Aged care financing is a vexed problem for the Australian government. It is already underfunded for the quality the community expects, and costs will increase dramatically. There are also significant concerns about the complexity of the system.

In 2021–22 the federal government spent A$25 billion on aged services for around 1.2 million people aged 65 and over. Around 60% went to residential care (190,000 people) and one-third to home care (one million people).

The final report from the government’s Aged Care Taskforce, which has been reviewing funding options, estimates the number of people who will need services is likely to grow to more than two million over the next 20 years. Costs are therefore likely to more than double.

The taskforce has considered what aged care services are reasonable and necessary and made recommendations to the government about how they can be paid for. This includes getting aged care users to pay for more of their care.

But rather than recommending an alternative financing arrangement that will safeguard Australians’ aged care services into the future, the taskforce largely recommends tidying up existing arrangements and keeping the status quo.

No Medicare-style levy

The taskforce rejected the aged care royal commission’s recommendation to introduce a levy to meet aged care cost increases. A 1% levy, similar to the Medicare levy, could have raised around $8 billion a year.

The taskforce failed to consider the mix of taxation, personal contributions and social insurance which are commonly used to fund aged care systems internationally. The Japanese system, for example, is financed by long-term insurance paid by those aged 40 and over, plus general taxation and a small copayment.

Instead, the taskforce puts forward a simple, pragmatic argument that older people are becoming wealthier through superannuation, there is a cost of living crisis for younger people and therefore older people should be required to pay more of their aged care costs.

Separating care from other services

In deciding what older people should pay more for, the taskforce divided services into care, everyday living and accommodation.

The taskforce thought the most important services were clinical services (including nursing and allied health) and these should be the main responsibility of government funding. Personal care, including showering and dressing were seen as a middle tier that is likely to attract some co-payment, despite these services often being necessary to maintain independence.

The task force recommended the costs for everyday living (such as food and utilities) and accommodation expenses (such as rent) should increasingly be a personal responsibility.

Making the system fairer

The taskforce thought it was unfair people in residential care were making substantial contributions for their everyday living expenses (about 25%) and those receiving home care weren’t (about 5%). This is, in part, because home care has always had a muddled set of rules about user co-payments.

But the taskforce provided no analysis of accommodation costs (such as utilities and maintenance) people meet at home compared with residential care.

To address the inefficiencies of upfront daily fees for packages, the taskforce recommends means testing co-payments for home care packages and basing them on the actual level of service users receive for everyday support (for food, cleaning, and so on) and to a lesser extent for support to maintain independence.

It is unclear whether clinical and personal care costs and user contributions will be treated the same for residential and home care.

Making residential aged care sustainable

The taskforce was concerned residential care operators were losing $4 per resident day on “hotel” (accommodation services) and everyday living costs.

The taskforce recommends means tested user contributions for room services and everyday living costs be increased.

It also recommends that wealthier older people be given more choice by allowing them to pay more (per resident day) for better amenities. This would allow providers to fully meet the cost of these services.

Effectively, this means daily living charges for residents are too low and inflexible and that fees would go up, although the taskforce was clear that low-income residents should be protected.

Moving from buying to renting rooms

Currently older people who need residential care have a choice of making a refundable up-front payment for their room or to pay rent to offset the loans providers take out to build facilities. Providers raise capital to build aged care facilities through equity or loan financing.

However, the taskforce did not consider the overall efficiency of the private capital market for financing aged care or alternative solutions.

Instead, it recommended capital contributions be streamlined and simplified by phasing out up-front payments and focusing on rental contributions. This echoes the royal commission, which found rent to be a more efficient and less risky method of financing capital for aged care in private capital markets.

It’s likely that in a decade or so, once the new home care arrangements are in place, there will be proportionally fewer older people in residential aged care. Those who do go are likely to be more disabled and have greater care needs. And those with more money will pay more for their accommodation and everyday living arrangements. But they may have more choice too.

Although the federal government has ruled out an aged care levy and changes to assets test on the family home, it has yet to respond to the majority of the recommendations. But given the aged care minister chaired the taskforce, it’s likely to provide a good indication of current thinking.

Hal Swerissen, Emeritus Professor, La Trobe University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Chiropractors in Australia will not be able to perform spinal manipulation on children under the age of two once more, following health concerns from doctors and politicians.

But what is the spinal treatment at the centre of the controversy? Does it work? Is there evidence of harm?

We’re a team of researchers who specialise in evidence-based musculoskeletal health. I (Matt) am a registered chiropractor, Joshua is a registered physiotherapist and Giovanni trained as a physiotherapist.

Here’s what the evidence says.

Remind me, how did this all come about?

A Melbourne-based chiropractor posted a video on social media in 2018 using a spring-loaded device (known as the Activator) to manipulate the spine of a two-week-old baby suspended upside down by the ankles.

The video sparked widespread concerns among the public, medical associations and politicians. It prompted a ban on the procedure in young children. The Victorian health minister commissioned Safer Care Victoria to conduct an independent review of spinal manipulation techniques on children.

Recently, the Chiropractic Board of Australia reinstated chiropractors’ authorisation to perform spinal manipulation on babies under two years old. But this week, it backflipped, following heavy criticism from medical associations and politicians.

What is spinal manipulation?

Spinal manipulation is a treatment used by chiropractors and other health professionals such as doctors, osteopaths and physiotherapists.

It is an umbrella term that includes popular “back cracking” techniques.

It also includes more gentle forms of treatment, such as massage or joint mobilisations. These involve applying pressure to joints without generating a “cracking” sound.

Does spinal manipulation in babies work?

Several international guidelines for health-care professionals recommend spinal manipulation to treat adults with conditions such as back pain and headache as there is an abundance of evidence on the topic. For example, spinal manipulation for back pain is supported by data from nearly 10,000 adults.

For children, it’s a different story. Safer Care Victoria’s 2019 review of spinal manipulation found very few studies testing whether this treatment was safe and effective in children.

Studies were generally small and were of poor quality. Some of those small, poor-quality studies, suggest spinal manipulation provides a very small benefit for back pain, colic and potentially bedwetting – some common reasons for parents to take their child to see a chiropractor. But overall, the review found the overall body of evidence was very poor.

However, for most other children’s conditions chiropractors treat – such as headache, asthma, otitis media (a type of ear infection), cerebral palsy, hyperactivity and torticollis (“twisted neck”) – there did not appear to be a benefit.

The number of studies investigating the effectiveness of spinal manipulation on babies under two years of age was even smaller.

There was one high-quality study and two small, poor quality studies. These did not show an appreciable benefit of spinal manipulation on colic, otitis media with effusion (known as glue ear) or twisted neck in babies.

Is spinal manipulation on babies safe?

In terms of safety, most studies in the review found serious complications were extremely rare. The review noted one baby or child dying (a report from Germany in 2001 after spinal manipulation by a physiotherapist). The most common complications were mild in nature such as increased crying and soreness.

However, because studies were very small, they cannot tell us anything about the safety of spinal manipulation in a reliable way. Studies that are designed to properly investigate if a treatment is safe typically include thousands of patients. And these studies have not yet been done.

Why do people see chiropractors?

Safer Care Victoria also conducted surveys with more than 20,000 people living in Australia who had taken their children under 12 years old to a chiropractor in the past ten years.

Nearly three-quarters said that was for treatment of a child aged two years or younger.

Nearly all people surveyed reported a positive experience when they took their child to a chiropractor and reported that their child’s condition improved with chiropractic care. Only a small number of people (0.3%) reported a negative experience, and this was mostly related to cost of treatment, lack of improvement in their child’s condition, excessive use of x-rays, and perceived pressure to avoid medications.

Many of the respondents had also consulted their GP or maternity/child health nurse.

What now for spinal manipulation in children?

At the request of state and federal ministers, the Chiropractic Board of Australia confirmed that spinal manipulation on babies under two years old will continue to be banned until it discusses the issue further with health ministers.

Many chiropractors believe this is unfair, especially considering the strong consumer support for chiropractic care outlined in the Safer Care Victoria report, and the rarity of serious reported harms in children.

Others believe that in the absence of evidence of benefit and uncertainty around whether spinal manipulation is safe in children and babies, the precautionary principle should apply and children and babies should not receive spinal manipulation.

Ultimately, high quality research is urgently needed to better understand whether spinal manipulation is beneficial for the range of conditions chiropractors provide it for, and whether the benefit outweighs the extremely small chance of a serious complication.

This will help parents make an informed choice about health care for their child.

Matt Fernandez, Senior lecturer and researcher in chiropractic, CQUniversity Australia; Giovanni E. Ferreira, NHMRC Emerging Leader Research Fellow, Institute of Musculoskeletal Health, University of Sydney, and Joshua Zadro, NHMRC Emerging Leader Research Fellow, Sydney Musculoskeletal Health, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.