Modest Expectations – Arthur Phillip

This is my 88th blog. I have not missed a week – and the sequential naming of the Modest Expectations to reflect that number in some way. 1988 – the Bicentenary of this Nation was quite a year. I received funding from the Commonwealth Department of Health to write a book where I asked a number of health professionals how and why they were there in Australia in 1988, at the time of the Bicentenary. It was called “Portraits in Australian Health” – not a particularly riveting title.

However, what I wanted to see in their recounting of their lives was why at that point of Australia’s history, they were where they were. The backdrop to each of the lives of those interviewed was Australia.

This idea was expanded by the BBC in 2004 where they identified celebrities and took them through their genealogical paces with a predictable chorus of “gosh” and “unbelievable” and “who would know?” as each of the atavistic eggs was unscrambled. All beautifully orchestrated.  By and large the people chosen were performers, who could act the part of the stunned inheritors of their family helix.

I suspect that the budget for these TV shows is generous, because it showed that people are curious about other people. “Celebrity” gossip is the fare of the magazines which concentrate on a vague representation of the truth. The BBC, as did I, actually did research!

My concept was relatively simple: sit the person down and let him or her talk. Some I had known before; others only by reputation and I tried to achieve some sort of balance. A few I regret using; others were incredibly important in tracing the path of the reason for their being health professionals and providing “a tapestry” for the 200 years.

However, in retrospect there were at least two major omissions in people from certain categories. There is no dentist in the book; the person I had singled out, because of his long family association with the profession declined to be interviewed; he died not so long after of cancer. That was the only rejection that I remember.

The other omission which, if I could I would rectify, was an Aboriginal person with a health background. On reflection, I should have asked Naomi Mayers, who was the Chief Executive Officer of the Redfern Aboriginal Service. Much later I had lunch with her and a number of Aboriginal people in Redfern and even then I had no inkling of her link to the Aboriginal singing group, the Sapphires. But I didn’t identify her and I regret it.

However, as I found as I met more and more Aboriginals, there was a rich cultural heritage, much of which was hidden from whitefellas. I have always been sceptical of the historical importance of bush tucker, which has acquired a following among well-heeled whitefellas. Much of the tucker available would hardly merit a feed, so tiny are the individual berry, fruit and the other flavouring agents.

However, what I have found very interesting and have met on various occasions were ngangkeri, the medicine men. When I was often visiting Wilcannia in the early 90s, I heard about the kadaitcha men who were still around. However, that was all, and after all “the feathered foot” left no trace; so how would a whitefella find out more. It was all intriguing and the more I was accepted the less I knew.

The Aboriginal society is “many nations” – after all, look at the difference in the culture across the nation. The problem is that in the confected restoration of Aboriginal culture, the diverse nature of the culture has been increasingly homogenised. That cannot be criticised as it recognises that the Aboriginal culture is not static; and given the improvement in communication and educational opportunities it is unsurprising that the Aboriginal is becoming less and less regionally distinctive. Having said this there will always be nests of such traditional culture.

The conundrum for such communities is how to preserve culture against the predatory nature of a culture of booze, fast foods , “black milk” and all the churning of this faddish instant googled-eyed Facebook age – yet not denying progress.

It would be a challenge now to find the Aboriginal health professional who would fit easily into a portrait of Australian health. In 1988, it was only four years since the first Aboriginal doctor graduated.

Charlie Perkins

Charlie Perkins

I was thinking about the first time I met Charlie. It was obviously in 1973, and up until that time, all I had heard about him was that he participated in the Freedom Ride to confront rural NSW concerning Aboriginal rights. To the urban Australian living in comfortable suburbia, Aboriginals were invisible.

As I child I remember receiving Church Missionary Society pamphlets about all those nice little Aboriginal children running around in Roper River Mission – so happy to be one of God’s lambkins. It was all so foreign, and the first time I saw real, live Aboriginal children was years later when I went with my parents to Central Australia. Part of the tour was a visit to the then Lutheran Hermannsberg Mission. We white children eyed off the Aboriginal children, who did likewise and giggled at this awkward bunch of kids from down south.  Nobody encouraged us to mix and eventually we got back on the bus and left. There were also the blackfella children in the settlements along the old Ghan route which then wound through the floodplain country and terminated in Alice Springs.

I remember I insisted in Alice Springs that my parents buy me a black ten-gallon stockman’s hat, and even though I have a large “scone”, the hat came down over my ears. My other purchase caused all sorts of bother, and when it was brought home it had its own “cordon sanitaire” because the ochre covering this large bowl was very thick and had never been fixed, so if you touched it, the ochre always stained your hands. Eventually the bowl disappeared from the house – as did the hat.

Hermannsberg Mission

However, there were several episodes of the ABC lunchtime serial “Blue Hills”, which have remained with me. These concerned a storyline where Aboriginal Heritage would lead to “a throwback” situation which meant that apparently white parents with Aboriginal blood could be confronted with a “piccaninny” child. Then, as the serial progressed, what relief – Aboriginal heritage was diluted – absorbed – assimilated – and joy of joy – no return to the noble savage. Well, that was the gist of the serial story and reflected the attitude of Australian suburbia superficially encased by a white picket fence of normality.

There were three films that I remember in my early childhood leading into teenage years. All had a variable effect on the development of my attitudes towards Aboriginal people. After all, I grew up in a world dismissive of our landlords. The 1947 film Bush Christmas starred a 12 year old Aboriginal boy from Woorabinda in Queensland, Neza Saunders, who showed how to eat a witchetty grub. At that moment, I wanted one to eat. A gourmet meal of witchetty grubs sadly still remains on my to do list.

The film Pinky explored the plight of the light-coloured black American in a 1949 film of the same name. I remember in the context of a society which, despite the pious comments of my schoolteacher, remained at its base racist. We, as children because we grew up in a homogeneous culture, did not have the basic experience to question. However, for me, it instilled in me a sense of unease, the word “miscegenation” still unknown to me.

This unease was reinforced by Jedda, a film where the central tragedy of the Aboriginal was played out in Charles Chauvel melodrama. Jedda was such a beautiful young image for myself, a teenage boy. Years later I went to Utopia, an Alyawarre settlement on the Andover Highway. As an Alyawarre woman, she had grown up there and later had a troubled relationship with the community.  I did speak to her on the telephone but she was away when I stayed in Utopia.

It was still a long time from Jedda before I was to run across Charlie Perkins. I do not know why but we had an immediate empathy. One problem I had noted was that Aboriginal reticence meant that you had to learn to speak through the silences. As one of my Aboriginal brothers would say, the non-verbal conversations with the various vocal clicks was difficult for whitefellas so used to voice communications. The other manifestation that was clear from a growing association with Aboriginal people was if a particular government meeting was thought irrelevant, the Aboriginal representative just did not turn up, but as the Aboriginals have come in from the fringe that dynamic changed. Aboriginal people can recognise tokenism.

In 1973 in Parliament House it was demonstrated very clearly that here was a nation wrestling with the Menzies’ legacy and in particular the engagement in Vietnam. Whitlam terminated Australian involvement, and both he and the Leader of the Opposition, Bill Snedden visited China that year. Snedden was privately concerned with the lack of involvement with Aboriginal People, since even though the 1967 referendum was an overwhelming affirmation of Aboriginal rights that was not easily translated into a workable outcome for our society.

Aboriginal tent embassy

Charlie Perkins, when he was young, had this busy enthusiasm about him. Snedden suggested that I might try and talk to him. The easiest way to talk to him was around the campfire which the Aboriginals had started outside Parliament House. We got on well from the start and spent a lot of time yarning around the fire. To me it was symbolic of establishing an understanding, and Charlie was appreciative that somebody from the Opposition had bothered to brave the fireside. It did not take long for the message to come back from one of the Nats who had seen me with Charlie around the fire saying: “Who’s that Communist working for Snedden?” The other occasion that I well remember was walking with Charlie across King’s Hall one evening, when Mick Young with Eric Walsh came up and said to Charlie without acknowledging me, “You coming to dinner, Charlie?” Charlie shot back, “No, I’m going to have a meal with Jack Best.” These are in the order of things inconsequential. Both Charlie and I wanted a better world and we threw out ideas, most of which drifted off in the camp fire smoke.

So did we, drifted away from one another. Much later when I met him when he was a senior public servant, he seemed to have lost much of this zest for life, but then that happens when you become a fully-fledged bureaucrat.

However, he was also fighting renal failure.

I read Pat Turner’s Charlie Perkins Oration this year, and even though I am not sure I agree with everything she said, she was right in saying that Charlie – the Charlie I knew – never backed down. Yet he showed a willingness to engage in all sides of politics. Later I was to have quite a bit to do with Congress, the Aboriginal Health Service which grew out his early activity in Alice Springs. It is a pity Charlie died while still a relatively young man, succumbing to one of the sequelae of that most deadly infections to Aboriginal people – the streptococcal bacteria.

Conquering that scourge of Aboriginal people still remains. It is not the only one.

Charlie to my mind was the first person who taught me the etiquette of equality of the whitefella in the eyes of the Aboriginal person.  I never attained the level that we could have called each other “brother”, but he enriched my life. Aboriginals were not a cute fringe eating witchety grubs, playing in mission dirt or conforming to a stereotype imposed on them.

Thanks, Charlie for being around when you were – brief as it was. However, you opened up a new perspective for me, and in so doing enriched my life in so many ways.

John Kitzhaber Concludes – A New Model for the Nation

Dr John Kitzhaber

A financially sustainable system designed for value and health can take many forms, but it must include five core elements:

  1. Universal coverage;
  2. Defined benefits;
  3. Assumption of risk by providers and accountability for quality and outcomes;
  4. Capped total cost of care through a global budget indexed to a sustainable growth rate; and
  5. Cost prevention by addressing the social determinants of health.

Here is one example. Starting with our current public-private financing structure, modify the three large insurance pools that currently define the US healthcare system.

  • Pool 1: To achieve universal coverage (element 1), restore the ACA individual mandate but ensure that people have affordable health plans in which to enrol. Expand Medicaid eligibility to include the 28 million people who are currently uninsured or create a new, affordable, publicly subsidized option to offer them. At the same time, move Pool 1 to a CCO-like capitated model that encompasses elements 2 through 5. If coverage in the individual market is unaffordable, those below a certain income level (e.g. 450 percent of the federal poverty level) could buy into Pool 1 with income-based cost sharing, which would make universal coverage more feasible. This is particularly important today as millions of people are losing their employment-based coverage and moving to Medicaid or the individual market.
  • Pool 2: Because Original Medicare is still paid through fee-for-service, the program must be moved to a capitated model. One approach would be to create incentives to enrol in a Medicare Advantage Plan (most of which are already capitated) and change the Medicare Advantage Plans that are still fee-for-service to capitated models that meet elements 2 through 4. Because reimbursement would now be based on managing cost and improving health, Medicare Advantage Plans would better incentivize providers to view their patients as a whole through, for example, nutrition counselling or working with social services for safe housing, thereby meeting element 5.
  • Pool 3: Allow the remaining markets—employer-sponsored medium and large group and self-insured markets—to operate as they do today, negotiating prices with health plans and using their market power to insist on capitated risk contracts with provider networks. The public sector price negotiations outlined below would provide a benchmark, giving employers additional leverage in negotiating prices in the commercial market. This advantage should be amplified by forming new partnerships with Unions

Continue the transformation by using the consolidated purchasing power of Pools 1 and 2 to negotiate one set of prices for both pools. This would include not only what providers are paid per beneficiary (risk-adjusted according to each beneficiary’s expected care needs) but also prescription drugs, medical devices, laboratory services, imaging, and all the other niche business models that have been established under the fee-for-service model to maximize revenue. This kind of price negotiation is what most large private employers (making up the majority of Pool 3) do today. Public payers should follow suit by using the consolidated purchasing power of the public sector—which is footing an ever-larger part of the bill—to get the best price and value for the United States of America community. If the public sector were so inclined, it would also be possible to both negotiate limits on individuals’ out-of-pocket expenses and ensure there are no caps on annual or lifetime benefits.

The result would be a new system of universal coverage built on our current public-private financing structure. With the majority of Americans in some form of capitated risk model, this new system (1) reduces the total cost of care through price negotiations, a global budget indexed to a sustainable growth rate, and provider accountability for quality outcomes; (2) preserves consumer choice and allows current insurers to compete for Pools 1 and 2 in a restructured market; and (3) delivers more and more value and health because it requires strategic, long-term, effective investments in the social determinants of health.

This is merely one way to design a new, health-focused, financially sustainable system. There are others. My objective here is not to advocate for the example I have just outlined here, but rather to spark a new debate that will lead to a better system. Instead of being constrained by what currently exists, we need to start with our objective, agree on essential elements, and then let the contours of the new system emerge. Long-term, this will serve us better than starting with a plan that may not meet the criteria needed to achieve our goal. For example, while both Medicare for All and a public option are ways to achieve universal coverage (element 1), neither directly addresses the total cost of care (elements 3 and 4) or focuses on increasing investment in the social determinants of health (element 5). Surely, we can imagine linking the total cost of medical care to a sustainable growth rate within the next few years. Then we can work backward to create a health system that meets the objectives of Democrats by expanding coverage and improving health and meets the objectives of Republicans by reducing the rate of medical inflation through fiscal discipline and responsibility.

COVID-19 and the Urgency of Now  

As the healthcare system has become ever more dependent on public debt, its financial underpinnings have become inexorably linked to the capacity of the government to borrow. That capacity has been suddenly and dramatically diminished by COVID-19 and by the business closures and high unemployment resulting from efforts to slow the spread of the coronavirus.

To prevent a complete collapse of the economy, there has been a massive federal intervention to keep credit flowing and to provide loan guarantees and direct payments to businesses and individuals. America will have to spend at least $5 trillion this year alone to sustain our economic infrastructure and to support its unemployed. This will leave us with an unprecedented budget deficit and a national debt approaching $28 trillion—with little or no capacity to absorb the 60 percent growth in health care spending that is projected by 2028 (from $3.7 to $6.2 trillion), especially when prices for medical goods and services are projected to account for 43 percent of that growth.

The pandemic is forcing us into an era of dramatic constraints on the public resources allocated to the healthcare system. Neither the government nor private-sector employers can afford the current system anymore, given the economic losses that both employers and individuals have experienced since February and the massive amount of public debt that has been accumulated just to hold our economy together. At the same time, those parts of the healthcare system that have been hit the hardest by COVID-19 are those most dependent on fee-for-service reimbursement, which exposes the basic flaw in a business model that depends on volume, regardless of the value of the services rendered.

This economic crisis means that, for the first time, the economic interests of workers, employers, the government, and many parts of the healthcare sector are aligned. The time to transform the system is now. We have crossed the Rubicon, and there is no going back. We can either watch our current system unravel, with millions more losing coverage and ever-widening income inequality, or we can work together to design a system that helps stabilize our economy and better serves the needs of the American people.

The Role of Unions

This is the moment for more states, facing huge general fund shortfalls, to move to a CCO-like care model for Medicaid, and for Congress, facing staggering debt, to create incentives for Medicare beneficiaries to enrol in a Medicare Advantage Plan and to move that program to a fully capitated model in which providers assume risk for quality and outcomes. Health professionals should be vocal advocates for both of these changes—and that advocacy should be backed up by the strength of the union movement to bring this model to the commercial market. This will require forging new alliances at the bargaining table between Unions and payers—both public and private.

Coverage of the cost of healthcare is, of course, part of the total compensation package, which means that in collective bargaining, wages are often pitted against health benefits. For public employees, general fund appropriations for healthcare compete not only with general funds for wages but also for essentials like increasing nurse staffing ratios, reducing class sizes, and investing in housing and other social determinants of health. The traditional goal in bargaining over healthcare is to reduce, to the greatest extent possible, out-of-pocket costs for Union members (which is very important).

The problem is that focusing only on this aspect of the total compensation package—without questioning the cost structure, quality, or efficiency of the care being purchased—suppresses wage growth. Without aggressively challenging the cost structure and value of the healthcare being purchased, the dollars spent on rising premiums flow into a system that redistributes them upward, taking money from the pockets of working Americans to enrich the profits of large corporations and wealthy individuals (further exacerbating income inequality).

A CCO-like model would be better because it caps the total cost of care without sacrificing quality and it realizes savings to invest in the social determinants of health—including wages. Particularly for workers making minimum wage or close to it, income is a primary driver of health.

Employees and employers have a shared economic interest in reducing the rate of medical inflation and in focusing on value and health. Providers, for the first time, now have an economic interest in changing the payment model from fee-for-service to capitated because this is the only way they can survive in an era that no longer can sustain debt financing. From the standpoint of the Labour movement, CCO-like models could result in increased wages, better staffing ratios, and more funding for education and other services that are critical to making our society more just.

This need for greater social investment must  emphasized. Reducing the total cost of care will assist all working Americans (not just those with union representation) because it will make not only their wages go further but also relieve them of the anxiety of not knowing whether the next illness will push them into bankruptcy. And it will give us, at last, the ability to address the conditions of injustice that underlie disease.

Let’s Begin Now!

Creating a new system with the five core elements will take time. But there is much we must do quickly. Because the economic consequences of the pandemic—particularly the increase in unemployment, with its associated loss of workplace-based coverage—are driving us toward Pool 1 (Medicaid, the uninsured, and the ACA marketplace), this is the logical place to start.

The most urgent coverage problem is for those who are not offered or have lost workplace-based coverage and whose income is too high for Medicaid (above 138 percent of the federal poverty level) but too low to afford the individual market. These struggling individuals are joined by a growing number of underinsured Americans who are technically covered by employer-sponsored plans but face copayments and deductibles so high that for all practical purposes they are uninsured. People of color—particularly Black, Hispanic, and Native American people—make up disproportionate numbers of both of these groups.

The state of Oregon offers an illustration of both the problem and the opportunity. By the end of April, 266,600 Oregonians had lost their jobs (an unemployment rate of 14.2 percent). An estimated 215,800 of these people will be eligible for Medicaid, 20,500 will move to the ACA exchanges, and 30,300 will remain uninsured.20 Because Medicaid is entirely financed with public resources and the ACA exchanges are heavily subsidized with public dollars, this amounts to a dramatic increase in public sector financing of healthcare. In terms of the healthcare model proposed in this essay, Oregon’s Pool 1 is expected to increase from 34.9 percent to 41.3 percent of the state’s population over a few months.

Furthermore, if 80 percent of those who lack health coverage in Oregon made use of coverage for which they are currently eligible—Medicaid or the subsidies available through the ACA marketplace—the number of Oregonians who are uninsured would drop from almost 250,000 to 34,000 (from 6.2 percent to < 1 percent). The only obstacle is the total cost of care.

Since states are facing enormous budget deficits and the federal government is facing a looming debt crisis, it is imperative that shifts toward public financing be accompanied by effective mechanisms to reduce the total cost of care through global budgets (indexed to a sustainable growth rate, with providers at risk for quality and outcomes). At the same time, such global budgets are now more appealing to many hospitals and primary care practices because of the sharp loss of revenue among those with fee-for-service models.

Mouse Whisper

I know we were all keen on Amy Klobucher, when she seemed to be the most articulate candidate back in those days when the Democratic race was like the first at Rosehill. She dropped out, and although considered as Biden’s running mate, she missed out here also to Kamala Harris.

However, the most final reason for her not getting the nod was:

She’s from Minnesota!

In explanation, no Minnesotan has ever made President, and such a judgement tends to stick once voiced. At least Barcelona is not in Minnesota.

Modest Expectations – Derby Day in Walla Walla

State Capital West Virginia

It was late in the day some years ago and we had just driven past the capital of West Virginia, Charleston. The golden capital strikingly stood above the low-level smog which was layered over the city itself. Here we were in the Alleghenies, a 640 kms portion of the Appalachia, a rich source of coal. Here pitched battles were once fought between the miners and the mine owners – called the coal wars. The reason lay in the fact that during this period more miners were killed here in accidents than were lost by the US armed forces in World War 1.

West Virginia had been carved from Virginia in 1863 during the American Civil War, partially because the West Virginians did not follow most of Virginia which seceded at the outbreak of the American Civil War. Yet the electoral base and its Democrat traditions lay in its workers, radical by American unionism standards, reinforced by the memories of the coal wars.

I wondered, as we approached the entrance to this property with its imposing edifice, whether it was a hotel where we could stay for the night. I drove in and the colonnaded entrance suggested that perhaps I had inadvertently driven into a private estate. However, I got out of the car, in jeans and all, and entered the building in all innocence to enquire what was this place.

The Greenbrier

The man behind the reception desk looked me up and down and said, “Sir, this is The Greenbrier.”

As I learnt very quickly, The Greenbrier was the place where Presidents stayed, and I found out there were references to them as far back as Polk and Tyler. I thought the car parking space for the resident golf professional at the time, Sam Snead, said it all. This was a comfortable Republican enclave in the heart of what was a poverty-stricken mining area. I remembered once, on a flight north in Australia, there was a dishevelled guy sitting next to me. We got talking, although I had difficulty understanding him; he turned out to be a miner going up to the coal mines in Queensland. He was from West Virginia, and his mumbled English was full of archaic constructions and words that meant nothing – it was a dialect probably based on 17th or 18th century English. In the end, in the light aircraft, the noise of the plane made it impossible to talk and we lapsed into silence.

But back to The Greenbrier. The Government had built a huge bunker at the hotel during the height of the Cold War, which had the capacity to house the whole of the Congress in the event of a nuclear attack. The facility had long been decommissioned by the time we had stayed. I believe I was punished for my disrespectful comment as the room assigned was so far from the main building that it almost collided with the fence and was well behind the bunker. Still, they allowed us into the dining room.

However, before that could occur, the reception desk clerk had said, “If you wish to dine in, sir, you will need a jacket.”

“No worries.” I had a jacket – a blazer in fact.

A key was pushed towards me. The Greenbrier had welcomed us, after a fashion. Menofregismo as the Italians would say.

West Virginia has always been reliably Democrat, but now no more.  The three Congress members are all Republicans; only one of the two senators is a Democrat and over 50 per cent of the time he voted with or for Trump, even in the impeachment he was only one who crossed over from his Democrats for Trump.

From being reliably Democrat, now West Virginia is almost the most Republican State if judged by the vote for Trump here recently – all changed in a decade! Biden received less than 30 per cent.

The use of coal is rapidly dying, so it would be a useful exercise for the Biden Government to determine how to restructure the West Virginian economy to phase out coal. It is more difficult than just bribing the mine owners to provide the semblance of work by keeping uneconomic mines open. However, it probably would be just as cheap for the Government to bypass the owners and pay the miners a living wage disguised as a redundancy package or employ them to resuscitate the once pristine landscape mined over the past 150 years.

After all, the wealthy and influential were prepared to invest in an opulent playground here, including the Congress shelter bunker. Notwithstanding that it had been decommissioned well before we stayed, here was further evidence of the very essence of privilege in one of the poorest parts of the country.

The latter part of the last century and into this, first as governor and then as Senator, Jay Rockefeller, the great-grandson of John D Rockefeller, as a Democrat (unusual because the rest of the family were solidly Republican) won most of his elections by huge margins. There is little doubt that during his long association with West Virginia he and the coal industry were on very good terms – for most of the time. However, towards his retirement, he began to realise the impact of coal on climate. Two years before his retirement, in 2012, he made in the following statement:

Scare tactics are a cynical waste of time, money and worst of all coal miners’ hopes. But sadly, these coal operators have closed themselves off from any other opposing voices and few dared to speak out for change – even though it’s been staring them in the face for years.

This reminds me of the auto industry, which also resisted change for decades. Coal operators should learn from both the mistakes and recent success of the auto industry. I passionately believe coal miners deserve better than they are getting from operators and West Virginia certainly deserves better too. 

Here in Australia the problem is that fear has gripped Joel Fitzgibbon, not any constructive thought. His livelihood lounging on the plush red seats of Parliament House is threatened. Forget about climate, but then there are unions agitating for retention of coal mining, and the power of the unions depends on these miners coughing up subscriptions – but for what? As with the car industry, government subsidy for the uneconomic only ends up improving the bottom line of the big foreign-owned companies.

The slick Monsieur Perrottet wants to restore his stained escutcheon by expanding the coal industry in NSW to pay off a short-term debt and in so doing leaving an incalculable environmental debt for generations of Australians; the feathery Premier just keeps talking to see if she can break the world record for not taking a breath. There is some in government with a contrary idea of how to lessen the coal dependency, despite export prices for both coking and thermal coal are being maintained.

Yet there is fear of divesting away from coal. This has been aggravated by the electoral results in Queensland, and by the “near-death experience” of Fitzgibbon in his seat of Hunter. The other NSW coal seats did not seem to mirror the same extreme behaviour.

There is another problem, and that is the Fly-in-Fly-Out miners. This expanding cohort should not be confused in the arguments over the hearts and minds of the local coal miners.

As one local Mount Isa correspondent has written:

The issue of Fly In Fly Out did not get much of a look-in in the federal election, perhaps because it is mainly seen as a state issue.

FIFO is convenient for workers who want to live by the coast but still enjoy high-paid jobs in remote locations.

It is also convenient for companies who have better control over their staff and their movements whether it be on chartered flights, mining camps or buses.

But it is a terrible deal for places like Mount Isa and the towns of North West Queensland which get all of the downsides of a large mining operation on their doorstep but few of the benefits.

Yes I understand that airports, motels, pubs and clubs, and the like do well out of a transient workforce but other businesses not so well.

The wear and tear of mining operations on roads and other facilities is a cost borne by those communities. And only this morning did I hear a speaker at a MineX breakfast talk about the need for a local work force because without that “we have no social licence to operate”.

The Queensland government recognised the issue with the Strong and Sustainable Resource Communities Act introduced last year to ban 100% FIFO mining near towns like Mount Isa and Cloncurry.

However, companies can get around this simply by posting one staff member locally which meets the wording of the act but not the intent.”

Balmain coal miners

Great is it not; with one selfish self-centred politician intent on contaminating the narrative of moving away from coal.  A leader, if one can term Albanese that, should have called him out immediately.  Or do I do Mr Albanese a disservice. Maybe he really wants to see the Balmain coal mines re-opened in his electorate.  Fitzgibbon can’t have it all his own way. After all, my late neighbour used to tell me that, as a boy, he would go around the corner to the coal dump and bring coal home for the stove and the fire. It was said that Balmain was then quite a sooty turn to behold.

As a 40-year resident, I remember seeing the entrance to the mine.   After all, to that smooth genius, Monsieur Perrottet, reopening the mine shafts under the Harbour would bring lots of “coal hard cash” and so convenient – or not. And what a jape – reopening a coal mine in a Green electorate. Problem is that is where Perrottet and his fellow travellers want to scar Australia, the wildlife do not vote. However, in Balmain, I am assured that Monsieur would find a different form of wildlife – one that rumbles around the suburb in their Land Cruisers looking for anybody with a lump coal in their political pocket. After all, Monsieur wants to demolish the White Bay Power Station – perhaps a new location for an underground coal mine.

But I stray from my West Virginian narrative – at least I have a narrative.

While America looks away.

I was rummaging through my old magazines and I came across a copy of a Harper’s dated August 1999, in which there is an article where two journalists were assigned to report on Cyprus – flipping a coin to determine which of them travelled to the Turkish Republic of Northern Cyprus and the other to the Republic of Cyprus. As the lead-in to that article, it was stated; “Cyprus remains partitioned, a case study in how ethnic hatred perpetuates itself but perhaps also a manual on how peace can be sustained in places like Kosovo”.

It was nearly 20 years later that my friend and I walked across the Green Zone that separated the two sides of the divided Nicosia, the major city of Cyprus.

There is something strange walking across what is essentially the line where battle formally ended.  A few peacekeepers wearing blue berets are moving around inside the buildings and the only sound is a radio blaring out modern pop. There is nobody to block our crossing through the rubble strewn street, only a strange sense of abandonment, although you know eyes are watching you in the CCTV cameras slung along your pathway. Passing from one side to the other met with little interference from the Cypriot or Turkish side.

Once we were across then there was the question of transport. We did not have to wait long before a taxi pulled up and took us to Kyrenia, a seaside town on the Turkish side where we had a pleasant seafood lunch. The taxi driver said he would return, and he did, punctually. The only noticeable difference from one side to the other was the appearance of mosques; the cars still drive on the left, irrespective of which side of the green lines one drives.

Cyprus is the only place outside the British Isles and the Republic of Ireland in Europe where there is a remnant link to the previous British occupation – driving on the left hand side of the road.

In 1878 Cyprus entered the British Empire under rather unusual circumstances. The Ottoman Empire had just been at war with Russia and were very much in danger of losing control of their capital Constantinople. The British intervened in the crisis on the side of the Ottoman Turks by sending a fleet to intimidate the Russians. The Ottoman Sultan was so thankful for the British intervention that he granted the control of the island of Cyprus to Queen Victoria. This lasted until 1960 when independence was gained. Throughout the 1950s a Greek terrorist group EOKA, under a former Nazi collaborator George Grivas, exacted a price on British occupation, a killing spree of British soldiers and Turkish Cypriots in the main.

The British still retain armed forces bases there on territory that was ceded to the United Kingdom on independence. That means that slivers of Cyprus remain British soil.

While there was a myth abroad that the Turkish and Greek Cypriot relations had been harmonious before the invasion but after Independence, that was far from the truth. The Green Zone actually began a line drawn by the British in 1963 because of strife between the two.

By 1974, the treatment of the Turkish Cypriots was bad enough for Turkey to intervene, and it did not take that long for the Greek Cypriots to quickly sue for peace. This led to fragmented jurisdictions, separated by a UN peace force which have, since the ceasefire, patrolled the Green Zone that extends across the island, cutting through Nicosia as mentioned above.

There the line has remained intact despite regular exchange of obscenities, rock throwing, and the more serious “cocking and pointing”.

When the Harper’s article was written there was very limited access across the border. The two journalists met once, face to face, for coffee in Pyla, a small fishing village within the Green Zone.

There may have been calm when we visited, but there was residual bitterness. We were there at a time before Erdogan came on the scene with all his populist fury. However, he probably recognises what one Greek Cypriot soldier said when asked whether he would retaliate: “No,” he said smiling, “We are careful not to provoke them, because we are the weaker side.” 

Erdogan must know that and after the defeat of Armenia recently, he may be tempted to have a “go” at Cyprus.

Apart from the increased access across the Green Zone, since the 1999 Harper’s article was written, another phenomenon has occurred. It was first evident when I picked up the menu at the hotel in Limassol where we were staying. The menu was not only in Greek and English but also in Russian. The Russians have made a large investment in Cyprus – either with or without Putin’s collusion. Who would know the extent of each?

Now there is a cohort of Russians who have not only invested in property but also have bought Cyprus passports, a practice contrary to EU rules. Under pressure from the EU, Cyprus has now withdrawn that permission to buy into the Republic. Unlike Armenia, Cyprus is a member of the EU, but the Russian passports have not been cancelled.

However, would that matter given that America is now  distracted and if the Turkish Cypriot grievances are inflamed by Erdogan, how would the Republic respond? Seek Greek support? It was not there in 1974.   Would it be now?

The European Union?  Does the EU want to go to war with Turkey, a member of NATO? After all, it was NATO bombing of Serbian held positions and a USA-brokered peace which, in the 1990s, ended that perennial obsession of the Serbs to dominate the Balkans.

This is different political chemistry, and one without a strong America, with a lame-duck President with Russian connections still at the helm. Cyprus has inhospitable mountainous areas. Don’t we know it? We got lost in the wilds of Cyprus, and only worked our way out by pointing the car down the mountains, but at least there was a track to follow.

So military conquest of Cyprus is not just a case of rolling up to seaside resorts like Limassol and Paphos in Turkish tanks. The mountains are perfect for guerrilla warfare.

So-called Russian peacekeepers could already be there to help – and themselves – as they have done in Armenia. They might be there to welcome the invading Turks.

As for the sovereign British bases, maybe Boris would let the Russians have them. After all, he could say it is part of his Brexit plan. Hopefully no one would write, as Queen Mary did with “Calais”, that Cyprus will be written on his heart.

Nevertheless, it should not be ignored that the Russians doing the Trump

Presidency have built up a seasoned defence force, which has honed its skills in Syria and elsewhere. Why not Cyprus? Why not indeed!

John Kitzhaber continues his analysis of the US health system…

Dr John Kitzhaber

Public Resources

We need to understand the central role of public dollars in our healthcare system. Healthcare is the only economic sector that produces goods and services which none of its customers can afford. This system only works because the cost of medical care for individuals is heavily subsidized with public resources. This happens directly through public programs like Medicare and Medicaid. It also happens indirectly through the tax exclusion for employer-sponsored health insurance and through the public subsidies in the individual insurance market established through the Affordable Care Act (ACA).

As a result, about 90 percent of Americans depend on public subsidies to help them cover the cost of their care—all except the 28 million Americans who remain uninsured. These people are not eligible for a public subsidy themselves, but through their taxes they help subsidize the cost of healthcare for everyone else. This egregious situation reflects the systemic inequality that exists not only in our healthcare system but also across our whole society.

Thus, the central issue in the healthcare debate involves the allocation of public resources, which represent a kind of fiscal commons. They are shared resources raised from society as a whole—and they should be allocated in a way that benefits all of us, not just some of us.

The National Debt

We also need to recognize that our healthcare system is increasingly financed with debt. Why? Because public resources are finite and Congress is borrowing ever more money to pay for existing programs and services—including health care. This fact is reflected in the congressional budget deficit and in our national debt. The national debt is the accumulation of years of budget deficits and represents the amount of money that has been borrowed to cover the difference between congressional spending and the tax revenue available to pay for it. Since healthcare now accounts for over 28 percent of the federal budget not spent on interest—and is projected to grow to 33 percent by 2028—it has become a major driver of the national debt.

This means that as the population ages and the cost of care continues to rise, the economic viability of the healthcare system will increasingly depend on borrowing money—and on the capacity of the federal government to absorb more debt. If the capacity to borrow is constrained, the financial underpinnings of the healthcare system begin to unravel. Since COVID-19 has created exactly this constraint on borrowing, a healthcare financing crisis that was on the horizon is now at our door.

Income Inequality

Furthermore, a growing share of the money borrowed to prop up our medical system is not being used to expand coverage. Instead, it is enriching the profits of large corporations and wealthy individuals. Let me be very clear: our current healthcare system is increasing income inequality through a process called rent seeking. This occurs when powerful stakeholders manipulate public policy to increase their own wealth without the creation of new wealth (i.e. they take more of the pie without making the pie bigger). For example, when the pharmaceutical industry convinced Congress to prohibit the government from negotiating drug prices for the 60 million Americans on Medicare, it distorted the market by putting the power in the sellers’ hands to set whatever prices they wish. After many news stories about “big pharma”, more people have become aware of concerns with drug prices. What seems to be less well known is just how profitable medical insurance is: in 2019, the seven largest for-profit insurers had combined revenue of over $900 billion and profits of $35.6 billion, a 66 percent increase over 2018.The result of the rent seeking that is evident throughout the health care industry is lower disposable income for the individuals who have to pay those inflated prices, increased profits for the companies, and wider income inequality.

Health versus Health Care

Finally, we need to recognize that the goal of the healthcare system should be to keep people healthy, not just to finance medical care. In other words, it needs to address the social determinants of health—access to healthy food and clean water, safe housing, a reliable living wage, family and community stability, and more—which have a far greater impact than medical care on the health of both individuals and communities. Yet the ever-increasing cost of care compromises our ability to invest in these things.

Today, healthcare providers and the system have different goals. While most care providers are trying to enhance people’s health, they nevertheless work in a system where the incentives are to increase profits and redistribute more wealth to the wealthy.

Confronting the Total Cost of Care

Improving health requires a financially sustainable system that ensures that all Americans have timely access to effective medical care

and

that makes long-term investments in the social determinants of health. To achieve these dual goals requires five core elements:

  1. Universal coverage;
  2. A defined set of benefits;
  3. A delivery system that assumes risk and accountability for quality and outcomes;
  4. A global budget indexed to a sustainable rate of growth; and
  5. A cost prevention strategy that allocates some of the savings to addressing the social determinants of health. A system that incorporates these elements can take many forms, but without all five we cannot achieve our goal of improving health in a financially sustainable way.

There are two primary obstacles keeping us from moving toward a new system focused on value and health: the way the debate has been framed, and the cost-shifting strategies that—until the pandemic—allowed us to avoid the growing discrepancy between the cost of the system and our ability to pay for it.

How the Debate Is Framed

For decades, the national healthcare debate has been paralysed largely because neither Democrats nor Republicans have seriously challenged the underlying healthcare business model—the debate has been over what level of funding to provide. The current business model is built around fee-for-service reimbursement. The more they do, the more they get paid. Since the fees paid for medical services usually are not linked in a meaningful way to a positive health outcome for the person receiving the care, the system incentives are aligned with maximizing revenue rather than maximizing health.

The Affordable Care Act (ACA) attempted to move away from this model with incentives to participate in accountable care organizations (ACOs), which are networks of providers that shared in savings if they delivered care more efficiently (called upside risk). The problem is that the ACOs were not required to assume any significant degree of downside risk, in which they had to refund a payer if the actual costs of care exceeded a financial benchmark. Furthermore, the ACA did not take on the rent seeking (transferring wealth to the wealthy) that accounts for so much of the cost in the system. As a consequence, the cost of health care grew from $2.6 trillion in 2010 to $3.6 trillion in 2019.

In the wake of the ACA, both major political parties have continued to debate only the extent to which we should fund the system, creating a false choice between cost and access. This false choice is reflected in the Republican view that the cost of health care is unsustainable and must be constrained, and in the Democrat view that any reduction in spending will reduce access. Both sides are right, if they remain wedded to the current business model.

Republican proposals to “repeal and replace” the ACA would simply reduce the public subsidies in the current business model, increasing the number of uninsured Americans and exacerbating the inequity that already exists. Democrat efforts to expand coverage through proposals like “Medicare for All” would significantly increase public subsidies but within the same inflationary fee-for-service business model, adding to the burden of debt that future generations will have to pay. To put it another way, Republican proposals increase inequity and harm people today; Democrat proposals increase the debt and harm people tomorrow.

Cost-Shifting Strategies

Framing the debate in this way allows legislative bodies to avoid directly addressing the cost of care by simply shifting that cost somewhere else, a strategy used by other third-party payers (insurance companies and employers). As the total cost of care increases, instead of seeking to reduce it, these payers take actions that shift the cost to individuals, who cannot afford it, or to future generations. Here are the most common cost-shifting strategies:

  • Reducing eligibility, cutting benefits, and/or raising co-payments and deductibles—all of which shift costs to individuals;
  • Reducing provider reimbursement, which may result in efforts by providers to avoid caring for those who cannot pay and/or lead to increased fees by providers when they are caring for people who are insured; and
  • Increasing debt-financed public subsidies, which shifts the burden to our children and grandchildren.

Importantly, none of these cost-shifting strategies reduce the total cost of care, which is the central structural problem in our system. Before COVID-19, we were able to rely on these strategies, particularly debt-financed public subsidies, to avoid the difficult choices necessary for a solution. But given the economic crisis we face now, we must directly confront the total cost of care. Fortunately, this gives us the opportunity to pursue new strategies that both redesign the current hyperinflationary business model and invest in those things that have the greatest impact on health and well-being.

To be concluded

Mouse Whisper

Out of an abundance of caution

ex abundanti cautela

In law, describes someone taking precautions against a very remote contingency. “One might wear a belt in addition to braces ex abundanti cautela”. In banking, a loan in which the collateral is more than the loan itself. Also, the basis for the term “an abundance of caution” employed by United States President Barack Obama to explain why the Chief Justice of the US Supreme Court John Roberts had to re-administer the Presidential oath of office, and again in reference to terrorist threats.

In reference to Chief Justice Roberts, who flubbed it the first time, Obama recognised the deep conspiracy and made him do it again – correctly. Our authority is the impeccable, Il pagliacco Guiliani.

Just a quote dripping with irony, it has become the favourite phrase of the month, and it seems that is how one formally approaches the Virus, but you must be in full evening dress with all medals displayed (sic).

For we mice it is more that we’re “Out of our barn dance our Cat’s in”.

Modest Expectations – The Two Noble Kinsmen

Leigh Sales, what planet are you on? Take your statement last week about those poor tradies who need to drive Uber at the weekend for extra cash. It was put into perspective a few nights later when – that “uber tradesman” Scott Cam was revealing as “chiselling” the Government out of a six-figure sum for his part time services. For his part-time activity he was not behind a steering wheel. He is the Wheel!

Ms Sales, “tradies” as you call them are doing very well, by and large. Probably given you are upwardly mobile, it is just conceivable that you employ a “tradie” or two. I like the word “tradie”; it fits into all forms of the alphabet a-gender

From personal experience, one of my “tradies” owns a hotel and the other has so much work, the last thing he requires is the wheel of car in the evening other than to go home. I suggest that Ms Sales profiles the Uber driver. I know anecdotally my Turkish-born taxi driver who has been driving me for years and who has had a network of drivers from the pre-Uber days, now drives for Uber in addition to his own clientele. However, I suspect that you will find a great many Uber drivers, who are first generation arrivals in this country.

One of the interesting aspects of taxi travel, of which I once did a great deal, always riding in the front seat, I learnt a lot about the outside world; it was the front seat to an ethnic collation.

However, the racial profile of taxi drivers has changed. I always remember a young Greek doctor who, when he first arrived in Melbourne in the mid 90s, could not believe the number of Greek taxi drivers here. Now there are less Greeks. Taxi driving is an indicator of a less established community. For instance, you may find that an increasing number of Sikhs, newly displaced from the Punjab, are a major taxi or Uber population. But freed from the bureaucratic entanglement of the old taxi cartel, Uber driving attracts the retrenched older person and the student out to make a quid – particularly overseas students. I do not deny that there is a poor postilion under-class, but it ain’t “tradies”.

Nevertheless, it made me think about the proposition of the under-utilised “tradie” workforce, if indeed there is such a thing.

Given that it is a local council responsibility to provide a home maintenance and modification service in addition to hospital adjustment to daily living (ADL) for patients returning home, I would have thought that if there were these Sales’ “tradies” out there looking for twilight cash, then they should be easily absorbed more usefully into an Australia-wide home maintenance and modification service co-ordinated as it is locally. It is difficult to gauge how prevalent these schemes are; I remember when I was running a community health program nearly 40 years ago, some of the more progressive local governments had begun to set them up, but in those days there was a bureaucratic separation between health and housing.

Michael Portillo has recently fronted a documentary on the UK public housing situation acting unfortunately as an apologist for (rather than he once was an acolyte of) Margaret Thatcher. She was guilty of poor decision making when she sold off the social housing stock for a pittance without any strategy for its replacement. Portillo himself tried to absolve her of the social vandalism.

The whole question remains of who pays for social housing but more importantly prevents the purchase for its speculative purchase to drive up prices and hence to conceal the underlying inflation in the economy. At the same time the tacit pact between big business and government suppresses the earning power of those who should be able to afford such housing, either by renting or purchase.

In any event, it is just another area for you to explore, Ms Sales, especially with all this talkfest going about us aged across Australia, rather than indulge in the mythology of the “poor tradie”.

Albanese and the Coal Scuttle

The Adani Coal Mine is a private mine. It’s been approved. It is going ahead. It’s not a Government mine… Finance has been the issue with the Adani mine, but it’s had its environmental approvals. I support the jobs that will be created by any project, any project in Queensland or anywhere else for that matter. What Government needs to do is to set in place strict environmental guidelines. When those guidelines are approved, then you have projects which go ahead if they receive private sector support. 

The first reaction to this Albanese mouthing is that the weasel should be removed as a protected species irrespective of the Albanese predilection to cuddle the animal.

Let us make an early prediction. Albo will have difficulty retaining his seat if he does not do a better job of explaining whether he will be emulating the Prime Minister and going into the House brandishing a lump of coal – Balmain coal – or not. After all, his electorate boasted a coalmine, and my late neighbour remembered as a boy running around the corner to pick up some lumps of coal for the family stove. The air was full of coal dust, pit ponies were still being lowered every day into the mine and there were several major accidents when men were killed. However, the coal was convenient to keep the stove going and the fire alight; ensuring the skies were grey.

It is written in the wind as far as you are concerned Mr Albanese. Go on a trip to Queensland, hug a replica of the Balcaldine tree, and desert a Sydney where the pall of brown smoke foreshadows summers of the future, where blue skies are an increasingly distant memory, as they were when coal was mined.

I have lived in the electorate long enough (although we were only recently redistributed to Albo) – long enough to have seen it desert its working class legacy to that of wall to wall cafés. I can remember the whistle signalling that work had commenced on Cockatoo Island across the Parramatta River. I can remember the odours from the soap factories, which had saponified the river for years. I had walked up the hill and been shown the entry to the Birthday and Jubilee mine shafts that had been sunk when Queen Victoria was in her venerable years. The area was a wasteland of weeds, but you could still see the access points to the mineshafts. The soil is thin and poor in Balmain and as you stir it you wonder how much of the contamination of the past is floating into the atmosphere. And the working class had to endure it, while the tycoons flourished.

Balmain coal mine

In Balmain, one of Paul Keating’s achievements in decontamination was the development of the old Ballast Point Caltex site into a magnificent public park; so much of the harbour waterfront was lined by industrial sites, now gradually renovated, although not necessarily reflected in the growth of liveable space. The working class has become educated, but the same tycoon-types still exist, now complicit with a rising rent seeker class, a.k.a. politicians.

Now, Albanese of Grayndler goes off to circulate in central Queensland, unfamiliar territory for a Sydneysider well versed in the rent seeker class who inhabit Sussex Street but will the Camperdown boy be seen at the end of the street in Moranbah? How much can a fleeting visit do for the Queenslander’s view of you, a Mexican arrayed in RM Williams clobber, your sombrero at a rakish angle to display your winning countenance.

Then that statement you made of: “if we don’t mine it, somebody else will.” A variant of “if we don’t kill our grandchildren than somebody else will”. How well you demonstrate the Hollow Man.

When you come back to your ex- coal mining electorate of Sydney, I’m sure you’ll get a rapturous welcome with us all waving soot laden miner’s lamps to welcome your return.

Oh, by the way, when you are hob-nobbing with the Adanis, tell them we exported coal from Sydney to India in 1799. It will inform how important your electorate has been in defining the genesis of Coal as an invaluable Export -and you as a reaper in the Carbon field, its representative.

Anti-Vaxxer – Prosecute for Genocide Part 2

According to a 2018 report by Complementary Medicines Australia, the country’s complementary medicines industry made $4.9b in revenue last year — including $2.77b in vitamin and dietary supplements — and is expected to grow by another $2b over the next five years.

Just a casual comment to indicate how much porcaria Australians are pouring into their bodies every year. What I find disgusting are the advertisements which show the happy family images loading up their shopping baskets with this stuff – as though a healthy young family needs it – and some of these naturopathic fanatics have the hide to fill their children up with these drugs while at the time perniciously undermining of the community’s health status, trying to claim that vaccination is harmful. Anti-vaxxers have been allowed to roam in this community.

We should take a leaf out of the Samoan legislative book, and prosecute and jail those who would willfully promote ant-vaccination messages and promote rubbish substitutes. To kick this matter along a letter will be sent to each politician in Australia, asking the simple question of whether they support vaccination or not. It will made very clear that a non-response will be taken as a “no”; and the results will then be published, so that at the next elections these enemies of the welfare of our children can be identified and dealt with at the ballot box – at least in the first instance. Legislation will follow.

Telling it how it is

Below is a note received from my private health fund. It is clear and needs to be read against the outpourings of the Grattan Institute.

I read the comment of one journalist the other day, who describes herself as “senior”. She reckons that she does not need all that private health insurance stuff – you know cataract, hip surgery and that unfamiliar set of lesions called “grab bag”. She boasts that she is fit and into marathon running. The association between long-distance running and knee and hip injury is still in dispute.

The problem is that the attitude being promoted by such comments constitutes an attack on community rating. Once community rating is destroyed, then life is a lottery as you enter the realms of catastrophic insurance and you being rated on your individual profile. You are laid bare – no community rating to protect you; warts and all, literally.

The other factor, which has had a disastrous effect on the health system, are all the cost shifting antics of the States, to which the health fund attests below. And even more outrageous, the diversion of money destined under the Commonwealth-State funding agreements being diverted to uses other than the health portfolio.

Anyway, in the meantime, read what is said by a health fund, which is not set up to make obscene profits to be repatriated offshore, but one where the membership is put first. Surprising, you say, but it does occur.

It can be a distressing time when you are admitted to a public hospital emergency department due to an accident or unexpected illness. 

Together with seeking medical care, you will be faced with another decision – do I use my private health insurance policy or Medicare to cover my admission?

What does it mean to be a private patient in a public hospital? 

To be privately covered in a public hospital means your private health insurance policy with us is covering your admission, rather than Medicare.  The admission costs can include your accommodation, theatre and medical fees. 

There are genuine and appropriate reasons to receive treatment as a private patient in a public hospital. However, its increasing prevalence in recent years has raised concern around the reliance of public hospital funding on private health insurance, and the impact this is having on premiums.

You may be approached by administrative hospital staff. Roles have developed within public hospitals and these staff, called patient or client liaisons, are responsible for signing up private patient’s health funds. There has been recent criticism made of the tactics used by these staff, so it is important you have the facts to make your own choice if you are approached: 

There is no obligation to use your private health insurance 

If you are eligible for Medicare benefits, you can choose to be covered as a public patient and all medically necessary inpatient costs will be covered by Medicare. You have a right to be a public patient, even if you have private health insurance, and this should not affect the level of clinical care you receive. 

The hospital may offer additional ‘perks’ if you choose to be a private patient.

Public hospitals are known to offer additional benefits to patients who choose to use their private health insurance, including free Wi-Fi, food vouchers or parking discounts. Information about being a private patient in a public hospital can be hard to find and varies between hospitals; particularly in regards to more important benefits such as guaranteeing choice of doctor, access to single rooms and specialised follow-up care. It is important to ensure you are receiving the right benefits by using your private health insurance. 

You could have out-of-pocket costs if you use your private health insurance. Your policy with us will apply to your admission if you choose to be a private patient in a public hospital. This means, you may be required to pay any excess, and the doctor who treats you may charge a gap for their services, above what Medicare and the health fund will cover. It is important to remember that if you are covered by our basic policy, no matter how it is promoted, any exclusions or restrictions of your policy will apply, so you may not be covered for the services you require.

Using your private health insurance can affect premiums. It has been reported that growth in private patient admissions in public hospitals has contributed to approximately 0.5% per annum increase to premiums over the past five years. This means, private health insurance premiums can be contributing to services that could be receiving public funding paid through taxes.

It is important to remember you have a choice when deciding how you will be covered for services in any private or public hospital.  

Be informed, be equipped with the right questions, and know your rights as a patient.

Amen.

Mouse Whisper

Some years ago, when Aleppo was still a beautiful place, an Australian senator was reported in The Weekend Australian as saying

“Syria is a country that has been a bastard state for nearly forty years.” However it should have read: “Syria has been a Baathist state for nearly forty years. The Australian regrets any embarrassment caused by the error.”

Sadly, no need to correct the statement these days.

Souk of Aleppo

Modest Expectations – Qin Shi Huang

So Donald had gone to the Walter Reed Hospital, the betting given his track record is that he may have been stented and sent back to the White House where there is probably the equivalent of a coronary care unit on site; but not in sight. It was recorded that a year ago his coronary artery calcium had been rising and was indexed at 133, which puts him the range of risking a heart attack within 3-5 years. But with a man who is so addicted to the sunny side of his street, we can only speculate about this particular episode. But from afar he does not appear well, a point I mentioned in my blog on 17 May this year.

Ironic that this news would come in the same week that that the Kooyong Papillon has been fluttering about retraining us elderly to avoid the poubelle of old age.

More about that next week, but really are we surprised?

An Apologia of Academics

In response to my comment on the creation of exotic names for senior positions, a former academic drew my attention to another university, which has gone for the Latin dictionary.

This particular university has appointed scientia professors, presumably on the basis that scientia being the Latin word for knowledge, those without that appellation are sine scientia – or in the vulgate of the Quad, dumbo professors.

Earlier in the year, the Royal Australasian College of Physicians wasted everybody’s time with a series of motions put to an Extraordinary General Meeting to form a cohort of what were to be called ‘Respected Fellows”.

One young female Fellow stood up and asked whether passage of this motion to set up this exclusive group would mean that all those who did not gain entry to the RF club were not respected. Same logic as the above comment about “scientia”.

Although this was a unsubtle way of interfering with the democratic processes by setting up a junta, it was soundly defeated. At least the College gave its Fellows the choice of whether they wanted this nonsense.

What is it all about? Is it only vanity? As I indicated in my comment in the last blog, I think this title escalation is a ridiculous affectation, and affectation is always a perfect subject for satire.

At the heart of all this titular mumbo-jumbo, it is probably about privilege – and privilege in this world of ours is one getting somewhere because one has been inducted into such an elite. It is very seductive to be enticed onto a ladder of privilege where ultimately the reward is the laurel accolade of smugness. Probably in about 400 CE, one would have found that there were a number of laurel wreaths strewn among the ruins of Rome.

Impartiality – the silent partner in Democracy

I have never met the Speaker of the House of Representatives, Tony Smith. When you read his curriculum vitae, he has all the characteristics of the modern politician growing up through a variety of politicians’ offices before being rewarded with a safe seat, which he plodded through in his initial years. However, he became Speaker of the House of Representatives after the demise of the unfortunate Bronwyn Bishop.

I knew Bill Snedden very well and one of his wishes was that after his speakership, which lasted from 1976 to 1983, the speaker, once elected to the role, would be immune from challenge in the House and generally challenge at the election. Snedden was concerned that the Speaker role be seen as even-handed, and having witnessed one of Whitlam’s crueller acts – the public humiliation of Jim Cope, which led to his resignation as Speaker, Snedden was determined to advocate some protection for the position.

When he resigned after the defeat of Fraser Government in 1983, he regretted that he had not another term to pursue the reform, yet he followed his own dictum that the Speaker on resignation as Speaker should exit Parliament immediately. He said inter alia “…under the Westminster convention, when the Speaker leaves the chair he leaves the House. I think this is right. This Westminster practice has been firmly in place all this century and considerations of which I have spoken have led to its acceptance. I have weighed this principle against other considerations, both political and personal. I have concluded that the Westminster practice is correct and, pursuant to it, I intend to leave the Parliament and will resign forthwith.”

Needless to say his wish did not come to pass and the Speakers have come and gone until Tony Smith was elected in the wake of Bronwyn Bishop’s disastrous stewardship. The Speaker’s standing as an impartial chair was severely compromised by her antics, and only compounded by Gillard’s previous ill-advised manipulation to have Peter Slipper installed as Speaker.

The Speaker’s role needs a person with a firm grip on the rules, but also common sense and a sense of humour and above all a person who exhibits impartiality.

One of Whitlam’s less desirable acts was his lack of defence of the then Speaker, Jim Cope. Cope’s “crime” was naming a Minister, Clyde Cameron. Whitlam failed to support him and Cope immediately resigned, barely holding back his tears. Later Cameron realized the gravity of what he had instigated and apologised to Jim Cope.

However, although Cope was visibly distressed, when the time came to elect his replacement and Giles, a Liberal party member was selected by the Opposition to contest the ballot against Labor’s choice, Gordon Scholes, a voice was heard clearly calling out in the House “How do you spell Giles?” It was Jim Cope. His sense of humour never deserted him.

Jim Cope was a good Speaker with only a hint of partiality.

Moving onwards to Tony Smith, Smith’s conduct in the House has been so impeccable that at the last election, he was elected unopposed, and in fact his nomination was seconded by the Member for Caldwell, a Labor MP who glowed as she seconded his nomination.

That is an important first step, but although it would be impossible to know definitely, his performance as Speaker has kept control of the proceedings so that mostly the feet are out of the gutter and if not he has ensured that they are lifted back onto the pavement. That is his immense value to Australia at a time when there is much partisan hatred in the air.

He does not attend the Liberal Party Room, which even Snedden did on occasions. That is another step towards achieving what Snedden fervently wished. Smith is loathe to use his casting vote. I have not read whether he subscribes to Denison’s rule laid down by that Speaker of the House of Commons.

Then he does not seem to flaunt the not inconsiderable perks of office, and while Snedden was the last speaker to dress in full regalia, Smith’s gravitas proceeds without having to dress up to emphasise this.

The main drawback to an independent speaker underneath all the constitutional bluster is that, unlike the British situation where one seat more or less doesn’t matter generally, in Australia each seat is at a premium. However, having looked at Smith’s seat of Casey, it is buffered by two Liberal-held seats where the suburbs bordering on his electorate if redistributed into his electorate (as probably will happen eventually )would be unlikely to change it from being a Liberal seat. Therefore, Smith is in a safe seat and unlikely to be defeated any time soon, which buys time if the notion of an impartial Speaker immune from political challenge is seen as a necessity for Australian democracy to be maintained.

I fear that installing a partisan clown in the Chair may be one tipping point for civil unrest.

I may overstate the point, but one cannot underestimate Tony Smith’s role in sustaining our democracy.

Yet the resulting conundrum of the unchallenged member is that it would effectively disenfranchise the voters in his electorate. It would be interesting to ask them whether they would pay the price for having such a person as the Speaker as their Member.

The Media & Private Health Insurance 

Guest blogger:  Terry Stubberfield FRACP*

Sometimes you just have to say something and not just grumble into your breakfast cereal about the latest media commentary.

Thus this response was prompted by Ross Gittin’s recent article in the Sydney Morning Herald (30.10.19) – “Funds cling on for dear half-life” – complete with image of grasping skeletal X-ray hand. This article made a number of claims without any supporting data.  

Gittins stated that patients are experiencing “huge out of pocket costs that they were not expecting”. Yet at the same time it is interesting to note that in the June 2019 quarter report from the Australian Prudential Regulatory Agency (APRA) the average out of pocket cost per service/episode for private hospital care for the quarter was reported as $314.51, compared with the cost for the June 2018 quarter of $308.73.

For consultant physicians 86.8% of medical services in the Private Hospitals attracted no Private Health Insurance (PHI) payment; by comparison, if you look back three years to June 2016, it was 85.3%. In other words more patients are paying no gap.  Furthermore, that payment for a consultant physician/specialist service was no more than $25, irrespective of how funded. Consultant physicians indeed having the lowest gap payment, of any medical group, if calculated as a percentage of the service cost, i.e. 1%.

In discussing the cost of the private health insurance industry Ross Gittins has concentrated on medical services. Reviewing the June 2019 quarter data provided by APRA the total funds paid by PHI during that quarter for selected areas were:

  • Medical Services $603m  
  • Accommodation and Nursing $2,789m
  • Prosthesis $543m#
  • Dental $697m
  • Optical $204m 
  • Physiotherapy $112m 
  • Chiropractic $77m.

The summary of the June 2019 quarter data presented by APRA states: “medical benefits paid per service … does not mean medical services overall decreased or increased in cost”. 

So medical services are just one piece of the puzzle.

Ross Gittins’ article simply jumps on the populist wagon where over-paid specialist doctors are the cause of the PHI sector’s woes when the data above raises serious questions about escalating costs elsewhere in the health system.

Mr Gittins also falls victim to the common error of lumping all medical specialists under one umbrella when there are multiple specialist groups: consultant physicians and consultant paediatricians for instance are those medical specialists whose expertise is predominantly cognitive; they manage the most complex conditions often for the life of the patient – adult and paediatric – on referral from general practitioners and other specialists. This referral system is one of the strengths of Australia’s health care system.

The APRA report doesn’t comment on “medical specialists” as if they are homogenous group, but appropriately deals with the different medical specialties separately.

In a speech given by Peter Kolhagen, APRA’s Senior Manager, Policy Development, to the Health Insurance Summit 2019, he questioned the health insurance funds for their tardy response to the impact of a range of issues and changes the delivery of health care in Australia – including regulatory and health demands. APRA appears to not single out medical specialists as the root cause of all the problems for private health insurance in Australia.

Gittins however uses surgery as a proxy for all medical specialists, which reflects his basic lack of understanding. Hence his final thought bubble in the Sydney Morning Herald article claims medical specialists are promoting private over public hospital care in order to line their pockets and that if there was not a private hospital system, “…they’d (specialists) do far more of their operations in the public system, probably doing more operations in total than they did before (to counter the huge drop in their incomes)”.

This is disturbing, simplistic and displays little understanding of the delivery of hospital care in Australia. The resources required to provide additional inpatient services to replace the current private hospital services, would be considerable,

Just add the annual recurring expenditure currently provided to private hospital care, (according to PHI data, of around $15 billion),

Then add the cost of infrastructure required and additional nursing and hospital medical staff required to provide much of the day to day health assessment, organisation and implementation of care.

Analysis of health care in Australia is a useful exercise, given that health care represents a significant proportion of government expenditure. However, Australians should not be inflicted with simplistic commentary that can only result in misleading the readers who rely on commentators like Gittins to give them useful and accurate information.

# A real growth increase of >10% in the past decade and I thank Stephen Duckett from the Grattan Institute for this information – and a matter which is obviously concerning enough for the Government to launch a separate inquiry into this increase in the cost of prostheses.

*Dr Terry Stubberfield is a consultant paediatrician practising in a regional Victorian city. He is President-elect of the Australian Association of Consultant Physicians.

A Royal Wave through a Crack in the Door

The door ajar; the recognisable face; the smile; the object of the smile a young lady with long hair, her face concealed; the furtive but practised royal wave; the door shuts; the young lady gone. New York wakes for another day.

I wondered where Prince Andrew Albert Christian Edward had been. I cannot remember in fact seeing him on television, except during his matrimonial tussles and briefly as a Falkland War hero.

In discussing his relationship with the “unbecoming” Mr Epstein, HRH made mention of the fact that he does not sweat.

Of course, he does not, HRH perspire. Would anybody question that fact?

However that is trivialising the seriousness of the claim.

However, on that note, HRH has suggested he does not sweat because he got an overdose of adrenalin during the Falkland War. Nearly forty years later, he says that the after effects persist. Did I hear that learned gentleman at the back of the room clear his throat and was that clang another’s jaw drop? It is known that the use of other drugs such opioids can be a cause of reduced sweating, but for how long?

It is a rare condition and because of his claim it cannot be readily attributable to a congenital affliction, especially as Dad and Brother Charles are shown often perspiring freely after a chukka or two.

However his anhydrosis claim could be tested very readily, if there was enough interest in pursuing HRH.

Otherwise, Your RH, the RAF Salmon Boars are prepared to recognise your outstanding claim with a special flyover.

In fact, the interview may be the start of another crack in the house of Windsor; it recovered from the last crisis – but then the Queen was twenty-years younger – and the potential consequences are not just airbrushing away a case of serial adultery as was the case with the Diana tragedy.

Broken is the crown …

However, this not just one indulged ageing man, who disputes whether he sweats or not on the basis of a highly unlikely reason, a figure of derision, a butt for satire, but a serious challenge to the integrity of society. If guilty, then he is a high profile child trafficker. Exploitation of children is as unacceptable as slavery. That other Elizabeth queen was deeply involved in the slave trade, but there is no record of her ever regretting it. No; she did not among her many achievements invent Teflon.

Just different times; different climes, the apologists murmur. Just poor Andrew Albert Christian Edward. This episode is mere fluff on the shoulder of humankind. No it is not!

Slavery may have been the legacy of the First Elizabethan Age; it would be a pity if trafficking in children is the legacy of the Second.

Mouse Whisper

The derivation of the term for a member of the British Conservative Party comes from the Irish “tóraidhe”, (pronounced tawra) referring to a bandit. Ultimately the root verb for “tóraidhe” implies “pursuit”, hence outlaw or bandit.

In the late 17th century Whigs were those who did not want James, Duke of York, to succeed Charles II, as he was Catholic. The Duke’s sympathisers became known as Tories, and the Duke was briefly James 11, until the powers that be did a reverse brexit – more a bradit and invited the Dutch House of Orange to juice up the monarchy.

Brexit Boris the Brigand is a real alliterative tongue-roller – but Bradit Boris has a distinctive dissonance.

In the absence of a photo of Boris the Brigand, here is Boris the pirate

Modest Expectations – The Spine

In an advertisement for the MD Anderson Cancer Center in a 2009 issue of Harper’s, a healthy triathlete smiles. His name is Bill Crews and under his name is the word “lymphoma” with a red line through the word. It is five years since he had been diagnosed and now following “an individual treatment plan”, he was in remission attested to which was completion of 14 triathlons at that point.

To celebrate his achievement a Bill Crews Remission Run was organised annually to provide funding for this Houston- based Cancer Center. Then there is a brief note in 2014 to say the website advertising the run is “inactive”. There is no record of Bill Crews dying – just that one word “inactive”.

It got me thinking, since my closest male friend also succumbed to lymphoma some years ago, although his course between diagnosis and death was far shorter. Once you get cancer, except for some skin cancers, you know your life will be limited. We all will die, but there is no need to face it until the doctor across the desk signals your mortality. You can of course avoid this confrontation by suiciding, being murdered, killed in an accident or sacrificed deliberately by those who would wage war.

What if I responded to the doctor after the sentencing: “I want you to tell me the exact day I am going to die.” What would be the response?

“Unfair question. Impossible to know.”

“OK, then will it be next week, week after… and this year, next year, sometime, never?”

We can be very precise with the input when we are provided with an individual treatment plan. Therefore, if you can give me such a plan, then it is reasonable to know the outcome, or what to expect. After all, infallibility is a power that some health professionals like to assume – well doctor, how long will I live? But then nobody writes on a funeral notice – he lasted x time longer than the doctors predicted or that the doctor got it so horribly wrong, he died well before the predicted date – perhaps in the middle of some surgical procedure, where the euphemism for “surgical vanity” is “heroic”.

The problem is that what I have written above is so foreign to how society is ordered. Most of us try and live in a predictable world. We expect that if we go to the gym in the morning it will be open at a certain hour. We know that lunch follows breakfast and we have a mid-morning coffee break.

Bill Crews probably had such a regimen. Cancer came; cancer went; but it never does. It marks time. How much of that time was consumed by unpleasant morbidity; how much did life become unbearable; and in the end, how much did he wish to live – all unanswerable now.

In fact, we live in a world of uncertainty. The flow of information from so many portals means that life is like traversing an Arabian souk. We never know what will happen next, but we always have the option of wanting or not wanting to know what we have bought – without it being varnished with fakery.

What does that all mean? Government, despite the various inputs, has to make the most cost effective allocation of resources in the face of all the individual treatment plans. There is no incentive for those manufacturing, distributing and prescribing the various medications to be less than optimistic. The cost of development of a drug is always stated as being so expensive so that the end product mirrors this expenditure. However, in the World of Optimism, who is going to undertake the rationing on behalf of community affordability. The plea, the crowd funding, the picture of the cancer sufferer, the hoped for remission mistaken for cure are all part of the emotional appeal. However, what price does one pay for a small addition to life of variable quality – what is an average of six months worth?

Policy should not be predicated on the outliers. Bill Crews had non-Hodgkins lymphoma. Through all the obfuscation surrounding survival rates, maybe his ten-year survival rate was about average when the last mention of Bill Crews was made.

Therefore, assessing the cost of Bill Crews’ treatment may be a useful indication of the individual cost for the condition. That statistic is just as important as knowing the relative success of the individual management plan and generalising from that one example.

But my whole case is predicated on two assumptions: the first is that the lack of mention of the poster boy by MC Anderson Cancer Center (now also with a red slash through the word “Cancer”) public relations, and the inactivity of the Remission Run from 2013 onwards means that Bill Crews is now cycling on a higher plane. In line with MD Anderson Center publications, I have not mentioned the word “death”.

The second is what Bill Crews’ individual management plan cost when everything was tallied, its figure would be useful enough to be used as a guide to cost – assuming that those costs could be found and adjusted for current prices.

Hopefully the responses, outraged or not by such reductionism, would be a welter of data trying to disprove my assumption. However, that could lead to a good controversy if the policy makers were listening, and cost could be determined with all the accompanying arguments laid out. Then tell the taxpayers!

The Senile Trail

Listening to the Health Minister, he talks about “self stigma” and that we should reach out for help. Well, may I tell you, if you bother to listen, Minister, self-stigma is a meaningless term, when you are crying spontaneously for no reason, when your body is at a point where you cannot undertake the activities you were once able to do; and you are alone. You reach out for what? The phone lines are always busy in the daytime. Trying reaching out at 3am in the morning wherever you are for help. About all that is left is the late night / early morning radio programs that provide an outlet to the old, the sick, the lonely who can’t sleep and who communicate with fellow callers from across the state or the country, through the radio: “How is Beryl from Cooma, we haven’t heard her on the show for quite a while, does anyone know?”

There is a great deal of breast-beating going on, because despite all the expense spent on input, nobody has a solution to care of the aged. I have been associated with nursing homes that work well, because there is a continuity in management and the constant positive is that those in charge worry and care for their nursing home community.

Being dependent implies that I have a carer, which fortunately I have “in spades”. I can no longer live independently unable to have shower, cook, dress and generally manage any housework efficiently – without help. It is frustrating knowing that when you are dependent, you have to wait – you have to learn patience without surrendering yourself to outright submission.

However, being in a wheelchair and then suddenly left facing a blank wall in an airport adds another dimension. The person responsible who leaves you without saying anything just adds that element of being ignored. It is no longer just waiting, you are being ignored and that adds a new reality. It is a sign that you a bit of garbage to be swept when the mood takes the handler. In the end, you lose your self-respect unless dementia beats you to that realisation.

Such are elements of growing old – such are the elements of being in care, where the rules are such that you – the resident – are governed by regulations engineered by government bureaucrats far away from your bedside. They call it compliance or accreditation – a meaningless term to indicate everything is under control. Unless you have a family, whether natural or manufactured, to act as the antidote, then every day is one day nearer to death, and increasingly you wish that day will come. Those words like “accreditation” have a meaning to those who love making paperwork look like an illuminated manuscript.

Are there any solutions beyond having a caring carer not an impersonal person – a shift worker with an inadequate handover when they come on duty, their measly remuneration ultimately dependent on some distant hedge fund?

All solutions are just a variation on that fact of individual care without the negative embellishment.

For instance, I mentioned in a previous blog the series shown on the ABC where four year olds visited an aged care facility over a seven-week period. Then the series finished, with an elaborate farewell antic. I wrote in my blog* at the time:

However, if the attempt of mixing the groups is just voyeuristic – “been there; done that”; then I believe the makers of this series have probably done a disservice to all involved if nothing further eventuates.

Old age is an increasing societal challenge. It should not be just a case of waste management. Yet I fear that is happening – and David Attenborough-like explorations of human foibles and cuteness should not replace serious consideration of what can be done.

The clue is in the series – get the elderly to tell their stories, whether they have a four year old audience or not. After all, it gives you a sense of relevance, even when you may be the only one listening. However even one child listening and responding with questions is a bonus. After all, I believe we are all storytellers.

My argument was not against the idea; my concern was it being generalised – the implication being that infant schools be co-located with nursing homes, so there is ongoing integration of experience – not just a one-off “gooey-eyed” curiosity but as part of a conscious government policy.

After all, each group’s experiences are transitory – the children grow up hopefully socialised to understand what it is to be old; and one of the aged care participants died between filming and release of the documentary. Such is life, as Mr Kelly is reported to have said.

It was ironic when the aged care report was released recently there was no mention of the documentary as one remedy – even seemingly by the ABC.

* Modest Expectations – Duckworth 30/8/19

Mount Augustus

 Uluru has been closed at last. To me, there has never been any question. The traditional owners should have the right to invite strangers to climb this extraordinary monolith. I have walked around the base which is measured at 10.6 kilometres and to me it felt ‘right”. Being a “whitefella” does not exclude you from being in touch with this extraordinary country. One of the things I have learnt from my association with the Aboriginal people is to know when the Land is accepting your presence.

The idea that climbing the Rock is akin to climbing a cathedral may satisfy some people as an excuse. However, the analogy does not hold. Tourists are like ants on the roofs and spires of famous cathedrals and churches; and prohibition to climb churches is more related to safety or privacy rather than it being a spiritual taboo.

The bogan chant of why can’t I go anywhere because this is Australia and I am Australian is OK if you are a self-absorbed narcissist who does not believe that any restrictions apply to yourself. There is a high-falutin’ word for this – “libertarian” and a more macho term – “individual”, its anthem: “I am what I am”.

Well, Mount Augustus may be just what you are looking for, to express your feeling and being what you are. Mount Augustus is technically a monocline but then for you guys, it is a “humongous Rock”. It is not red and bald like Uluru – it is covered by bush and it is still called by the “whitefella” name rather than its Wadjari name of Burringurrah.

Burringurrah / Mount Augustus

However, it is the largest rock in the world and I went there 20 years ago; so it exists and has not shifted. It is a bit inconvenient being 500 kilometres inland from Carnarvon. Uluru is tiny compared to Burringurrah. There is an eponymous Aboriginal settlement close to the monocline.

Rather than walking around the base, we were carted around the 43 kilometres in a minivan at a hair-raising speed by a male nurse then living in the outstation. The trip ended back near the settlement, when the van hit a large pothole and lost its wheel. Fortunately the sand provided a cushion and we were all uninjured and trudged back to the settlement. It just emphasised how huge this Rock is.

Currently, the local Wadjari people allow visitors to climb Burringurrah but unlike Uluru, there is scrub and a trail, which takes around five hours to climb and return.

Watch this space! I remember when Uluru was Ayers Rock and was hard to get there.

Burringurrah speedway

Sydney Ferries Fiasco – A form of naval gazing

Guest Blogger: Neil Baird#

It could be said that the only thing keeping the New South Wales Liberal/National Coalition state government in power is the even greater incompetence of the State Opposition. If the latest controversy over the renewal of the Sydney Ferries fleet is any indication, the Gladys Berejiklian led coalition is certainly not an exponent of open government. The Opposition has only now awakened to an announcement that was made nine months ago in February.

Unusually, the announcement about Sydney’s ferry renewal was made from Liberal Party headquarters and not from the Minister for Transport’s office. Sure, the party was in election mode but what were they doing issuing a press release announcing a $1.3 billion project in such an underhand way? What was the government trying to conceal? Why will just 13 comparatively simple and small ferries cost $ 1.3 billion? That figure appears grossly excessive. Or does that include running and maintenance costs for nine years as mentioned in one report? Why would the government not be more transparent?

Given their other shenanigans with the Northern Beaches and Mona Vale hospital projects, for example, taxpayers have every right to be suspicious. For the record, the three larger ferries are to be built in Indonesia, presumably by Penguin Marine; the 10 smaller ones are being built by Jianglong in Zhuhai, China. The local firms mentioned below Ross Roberts/Harwood Marine were never invited to tender. Nor was anyone else apparently.

It has since been fully revealed, in an 23 October 2019 press release from Opposition Leader, Jodi McKay, that the fleet replacement was a “done deal” by 27 February 2019 when the Liberal Party announcement was made.

The story goes that in early February this year a couple of Australia’s leading ferry builders had been approached with a vague invitation to tender for the ferries. Apparently they didn’t respond to the approach. So did at least one leading firm of naval architects. None could be bothered to respond as they had such bad previous experience in dealing with Sydney Ferries, apart from being very busy anyway.

The subject went quiet for a few months and has only now been revived by Ms McKay who seems to have confused the facts.

Simply put, after endless problems, mainly with the maritime union, the operations, but not the ownership, of Sydney Ferries has not officially been privatised. It is a public-private arrangement, which avoids the need to go out to tender. The French-owned transport conglomerate, Transdev have contracted to operate the ferries, and seem to have eliminated most of the problems when it was run by the NSW Government.

Yet the curious way the ferries were ordered remains, with virtual concealment of the nature and cost of project from the taxpayers of NSW.

While Ms McKay has revealed some of facts, other parts of the story are off-beam. While the Trade Unions have been one of the major reasons for the problems at Sydney Ferries, the relative absence of shipbuilders in NSW has not helped.

However, she is partly correct. The ferries could have been built locally, as she advocates, but the only company in the NSW with experience in building ferries of the size ordered is Harwood Marine of Yamba in Northern NSW.

Strangely, Harwood was not even approached or invited to tender. Indeed, the managing director of Harwood was unaware of the government’s intentions until very recently. Harwood has been busy with a major expansion of its company’s facilities including, ironically, a 60 metre shed in which large aluminium ferries could be built. Equally ironically, those who could have benefitted – the local youth workforce in a town where unemployment stands at 23 per cent – didn’t get a look in.

Apart from Transdev, which is expected to correct Sydney Ferries’ inadequacies, one major local firm will benefit from the association with Transdev. That is the Port Macquarie-based company, Birdon, which moreover has been contracted to build ferries in China and Indonesia for Transdev.

Birdon is a highly reputable company, as is Transdev. This fiasco is no reflection on either. The government may well get a good deal in the end. However, the problem is the opaque process that the government followed. The State Opposition has been unaware of such a major project, until the belated statement from Ms McKay. It is also a major problem that Harwood, a significant employer and highly reputable local shipbuilder was not even asked to express interest in the project.

The taxpayers of New South Wales have not been well served by its politicians.

We have not heard the end of this.

# Neil Baird is non-executive Chairman of Baird Maritime, a global maritime trade publisher. Among his other positions, Neil is a long-serving director of the Australian Shipbuilders Association.

Mouse Whisper

Once I heard the confession of a poker-faced mouse whisperer despite it being difficult to squeeze into a murine confessional box.

In January 2004, I was in grade 12 of high school and about to graduate. I operated a profitable web design business as a part time job for some spending money. Seeing as my legal name is Mike Rowe, I created the domain MikeRoweSoft.com for my portfolio. The Canadian lawyers of Microsoft didn’t like this (I really don’t know how they found my site, I had 2 visitors a day. One was me (sic), one was my mom). They sent me a couple of emails and a large legal document telling me to give up my domain name. I asked for $10k. They said no. I went to the media. Hilarity ensued.

Since then I’ve been a full time professional poker player for the last 3 years. I’ve made enough to buy a condo and live very comfortably in that time. I have finished 5th in the PokerStars Sunday Million for $97,500 as well as 31st at the PokerStars Caribbean Adventure earlier this year for $40,000. So I guess you can ask about the poker stuff as well if anyone wants to.

And no, I didn’t sell out for an XBox.”

The site was still active in 2017, but not now.