AUSTRALIA describes its health system as providing universal coverage. According to the World Health Organization, universal health coverage means equitable access to high quality care when it is needed and without causing financial stress for patients and their families.

Results from the Australian Health Consumers Sentiment Survey undertaken in December 2018 and October 2021 suggest that health care affordability continues to be a concern for Australians, despite the claims that we have universal health coverage through Medicare.

Working together, the Consumers Health Forum of Australia, the Australian Institute of Health Innovation, and the National Health and Medical Research Council-funded Partnership Centre for Health System Sustainability co-designed the survey with a focus on finding out what matters most to health consumers.

The survey, supported by the Commonwealth Department of Health and the Australian Commission on Safety and Quality in Heath Care, highlights the gaps identified by 5100 health consumers in 2021 and compares the results with pre-pandemic experiences and opinions of over 1000 health consumers surveyed in 2018.

When consumers were asked how confident they were that they could afford needed care if they were to become seriously ill, around a third said they were not confident (about 37% in 2018 and 29% in 2021). Furthermore, Australians living with at least one chronic condition, who access care more frequently and have greater experience of the health system, were less confident they could afford needed care if they became seriously ill. In 2018, about 43% of Australians with chronic conditions were not confident they could afford needed health care, compared with 31% in 2021.

Worryingly, about 9% in 2018 and 6% in 2021 said they could not pay for needed health care or medicines over the past 12 months. Extrapolating the 6% from 2021 to the Australian population, this represents approximately 1.5 million Australians who do not have enough money to pay for needed health care.

Almost a quarter of survey respondents in both years indicated that they did not fill a prescription or missed doses of medication, and the reason given by approximately 30% of these was “… because I could not afford it”. Preliminary results show that in 2021, people who did not fill a prescription, missed a dose of medicine, or did not visit a doctor when needed because of cost were more likely to have recently lost their job or had their hours of work reduced in the past 12 months.

We are exploring the differences between 2018 and 2021 to see whether access to increased social security payments during the pandemic including JobKeeper and JobSeeker may have had a positive impact and reduced the proportion of people unable to afford care or medicine in 2021.

A significant proportion of Australians reported not having private health insurance (54% in 2018 and 42% in 2021), and the most common reasons for not having private health insurance were simply “Can’t afford it” or “It’s poor value for money”. With many Australians confused about what is actually covered by private health insurance, the industry and the myriad of complex products and options that change from time to time need to be simplified.

With the cost of living rising significantly in Australia over the past 2 years, and many Australians reporting that they are struggling with the cost of housing, petrol and food, it will be important to monitor opinions and sentiment about health care affordability, and for policy settings to adjust accordingly if we are to realise our national commitment to universalism.

We know from analyses published over several years by the Organisation for Economic Cooperation and Development (OECD) that Australia has higher than the OECD average out-of-pocket health costs and this has been raised for several years in other reports. For example, variation in private specialists’ fees in Australia has been an ongoing debate. There appears to be no sound evidence or rationale for the variation, and no data linking higher quality of care with higher fees. Despite practical and implementable solutions being proposed, such as covering the cost of diagnostic services and funding telehealth joint consults between GPs and specialists to reduce referrals, we are yet to see a comprehensive strategic response from government to reduce out-of-pocket health care costs.

What’s next?

The voice of health consumers is weakly embedded in many health systems. Health consumers are ready to engage, but it appears that health systems lag behind in forming genuine and productive partnerships with health consumers. The Australian Health Consumer Sentiment Survey, when repeated every 2 years, will provide a timely, rich and nuanced data source to inform policy, practice, and health system reform. Above all, what is needed is evidence-based decisive action under a cohesive strategy developed and co-designed with health consumers.


Our sincere appreciation goes to many people involved in this work, particularly Dr Louise Ellis, Dr K-lynn Smith, Genevieve Dammery, Chrissy Clay, James Ansell, and Jenna Gray and to all Australians who completed our survey: thank you sincerely for sharing your views with us.

Associate Professor Yvonne Zurynski is Associate Professor for Health System Sustainability at the Australian Institute of Health Innovation, Macquarie University, and co-lead for the Observatory on Health System Sustainability within the NHMRC Partnership Centre for Health System Sustainability

Leanne Wells is the Chief Executive Officer of the Consumers Health Forum of Australia.

Professor Jeffrey Braithwaite is the Founding Director of the Australian Institute of Health Innovation, Macquarie University, and leads the NHMRC Partnership Centre for Health System Sustainability.



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

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The ALP's plan to invest $970 million in general practice care and strengthening Medicare is a good one
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3 thoughts on “Great health system, but I can’t afford it

  1. Oliver Frank says:

    Medicare subsidises only some of the services that doctors and some other health professional provide, and almost none of the services that dentists provide, so it can’t be called “universal coverage”, without an explanation that it means only that all Australians can access that limited range of Medicare benefits.

  2. Professor Helena Teede says:

    Excellent article on a major problem. As healthcare providers it is such a privilege to work in a health system that strives to be universal, but we also have a job as custodians of this system to fiercely protect it, Out of pocket fees need to be regulated and funding distribution reevaluated.

    The community are ultimately both the Funder and beneficiary of healthcare and they deserve a front row seat in codesign to protect our health system.

  3. Andrew Nielsen says:

    It is a question of priorities. Many people who are just as financially badly off as those who genuinely cannot afford medications can afford drugs and alcohol.

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