To the Editor: I would like to comment on a recent article by Young and Dobson on the decline of bulk-billing and the increase in out-of-pocket expenses.1

It is true, as the authors state, that "Australia has no legislation restricting how much a general practitioner can charge for a consultation". It is a shame that they did not take equal time to point out that there is no binding requirement on governments to ensure that Medicare rebates remain within striking distance of the real cost of service provision.

Policy change is required — with as much political and moral urgency as Young and Dobson advocate for patient access reform — to enable doctors to provide affordable healthcare under a fee-for-service system without being penalised for accepting a substantial number of elderly or socially disadvantaged patients. Primary healthcare policy needs to be adjusted to maintain rebate justice for low-income patients by linking patients' rebates to their doctors' real-life market costs (or even to relative value studies), not budget "bottom lines".

Is the patient to be out of pocket, or the doctor? Surely, both positions are equally unfair, and equally unlikely to bring about an equitable system.