Skip to Main Content

As an Australian living in California and doing research on health policy, I’ve taken an interest in the ongoing debate among Californians about the benefits of moving to a single-payer health care system.

In my home country, the government’s Medicare policy covers health care costs for its citizens. There’s a set fee for physician consultations, and most medicines and procedures are subsidized. While it was perhaps a blessing to grow up with this system, it didn’t prepare me for health care coverage in the United States.


I started a postdoc in health policy at the University of California, San Francisco, in February 2018. Although my health insurance was technically covered by UCSF from the outset, I was told I would have to pay out of pocket and seek reimbursement for the first few months and that getting a claim processed before I had a Social Security number or a primary care provider would be painful.

That sounded fine, because my asthma, which I have been living with since my late teens, rarely becomes problematic. So I decided to hold off refilling my medications until the paperwork was sorted out.

That worked for a week or so. Then my lungs realized they were no longer breathing in the warm air of an Australian summer.


I took my wheeze and my wallet to the local pharmacy, thinking that the process for getting asthma medications would be like they are back home. What a miscalculation. While a canister of albuterol is available over the counter in Australia for about $8, I was told that I’d need to pay a $270 consultation fee to get a prescription for the inhaler and about $80 for the medicine itself. Needless to say, I came to appreciate the full musical repertoire of my lungs over the ensuing weeks.

Eventually, the paperwork for my health coverage was completed, my breathing improved, and I learned the basics of how things operate here. To my surprise, I also realized that, with decent coverage, the health care available in California is fantastic.

Compared to my situation in Australia, I pay less in California to see a physician, I find it easier to get in touch with my clinicians and make appointments for health care services, and I pay substantially less for my medications. My primary care provider has also been able to improve my asthma treatment.

How can that be?

Although the Australian government has imposed a ceiling on how much a physician can be reimbursed for a patient consultation, there is nothing stopping physicians from charging patients more. In my experience, general practitioners often charge up to double the $25 Medicare fee, while specialists routinely charge hundreds of dollars more than their Medicare rates. The competition among specialists has become like a high-end retail market, in which the more one charges the more people believe the product is of superior quality. This leads to patients often being referred to the same overcharging clinics.

When it comes to medicines, Australians are at the mercy of what the government includes on its Pharmaceutical Benefits Scheme (PBS). This is a list of essential medicines that are available by prescription at a subsidized price. The typical copay for an employed adult is about $35 for a month’s supply of medication. But if a medication is not on the PBS, or a doctor wants to prescribe it for something other than its recommended use, patients must pay the unsubsidized price.

My general practitioner in Australia wanted to prescribe a drug called montelukast for my asthma, until he realized it would cost me $75 a month because the drug is not approved for asthma (according to the Pharmaceutical Benefits Scheme). We tried alternatives, and ultimately settled on a sub-standard regimen.

Since being in the U.S., I’ve been paying about $3.30 per month to use montelukast, and my asthma symptoms have improved.

My early experiences in California demonstrated how uncomfortable and deflating it is to live here without adequate insurance. This is something the 5% to 10% of Californians without insurance, and the many more who are underinsured, deal with every day. A single-payer system would bridge that gap. Experts say it would also improve administrative efficiency and reduce drug costs to the extent that there would be about a 5% decrease in net health care spending. That’s right: a single-payer system that covers all Californians would actually save money.

At the same time, it’s essential to consider the potential problems a single-payer system may introduce. With doctors able to charge well above the government rate, and a non-exhaustive drug formulary, Australia certainly doesn’t set the perfect example.

As someone who has experienced health care systems from two different sides of the Pacific and as a health policy researcher, I don’t think Californians should get on board a single-payer system without a guarantee that those who are currently appropriately insured will continue to receive, at a minimum, their existing level of health care.

David Boettiger is a health policy research fellow at the University of California, San Francisco, and a citizen of Australia.

  • Great article discussing the two systems. Asthma is a great example, but unfortunately the system is much more complex for those with other chronic conditions. My medication for an autoimmune disease is $39AUD for all Aussies, but over $5,000USD without insurance. Every month. So in Aus you never have to worry about accessing the drug, but in the US I worry about it constantly. I appreciate you have received great care here and want that to continue, but it hides the fact that there are countless Americans without access to lifesaving drugs that are available in Aus. There mental toll it puts on you knowing at any moment your disease can come back because you can’t access meds. This toll is not even a thought to Australians, and thank goodness for that!

  • hi David, I am a US citizen by birth, moved to Australia in 1990 and have lived back and forth since that time, currently living permanently in AU, so I too have experienced both health care systems. I agree that the US needs both public and private systems and while I worked for the CSU system I also had great health insurance and a good prescription plan. I currently pay for private cover in AU. That said, last year I was diagnosed with breast cancer and and the care I received in Australia I feel was far better than what I would have received in CA, mostly due to the continuity of care there and the excellent communication between my 4 doctors. I did go private for all my care. My biggest gap pay was to the plastic surgeon who did the breast reconstruction. My brother had been diagnosed with bladder cancer at the same time as my diagnosis, lived in Florida, had very fragmented care and unfortunately died 6 months after diagnosis, not related to the care but the diagnosis. All my family and friends in CA said the continuity of care I received in AU was far superior to what I would have received if I had lived in Ca.. So I think good and not so good in both countries and that both a single payer and private system need to co-exist in order to provide adequate coverage for everyone….Just my take on a very complex and contentious issue.

Comments are closed.