in cancer treatment and, for some cancers, earlier detection through screening programs (bowel, breast and cervical).

The reduction was mostly the result of falls in lung, prostate and bowel cancer deaths among men, and falls in breast and bowel cancer deaths among women.

The five-year survival rate from all cancers has increased from 47 per cent to 66 per cent over the past 20-odd years. And among people who've already survived five years, the chance of surviving for at least another five is 91 per cent.

There's been a 20 per cent fall in the rate of heart attacks in recent years and death rates from heart disease have fallen by almost three-quarters over the past three decades. The rate of strokes has fallen by 25 per cent in recent years and the death rate from strokes has fallen by more than two-thirds.

In just over 20 years, the death rate from asthma has fallen from a peak of 6.6 per 100,000 people to 1.5 deaths. The rate of people being hospitalised for asthma has fallen by 38 per cent.

And the rates of death through most causes of injury - accidents, drowning, suicide and homicide - are down by 3 per cent to 5 per cent in less than a decade.

We're even feeling better. More than half of those 15 and over consider themselves to be in excellent or very good health, with another 30 per cent saying their health is good. This is up a bit on a similar survey in 1995.

What's more, even the oldies are feeling pretty good. Among people aged 65 to 74 living in households, more than three-quarters rated their health as excellent, very good or good. Among those 75 and older, it was two-thirds.

It would be wrong to think everything about our health and healthcare is fine but, just this once, we'll celebrate what's going right.

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Hockey’s budget applies a chopper, not a brain

According to Treasury secretary Dr Martin Parkinson, the budget is replete with ''structural reforms''. According to his boss Joe Hockey, it will ''drive the productivity required to generate economic growth''. Sorry, not convinced.

As a vehicle for micro-economic reform, the budget gets less impressive the more I study it. Parkinson seems to be referring to reforms to the structure of the budget itself, which will build ''fiscal resilience'' over the coming decade.

That's true enough in terms of returning the budget to a sustainable surplus (business cycle permitting). In the process, however, the budget cuts will do little to raise the efficiency with which the government performs its own tasks, nor the efficiency of its interaction with private industries.

Rather than making what the government does more cost-effective, it just stops doing as much. It makes the federal government smaller, but not better. It's a giant exercise in cost-shifting: to people on pensions, to the young jobless, to university students, to the sick and, to the tune of $80 billion, to the states.

It's about crude spending cuts, not about using science to improve efficiency. Does anyone seriously believe imposing yet another temporary increase in the ''efficiency dividend'' on the public service will lead to cost savings without any decline in the quantity and quality of services provided to the public?

Hockey's talk of productivity improvement seems mainly a reference to the budget's increased spending on public infrastructure. I guess we shouldn't complain about the Liberals' belated recognition that adequate infrastructure increases the productivity of the private sector - it would be news to Peter Costello - but the money does need to be well spent to maximise the benefit.

Monuments and pork-barrelling do little for productivity. And I'm not convinced the Libs' bias - federal and state - towards expressways and against public transport is the way to get the greatest productivity gain.

Next exhibit on the micro-reform list would be the deregulation of university fees. The claim that this will unleash competition and so make the tertiary education ''industry'' a lot more efficient is so debatable I'll leave it for another day.

Along with Tony Abbott (St Ignatius, Riverview) and Christopher Pyne (St Ignatius, Adelaide), Hockey (St Aloysius, Sydney) has repudiated the Gonski reforms which would have put federal grants to schools on a needs basis. He's left grants to private schools unreformed and unmeans-tested, while grants to public schools will cover an ever-declining share of their costs.

Leaving aside questions of fairness (and partiality), this is a micro-reform negative. Adjusting grants to reflect students' disabilities would have done much to increase the skills, employability and workforce participation of kids at the bottom of the distribution. It could have been done more cheaply than Labor planned by reducing grants to privileged schools to compensate.

Medical services account for 9.5 per cent of gross domestic product, meaning we have few industries that are bigger, even though much of the industry is government-owned or heavily government-subsidised.

There is plenty of room for the reform of excessive schedule fees for certain procedures, perverse incentives and overservicing, particularly by the corporate sausage-machines that have been permitted to take over so much of general practice.

The doctors' union could be obliged to allow nurses and other health professionals to perform many routine procedures. Many evidence-based reforms could be implemented to reduce waste and increase productivity in public hospitals without reducing the quality of care.

Much could be done to reduce the cost of the pharmaceutical benefits scheme by taking a tougher line with foreign drug companies over generics and the ''evergreening'' of patents, not to mention the chemists' union.

Paradoxically, overseas experience says greater efficiency can be achieved by imposing a cap on the growth in total scheme spending, thus requiring medical representatives to make harder choices about which new drugs are really worth listing.

So what was done? Hockey introduced a $7 charge on GP visits, tests and scans that will be costly to collect and will get at the corporate overservicers by hitting every patient and will discourage the poor from seeing the doc, whacked up an already high co-payment for pharmaceutical scripts and slashed projected grants to public hospitals.

For good measure, Hockey stopped wasting money on all that preventive medicine stuff. Brilliant. Must have taken a genius to dream all that up.

Finally, ''corporate welfare''. The foreshadowed toughness didn't materialise, save for a brave decision to take the ethanol subsidy from a very generous political donor. But the opportunity for sharing the pain - and doing much to force change on a lot of corporate ''leaners'' - was missed.

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Less to the budget than meets the eye

The more of the budget's fine print I get through, the less impressed I am. It's not a budget so much as a flick-pass.

On its main goal of returning to surplus, you can accept the plausibility of its projections that budget balance will achieved by 2018-19 without being terribly impressed by the quality of its claimed "structural" savings.

The policy changes proposed yield savings over the four years to 2017-18 totalling $38 billion (on an accruals basis). Contrary to all the government's rhetoric, almost a quarter of these savings come from increased tax collections.

But get this: fully 46 per cent of the total savings come in the fourth year. Until then, net savings are quite modest. There are various reasons for this delay. One is political: Tony Abbott is keeping some core promises by not breaking them until after the 2016 election.

Another is macro-economic: Joe Hockey is delaying the big cuts until he's confident the economy will be strong enough to absorb them. Yet another is that the Labor government's back-end loading of its new spending programs meant some very big bills fell due in the year beyond last year's forward estimates (where they were harder to see).

But there's one more reason: 2018 is the first year when the expiry of various agreements allows the feds to really start screwing the states on grants for public schools and public hospitals. From then on, grants will be adjusted only in line with inflation and population growth.

This means almost all of Hockey's cumulative savings of more than $80 billion on payments to the states for schools and hospitals over the decade to 2024-25 occur beyond the forward estimates.

Before the election, Abbott and Hockey claimed repeatedly to be able to return the budget to surplus by eliminating waste. In truth, they've identified and eliminated little or no genuine waste.
Rather, they've defunded worthy causes (grants to charities and cultural activities, overseas aid), imposed new user charges (Medicare benefits, the real interest rate on HECS), whacked up existing user charges (pharmaceutical benefits, university fees) and tightened up means-testing (family tax benefit B).

But a lot of the longer-term savings come from lowering the indexation of payments from a wage-related index to the consumer price index. In the case of pensions, this will cause the relative value of pensions to fall continuously over time, pushing the aged and disabled below the poverty line.

In the case of payments to the states for schools and hospitals - whose main cost is wages - it leaves an ever-widening gap the states wouldn't have a hope of covering by increased efficiency, only from other revenue sources. (The cost of medical supplies grows much faster than the CPI.)

As well as meaner indexation, there's a lot of two or three-year pauses in indexing thresholds or payments (family tax benefit, some medical benefits schedule fees, the Medicare levy surcharge, the private health insurance rebate, grants to local governments).

Note, these are largely temporary savings to the budget, though there's some ongoing saving because of the lower base (in real terms) established before indexation is resumed.

And note this. Hockey justified his exclusion of the cost of superannuation tax concessions from his efforts to curb the allegedly unsustainable growth in the cost of population ageing by saying tax expenditures would be considered as part of the coming review of taxation. In truth, he did fiddle with tax expenditures when it suited him (the mature age worker tax offset and the dependent spouse tax offset).

See what this means? If the Coalition ever does get around to reforming the concessional tax treatment of super, capital gains and negative gearing - each benefiting mainly high income-earners - it will do so not as part of the effort to balance the budget, but as part of a revenue-neutral tax reform package where the savings are used to (I bet) cut the top tax rate, with increased collections from the GST shared between the premiers and a lower rate of company tax.

The budget was a giant attempt to get back to surplus solely by cutting spending and not increasing taxes. It failed. Not so much because of the temporary deficit levy or the resumption of indexing the fuel excise, but because the cumulative $80 billion saving from short-changing the states on schools and hospitals - almost a quarter of the total saving - will have to be covered by increased state taxation.

A tax increase flick-passed to the states is a tax increase avoided? Any serious increase in state tax revenue would have to be made possible by the feds, in any event.

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Why health spending is sustainable and will be sustained

If you had a problem that required an operation and the doctor offered a procedure with a 90 per cent success rate or one with a 10 per cent failure rate, which would you pick? Most people say they prefer the one with the high success rate but, of course, they're equally risky. Point is, we can react quite differently to the same information depending on how it has been "framed", as the psychologists say.

When politicians engage in "spin" they're framing a problem or a solution in a way they hope will maximise the public's sympathy, a way that highlights those aspects the pollies want to draw attention to and draws attention away from aspects they don't want us to think about.

As Tony Abbott and Joe Hockey soften us up for an especially tough budget in May, we'll be subjected to much spin. Already the idea of imposing a $6 patient co-payment on GP visits has been floated, to which federal Health Minister Peter Dutton added the comment that the growth in the cost of Medicare was "unsustainable".

Spending on healthcare is highly germane to Treasury's projections that, if no changes are made to policies, the federal budget is likely to stay in annual deficit for the next 10, even 40 years.

But let me frame the projected growth in spending on healthcare in a way you won't hear from the pollies. It's a safe prediction that the real incomes of workers and households will continue growing by a per cent or two each year in the coming 10 or 40 years, just as they have in the past 40.

So, as each year passes our incomes will grow a little faster than the prices we're paying for the things we buy, leaving us to decide how to spend that extra "real" income. Every income earner and family will make their own decisions, but our past behaviour gives us a fair idea of what we'll decide.

We won't be devoting our additional real income to spending more on food, clothing and other basics. Their share of our total spending is likely to continue falling. We will be spending a higher proportion of our incomes on housing - hopefully on better-quality housing rather than just keeping up with rising prices - and on improvements in household electronics such as television, home computers and the like. We'll probably spend more on educating ourselves and our children.

And it's a safe bet we'll want to spend more on healthcare. It's hardly surprising that, as we become more prosperous, we're prepared to devote a higher share of our income to staving off death and ensuring those extra years are as free from pain and disability as possible.

Can you think of a higher priority? And the good news is that medical science is forever coming up with better pills and prosthetics, as well as better and less invasive surgery. The bad news is that the new stuff is invariably much more expensive than the technology it replaces.

And, as surgeons get better at doing particular operations, they're able to perform them on a wider range of patients, particularly the elderly.

After I started suffering angina about the time of the Sydney Olympics, and ended up having open-heart surgery, my GP told me that until this operation was developed, all the medicos could have done was give me pills that didn't work. I would just have had to keep tottering about until a heart attack carried me off. By now I'd be long dead.

If healthcare was something we bought in the marketplace, like most things we buy, that would be the end of the story. We'd go on spending a growing proportion of our increasing real incomes on healthcare and there isn't an economist or politician in the country who would see a problem.

In fact, most of the nation's spending on healthcare is done by governments, federal and state. Public hospitals are "free", visits to doctors are subsidised by the federal government and pharmaceuticals - and chemists - are subsidised by the feds.

We do it this way because, like people in almost every rich country, we believe healthcare shouldn't be denied to those who can't afford it. That's fine. But doing it this way introduces a host of additional problems: scope for greater inefficiency in the delivery of care, ideological responses from those who believe government spending is wasteful and excessive by definition and cognitive dissonance by all those punters who want ever more healthcare available to them, but don't want to pay more tax to cover the cost.

We know from successive Treasury studies that the ever-rising cost of healthcare - caused not so much by the ageing of the population as by the ever-rising cost of advances in medical technology - is by far the greatest reason for the projected increase in budget deficits. It's rarely made clear, however, that all these studies assume a limit on the growth in taxation.

Contrary to politicians' framing of the matter, the growing cost of healthcare is sustainable for the simple reason the electorate's demands leave them with no choice but to sustain it. What's unsustainable is the politicians' pretence that taxes won't have to rise.

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The four business gangs that run America

IF YOU'VE ever suspected politics is increasingly being run in the interests of big business, I have news: Jeffrey Sachs, a highly respected economist from Columbia University, agrees with you - at least in respect of the United States.

In his book, The Price of Civilisation, he says the US economy is caught in a feedback loop. "Corporate wealth translates into political power through campaign financing, corporate lobbying and the revolving door of jobs between government and industry; and political power translates into further wealth through tax cuts, deregulation and sweetheart contracts between government and industry. Wealth begets power, and power begets wealth," he says.

Sachs says four key sectors of US business exemplify this feedback loop and the takeover of political power in America by the "corporatocracy".

First is the well-known military-industrial complex. "As [President] Eisenhower famously warned in his farewell address in January 1961, the linkage of the military and private industry created a political power so pervasive that America has been condemned to militarisation, useless wars and fiscal waste on a scale of many tens of trillions of dollars since then," he says.

Second is the Wall Street-Washington complex, which has steered the financial system towards control by a few politically powerful Wall Street firms, notably Goldman Sachs, JPMorgan Chase, Citigroup, Morgan Stanley and a handful of other financial firms.

These days, almost every US Treasury secretary - Republican or Democrat - comes from Wall Street and goes back there when his term ends. The close ties between Wall Street and Washington "paved the way for the 2008 financial crisis and the mega-bailouts that followed, through reckless deregulation followed by an almost complete lack of oversight by government".

Third is the Big Oil-transport-military complex, which has put the US on the trajectory of heavy oil-imports dependence and a deepening military trap in the Middle East, he says.

"Since the days of John D. Rockefeller and the Standard Oil Trust a century ago, Big Oil has loomed large in American politics and foreign policy. Big Oil teamed up with the automobile industry to steer America away from mass transit and towards gas-guzzling vehicles driving on a nationally financed highway system."

Big Oil has consistently and successfully fought the intrusion of competition from non-oil energy sources, including nuclear, wind and solar power.

It has been at the side of the Pentagon in making sure that America defends the sea-lanes to the Persian Gulf, in effect ensuring a $US100 billion-plus annual subsidy for a fuel that is otherwise dangerous for national security, Sachs says.

"And Big Oil has played a notorious role in the fight to keep climate change off the US agenda. Exxon-Mobil, Koch Industries and others in the sector have underwritten a generation of anti-scientific propaganda to confuse the American people."

Fourth is the healthcare industry, America's largest industry, absorbing no less than 17 per cent of US gross domestic product.

"The key to understanding this sector is to note that the government partners with industry to reimburse costs with little systematic oversight and control," Sachs says. "Pharmaceutical firms set sky-high prices protected by patent rights; Medicare [for the aged] and Medicaid [for the poor] and private insurers reimburse doctors and hospitals on a cost-plus basis; and the American Medical Association restricts the supply of new doctors through the control of placements at medical schools.

"The result of this pseudo-market system is sky-high costs, large profits for the private healthcare sector, and no political will to reform."

Now do you see why the industry put so much effort into persuading America's punters that Obamacare was rank socialism? They didn't succeed in blocking it, but the compromised program doesn't do enough to stop the US being the last rich country in the world without universal healthcare.

It's worth noting that, despite its front-running cost, America's healthcare system doesn't leave Americans with particularly good health - not as good as ours, for instance. This conundrum is easily explained: America has the highest-paid doctors.

Sachs says the main thing to remember about the corporatocracy is that it looks after its own. "There is absolutely no economic crisis in corporate America.

"Consider the pulse of the corporate sector as opposed to the pulse of the employees working in it: corporate profits in 2010 were at an all-time high, chief executive salaries in 2010 rebounded strongly from the financial crisis, Wall Street compensation in 2010 was at an all-time high, several Wall Street firms paid civil penalties for financial abuses, but no senior banker faced any criminal charges, and there were no adverse regulatory measures that would lead to a loss of profits in finance, health care, military supplies and energy," he says.

The 30-year achievement of the corporatocracy has been the creation of America's rich and super-rich classes, he says. And we can now see their tools of trade.

"It began with globalisation, which pushed up capital income while pushing down wages. These changes were magnified by the tax cuts at the top, which left more take-home pay and the ability to accumulate greater wealth through higher net-of-tax returns to saving."

Chief executives then helped themselves to their own slice of the corporate sector ownership through outlandish awards of stock options by friendly and often handpicked compensation committees, while the Securities and Exchange Commission looked the other way. It's not all that hard to do when both political parties are standing in line to do your bidding, Sachs concludes.

Fortunately, things aren't nearly so bad in Australia. But it will require vigilance to stop them sliding further in that direction.

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Exertion, not avoiding it, makes us happy

Forgive me for saying so, but don't you think you'd be better off going for a run - or even a brisk walk - than reaching for another mince pie? (The ones my wife made this year were irresistible.)

Chances are you don't think it. Or maybe you think it, but you don't intend to act on it. If you can't take a day off on Boxing Day, when can you?

I hate to say it, but humans have a slothful streak. We want to live comfortable, enjoyable lives and we assume the less physical effort this involves the better. But one of the most unremarked and remarkable discoveries of our times is that it doesn't work like that.

As a writer about economics, I suppose I'm required to be an advocate of progress. But I'm learning progress can be a tricky beast. Sometimes it involves moving away from the practices of the past as far and as quickly as possible. But occasionally we discover we need to retrace our steps.

A major element of humankind's progress - of our civilisation - has been our unrelenting efforts to take the effort out of all we're required to do to live our lives. That story begins with our discovery of first stone, then metal tools. It progresses to our discovery that settling in one spot and farming crops and animals was a lot safer, more comfortable and prosperity-inducing than hunting and gathering.

Fast forward to the industrial revolution, which began in the second half of the 18th century. It, too, was fundamentally about taking the physical effort out of work, first with the discovery of steam power, then later, electricity and the internal combustion engine - all of them powered by the burning of fossil fuels.

Along the way we invented a multitude of ways to mechanise work - from the spinning jenny to the typewriter - thereby greatly reducing the number of workers needed to produce a given quantity of goods and services or, looking at it another way, allowing a given number of workers to produce a much greater quantity of goods and services.

Whichever way you look at it, our unceasing search for new and better ''labour-saving'' devices has greatly increased the productivity of our labour - the quantity of goods and services the average worker is able to produce in an hour - and this explains why our material standard of living is many times higher than it was at the time of white settlement in Australia.

Usually, this is what economists portray as the object of this grand exercise, making ourselves richer. But it's equally true that a central element of the exercise has involved taking the physical exertion out of work. We haven't ended up doing a lot less work than we used to, but our work has become much less physical and much more mental, requiring us to be a lot better educated and trained.

More recently - and particularly with the advent of the information revolution - we've moved from taking the physical effort out of work to also taking it out of leisure. We drive when we could walk or ride around our suburbs at the weekend. For home entertainment we no longer sing or recite to each other, but turn on some electronic device. And the commercialisation of sport means not only that we watch professionals rather than playing ourselves, but needn't even leave the house to watch a game.

This is where we've overreached, however. This is where nature is striking back. Combine the way machine-produced food has never been more enticing, more plentiful or as cheap with the success of our efforts to strip physical exertion from work and leisure, and you get an obesity epidemic.

And it's not just that. As each year passes the medicos uncover ever more evidence of the many ways our lack of exercise is contributing to our ill-health, including heart disease, type II diabetes, high blood pressure, cancer, depression and anxiety, arthritis and osteoporosis.

To put it more positively, and to borrow a slogan from the American College of Sports Medicine, exercise is medicine. This is what I find so remarkable, so surprising.

Recent research by medicos in Texas has found that previously sedentary women who began moderate aerobic exercise a third of the way into their pregnancy had significantly fewer caesarean deliveries and recovered faster after the birth.

Research by Dick Telford and colleagues at the Australian National University has found that primary school children who are more physically active and leaner get better academic results and, even more so, that primary schools with fitter children achieve better literacy and numeracy.

Research quoted on the Exercise is Medicine website says active people in their 80s have a lower risk of death than inactive people in their 60s.

Regular physical activity can reduce the risk of recurrent breast cancer by about half, lower the risk of colon cancer by more than 60 per cent, reduce the risk of Alzheimer's, heart disease and high blood pressure by about 40 per cent and lower the risk of stroke by 27 per cent. It can decrease depression as effectively as Prozac or behavioural therapy.

According to the site, a low level of fitness is a bigger risk factor for mortality than mild-to-moderate obesity. And regular physical activity has been shown to lead to higher university entrance scores.

But here's the bit I like best (and know from experience is true): research shows that exercise makes you feel better, reducing stress, helping you sleep better and feel more energetic. The unexpected truth is that it's exertion, not the avoidance of it, which makes you happy.

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Wellbeing index gives better picture of mining boom

DON'T believe the doomsayers.This week's national accounts indicate the economy is slowing to something a bit below trend but the critics of the great god gross domestic product are right: it is a quite inadequate and often misleading measure of the nation's progress.

This is why, for more than a year, the Herald has commissioned Dr Nicholas Gruen, principal of Lateral Economics, to calculate a broader index of wellbeing, which we have published within a few days of the release of the Bureau of Statistics' quarterly national accounts, with GDP as their centrepiece.

Our purpose has been to supplement rather than supplant the official figures, which have valid - if narrower - uses and were never intended to be treated as the nation's all-encompassing bottom line.

The Herald-Lateral Economics wellbeing index uses the national accounts to produce a modified version of GDP called "net national disposable income". This adjustment takes account of the annual depreciation (using up) of man-made capital and of the income earned within Australia which isn't owned by Australians.

It also shifts the focus from the value of the nation's production to how much disposable income the nation's households have available to spend on consumption or save, in the process allowing for the change in the prices of our exports relative to the prices of imports.

To this figure the index adds adjustments for the value of the net depletion of natural resources (after allowing for new discoveries), the estimated cost of future climate change, all levels of education and training, changes in income inequality, various measures of the nation's health and employment-related satisfaction.

All this means the index is well placed to help answer a question on many people's minds: what will we have to show for the resources boom?

Unlike GDP, the wellbeing index takes account of the loss of the minerals dug up and sent overseas, not just the export income earned from doing so. It also takes account of the loss of real income we have suffered from the end of the first stage of the boom: the marked decline in the world prices of coal and iron ore during the three months to the end of September.

This was the main factor that converted the growth of 0.5 per cent in GDP during the quarter - a measure of the quantity of goods and services produced in the economy - to a fall of 0.7 per cent in our net national disposable income.

But the accounts confirm that Australian households are continuing to save the high proportion of their disposable incomes. So that is proof we have been saving rather than spending some of our windfall gain from the boom.

But the broader index shows we have also increased our investment in the education and training of our workforce. So much so that, despite the fall in export prices, the index rose by 0.2 per cent during the quarter.

We should be using our good fortune to raise the value of workers' labour and improve their lives in the years ahead - and the wellbeing index shows we are.

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How to improve health without paying more to doctors

It's a well established fact and most of us have at least heard of it. It's also a surprising fact. But it's a fact that doesn't get nearly as much attention as it deserves - not from our politicians, the media or the public.

It's known to social scientists and medicos as the "social gradient" or the "social determinants of health". And it means there's a strong correlation between socio-economic status and health. The higher your status, the better your health.

To put it the other way, the lower a person's social and economic position, the worse their health. And the health gaps between the most disadvantaged and least disadvantaged socio-economic groups are often very large.

One organisation that's taken a great interest in the phenomenon is Catholic Health Australia. It has commissioned the national centre for social and economic modelling (NATSEM) at the University of Canberra to produce two reports on the subject, one of them released this week. It has also produced a policy paper of its own. I'll be drawing on all three documents.

You may think the explanation is pretty obvious: the more money you've got, the better health care you can afford. You can also afford a more nutritious diet. And the better educated you are, the more aware you're likely to be of the risks to health from smoking, excessive drinking and insufficient exercise.

These things are part of it, no doubt, but it's not that simple. Medicare is, after all, free or cheap to all. And who doesn't know that smoking damages your health?

There's growing evidence that status and power affect health. The lower you are in the hierarchy, the worse your health is likely to be. A fair bit of it seems to be psychological.

A study of men in England found life expectancy of 78.5 years for a professional worker, 76 years for a skilled non-manual worker and 71 years for an unskilled manual worker.

According to a paper by the American College of Physicians, job classification is a better predictor of cardiovascular death than cholesterol level, blood pressure and smoking combined. And non-completion of high school is a greater risk factor than biological factors for the development of many diseases.

The earlier report from NATSEM found that if people in the most disadvantaged areas of Australia had the same death rate as those in the most advantaged areas, up to two-thirds of premature deaths would be prevented.

Among Australians aged 25 to 44, only 10 per cent of those who are least disadvantaged report having poor health, whereas for those who are most disadvantaged it's up to 30 per cent. Among Australians aged 45 to 64, the most disadvantaged are up to 40 per cent less likely to have good health than the least disadvantaged.

Early high school leavers and those who are least socially connected are 10 per cent to 20 per cent less likely to report being in good health than those with a tertiary education or a high level of social connectedness.

Those Australians who are most socio-economically disadvantaged are twice as likely as those who are least disadvantaged to have a long-term health condition. More than 60 per cent of men in jobless households report having a long-term health condition or disability, and more than 40 per cent of women.

The socio-economic factors best at predicting whether people smoke are education, housing tenure (whether you rent, are paying off your home or own it outright) and income. Less than 15 per cent of individuals with a tertiary education smoke.

Among women aged 25 to 44, less than 20 per cent of those in the most advantaged socio-economic classes are obese, compared with up to 30 per cent of those in the most disadvantaged classes. The likelihood of being a high risk drinker for younger adults who left school early is up to two times higher than for those with a tertiary qualification.

See what this is saying? There are two ways to improve the nation's health. One way is to spend a lot more taxpayers' money on health care. That's the solution we're always hearing about, especially from doctors.

The other way is to reduce socio-economic disadvantage; to narrow the gap between the top and the bottom, not just in income but also in educational attainment (completing secondary education), housing tenure (more affordable rental accommodation) and the way people are treated at work.

This is the solution we rarely hear about. It too would cost money, of course. But it would make more people happy as well as healthy. And it would also save taxpayers money. Just how much is what NATSEM attempts to estimate in this week's report.

If the health gaps between the most and least disadvantaged groups were closed (an impossible ideal, but one we could work towards), up to 500,000 Australians could avoid suffering a chronic illness. Up to 170,000 people could enter the labour force, generating up to $8 billion a year in extra earnings.

That would produce savings in welfare payments of up to $4 billion a year. Up to 60,000 fewer people would need to be admitted to hospital annually, producing savings of $2.3 billion. Up to 5.5 million fewer Medicare services would be needed each year, saving up to $275 million. And up to 5.3 million fewer prescriptions would be needed each year, saving the pharmaceutical benefits scheme up to $185 million a year.

But the real point is that when we choose to allow the gap between rich and poor to widen each year - including by allowing the dole to stay below the poverty line - we're casting a blind eye to the ill health it causes.

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Propping up private heath insurance unfair, inefficient

Despite the untiring efforts of Julia Gillard and Tony Abbott to make themselves seem poles apart in their policies - he/she is hopeless, I'm really good - the ideological gap between the two sides has never been narrower.

If you look carefully, that's true even in one of the few remaining points of ideological difference: the funding of healthcare, particularly private health insurance.

When John Howard resumed leadership of the Liberals in 1995, he abandoned their long-standing opposition to Labor's Medicare (and Medibank before it). But that didn't stop him using a succession of carrots and sticks to get people back into private health insurance.

When Labor returned to power in 2007, it lost no time in seeking to water down those incentives. In its first budget it raised the income thresholds at which middle- and high-income earners became liable for the additional, 1 per cent Medicare levy surcharge if they didn't have private insurance.

In its second budget it sought to means test the 30 per cent health insurance rebate, reducing it for higher-income earners and removing it for those even higher up. Labor seems to have wanted this as part of its efforts to pare back all the middle-class welfare Howard introduced to health and social security payments.

But the measure was knocked back by the Senate, mainly because of the implacable opposition of the Libs. Labor has sent the bill back to the Senate every year since then, only to have it rejected.

This week the newish Minister for Health, Tanya Plibersek, is conducting discussions with the independents and the Greens in the hope of having more success this year. Strangely, if the Greens join forces with the Libs to block the bill one more time, it will be because they profess to believe it doesn't go far enough.

Plibersek has sought to demonstrate the unfairness of the rebate with figures showing that while just 12 per cent of couple taxpayers earn more than $160,000 a year between them, they account for 21 per cent of the couples benefiting from the rebate - worth, typically, about $1000 a year. For single taxpayers, the 14 per cent earning more than $80,000 a year account for 28 per cent of the singles getting the rebate. It's a concession for the well-off.

The health funds and the Liberals oppose the means test because, they claim, it would lead many people to abandon private insurance.

Leaving aside the question of why that would be such a bad thing, this is a weak argument.

Treasury's calculations show that only about 0.3 per cent of the 10 million people with insurance would quit. And it's not hard to see why. Higher earners are essentially compelled to hold private insurance by the Medicare surcharge. And Labor's plan actually involves increasing the size of that stick.

It's clear Labor's motives are to make the system a little less unfair and save the budget a little money (its means test would reduce the $3 billion annual cost of the rebate by about $700 million) without harming private insurance.

So, just as the Libs now accept the legitimacy of Medicare, so Labor now accepts the legitimacy of taxpayer-subsidised and enforced private health insurance. One of the few remaining ideological gaps has greatly narrowed.

The pity is that, as John Menadue and Ian McAuley explain in a new paper published by the Centre for Policy Development, subsidising private health insurance doesn't only advantage the better-off (including yours truly), it makes healthcare more expensive than it needs to be.

Healthcare costs to the community - whether funded by the taxpayer or privately - are already growing rapidly and are set to keep outpacing most other costs, becoming by far the greatest pressure on government budgets.

That makes healthcare the greatest source of pressure for rising taxes. Nothing wrong with that - provided we get value for money. But that's just where private insurance lets us down.

Howard's subsidy of health fund premiums was really a vote-buying election promise and a gift to the well-insured Liberal heartland. He tried to justify it by claiming that getting more people into private insurance would relieve the pressure on public hospitals.

As all the experts predicted at the time, it didn't work. It shifted patients from public to private, but it also shifted doctors from public to private, leaving public queues little changed. It did, however, subsidise the better-off in their efforts to jump the queue.

As anyone who's done high school economics could tell you, the benefit from a government subsidy of the price of something is shared between the buyer and the seller. The health funds have become a lot more profitable than they used to be.

All arrangements that separate the true cost of something from what you appear to pay for it at the counter encourage overconsumption, overservicing and overcharging. That's true of Medicare as well as private insurance.

But unlike private insurance, Medicare has countervailing advantages. Being a single national payer, it has lower administrative costs and, more to the point, greater ability to counter the market power of healthcare providers.

Our many private health funds have little ability - and little incentive - to counter overservicing and overcharging. It's a well established principle in health economics that those countries with the greatest reliance on private insurance to finance healthcare have the most expensive healthcare - without a commensurate improvement in their health. The United States is the classic case.

Using carrots and sticks to prop up private insurance not only subsidises a two-class health system, it delivers its greatest benefit to the incomes of medical specialists. Great idea.

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Bitter pill when politicians swallow big pharma's spin

Politicians always profess great sympathy for people struggling to keep up with the cost of living but often fail to put that sympathy into practice. Economists like to divide the economy into consumers on one side and producers on the other. They believe the economy should be run for the benefit of consumers, not producers. The consumer is supposed to be king.

Ostensibly, pollies think the same. But they're always doing deals with producers that allow them to charge higher prices at their customers' expense.

Why would politicians do such a thing? Because the producers are usually better organised. They have more to gain from a higher price - or lose from a lower price - than individual consumers have to lose or gain. Consumers are amateurs; producers are professionals and they put a lot of effort into lobbying governments.

But there's another factor. Every voter with a job is a producer as well as a consumer. Politicians care about jobs. And when producers offer to create new jobs - or, more likely, threaten to sack workers if they don't get what they want - the pollies usually play ball. They're easily conned.

Consider the case of pharmaceuticals. When a drug company - usually a big American or European corporation - discovers and develops a new medicine, it is granted a patent that amounts to a 20-year monopoly on the production of the medicine. If the medicine is highly effective, the monopoly allows the company to charge a very high price.

The standard justification for patents is that, by holding off competitors, they allow the company a period of grace in which to recover its research and development costs and make a big profit, thus encouraging more invention, to the benefit of society.

This explains why pharmaceuticals are so expensive in the United States. But the companies are prevented from charging such high prices in Australia by the operation of our pharmaceutical benefits scheme.

Under the scheme most drugs are, in effect, bought by the federal government, then sold to patients at heavily subsidised prices. This makes the government a "monopsonist" - a single buyer - and so gives it the ability to beat down the prices the drug companies are able to charge.

This explains why patented pharmaceuticals are so much cheaper in places such as Australia and Canada than they are in the US. The Aussie taxpayer benefits, as does the patient required to pay a smaller out-of-pocket contribution towards the cost of the drug.

Great stuff. But here's where the story gets bad. When a drug's patent expires, any drug company is allowed to start producing that drug in competition with the former patent holder. They can't appropriate the drug's trade name, of course, so they're known as generics. Generics are tightly regulated to ensure they're just as effective as the drug being copied.

So when a drug comes off patent and a lot of cheaper generics come onto the market, you'd expect the price of the trade-name drug to fall sharply. That's what happens in the US and in many other countries, but not in Australia. Why not? Because our pharmaceutical benefits scheme goes easy on the former patent holders. It drops the price by a bit, not a lot.

And it leaves it up to the prescribing doctor - and sometimes the patient talking to the chemist - to say whether a generic may be substituted. Many doctors and patients have an irrational attachment to the brand name, even though it's a lot dearer.

Last year the Rudd government proudly announced it had cut a new and tougher deal with the drug companies, represented by Medicines Australia, which would save the taxpayer $1.9 billion over five years.

The patents of a lot of expensive drugs will expire in the next few years. The deal involved cutting the prices of these drugs by 16 per cent and cutting the prices of generic drugs by 2 or 5 per cent from the start of this year.

But a health economist at the University of Sydney, associate professor Philip Clarke, and his colleague Edmund Fitzgerald, argue the deal still leaves our off-patent and generic drug prices much higher than they are in most developed countries. They quote the example of statins, the cholesterol-lowering drugs, where the patents of the various types have expired or soon will. Statins account for about 16 per cent of the total cost of the pharmaceutical benefits scheme.

They surveyed the wholesale price of Simvastatin 40mg in 10 developed countries and found our price was the highest: 50 per cent more than the next highest country and more than four times greater than the average price.

The lowest price was in New Zealand, which stages competitive tenders between the drug companies. Its price is just a fraction of our wholesale price of $1 a tablet. And even in the US, chains such as Kmart Pharmacy sell that statin for $15 for 90 tablets.

Clarke and Fitzgerald estimate that, compared with prices in England and Canada, the Rudd government's deal with the industry lobby will cost taxpayers and consumers $1.7 billion more over its five-year term. And that's just for the statin group of drugs.

The saving would be even greater, no doubt, if the government were game to take a firmer line on the prescribing habits of doctors.

Why would a government that professes to care so much about our cost of living cut such an expensive deal with the drug producers? Because, in practice, it gives a higher priority to maintaining an industry that makes the actual pills in Australia.

And the largely foreign-owned drug companies have conned it into believing that, unless it forces Australian consumers to paying much higher prices for off-patent drugs than people in other countries pay, the local industry will curl up and die.

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PUBLIC HEALTH CONSEQUENCES OF THE GLOBAL FINANCIAL CRISIS

Talk to AFPHM Congress, Sydney
May 20, 2009

Because I’m no expert on public health, I’m going to focus on the nature, size and duration of the crisis, and say something about the likely impact of the crisis on the developing countries and on Australia, leaving Steven Jan to focus on what the crisis will do to the social determinants of health.

I must start by warning you that economists are hopeless at forecasting what will happen in the economy. All they - or I - can do is offer you educated guesses, which will probably be wrong for reasons we haven’t thought of. But humans are incurably curious animals, with an insatiable desire to know what the future holds, so they go on asking economists for their predictions, and economists go on pretending to know what will happen. Now I have your informed consent, I’ll get down to it.

I’m going to skip explaining the origins of the financial crisis and take up the story at the point where the crisis reached its climax in mid-September last year with the collapse of the US investment bank Lehman Brothers. This prompted panic in global financial markets, which froze. The global banking system rocked on its foundations as governments in the US, Britain and continental Europe struggled to avert the collapse of various banks. The whole world watched these frightening events on television every night and the effect was a sudden loss of confidence among businesses and consumers in many countries. Around the world, fearful consumers tightened their belts and abandoned plans for big purchases, while businesses postponed expansion plans and wondered about laying off staff. In consequence, the global economy hit a wall at that moment. It dropped off a cliff. Just about every developed country contracted - went backwards - in the last quarter of 2008, and the contraction continued in the first quarter of this year. Over that six month period, the US economy contracted by more than 3 per cent, Europe by more than 4 per cent and Japan by maybe 6 per cent.

Those are huge figures. Australia would also have contracted over that six months, but by a lot less (we’ll get the figures for March quarter a fortnight today). Most developed economies had been slowing (as we had) or were in already in recession before the crisis reached that climax in September, but from that point it became indisputable that the global financial crisis had become a global recession, that the problem had spread from Wall Street to Main Street, from the financial markets to the ‘real’ economy of production and consumption that you and I inhabit.

As the immensity of the global contraction slowly dawned on officials, the IMF - the International Monetary Fund - revised down its forecast for growth in the world economy in 2009 five times in seven months. Its latest prediction is that the world economy will contract by. 1.3 percent in calendar 2009. This would be the first annual contraction in 60 years. It compares with record world growth of more than 5 per cent just two years earlier (2007). Virtually every advanced economy is in recession and the advanced countries as a whole are expected to contract by 3.8 per cent. The developing countries should grow, but by just 1.6 per cent. Normally, any rate of global growth below 2 per cent is regarded as a world recession, because recessions usually roll around the world, hitting different countries at different times, because the developing countries always grow a lot faster than the advanced countries (because they’re coming off a low base) and because they aren’t as closely connected to the advanced countries as the advanced countries are to each other.

The IMF is predicting that the world economy will grow by 1.9 per cent the following year, 2010, with the developing countries recovering to 4 per cent (still weak by their standards), but the advanced economies just breaking even. This, of course, would still be in recession territory.

The IMF is uncharacteristically gloomy about this recession. It’s worried by two unusual features of the present episode: first, unlike most recessions, this one has been caused by a crisis in the financial system, and second, it’s highly synchronised - everyone’s going down together, partly because of shared trauma of the events in September-October. History tell us that recessions brought on by financial crises are deeper and longer, with a weaker recovery. History says the same about synchronised recessions. Put those two negatives together and you’ve got a particularly bad prospect.

The IMF has legitimised the comparison of this recession with the Great Depression, suggesting that this episode be known as the Great Recession. However, economists are confident we won’t see anything as bad as the Depression because we’ve learnt from the gross mistakes we made then. In particular, we have four factors going for us. First, we haven’t stood around watching banks collapse, but have done everything necessary to prop them up. Second, we’re well aware of the risk of deflation (widespread and continuous falls in prices) and will resist it, understanding that, in such circumstances, printing money helps rather than harms. Third, we don’t see any virtue in balanced budgets at such a time, and are applying large amounts of timely fiscal stimulus. Fourth, no one imagines a resort to competitive currency devaluations or higher trade barriers offers a viable solution to a global problem, even if domestic political pressures make them tempting.

How bad and how protracted will the Great Recession end up being? I don’t know. Even if it’s not as bad as some people fear, it will be plenty bad enough. The main risks are, first, a new crisis somewhere in the global financial system, and second, inadequate efforts to fix the balance sheets of ailing banks, so that businesses and households fail to receive the flows of credit necessary to allow them to resume normal activity.

On the positive side, world financial markets are a lot more settled than they were, there are reasonably convincing signs that the US, which has already been in recession for a record 17 months, is stabilising and could start recovering later this year - although it could still be a year or more before there was any improvement in unemployment - and there are convincing signs that China is recovery, just as the recovery from the Asian crisis of 1998 was much stronger than (more V-shaped) than we expected. Developing economies are more resilient than advanced economies; they have a greater ability to bounce back.

Last week’s budget argued that Australia’s recession - which has hardly got started yet - will be much less severe than those of the major developed economies and much less severe than we experienced in the recessions of the early 1980s and early 1990s, even though the recession itself will last longer: three years, rather than one year in the 80s and two years in the 90s. But whereas the rate of unemployment peaked at 10 per cent in the 80s and almost 11 per cent in the 90s, this time it will peak at only 8.5 per cent, in the second half of next year. Treasury is certainly right in arguing that, when recovery finally arrives, the usual pattern is for the economy to bounce, achieving surprisingly high rates of growth as it comes up off the floor. There are three good arguments for Treasury’s relative optimism. First, thanks to the four-pillars policy and strong regulation, our banking system is in very good shape. Second, the alacrity with which we slashed interest rates and applied budgetary stimulus to the economy after September last year will prevent the economy from descending too far into the depths. Third, the recovery in China, as it switches its engines of growth from export demand to domestic demand will limit the fall in our export income. The counter argument is that we haven’t yet felt anything like the full effect of our loss of income arising from the collapse of coal and iron ore prices, nor from the rise in unemployment and the debilitating and hence compounding effect this will have on business and consumer confidence.

Edging closer to our goal of assessing the consequences of all this for public health, let me just make the obvious point that the burden of recessions is shared most unequally, with the increase in unemployment concentrated heavily on the unskilled, early school-leavers and the disadvantaged, including Aborigines and the mentally ill. Considering what we know about the social determinants of health, this does not bode well. However, though an increase in health problems as a result of the recession may lead to the overstraining of unchanged levels of provision, I don’t believe that explicit cutbacks in government health spending will represent a significant addition to the problem.

Finally, let me turn to the problem in the developing countries. On the face of it, their economies will grow faster than those of the advanced countries, but this is misleading. The developing countries’ rapid population growth means they need to grow at faster rates just to stop going backwards. In these countries I think we will see both an increase in the demand for medical assistance and a decrease in its supply. The reduction in supply will come from increased pressure on government budgets (less revenue but more spending demands), reduced official and unofficial aid, and less ability on the part of patients to bear out-of-pocket costs. In 23 developing countries more than 30 per cent of their total health spending is funded by donors. I am hopeful, however, that, where countries are obliged to apply to the IMF for financial assistance, the criticism the fund received for its mishandling of the Asian crisis will make it less inclined to provide assistance conditional on ultra-harsh cutbacks in government social spending.

According to the World Bank, each 1 per cent decline in growth causes 20 million people to be pushed into poverty. After for once enjoying a period of decent growth - a half-decade above 5 per cent a year - Africa is forecast to manage growth of just 2.8 per cent this year. So I don’t doubt that the Great Recession will lead to great suffering among the world’s poor. In developing countries as in Australia, the burden of economic downturn will be distributed unequally and unfairly, with the poor bearing most of the brunt. Similarly, in any competition for inadequate public health resources, you’d expect to see the better-off elbowing out the poor.

Even before the onset of the global recession, only a handful of African countries were on track to meet the Millennium target of halving the share of the population living on less than a dollar a day by 2015. But the gloom and doom is not total, however. One small mercy is that, at a time of global recession, you’d at least expect to see food and energy prices coming down. Another is that the African economies’ generally improved economic management in recent years leaves them better positioned to weather the crisis than they were a decade ago. It’s also fortunate that so many of the world’s poor live in China and India, which are likely to recover fastest.

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