Our oldies have never had it so good

Don’t let anyone tell you Scott Morrison is out of touch. When he says that, if he had the money, he’d increase the age pension rather than the dole, he’s reflecting the views of most older Australians. Everyone knows it’s the old who are the deserving poor.

Except it ain’t true. It was true once, but not for many years.

You might expect the Prime Minister to be better informed than the average punter, but Morrison is from the new breed of politician who see a leader’s job as to reflect the voters’ misperceptions back to them. Read the focus group reports, not the briefing notes.

Something Morrison clearly hasn’t read is the research briefs published last week summarising the findings of the Centre of Excellence in Population Ageing Research – an outfit funded by the federal government to ensure it (and the rest of us) are well-informed about matters such as the adequacy of the age pension.

According to the centre’s director, Professor John Piggott, of the University of NSW, “our analysis shows that standards of living of older people have improved over the last decade . . . Households reaching retirement age today have incomes about 45 per cent higher than those reaching the same milestone 10 years ago.”

That’s a real increase of 45 per cent, after taking account of inflation. How could it be possible? Because the pension is indexed to wages rather than prices, and wages grow by a per cent or two a year faster than prices (until recently, anyway).

As well, the Rudd government made a discretionary increase in pensions on top of indexation.

The centre’s figures show that 62 per cent of age pensioners get it at the full rate, with a quarter getting a part-rate pension because of their other income, and another 13 per cent on a part-rate because of the high value of their non-housing assets.

The centre finds that the rate of poverty (measured as less than half the median household disposable income) among everyone aged 65 and over is only a fraction higher than for everyone aged 15 to 64.

Even so, by now it’s wrong to think of many people retiring with nothing to support them but the pension. Our retirement income system rests on three pillars, with the means-tested, flat-rate age pension being only the first.

The second pillar is compulsory employer superannuation contributions under the “super guarantee”, which began formally in 1992 and reached 9 per cent of wages in 2002. Today it’s 9.5 per cent.

By now, therefore, most people should be retiring with some super savings, maybe quite a lot. The centre says that, in 2016, the median (most typical) super balance for individuals aged 60 to 64 was $68,000, whereas the arithmetic average was three times that, at $214,000 – pushed up by a small number of very much higher balances (including mine).

The median is held down by the typically much lower balances of women, which average 64 per cent less than men’s. Even here, however, the centre says the gap has almost halved over the past decade.

The retirement income system’s third pillar is voluntary super contributions, which are “tax-advantaged”.

Compulsory and voluntary super contributions are already sufficient to mean that 40 per cent of people on the age pension have super and investments as their main source of income. And 20 per cent of older people have so much other income as to make them ineligible for the pension.

But the system actually has a fourth pillar: home ownership. (And a fifth: assets and other savings outside the first four pillars.)

Get this: three-quarters of age pensioners own their home. The centre estimates that, on average, living rent-free in your own home yields a saving of more than $10,000 a year. (As well, the oldest households receive health-related savings averaging about $25,000 a year.)

So significant is the fourth pillar of home-ownership that it’s implicitly assumed in judging the age pension’s adequacy – meaning the quarter of age pensioners who mainly rent privately are justified in complaining about the trouble they have making ends meet.

About 40 per cent of renters aged 65 and over are below the poverty line. And, among those of them living alone, the poverty rate rises to 60 per cent.

If Morrison really cared about the elderly poor, he’d raise the pension rent supplement, which wouldn’t cost much.

In truth, however, his remarks last week were probably more about signalling: the aged – particularly the better-off aged; those dreading Labor’s plan to abolish unused dividend franking credits - should see themselves as part of his party’s “base”, whose interests he represents and will fight for.

Renters of any age aren't part of the base. Nor are the young part of it – and others with a greater risk of finding themselves on the dole – so their interests take a lower priority. Don’t say he didn’t tell you.

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How governments shift income from rich to poor

Everyone knows the gap between high and low incomes has grown. But much of what we think we know about why it’s happened, and what the government has been doing about it, is probably wrong.

For instance, many people imagine that the main thing governments do to reduce the gap between rich and poor is to raise much of their revenue via the most “progressive” tax in their arsenal, income tax. (A progressive tax takes a progressively higher proportion of tax from people’s income as incomes get higher.)

Sorry, that impression’s wrong.

Another strongly held perception is that, if the gap between high and low-income people is growing, it must be because of something the government is doing. For instance, stages two and three of the Turnbull government’s three-stage, seven-year tax plan are intended to make income tax significantly less progressive.

Sorry, it’s only partly true that growing inequality is caused by government policy.

Yet another misperception is that the inequality of incomes increases as each year passes.

These misunderstandings are what’s so great about the Australian Bureau of Statistics’ publication last month of its six-yearly “fiscal incidence study”, for 2015-16. It’s the most comprehensive guide to what’s been happening to income inequality and, in particular, how it’s been affected by government policies.

Professor Peter Whiteford, of the Australian National University, has written an excellent summary of the study’s findings.

The study allocates the federal and state taxes we pay between the nation’s eight million households, then allocates federal and state government spending to those households. (Some taxes, such as company tax, it can’t attribute to households. Nor some classes of government spending, such as spending on defence and law and order. But these omissions should roughly cancel out.)

So, on one hand, the study takes account not just of income tax, but also all the other, federal and state “indirect” taxes, most of which are “regressive” – they take a higher proportion of low incomes than high ones.

On the other hand, it takes account not just of government benefits in cash (pensions, the dole, family allowance), but also in kind - particularly healthcare (subsidised doctors and pharmaceuticals, free public hospitals, subsidised private insurance), subsidised aged care and childcare, plus pre-school, school, technical and university education.

So it starts with households’ “private income” – the money people earn from wages, profits, investments and superannuation payments – then subtracts the taxes they pay and adds the value of government benefits they receive in cash and kind to get their “final income”.

Get it? The difference between a household’s private income and its final income is the net monetary effect of all the things federal and state governments’ budgets do to the household’s budget.

It shows the extent to which government budgets redistribute income between high and low-income households.

Before we get to that, however, note that most economists believe the fundamental cause of rising inequality is changes in private incomes arising from globalisation and skill-biased technological change which, over many years, have caused the wages of high-skilled workers to grow much faster than those of low-skilled workers.

But the usual way to measure inequality is to compare not individual workers, but individual households, many of which contain two workers, plus dependent children.

It seems likely that, over the decades, the growing gap between high and low wages has been offset by the growing incidence of two-income families.

And note this: in more recent times – the six years between 2009-10 and 2015-16 - there’s been no increase in inequality.

Turning back to the effect of government budgets, the study shows they redistribute a lot more income than many people realise.

Get this: In 2015-16, the poorest 20 per cent of households (mainly pensioners) started with private income averaging just $168 week but, after taking account of their pensions and health and aged care benefits, their final income almost quintupled to $808 a week.

At the other end of the spectrum, the best-off 20 per cent of households (mainly two-income couples with good jobs) started with private income averaging $2863 a week, but had that cut to final income of $2168 a week, a loss of almost $700 a week.

How come? Well, on average they paid $714 a week in income tax and $178 in other taxes, but received just $16 in social security benefits and $192 in non-cash benefits, mainly school education.

Look now at the middle 20 per cent of households and, on average, their final income was only a little different from their private income because the taxes they paid were pretty much offset by the benefits in cash and kind (particularly education) they received.

See what’s happening? Government budgets are highly effective at transferring income from the top 40 per cent of households to the bottom 40 per cent.

And it’s not just progressive taxation that does this. Surprisingly, most of it’s done on the spending side of the budget.

The most common way of measuring inequality is the “gini coefficient”, where zero represents perfect equality between households and 100 represents one household getting all the income.

The study shows a quite high coefficient of 44.2 for private income being reduced to 24.9 for final income.

Now get this. Of this overall decline in inequality of 19.3 points, the progressive income tax scale explains only 4.5 points. And the regressive effect of other taxes reduces this by 0.8 points.

So the remaining 15.6 points of decline in inequality are explained by 8.1 points coming from governments’ cash social security payments, plus 7.5 points coming from the effect of governments’ benefits in kind, particularly health and aged care and education spending.

The first bit should be no surprise. As Whiteford reminds us, Australia’s system of social security payments is the most heavily means-tested in the world.

The big surprise is that our generally non-means-tested benefits-in-kind should do so much to reduce inequality.

My guess is that the high proportion of health and aged care benefits going to age pensioners does much to explain this.

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The taxes we pay come back to us - now or later

As we roll on to the federal election, there’s a surprising number of economic problems we should be discussing, but probably won’t.

For the longer term, the most important problem is the likelihood we’re not doing enough to meet our Paris commitment to reduce greenhouse gas emissions - which is, in any case, inadequate.

Linked with this is the appalling mess we’ve made of privatising electricity. Despite (and partly because of) Tony Abbott’s wrong-headed abolition of the carbon tax, this has left us paying power prices far higher than they need to be.

Linked with soaring electricity prices are soaring gas prices, caused by the gas companies’ gross overestimate of the amount of gas available for export through the many liquefaction plants they built. Absurdly, it would now be cheaper for local users to import gas from the world market.

The most pressing problem we should be discussing is the causes of the four-year-long run of weak growth in wages, which is not just crimping living standards but is by far the greatest threat to the holiest of holies: Jobs and Growth.

Then there are such minor matters as the way the burden of our years of weak growth has fallen mainly on youth leaving education, the way the “gig economy” threatens to undermine decent working conditions, the appalling run of seemingly respectable firms accused of cheating their employees and the terrible hash federal and state governments have made of TAFE.

The misbehaviour of the banks is being following by growing evidence of the misbehaviour of for-profit providers of childcare, aged care and before long, no doubt, disability services. What makes these people think they can mistreat their government-supported clients with impunity?

But if few of these problems are likely to get much attention from our campaigning politicians, what will? They’ll be arguing about their tax cuts being better than the other crowd’s.

With the budget still in deficit and the public debt still rising a decade after the global financial crisis, you’d think a decade of tax cuts is the last thing we could afford, but let’s do it anyway.

Why the obsession with tax? Partly because a government behind in the polls is trying to buy some popularity, partly because the more we obsess about tax the more our attention is drawn away from problems the government can’t or won't fix, but also because a lot of powerful and highly paid men (and I do mean mainly men) will not rest until tax has been “reformed” in a way that means they pay less and others more.

These well-off men are convinced they’re asked to pay far too much. They convince themselves of this by focusing on income tax and seeing it as a “burden” we have to bear without anything coming back our way.

In truth, we pay plenty of other federal and state taxes, which usually fall more heavily on the poor than the rich. And the taxes we pay come back to us as government benefits in cash (pensions, the dole, family allowances) and kind - particularly healthcare (subsidised doctors and pharmaceuticals, free public hospitals, subsidised private insurance), subsidised aged care and childcare, plus pre-school, school, technical and university education.

Every six years the Australia Bureau of Statistics conducts a “fiscal incidence study” in which it allocates the federal and state taxes we pay between the nation’s 8 million households, then allocates federal and state government spending to those households. (Some taxes, such as company tax, it can’t attribute to particular households. Nor some classes of government spending, such as on defence and law and order. But these omissions should roughly cancel out.)

The bureau published its study for 2015-16 last month. It found that, on average, households received $76 a week more in government benefits than they paid in taxes.

Break the households up by life stage, however, and you get a very different picture. For our 1.3 million single-person households aged under 65, the taxes paid by those under 35 exceeded benefits received by $171 a week. For those aged 35 to 54, this increased to $204 a week.

Why? Because most of them had jobs and were in good health, but none had children, meaning they got no family payments nor government spending on school education.

Our 1.4 million couple-only households aged under 65 are the big net contributors. For those under 35, their taxes exceeded their benefits by $480 a week. For those 35 to 54, it rose to $618 a week.

Our 2.5 million couples with dependent children paid a lot of tax, but also got back a lot of benefits, particularly family allowance, a lot of education spending and a fair bit of healthcare. All told, they paid just $42 a week more than they got back.

Skipping half a million single-parent households with dependent children (big net gainers) and a further half million couple households with non-dependent children (modest net payers), we come to the 1.8 million single or couple households aged 65 and over.

The couples got back $452 a week more in benefits than they paid in tax. That’s because they pay little tax, get a lot in pensions and get huge spending on health and aged care. Single retirees get back a net $576 a week, thanks to even greater spending on health and aged care.

So, younger working singles and childless couples are big net payers, couples with children roughly break even, and oldies really clean up. Just as well we all get old.

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Private health insurance is a con job

You won't believe it, but my birthday was on Tuesday and I got a present from the federal government. I also got a card from my state member, sending his "very best wishes" for reaching such an "important milestone" in my life.

I almost wrote back asking him to alert the Queen to be standing by in 30 years' time. Instead, my ever-sceptical mind told me the pollies have awarded themselves privileged access to the private information we're obliged to give the electoral commission.

So, what was my fabulous federal birthday present? Apparently, I'm now so ancient and infirm I get a bigger private health insurance tax rebate.

I never tire of pointing out that, contrary to what people say, our cost of living, overall, has not been rising strongly, unless you regard 2 per cent a year as "soaring".

It is true, however, that a few, easily noticed prices have risen a lot – including the government-regulated price of private health insurance.

My "important milestone" reminds me that people have been complaining about – and I've been writing about – the high cost of private health insurance for as long as I've been an economic journalist.

And the opposition leader of the day – Bill Shorten, as it happens – hasn't resisted the temptation to exploit people's disaffection by putting it firmly on the agenda for this maybe-there'll-be-an-election year.

The popular view is that everyone needs private insurance – if only they could afford it. Which about half of us can't.

Opinion polling by Essential has found that, although a clear majority of people believe "health insurance isn't worth the money you pay for it", 83 per cent of people believe that "the government should do more to keep private health insurance affordable".

The former opinion is right; the latter is delusional. Governments have been trying to keep health insurance affordable on and off for decades, while its cost just keeps climbing.

Why? Because it's a self-defeating process. The more you do to make insurance affordable, the easier you make it for the people running the health funds, the owners of private hospitals and the surgeons and other procedural specialists who work in hospitals, to raise their prices and fatten their profits.

Which the pollies fully understand.

In the old days, health funds were owned by their members, except for the government-owned Medibank Private. These days, three of the biggest funds – Medibank Private, Bupa and NIB – are for-profit providers, thus increasing the pressure on the government to allow big price rises and reducing the chance of getting value for money.

As Ian McAuley, of Canberra University, has written, from a policy perspective health insurance is a high-cost and inequitable way to fund healthcare.

Only 85 cents of every dollar passing through private insurance makes its way to paying for healthcare. And only if you can afford it do you share in the government subsidies taxpayers provide.

From the customers' perspective, it's a con job. Most people under 60 get back only a fraction of what they pay. Often when you do claim you don't get what you expected, because you don't get choice of doctor or a private room, you're caught by ever-changing exclusions from your policy, or because no one warned you about a huge gap payment.

Many buy insurance to avoid waiting times for elective surgery. But if private insurance didn't exist, surgeons would have to earn more of their income from public hospitals and waiting times would be shorter. It creates the problem it purports to solve.

Health insurance is such bad value that, when John Howard sought to prop up the private system, he had to make it subject to a tax rebate. When that didn't work he imposed a Medicare levy surcharge on better-off people who don't have insurance, and imposed escalating prices for people who aren't in a fund by the time they're 31 (which is a con trick on the innumerate).

When the Hawke government reintroduced Medicare, it intended that the universal, taxpayer-funded provision of high quality hospital and medical care would make private insurance unnecessary. Those who preferred the snob status of private care could pay for it from their own pocket.

This is why Labor long opposed public support for private insurance. Shorten, however, has taken a populist line, carrying on about the big increases in premiums and promising to cap them at 2 per cent a year for two years.

Another con. The profit-driven funds would respond either by excluding more procedures from coverage, or by demanding catch-up increases once the cap was lifted (as happened last time).

Private insurance is so counter-productive and so unfair that the best thing would be to end the subsidies and use the saving to improve the performance of the public system. (Howard's claim that his tax rebate would reduce the pressure on public hospitals was always just a fig-leaf to hide his attempt to prop up the two-class system.)

A less politically controversial alternative was first proposed in an Abbott government federalism discussion paper: use the saving to introduce a commonwealth hospital benefit, where the same amount would be paid to the hospital someone chose to go to, whether public or private.

Private hospital beds would stay in the system – at a price fixed by the government – but the parasitic private funds would be out on their own.

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Econocrats are giving up on smaller government

You may not have noticed, but the Productivity Commission's search for "a new policy model" for reform, in reaction to the breakdown of the politicians' "neoliberal consensus", offers better prospects for finally getting the budget under control.

That's because, although the commission doesn't say so, its reformed approach to reform represents a retreat from a central tenet of neoliberal doctrine for the past 30 years: the goal of Smaller Government.

The retreat makes sense for three reasons. First, because attempts to reduce government's role in the economy – think privatisation, deregulation and cuts in government spending – are central to the populist revolt against neoliberalism.

Second, because the smaller-government push has had little success and, particularly in recent times, some spectacular failures – think the attempt to reform TAFE by making vocational education and training "contestable" by for-profit providers, which the commission now admits was a "disastrous intervention".

Third, because, paradoxically, abandoning the goal of smaller government offers a better prospect of budget repair and a return to "fiscal sustainability" (low public debt) via greater control of government spending over the medium term and a lifting of the fatwa against explicit tax increases.

That's partly because, as we've learnt since the ill-fated 2014 budget, the electoral opposition to significant cuts in spending on social security (read the age pension), healthcare and education actually exceeds the resistance to hypothecated tax increases (those linked to worthy spending programs).

But it's also because, as we've known for decades, but chosen to ignore, there's little empirical evidence of a correlation between the size of a country's public sector and its rate of economic growth or macro-economic stability.

Nor has there ever been much empirical evidence that the willingness of high income-earners to work hard - as opposed to "secondary earners" (mainly married women choosing between part-time and full-time work) – is greatly diminished by high rates of income tax.

If there's little evidence favouring smaller government, why's it been central to the neoliberal project? Because a presumption against government intervention is built into the assumptions of the economists' neoclassical model, and because limiting the size of government minimises the taxes and maximises the freedom of the rich and powerful.

The Productivity Commission's new reform agenda unconsciously reveals how much the old agenda of the past 30 years was influenced – and constrained – by the goal of smaller government.

If you're trying to improve productivity, there are two broad approaches. One is to reduce the role of government by privatising government-owned businesses (including natural monopolies), outsourcing the provision of government services, reducing government regulation and reforming taxation in ways believed to improve incentives to work, save and invest.

The alternative approach is to focus on ensuring the nation's education and training system delivers the best skill formation possible – including those skills most useful in the digital economy – and on ensuring spending on public infrastructure is both sufficient and sufficiently well directed to maximise the private sector's productivity, particularly in the big cities.

Get it? The commission's new reform agenda approaches productivity improvement more directly, accepting that the old agenda is well into diminishing returns. In the process it's shifted the goal from smaller government to better government.

The great side benefit of the commission's new policy model is that, as well as seeking to give micro-economic reform a new direction, it improves governments' chances of regaining control over their spending.

As successive federal and state intergenerational reports have shown, by far the greatest source of future growth in combined federal and state spending will be healthcare. The second biggest area of combined spending is on education and training.

The standard, Treasury and Finance-promoted approach to restraining these two spending areas adopted in the Abbott government's first budget was simply to shift a big chunk of spending off the federal budget and on to the budgets of households (the co-payment for GP visits) and the states (slashed federal grants for public hospitals and schools).

The vehemence of the public's opposition to these cuts not only rendered them impossible, it warned off governments of either stripe from trying such an approach again. Malcolm Turnbull's surprise embrace of needs-based school funding covered his retreat from cuts in grants for schools.

The alternative approach to controlling the rate of growth in spending on health and education over the medium term is to get deep into the nitty-gritty of what the respective systems do and how well they're doing it.

It's not hard to believe that improving the quality of service they deliver to patients and students could also reduce waste and inefficiency, thus slowing the rate at which their costs are growing.

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Sorry, but Medicare needs to change

The apparent success of Labor's scare campaign on the Coalition's alleged plans to "privatise Medicare" at last year's election tells us many things – how much we care about the good performance of our healthcare system, how much we like the way healthcare is paid for under Medicare, and how suspicious we are of politicians' plans to change things.

But Medicare is showing its age. It was designed by health economists in the 1960s, implemented by Gough Whitlam in the 1970s, dismantled by Malcolm Fraser, then reinstalled by Hawke and Keating in the 1980s.

Our health has changed a lot since then. Whereas the system is designed to cope with acute illnesses – you catch a bug or have an accident, so you go to your GP, who fixes the problem or refers you to a specialist or, in the extreme, rushes you to hospital – these days we're more likely to suffer from chronic conditions, such as diabetes, mental illness, lung cancer or cardiovascular disease.

That's because higher living standards, improvements in public health and advances in medical technology have reduced the incidence of accidents and infectious diseases, leaving us living lives that are longer, but more anxious and overweight, while suffering from conditions that will stay with us until we drop off.

If you don't have a chronic illness yet, you probably will.

Trouble is, the ageing Medicare system isn't well-suited to this change. GPs are paid according to the number of patients they see for a few minutes – "fee for service".

They're not rewarded for helping patients change their behaviour in ways that prevent the onset of chronic diseases, nor for helping patients manage their conditions in ways that stop them getting worse over time, or needing to go to hospital.

As healthcare has become more expensive, it's clearer that visits to GPs and other frontline health professionals are relatively cheap, whereas visits to specialists are much dearer. Operations and stays in hospital are hugely expensive.

Get it? We could improve people's health and happiness and reduce expense if we made sure the "primary care" provided by GPs and others was as effective as possible in preventing and managing chronic conditions, reducing the need to call on specialists and hospitals.

All this is the thinking behind the Productivity Commission's advocacy of a "new policy model" that shifts tax changes, deregulation and privatisation onto the backburner, and shifts healthcare (and education and cities) to the forefront of economic reform.

The health system suffers from its division of responsibility between federal and state governments, with the states responsible for public hospitals and the feds for most of the rest.

Lack of co-ordination between the parts of the system generates much wasted time and money, not to mention inconvenience and frustration for patients.

So the commission wants a renewed effort to achieve an integrated system.

"The international and Australian experiences with integrated care indicate that, if properly implemented, it leads to gains in health outcomes for patients, improvements in the patient experience of care, reductions in costs, and improved job satisfaction for clinicians," the commission says.

The place for this integration to occur is at the local, regional level. There are about 30 regions in Australia. The commission wants regional health authorities to have freedom to modify national arrangements to suit local conditions.

Public hospitals have already been organised into "local hospital networks" but, after protracted disagreement between Labor and the Coalition, the feds are only now setting up private "primary health networks" contracted to co-ordinate patient care in their locality, including by working collaboratively with the local hospital network.

It's almost inevitable that big outfits like hospitals – but even doctors' surgeries – tend to be run for the convenience of the outfit, rather than the patient.

But the commission wants changes that encourage the system to focus on patients rather than suppliers.

"Patient-centred care gives prominence to the preferences, needs and values of consumers. In a better system, patients' time would be recognised. Patients would be given the information and power to be co-contributors to treatments and disease management," the commission says.

"Medical records would be owned by patients and they would be able to add comments. The commission sees such rights to data as a broad requirement across many public and private services. Where choice was feasible, it would be facilitated."

The digital age has largely eliminated the excuse for different parts of the system – including different doctors – not keeping each other fully informed, and doing so via the patient's own, digitised and portable medical record.

This idea isn't new, but doctors have been dragging their feet and governments need to renew their determination to make it happen.

Using fee-for-service as the main way of paying doctors encourages activity (more visits) whereas it would be better to reward outcomes – successful efforts at preventing chronic conditions or stopping people from needing to go to hospital.

Fee-for-service would continue under a regionally based integrated care model, but its role would diminish as primary health networks and local hospital networks found other ways to remunerate GPs for clinical outcomes.

Little of all this is new, and governments are unlikely to do it all next week. Rather, it's the commission setting priorities for economic reform in general, and healthcare in particular, and urging governments to get on with bringing it to pass.

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Economic rationalists regroup under populist attack

Reading the Productivity Commission's grand plan to "shift the dial" on micro-economic reform gives me a feeling of deja vu all over again.

When I started in this business in the mid-1970s, macro-economics had become a pitched battle between Keynesians and monetarists. It took years for a resolution of that conflict to emerge.

The monetarists didn't win the war, but they did win a lot of battles, and management of the macro economy was changed forever.

Today's great conflict in economics comes in the aftermath of the global financial crisis, as politicians in all the advanced economies abandon the "neoliberal consensus" under pressure from the populist revolt against privatisation, deregulation, austerity and all the rest.

You could say the global rethink of economics began immediately after the crisis, but it's just in the Productivity Commission's latest report proposing a "new policy model" for future change that we see our local "thought leaders" among economic rationalists shifting to an agenda that responds to the criticism of the old approach and proposes a new set of reforms aimed at improving productivity while giving voters far less cause to object.

Why so few commentators have perceived the significance of this "dial shift" is hard to fathom.

Read the report and it sticks out like organ stops. For some years since the crisis, the bosses of the International Monetary Fund, the Organisation for Economic Co-operation and Development, and even the Bank of England have said we need economic growth to be more "inclusive".

Now the Productivity Commission agrees and has reshaped its reform agenda accordingly.

The old agenda accepted the conventional wisdom that economic efficiency and equity (fairness) were in conflict. Since the crisis, however, economists at the fund and the OECD have been producing evidence that increasing inequality inhibits economic growth.

Now our commission agrees, arguing that its proposed shift in the reform dial will avoid "too great a dispersion in incomes, given evidence that this can, in its own right, adversely affect productivity growth".

In shifting reform priorities from changing tax incentives, moving the balance of wage-setting power in favour of employers, deregulating and privatising, to reforming healthcare, education and cities, the commission is attempting to humanise reform.

In setting its main priorities as improving the quality of services delivered to patients, students and commuters, the commission has made ordinary punters the main beneficiaries. What's that if it's not more "inclusive"?

Low and middle-income earners would be the chief winners because the better-off are better able to buy their way out of bad medical treatment, bad teaching and long commutes.

And get this: more efficient and effective healthcare, teaching and cities bring intrinsic benefits to the lives of ordinary people, whether or not they ever "shift the dial" of the measures of productivity that the commission takes so literally (which they quite possibly won't).

The commission's "new policy model" is far better fitted to an economy ever-more oriented to the services sector, and to an economy where the value of knowledge becomes more apparent as each year passes.

What seems to have bamboozled the commentators is the notion that nothing on the commission's new reform agenda is particularly new.

True, but silly. In economics, there's not much that's new under the sun. Sure economists have been rabbiting on for years about the need to reform healthcare and education and – much more recently – "urban economics".

What's new is not the topics but the priority and emphasis they've been given. What's new is sorting through a list of old potential reform topics to find those that tick the efficiency box and the fairness box.

Another uncomprehending reaction has been that many of the specific reforms the commission advocates – road-use charging, for instance – would be politically difficult, and most unlikely to be taken up by the Turnbull government.

True, but beside the point. What's significant is the radical change in thinking about the nature and direction of economic reform, not how long it will take for those reforms to be made.

I've been around long enough to see plenty of politically impossible reforms come to pass.

A more perceptive critique of the "new policy model" is that it takes us straight into territory where the states have as much say as the feds, if not more. No easy country.

And while it's true ordinary voters have much to gain from the new agenda, it's equally true that vested interests in the health, education and city industries have much to lose.

One further lesson from economic rationalism's poor record in recent times is that if you're not game to take on powerful rent-seekers, you won't get far.

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Report heralds big change in economic reform priorities

Government reports come and go with great rapidity. Some are acted on, most are quickly pigeonholed. Last week Scott Morrison tabled a report from the Productivity Commission called Shifting the Dial, but it was soon lost amid all the excitement about raids on a union and politicians being thrown out of their jobs.

Despite this inauspicious beginning, let me make a fearless prediction: when the history of the economy in the early decades of the 21st century is written, this report will get prominence.

Why? Not because this government or the next will rush out to implement its recommendations, but because it will be seen as a turning point in the thinking of the nation's economic advisers.

The populist revolt against the doctrines of "neoliberalism" – or economic rationalism, as we've called it in Australia – has been apparent for most of this year. It's been apparent since the middle of the year that the long-running bipartisan consensus in support of neoliberalism in the advanced economies has collapsed.

But where to now? The economy and its apparatus are far from perfect and there's always something that needs working on. The econocrats need something to be working on to justify their existence, so what are they to do now that so many citizens are jack of deregulation and privatisation?

Well, now we know. Ostensibly, the commission's report is just the first of many five-yearly reports on ways to improve the economy's "productivity" – its ability to increase its outputs of goods and services faster than the increase in its inputs of land, labour and capital – the magic that's made us so much richer than our great-grandparents.

The Productivity Commission, would you believe, is preoccupied with productivity. Same old, same old.

Don't be deceived. The commission – formerly a leader of the economic rationalist charge – has taken the initiative in proposing an agenda for economic improvement that's quite different to what we've had so far.

Its new agenda attempts to restore public support for economic "reform" (a word it tries to avoid) by responding to popular criticism of the push that, while well-intentioned and necessary when it originated in the Hawke-Keating years, has since seemed to degenerate into "bizonomics" – what's good for big business is good for the rest of us.

Gone is the unending obsession with tax reform (cutting the rates of tax on companies and high-earning individuals) and industrial relations (cutting penalty rates and shifting bargaining power in favour of employers).

In their place, the commission focuses on three big issues: healthcare, education and cities.

On health, it argues there needs to be more emphasis on preventing and managing the growing incidence of chronic illnesses, such as diabetes. This may involve less reliance on paying doctors according to fee-for-service.

The health system – state-run public hospitals in one box, most doctors in another and pharmaceuticals in a third – needs to be better integrated so as to make it more centred on the needs of patients rather than the suppliers of health care.

This greater co-ordination should happen at the local level.

On education, too many students are being let down at every level.

The commission finds that school results are deteriorating, vocational education and training is "a mess" and universities are more concerned with publishing research papers than improving teaching standards.

As for cities, they produce a growing portion of our gross domestic product – about 80 per cent, with Sydney and Melbourne accounting for half of that.

By the time we reach 2050, almost 11 million extra people will be squeezed into our capital cities, according to Morrison.

The social costs of congestion in our capital cities will grow from almost $19 billion a year in 2015 to more than $31 billion a year by 2030, we're told.

See how different all this is to the economic reform talk we're used to?

It's shifted the focus from business to the "non-market economy" run mainly by government bodies. It's less concerned with mining, farming and manufacturing, and more with the services sector.

Its approach to reform is bottom-up – concentrate on the needs of patients and students, on getting to work – not trickle down.

Putting it another way, it's people-friendly, not business-friendly.

The three issues are two-sided: they directly affect the wellbeing of individuals, but also the nation's productivity, as a healthier, better-skilled workforce gets to work more easily.

This means the "reform agenda" ought to be a lot more relevant and appealing to ordinary voters. It also means it can be pursued by either side of politics.

One of the great objections to the old agenda was fear that it benefited the better-off at the expense of the rest of us.

Rest easy – the commission has got the message.

"A key issue will be to ensure that future economic, social and environmental policies sustain inclusive [note that word]growth – by no means guaranteed given current policy settings, and prospective technological and labour market pressures ...

"One of the advantages of better healthcare, education systems and cities is that they provide strong prospects for improving lifetime outcomes for people from all backgrounds.

"Indeed, improvements in these areas have the potential to decrease health inequalities, and reduce job insecurity and wage risks for those whose skills are at most risk from technological change," the commission concludes.

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How Medicare needs to be improved

It's the time of year when treasurers and finance ministers, asked about the content of the budget, reply with righteous indignation that we'll just have to wait, as though they've been asked to break the official secrets act, while their ministerial colleagues are busily leaking or even announcing large slabs of what's to come.

Why do politicians indulge in this tiresome charade? Because they want to be sure we know about the nice bits, while delaying our knowledge of the nasty bits as long as possible.

They haven't yet leaked much about what lies in store on healthcare, though what we have been told is benign. The government, which in its first budget told us healthcare spending was growing "unsustainably", is adding a lot of hugely expensive new drugs to the pharmaceutical benefits scheme.

And it seems the freeze on the rates of Medicare rebates – including bulk-billing payments to doctors – is to be eased, at a cost of $500 million over several years.

There's sure to be some bad news on health hidden in the budget but, after the success of Labor's scare campaign at last year's election, alleging the Coalition wanted to "privatise" Medicare, it's a safe bet it won't be too terrible. No one got a bigger scare than Malcolm Turnbull.

Voters have always been strongly attached to Medicare – by which they mean not having to shell out when they go to a bulk-billing GP – and Labor was trying to reawaken voters' resentment when, in its first budget, the government proposed a GP co-payment of $7 a pop.

The element of truth in Labor's scare was that, if you froze bulk-billing rebates for too long, GPs would begin to break out and start charging their own co-payments.

That's the political reason the freeze is to be eased. The Turnbull government will never again make controversial changes its opponents could characterise, however wrongly, as "privatising" Medicare.

Most of the things you could do to limit the growth in healthcare spending involve cutting the incomes of doctors, or at least restraining the rate at which they're growing.

So, whenever governments try, the doctors resort to their own scare campaign, telling their patients – the older and more pitiable the better – the government is forcing them to charge, say, $3000 for having their cataracts fixed.

Few people could afford to pay such prices – which is why, in reality, they'd never happen – but that doesn't stop old ladies taking their indignation to a slavering tabloid media or beating down the doors of their local member.

But it's a great pity to have the government running scared of making changes to Medicare. There's a lot of inefficiency in our present arrangements which, if we could reduce it, would slow the rate at which the healthcare bill is growing and so ease the burden on taxpayers, without harming patients.

Indeed, as Dr Stephen Duckett (a real doctor, not a medico), of the Grattan Institute, argues in a new report, Building better Foundations for Primary Care, a more efficient system could give some patients better care by reducing the need for them to go into hospital.

Much has changed since Medicare was first installed in the 1970s. It needs to be brought up to date without weakening its key features.

One thing that's changed is the rising average age of the population, meaning that more doctor visits are about chronic (lasting) conditions – such as diabetes, asthma or heart disease – rather than acute (temporary) problems.

So GPs need to spend more time helping their patients manage their chronic conditions (older patients will often have more than one), which requires longer but (we hope) fewer consultations.

But, as Duckett and his colleagues explain, Medicare's present system of rebated fee-for-service, acts to discourage such better assistance to chronic sufferers.

It gives GPs a financial incentive to increase the number of services provided, but also keep them short.

It would be better to pay GPs a (higher) fee for successfully managing a patient's chronic condition. But that's well down the track. First things first.

"Primary care" is the medicos' term for a patient's first point of contact with the healthcare system. It could be a hospital emergency ward or an "allied health service", but mainly it's GPs.

Health experts have long known that the key to an efficient and effective health care system is to get primary care working well. GPs get paid a lot less than specialists, but they're probably more important to ensuring good patient care.

Our primary care doesn't work well enough to be called a "system", mainly because of squabbling between federal and state governments and the absence of clear lines of responsibility.

Duckett says we need a primary care agreement between the two levels of government and the primary health networks, which should be given more resources, responsibility and accountability.

But first we need much more information about what happens in general practice, so sensible targets can be set for improved performance.

Since almost all GPs use a computer program when seeing patients, such (de-identified) information could be supplied with little additional effort or cost.

If the government is about to ease the screws on GPs' incomes to the tune of half a billion dollars, it should make this conditional on them providing the information needed.

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Someone has to give if we’re to fix the budget

The nation's budget problem still won't be solved when, one day in the distant future, we get the federal budget back into surplus. Only a change in strategy is likely to produce a sustained solution.

As successive intergenerational reports demonstrate, on present policies government spending will just grow and grow, requiring ever-higher taxes.

If we don't like that idea – or politicians regard it as an impossible sell – we need to think a lot harder about what we're spending on, why it's growing so fast, what things we should stop spending on, and how we can make our spending more effective, in the process slowing the rate at which it's growing.

The five biggest areas of spending include welfare benefits, health, education and infrastructure. Infrastructure's too important to share a column, so we'll return to it.

But it, plus health and education, are even bigger when you remember how they dominate the states' budgets – a reminder that federal and state budgets need to be considered together, and that cutting federal grants to the states, and cost-shifting by the states back to the feds, aren't genuine solutions.

Of three categories – welfare benefits, health and education – the intergenerational reports make it clear health will be by far the fastest growing.

That's not so much because of ageing as because advances in medical technology are hugely expensive, and it's quite unrealistic to imagine that Australian voters will settle for anything less than gaining subsidised access to the latest and best technology ASAP.

Since this is the political reality, the problem (and much of the pressure on budgets) is easily solved.

Our politicians simply need to be brave and tell voters the truth: if they want ever more and better healthcare then, as with everything else, they'll have to pay more for it – in the form of, say, regular increases in the Medicare levy.

That's the fundamental solution, but we could also do more to slow the rate of growth in healthcare spending by removing at least some of the waste and inefficiency that everyone in the system tells us exists.

Much could be done to make education spending more effective. Instead, however, since the national knockback of the 2014 federal budget, the government's done little but crack down on the previous year's crackdown on the welfare cheats the Liberal hard right has convinced itself are ripping off billions every year.

Sorry, not nearly good enough. Nor is preaching the evils of tax increases while you wait for bracket creep to claw back the eight successive tax cuts we were awarded when Peter Costello thought the resources boom would run forever.

The trouble with many professed supporters of Smaller Government is that they want to have their cake and eat it.

They want to reduce government spending so they can pay less tax, but they don't want to give up the middle-class welfare they enjoy – much of it awarded to them by the great man who didn't believe in smaller government, John Howard.

Much of Howard's handouts to the comfortable came in the fifth big spending area, tax expenditures – which have the same cost to the budget as ordinary expenditures, but are hidden away on the tax side where they aren't noticed.

These include various new benefits for supposedly self-funded retirees, the private health insurance tax rebate, big increases in grants to non-government schools and Costello's unsustainably generous increase in superannuation tax concessions for high income earners.

To be fair, Malcolm Turnbull has made a good start to cutting back the super concessions – over the vociferous opposition of his hard right backbench.

More must be done to cut back rapidly growing tax expenditures.

But if we're genuine about achieving fiscal sustainability while restraining the rise in tax rates, we need to embrace a new principle to sit beside our heavily means-tested welfare system (which is the main reason Australia's overall level of taxation is so much lower than almost every other developed economy).

The companion principle should be: we're no longer prepared to subsidise positional goods in the name of encouraging "choice".

We'll put all our effort into providing a good public health system and a good public education system, and that's it.

Of course, it's a free country and if you think you can do better than the public system by making private arrangements, feel free.

But don't expect other taxpayers to subsidise your efforts to get better than they're getting.

In any case, the easier you make it for punters to enjoy positional goods, the less positional you make them, cheating the better-off of their feeling of superiority.

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'Nanny state' is cover for exploitation by commercial interests

Oh no, the nanny state brigade is at it again. In their certainty they know what's best for us, they're back with their social engineering, wanting to punish us for being fat and use a tax on sugary drinks to push us towards "healthier choices".

On Wednesday the Grattan Institute will release a report urging the federal government to impose an excise of 40¢ per 100 grams of sugar on non-alcoholic beverages that contain added sugar.

What part of personal freedom don't they understand? If people want to drink sugary drinks, why should anyone else try to stop them? What harm are they doing to others?

Surely this is a matter of personal choice and responsibility. If being fat is bad for the health, it's up to the individual to accept responsibility for their own fate and decide to eat less and exercise more.

How much of our lives is the government going to take over? What willpower will be left if they keep doing more of this stuff?

Actually, I'm never convinced by these arguments from the professed defenders of our personal liberty.

Whenever I hear people banging on about "the nanny state" I wonder about their motives. Many of the critics are trying to keep government small so they're required to pay less tax.

These souls are often full of their own virtue. They attribute their comfortable circumstances entirely to their own efforts (forgetting the outside help they invariably had) and can't see why they should help others who aren't as disciplined as they are.

As for the libertarian think tanks leading the charge against the nanny state, you wonder how many of their undisclosed (but tax deductible) donations come from alcohol, tobacco and food companies anxious to resist any government measure limiting their freedom to profit from unhealthy products.

As the Grattan report – written by Hal Swerissen and Professor Stephen Duckett, a leading health economist – reminds us, there's little doubt that excessive overweight increases the risk of premature death, diabetes and cardiovascular disease.

Yet the incidence of obesity – a body mass index of more than 30 – is growing in the rich countries. The proportion of obese Australian adults is 28 per cent, up from less than 10 per cent in the 1980s. That's not counting the further 36 per cent who are overweight.

About 7 per cent of Australian children are obese, up from a negligible number in the '80s.

Although it may have plateaued among children, obesity continues to worsen among adults and seems likely to increase further.

Research suggests the main cause is overeating of processed food laced with sugar, fat and salt, which grows ever cheaper and available. The amount of exercise we get hasn't changed much over that time.

Health authorities and governments have been worried about an "obesity epidemic" for years, but nothing they've done so far seems to have worked.

This is probably because they've been tiptoeing around the powerful commercial food interests, focusing on individual responsibility, physical exercise and voluntary food labelling.

I agree it's time we did something more assertive and, though a tax on sugary drinks is far from a cure-all, it's a good place to start.

Lots of other countries are doing it, and have shown it works in discouraging consumption of sugary drinks and reducing obesity somewhat.

For us to impose it as a federal excise would be simple and administratively cheap. We already have excises intended to discourage us from smoking and overconsuming alcoholic beverages.

It would be paid by manufacturers and importers, then passed on to consumers, which would encourage people to move to bottled water, artificially sweetened drinks or even tap water.

A principle of libertarianism is that you should be allowed to do as you please as long as you're not harming others.

But as well as harming themselves, the obese also harm the rest of us. Evidence shows that, relative to others, the obese make more use of doctors, hospitals and pharmaceutical benefits.

All these impose higher costs on other taxpayers. Obese people are more likely to be on welfare benefits and less likely to be employed and paying income tax, which imposes further cost on other taxpayers.

Grattan estimates the cost to the rest of us is about $5 billion a year. The sugary drinks tax would recoup about $500 million a year of that.

Libertarianism assumes no one could possibly know our best interests better than ourselves. That's because we are unfailingly rational in the decisions we make. We have an iron will which stops us doing anything we later come to regret or being influenced by the behaviour of those around us.

In reality, all of us have a problem with self-control in at least one area of our lives and probably several.

And here's the bit nanny's critics never get: most of us are pleased when governments help us with our self-control problem by taking temptation out of our way.

Governments have used compulsory seat belts and random breath testing to reduce road deaths per head of population by more than 80 per cent. They've used sky high tobacco tax, bans on indoor smoking and other things to cut the rate of smoking by more than half.

It's high time they stood up to the processed food industry and did something effective about obesity.

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Who really wins from Mediscare

The success of Labor's "Mediscare" in this election is worrying - but not for the reason you may imagine. Its greatest effect may be to fatten the incomes of medical specialists and corporate medical suppliers.

Scare campaigns are often effective politically, but they can impose a high price on the country's good government.

Tony Abbott's highly successful scare about depredations of the carbon tax at the last election has left us bereft of an effective and relatively low-cost means of reducing our greenhouse gas emissions at a time when climate change is worsening and we've been obliged by international pressure to agree to a tighter target.

Bill Shorten's claim that the Coalition is bent on privatising Medicare could leave us with politicians of all colours lacking the courage to do anything to restrain the rapid growth in federal and state spending on healthcare by insisting on greater efficiency and more realistic charges for medical services.

The people who work in the House with the Flag on Top take just a few days after an election to reach agreement on why the winners won and the losers lost.

Right or wrong, this conventional wisdom sticks in the minds of pollies on both sides for many years.

Should the politicians conclude that the wrath of voters will descend on any government caught making any change that could, by any stretch, be described as privatising Medicare, the people making excessive incomes out of healthcare will be laughing and the rest of us will be paying.

Labor's Mediscare was more subtle than Abbott's crude claims that the carbon tax would wipe out Whyalla and lift the price of a lamb roast to $100.

Its distortion and exaggeration was based on the meaning attached that emotive word "privatisation". We know from repeated polling that voters overwhelmingly disapprove of all privatisation.

The righteous indignation with which ministers condemned Labor's claim as "extraordinarily dishonest", an "absolute lie" and "some of the most systematic, well-funded lies ever peddled" rest on a narrow interpretation of the word.

Privatisation means taking a profitable government-owned business and selling it off to private interests. Since Medicare isn't a profitable business, the claim is absurd.

Labor, however, was using the word more broadly to mean any change that involves reducing the role of government and increasing the participation of private businesses.

Its pretext for making its claim was the Turnbull government's intention to save a little money by shifting the processing of Medicare's many bank transfers from its giant cheque-writing agency, the Department of Human Services, to a private provider.

We wouldn't even have noticed this back-office switch, but Malcolm Turnbull felt obliged to swear the proposal would be abandoned.

But the effectiveness of this scare - and the vehemence of the Coalition's denials - rests on its large element of truth.

Labor was relying on voters remembering Abbott's broken promise to leave Medicare untouched with his first budget's plan to impose a $7 co-payment on pathology tests and GP visits.

The outcry forced him to abandon that plan. In subsequent budgets, however, the government has sought to achieve savings by ending the extra bulk-billing incentives paid to providers of pathology tests and by continuing from 2014 until 2020 the freeze on increases on the schedule fees doctors receive under bulk-billing.

Here the doctors' union has been doing Labor's work by scaring their patients with claims this would force them to abandon bulk-billing and charge big co-payments.

This is untrue in the case of path tests (where the schedule fee far exceeds the costs incurred by the two big public companies that bulk-process three-quarters of our tests) and greatly exaggerated in the case of the continuing freeze on schedule fees.

But what does the public take the word Medicare to mean? I think we're mainly referring to bulk-billing and the federal grants for state government public hospitals, which are conditional on hospital services being free of direct charge.

The public loves bulk-billing because it provides the illusion of something for nothing. But the Coalition has decades of hostility to bulk-billing. The $7 co-payment was an attempt to break it down immediately and the continuing freeze on schedule fees will break it down slowly.

This was the element of truth in Mediscare. What's more, the Coalition still plans to press on with most of Abbott's cuts in grants for public hospitals of $57 billion over 10 years.

The public's attachment to bulk-billing may be irrational, but health economists have two rational reasons for wanting it to survive.

First, it adds to the overall efficiency of the healthcare system by reducing the amount doctors need to spend on billing and collecting money. This is why doctors' initial opposition to bulk-billing turned to support.

Second, because its continuation is so valuable to doctors, bulk-billing gives the government of the day the ability to limit the annual increase in GPs' and pathologists' fees - provided it doesn't push the doctors too far.

Ever-rising healthcare costs are the biggest single threat to combined federal and state budgets. There is scope for the removal of inefficiencies that do more to line medical pockets than benefit patients.

In every case, doctors will resist the removal of those inefficiencies by telling their patients it's an attack on Medicare, not the doctors' wallets. That's why the success of Mediscare is a worry.

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Doctors share blame for a sick budget

Some of my best friends are doctors. These days, I even have in-laws who are doctors. I've just become a grandad and my tiny grandson stands a fair chance of ending up as a doctor, too.

But I'm still a journo, and have to do my job. So let me let me adapt something Kerry Packer said about a youthful Malcolm Turnbull: never get between a doctor and bag of money.

If you wonder why it will be so long before we get the federal budget back into surplus, doctors are part of the reason.

If, as Scott Morrison keeps telling us, the trouble with the budget is a spending problem, not a revenue problem, the government's decision last week to greatly increase our spending on defence has just made the problem a lot worse.

That's the problem with saying government spending is the problem. Politicians – of all stripes – are much keener on increasing spending than on reducing it.

A lot of the growth in spending – especially if you include the state governments – is coming from spending on healthcare. Part of it's the ageing of the population, but most of it's the higher cost of new pharmaceuticals, prosthetics and medical procedures.

There's actually nothing terrible about that. If we're getting a little more prosperous each year, what's more natural than that we choose to spend a fair bit of that increase on improving our health?

If so, the problem isn't our spending, it's our reluctance to pay for it. Which means the real problem with the budget is the aversion of pollies on both sides to confronting voters with that simple truth: if you want more spending on better healthcare you're welcome to it but, as with everything else in life, you'll have to pay more for it.

The problem with the debate about spending and taxing is that government budgets are so huge – about $430 billion a year, and a lot more if you add in the states – with so many taxes spent on such a multitude of things – that it's easy for each of us to lose our sense of cause and effect, in a way we'd never do with our own, household budget.

But to say that spending on healthcare should and will continue growing strongly – so the pollies had better learn to live with that fact – is not to say that every dollar spent on health is a dollar well spent.

Every doctor I know tells me there's plenty of waste in the health system. Governments should be trying to find and eliminate that waste, thereby giving taxpayers better value for money, as well as slowing the rate of healthcare spending's inexorable rise.

Here I have to tell you that, under the greatly improved leadership of federal Health Minister Sussan Ley, and after the public's summary rejection of the harebrained idea of imposing a $7-a-pop patient co-payment on GP visits, the Health Department is making a much better effort to identify and remove waste.

Trouble is, just because a payment is judged unnecessary doesn't mean there isn't someone for whom that payment is part of their income. Threaten to take it away and all hell breaks loose as they fight to protect that income. Especially if they're a doctor.

Late last year the Turnbull government proposed saving $650 million over four years by removing bulk-billing incentives for pathology services and reducing them for diagnostic imaging.

The boss of the nation's most powerful union, aka the Australian Medical Association, was out of the blocks within moments, prophesying death and destruction.

Doctors would have no choice but to impose their own charges on patients, many of whom would struggle to afford them, leaving some poor people declining to get the tests they needed.

Yeah, sure.

Some years ago the Labor government tried to save money by cutting the rebate for eye operations. The ophthalmologists created an enormous stink, telling every little old lady they could find they'd have to start charging thousands for a cataract removal and urging them to write to their local member.

It worked. The Labor government beat a hasty retreat. Some years later, a doctor mate told me everyone in medicine knew the opthos were raking it in. The fees in the medical benefits schedule had been set long before the procedure had become highly automated, allowing surgeons to do far more operations in a day.

Everyone in medicine knew this, but while the opthos were bludgeoning the government, they kept their mouths shut – a practice known as "professionalism".

It's a similar story with pathology rebates. Advances in automation have made the rebates far higher than they need to be – which is why the special bulk-billing incentives aren't needed.

And because automation also offers big economies of scale, we now have about three-quarters of the nation's pathology tests being done by just two big companies, both listed on the stock exchange – a small fact the AMA boss didn't feel he needed to mention.

For once, this isn't about greedy specialists. This is a fight to protect the excessive profits of two big listed companies. But please still write to your local member.

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Too many 'no-brainer' cures for health, education

If the tax system and industrial relations aren't high priorities on my reform agenda, what does deserve to be at the top of the list? It's obvious: health and education are crying out for attention.

There are many reasons why economic reformers should be paying more attention than they are to education and health. One is that they're bedrock responsibilities of government.

The second is that each of them constitutes a major industry, big enough for a poor performance to be significant at the macro-economic level. Together they account for 11 per cent of gross domestic product, but for technical reasons this understates their significance.

A better indication of their contribution to economic activity is given by their shares of total employment. Education and training accounts for 8 per cent all jobs, making it a bigger employer than manufacturing.

Health care and social assistance is actually our biggest industry by far, accounting for almost 13 per cent of all jobs. All told, these two public sector-dominated industries account for more than one worker in five, 2.5 million souls.

A third reason for giving health and education more attention than economists have done is that their unavoidable – and, indeed, desirable – high degree of government regulation and participation means normal market disciplines are missing, making them more susceptible to waste and ineffectiveness.

Every doctor or health worker will tell you of waste in the health system, while the anti-government brigade is right in saying there's little evidence of improvement to show for all the extra money we've pumped into education in recent years.

A fourth reason is the intrinsic importance of both industries. Not many industries have more significant effects on our lives, wellbeing and quest for longevity than healthcare. Education hugely influences the quality of our lives and, to get mercenary, our earning capacity as individuals and as a nation.

It's amazing how business people and economists wring their hands over our supposedly weak productivity performance without ever concluding it means we should leave no stone unturned to get education right at every level, from early childhood development to post-grad research.

In the era of the information economy, any country that's stuffing up education at almost every level the way we are is asking to be relegated to the ranks of the poor and needy.

The final reason is that, precisely because government involvement in health and education is unavoidable, they constitute a major part of government spending – federal and state – and thus a major part of the other dimension of our economic challenge: budget repair.

Study the successive Treasury intergenerational reports – federal and state – and a single fact leaps out: the one, overwhelming threat to future budgets is the projected ever-growing cost of health care, only part of which is explained by an ageing population.

Which brings me to the point: econocrats are frequently involved in governments' unceasing decisions about health and education, but that involvement is much more focused on achieving budget savings than on ensuring all the government regulation and subsidisation of health and education leaves us with health and education systems that deliver Australians value for money both socially and economically.

Like so many of the interest groups, econocrats are obsessed with funding education and health rather than ensuring both systems are working in ways that have found a good trade-off between fairness and efficiency and effectiveness.

Quite frankly, when Treasury and Finance put on their expenditure review committee hats their contribution to the decision-making process is more likely to be welfare-diminishing than welfare-enhancing.

Their first besetting sin is short-sightedness. Forgetting (as we usually do) that knowledge is valuable for its own sake, education is all about long-term investment in human capital. But who can worry about that when we're pulling out all the stops to ensure this year's budget deficit doesn't look bad?

In health, it's obvious that well-chosen preventive health measures will yield big payoffs to taxpayers down the track. But when the heat was on in the first Abbott/Hockey budget, preventive health measures were among the first items thrown on the bonfire.

The econocrats' other besetting sin is what I call "no-brainer" economics. Don't bother learning about the specifics of the field you're dealing with, don't consult the health economists – if there are education economists out there I wish they'd get in touch – just wade in with your pocket-rocket model of all markets and propose "getting the [exclusively monetary] incentives right" and "introducing competition" from for-profit providers (such as shonky vocational "colleges").

Is this the best economists can do? If so, they're part of the problem and need reforming.

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Let’s not repeat our many competition stuff-ups

The belief that increased competition leads to greater efficiency and higher productivity is one of the articles of faith for admission to the economic priesthood.

Economic practitioners often know little about the peculiarities of particular markets – about their specific areas of market failure – and often don't think they need to know because what they do know about is their profession's two magic answers to inefficiency.

The first is to "get the incentives right" (the claimed rationale for much tax reform) and the second is to increase competitive pressure.

There's a lot of truth to both propositions, but not as much as it suits economists to believe. Because it comes from their model of markets, many economists' belief that the more competition the better – and the more choice the better – is so deeply ingrained it requires no empirical confirmation.

This makes economists chronic sufferers from what psychologists call "confirmation bias" – they make a mental note of all the examples they see that seem to confirm their pre-existing views about how the economy works, but quickly forget those examples that don't.

So when the Turnbull government confidently asserts that implementing the many recommendations of Professor Ian Harper's review of competition policy will do much to lift the economy's rate of productivity improvement, few economists are inclined to demur.

Many of the reforms Harper proposes make much sense: ending the protection of chemists, coastal shipping and the owners of taxi licences and intellectual property, rationalising the pricing regimes for roads and water, and changing to an "effects test" in trade practices law.

Initially, Harper wanted deregulation of liquor licensing laws, but pulled back when economists who did know about the market failures in the area showed him evidence of the significant "negative social externalities​" (e.g. people getting bashed outside pubs) associated with alcohol consumption. Who knew?

Unfortunately, Harper's church-going ways haven't helped him appreciate the potentially adverse effects on family life – family life? Why would an economist know or care about family life? – arising from further deregulation of retail trading hours.

We'll see how many of Harper's braver proposals are actually implemented. In any case, most of them are up to the premiers, not the feds.

But the most potentially alarming is Harper's proposal that the principles of competition policy be extended to the domain of "human services" – healthcare, education and community services – which is mainly the responsibility of the states.

There's no denying that health and education are areas of huge government spending and economic significance, replete with inefficiencies and ineffectiveness. They ought to be much higher on the reform agenda than yet more tinkering with the tax system and the wage-fixing rules.

But to frame them as part of competition policy is an old economists' trick: take an area that's always been outside the marketplace and marketise​ it. Take the world as it is and make it more like the textbook assumes it to be.

Apply the economists' two magic answers – getting the incentives right and introducing competition and choice – and everything will fix itself without the economists ever needing to come to grips with the causes of the particular inefficiencies that are causing the problem.

Brilliant. But often disastrous. Think of the string of stuff-ups that have followed the econocrats' efforts to contract-out the provision of government services.

Think of the allegations of widespread rorting by operators of the job services network that replaced the Commonwealth Employment Service.

Think of the way contracting-out of childcare services allowed the rise and collapse of ABC Learning, at great cost and inconvenience to parents and taxpayers.

Think of last week's collapse of Vocation Ltd and the much wider rorting of the misguided experiment with profit-motivated provision of higher education. Federal and state "reformers" are totally stuffing up vocational education in response to the problems with TAFE.

Think of all the money federal taxpayers have pumped into private schools in the sacred name of choice, without any evidence of this wider competition leading to higher standards of education on either side of the fence.

Think of all the effort put into the MySchool website to promote choice and competition while our scores continue to slide on the international indicators of literacy and numeracy.

Even the pink batts scheme is an example of the disaster – and death – that can follow when you naively give profit-motivated business people a pipeline into government coffers.

Sorry, econocrats. If you want to achieve genuine improvements in the delivery of health and education and community services, you'll have to try a mighty lot harder than applying magic answers.

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Go to ex-bureaucrats' blogs for the good oil on policy

Dr Ken Henry, a former Treasury secretary, says he can't recall a time when the debate about public policies has been poorer. I can't either, and I guess the dreaded MSM - mainstream media - is part of the problem.

But if the challenge of digital disruption has tempted the mainstream to devote more time to political colour and movement and less to debating government policies, there's one respect in which the internet has made things better.

The advent of blogging has given anyone who wants to the ability to air their thoughts to the world. A lot of blogs come under the heading of you're-entitled-to-your-opinion, but sometimes they're written by people who know a lot more about the topic than most of us and have a valuable contribution to make.

That's particularly true when academics take to blogging. One of the earliest bloggers about economic policy  was Professor John Quiggin, of Queensland University. Other high quality Australian blogsites are Club Troppo, Core Economics and, for the more libertarian, Catallaxy Files. (There was a blog called Ross Gittins, Corrected but they seem to have given up.)

The best academic blogsite is undoubtedly the uni-sponsored The Conversation. To have all those academics writing short, timely, readable pieces in their area of specialty is an invaluable contribution to the policy debate.

And then there's the blog of the former bureaucrat John Menadue, called Pearls and Irritations. Menadue brings in other contributors, and his blog is the place to go to see ex-bureaucrats casting a critical eye over present government policy.

These guys know where the bodies are buried, and no one sees through the political smoke and mirrors  more easily than they do.

Earlier this year Menadue teamed up with the former econocrat Dr Mike Keating to instigate a special series on the many challenges facing the government today, called Fairness, Opportunity and Security, with a wide range of contributions from ex-bureaucrats (including Stephen Fitzgerald, David Charles, Andrew Podger and Jon Stanford), academics (including Michael Wesley, Ian Marsh, Ian McAuley and Julianne Schultz) and academics who've spent time in government (including Ross Garnaut, Glenn Withers and Stuart Harris).

Now Menadue and Keating have turned the series into a book of the same name, published by AFT Press, which they asked me to launch last week. It covers 13 topics ranging from the role of government to the economy, foreign policy, health, the environment and Indigenous affairs.

In his discussion of the way vested interests seem to have excessive influence over policymaking, Menadue notes the remarkable rise of the lobbying industry, estimating there are now more than 1000 lobbyists operating in Canberra.

"The health 'debate' is really between the minister and the Australian Medical Association, the Australian Pharmacy Guild, Medicines Australia and the private health insurance companies," he writes.

"The debate is not with the public about health policy and strategy; it is about how the minister and the department manage the vested interests."

Menadue says much of the policy skills in Canberra departments have been downgraded and policy work is contracted out to accounting and consultancy firms. Policy work within the government is now undertaken more in specialist organisation such as the Productivity Commission.

"Departmental policy capability has been seriously eroded. That is the real story behind the problems of the pink batts scheme."

As for the "inexperienced and young ministerial staffers", they're "much more likely to listen to vested interests".

On foreign affairs and internal security, the blog collection says we've become overdependent on the United States at the expense of our relations in our region. As Paul Keating once said, we should be "finding our security in, not from, Asia".

In dealing with the threat from terrorism, "a balance needs to be struck between national security and the freedoms essential for a civil society, including the humane treatment of refugees. The politicisation of security has arguably made us less safe."

On Medicare we're told it "has stood the test of time but it now represents the single biggest budgetary challenge and it is over 30 years since it has been seriously reviewed and reformed".

On superannuation, Andrew Podger, former head of various government departments and now a professor at the Australian National University's Crawford School of Public Policy, makes a plea for considered and balanced reform rather than piecemeal tinkering.

You'll go a long way before you find someone providing a more authoritative, independent and sensible commentary on budget repair and other fiscal matters than Mike Keating, former head of the Finance department and Prime Minister's and Cabinet.

In this book he has hardheaded things to say about the dream of lower taxation, which "has been embraced by all political parties without any evidence that, given our already low starting point, less taxation will in fact lead to higher economic growth, let alone pay for itself".

He quotes John Howard saying that tax cuts should be considered only "after you have met all the necessary and socially desirable expenditures".

All the evidence is that these spending demands, even if efficiently funded, are most unlikely to be fiscally sustainable without a modest increase in taxation relative to gross domestic product.

"Indeed, Australia already has lower taxation than almost any other advanced nation, but we aim to provide the same level of public services and welfare as the others," he writes.

"Thus the biggest challenge facing modern governments is the gap between expectations on them and their capacity to deliver.

"In these circumstances, encouraging unrealistic expectations of tax cuts is only making government more difficult."

Reading this collection of blogs leaves you with the impression the good bureaucratic advice our successive governments have needed to do a better job of running the country now resides outside the public service, in the minds of the retired bureaucrats who're from the days when they were expected to know about policy.

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Our poor treatment of mental illness is costing us

Don't take this as implying that I condone the misuse of taxpayers' money, but the almighty to-do over politicians' "entitlements" reminds me that small things annoy small minds.

If you think the odd unnecessary $5000 helicopter ride constitutes the worst of the wastage of our money – or that it makes much difference to the $430 billion the federal government spends each year – you haven't done enough thinking.

As several people reminded me at the Byron Bay Writers' Festival at the weekend, such matters as politicians' pay and perks pale into insignificance compared with the threat to our way of life posed by climate change and other continuing environmental damage.

My conscience tells me that, for as long our response to that threat remains so inadequate – including our inadequate contribution to the success of the Paris climate change conference in December – I shouldn't be writing about anything less consequential.

But we ought to be able to juggle more than one problem at a time, and although climate change is our most pressing problem, it's far from our only one.

One combined threat and opportunity that 'coptergate prevented from getting the attention it deserved last week is one we should have been on to long ago. It was raised in a noteworthy speech to the National Press Club by Professor Allan Fels, now chairman of the National Mental Health Commission (and with a family interest in the topic).

Fels' point was that we've been making a hash of mental health for ages, but that if we got our act together, we could not only reduce the misery of up to 3.7 million Australians, but eventually do everyone else a favour.

Fels is, of course, a professor of economics. So he spoke with authority when he argued that mental health is not just a significant social issue – although that should be enough to make us pay attention – it's a significant economic problem as well.

"Mental health is a significant problem for our economy – as significant as, often more significant than, tax or micro-economic reform," he says. (More significant than tax? Not possible.)

"Many people do not get the support they need, and governments get poor returns on substantial investment. The economic or gross domestic product gains from better mental health would dwarf most of the gains – often modest ones – being talked about in current economic reform debates."

The Organisation for Economic Co-operation and Development estimates that the average overall cost of mental health problems to developed countries is about 4 per cent of GDP. In Australia, this would equate to more than $60 billion a year, or about $4000 for each person who lodges a tax return, or more than $10,000 a family.

Those costs include the direct costs of treatment, plus the indirect costs, such as disability support pensions, imprisonment, accommodation and so on, plus the costs of lost production and income, plus the costs to carers and families and their reduced participation in the workforce.

But just what is the mental illness we're talking about? Of the 3.7 million Australians estimated to have mental health problems in any year, 3 million have a mild to moderate condition, such as anxiety or depression at a clinical level.

It's because so many people with "common" mental disorders are employed – and unemployed – that mental ill-health has such big implications for economic production and productivity. It causes about 12 million days of reduced productivity each year, arising from absenteeism and "presenteeism" (being at work but not getting much done).

The remaining 700,000 people have persistent complex and chronic illness, such as schizophrenia or severe depression.

Seven people die every day from suicide, about double the road toll. But while the number of deaths on our roads has diminished substantially, there has been no major reduction in the suicide rate over the past decade, we're told.

Death from suicide among Aboriginal and Torres Strait Islander peoples is twice that of non-Indigenous Australians.

Fels says there are excellent examples of suicide prevention, treatment, follow-up and "postvention" in Australia.

Even so, the government review conducted by Fels concluded that much of the $10 billion a year the feds spend on mental health "is neither effective nor efficient".

Almost 90 per cent of it is spend on "downstream programs", such as income support for sufferers, payments to support state hospitals and mental health-related medical and pharmaceutical benefit payments.

"Much of this is payment for failure, payment for failure to treat the problems early and cost-effectively," Fels says.

"I believe this heavy expenditure could be reduced with greater emphasis and investment in prevention, early detection, a focus on recovery from mental ill-health and the prevention of suicide."

If we enable people to live contributing lives – to have relationships, stable housing, and to maximise participation in education, employment and the community more broadly – we will help build economically and socially thriving communities and a more productive Australia, Fels says.

I'm not a believer that things we should be doing for social or cultural reasons must first be asked to justify themselves on economic grounds. We're rich enough to afford to look after those among us with problems, and to pursue knowledge for its own sake.

But the argument that doing better on mental health would improve economic outcomes seems unassailable.

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Everyone wants a slice of a higher GST

Norman Lindsay called it the Magic Pudding. Economists call it opportunity cost. In the untiring campaign by some for an increase in the goods and services tax, a new magic pudding has been created. The trouble is, opportunity cost is real, but magic puddings aren't.

Put at its simplest, the concept of opportunity cost says that if you've got a dollar, you can only spend it once. This truth might be glaringly apparent, but it's surprising how often grown men (and, less commonly, grown women) forget it.

By contrast, the original magic pudding allowed its owners to "cut and come again". No matter how many times they cut themselves a slice, the pudding would magically grow back.

Just the most recent proposal for a higher GST – of 15 per cent – comes from the Premier of NSW, Mike Baird. He wants it to help the state governments raise more taxation to help them pay for the ever-growing cost of their public hospitals and still balance their budgets.

But Baird and some of his fellow premiers aren't the only people with designs on the extra revenue a higher GST would bring. He's been spurred by the knowledge that, so far, Prime Minister Tony Abbott is sticking with the plan announced in last year's budget to move to a less generous way of indexing federal grants to the states for their public hospitals and schools from 2017, which would cause those grants to grow by $80 billion less than they would have, over the following decade.

There are people cynical enough to believe this cut was aimed at softening the premiers up and obliging them to agree to an increase in the GST as the only solution to their future funding problems.

But do you see what this means? It means a big slug of the extra revenue raised by a higher GST would go towards solving the feds' budget problems, not the states'. Suddenly, the pot of gold isn't looking so big.

But that's not all. There are a lot of economists and business people urging that the proceeds from the higher GST first be used to abolish various state taxes regarded as "inefficient" – that is, ones that have the effect of seriously distorting the choices people make.

Top of the list of inefficient state taxes is stamp duty on the transfer of commercial and domestic properties, and the tax on insurance policies. But some business people have their eye on using the GST to replace payroll tax. And a lot of landlords would like to get rid of land tax.

But why stop at eliminating state taxes? Why not use it to reduce a few federal taxes you don't like?

Big business is very anxious to "reform" the tax system by using a higher GST to cut the rate of company tax. And many high income-earners believe it vitally important to cut the top personal tax rate, lest all our top people migrate to countries where taxes are lower (Malaysia, say).

It's clear Treasurer Joe Hockey would very much like to cut company tax and the top tax rate for individuals, if only the boss could summon the courage (and Hockey's powers as a salesman were magically transformed).

But Hockey has another problem he'd no doubt like the GST's help with. He knows that the main thing he's using to allow him to project slowly declining budget deficits in coming years is ever-rising collections of income tax, caused mainly by "bracket creep" – inflation pushing people into higher tax brackets.

The trouble is, after a while, people notice the higher tax rate they're paying on any overtime or pay rise. When they do, they tend to get pretty stirred up and look for a politician to blame.

So Hockey knows that, before long, he'll need to have a tax cut that gets people on tax rates below the top one back into lower brackets. It would be nice if he could make up some of this lost revenue by increasing the GST.

See the magic pudding? There's a host of different groups pushing for higher GST, but they all want to use the proceeds to pay for something different. Between them they have plans to spend each extra GST dollar many times over.

That's true even if, as well as simply increasing the rate to, say, 15 per cent, we also extended it to cover food, education, health and financial services.

And don't forget this: because the GST is universally acknowledged to be a "regressive" tax – it takes a higher proportion of low incomes than of high incomes – it would have to come with a lot of "compensation" for low- to middle-income earners, in the form of increases in pensions and the family allowance and cuts in income tax at the bottom.

All this compensation would have a cost. In other words, the net proceeds from raising the GST would be a lot lower than the gross.

If you get the feeling the debate about increasing the GST has entered the realm of fantasy, you're not wrong. Once the more fanciful ways of using the proceeds had been eliminated, the number of people pushing for it would be greatly reduced.

If you get the feeling this means the GST won't be going up any time soon, you're not wrong, either. I won't be losing any sleep over it.

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