Budget 2021 – looking beyond the dollars

THE 2021–22 Budget is being sold as an optimistic recovery plan, with a focus on restoring the economy in the wake of the coronavirus disease 2019 (COVID-19) pandemic. The demands of the pandemic and its impacts were not the only issues forcing government actions and expenditures; there was also the push for increased support for women’s issues and commitments to address mental health and aged care. The government responded by spending big, but is this enough?

Aged care and mental health are both wicked issues and the pandemic further highlighted long-standing problems. The government has received a plethora of expert advice and guidance on the need for major reforms, restructuring and refinancing, but has largely foregone the hard work involved in doing this and opted instead for dollar largesse.

These once-in-a-decade commitments of large sums of taxpayers’ dollars demand scrutiny of what this will deliver. Looking the gift horse in the mouth and examining the devils in the details are imperative.

The commitment of $17.7 billion over the next 5 years to aged care in response to the recommendations of the Royal Commission, tabled on 1 March 2021, must be viewed in the light of the demand for aged care services, the time frames involved, the need for sustained resourcing, and funding commitments into the next decade and beyond. It is then revealed as merely a down payment on a huge and growing need.

It will deliver 80 000 home care packages over the next 2 years, but there are almost 100 000 people on the waiting list. Despite horror stories of abuse and clinical failures, spending on aged care quality and safety gets just a 1-year hit in 2021–22 with funding from the COVID-19 Response Package and then reverts to previous levels.

The government has not responded to the recommendation for a Seniors’ Dental Scheme (and funding for the National Partnership Agreement for public dental services for adults has been extended for only 1 year at current levels) and has delayed consideration of recommendations for social supports for the elderly (clearly the Minister doesn’t watch Old People’s Home for Four-Year-Olds).

The government’s written response to the Royal Commission recommendations highlights huge delays in implementation. The Review of Aged Care Quality Standards begun in March 2021 and will not be completed until December 2022; the design of a new Home Support Package will take several years; allocation of care packages direct to consumers will not begin until July 2024.

Under such circumstances a bipartisan approach to aged care reform is essential; this package will only be “transformative” as promised if it continues, with research, reporting, evaluations and finessing, well beyond the current election cycle.

The mental health package ($2.3 billion over 4 years) also has commendable provisions, but it too should be seen as the first phase of a much larger, more complex, more integrated approach. It is underfunded on the basis of need and does not represent a full response to the Productivity Commission report. There is no focus on outcomes and who is accountable for delivering these, and more needs to be done to better integrate services (including substance misuse services) for people with mental illness. There is no recognition that many of the key determinants of mental health (income, housing, social justice) are in portfolios other than health.

The importance of the social determinants of health is ignored by this government, particularly when it comes to First Nations people. This Budget has nothing to address the crisis of black deaths in custody and inadequate resources for domestic violence, Indigenous people living with disability, and legal services.

It is encouraging to see the partnership with Aboriginal Community Controlled Health Organisations (ACCHOs), which will receive $90 million over 3 years under a new funding model. There is also funding for ACCHOs to expand into aged care. The pandemic has highlighted that placing decisions and power with Indigenous communities is an important driver for success in closing the gap on Indigenous disadvantage. However, overall expenditures on Indigenous health will decline in real terms over the forward estimates, a sad revelation of the government’s priorities.

Even in the absence of real reforms, all the initiatives touted by the government need workforce and there is little to meaningfully address this, despite the rhetoric around jobs creation. Tertiary education costs are rising; doctors need more than pay increases to stay in rural areas aged care registered nurses need more than a one-off bonus; training places are meaningless if wages are inadequate; new mental health services demand more psychiatrists, psychologists and mental health nurses; and Indigenous clinicians and health care workers are essential for cultural safety.

The list of what is missing from the budget is long and includes tackling obesity, addressing “long COVID-19”, the impact of climate change on health, and – most notably – out-of-pocket costs as a barrier to needed medical care.

Dr Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney. She has worked as a political advisor on health for the Democrats in the United States House of Representatives, for the Australian Labor Party in the Australian Parliament, and for the US Surgeon General during the Obama Administration.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.