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Ageing and health costs: Managing the future Australia’s population is ageing—the evidence for this is clear and compelling.
Falling fertility, the ageing of the ‘baby boomer’ generation, declining mortalityand increased life expectancy are combining to increase the number and proportionof the population that is elderly, that is, those aged 65 years or more. This trendwill accelerate over the next 50 years to such an extent that the numbers of elderlywill have increased from the present 2.5 million to around 7.2 million in 2051(ABS 2003). The implications of an ageing population for healthcare costs have been the focus of much analysis and commentary in the past decade. Most recently, the Treasurer’s Intergenerational Report (2002) concluded that ‘a steadily ageing population islikely to continue to place significant pressure on Commonwealth government The extent to which finances’, and that ‘Commonwealth health and aged care spending is projected Australia’s ageing to grow significantly, due to the increasing cost of new procedures and medicines, with the ageing of the population also increasing demand for health spending’.
The extent to which Australia’s ageing population constitutes an impending an impending crisis for crisis for our health system is open to question. Extrapolation of today’s health our health system is service utilisation and cost figures into the future can give rise to predictions that the costs of providing health care to such a sizeable older population will open to question. be prohibitive and could place significant strain on our health system. But is this so? This paper examines the approaching demographic ‘problem’, discusses whether or not we are in fact facing an impending ‘crisis’, and providespolicy suggestions to meet and manage the challenge ahead.
Demographic projections
The most recent demographic projections (ABS 2003) suggest that Australia’spopulation will grow from 19.7 million in June 2002 to between 23.0 million and31.4 million in 2051, the difference being due to varying assumptions aboutfertility, net overseas migration and life expectancy at birth (see Table 5.1). TheABS report also provides projections for the ageing of Australia’s population. Theseshow that: • the median age of the population will increase from the present 35.9 years to between 46.0 years (Series A) and 49.9 years (Series C) in 2051; • life expectancy at birth is projected to increase from the present 77 years for males and 82 years for females to around 84 years and 87 years respectivelyin 2051; • the proportion of people aged 65 years and over will grow from 13 per cent in June 2002 to between 27 per cent (Series B) and 30 per cent (Series C) in 2051.
That’s more than double the present percentage; • the proportion of ‘old-old’ people (those aged 85 years and over) will increase from 1.4 per cent of the population in June 2002 to between 6 per cent and 9 per cent of the population in 2051. Their numbers are projected to grow fromthe present 280 400 to between 1.5 and 2.7 million by 2051.
Australia’s Ageing Population: Fiscal, Labour Market and Social Implications Table 5.1: Population projections to 2051 under varying assumptions
Growth rates for those aged 85 years and over are projected to be more rapid than forany other group in the population. Two growth peaks are expected, coinciding withthe ageing of persons born after the two World Wars. The first peak (of 7 per cent) willoccur in 2006, 85 years after the post-World War I baby boom of 1921, while thesecond will occur in 2032, 85 years after the post-World War II boom year of 1947.
In contrast, the proportion of young persons in the population (those aged under 15years) is projected to fall over the next 50 years from 20 per cent (4 million persons)to between 12 and 15 per cent (2.8 million to 4.8 million) in 2051. As well, theproportion of people of working age (between 15 and 16 years) is expected to fallfrom the present 67 per cent (13.2 million people) to between 57 and 59 per cent(13 and 17 million people) in 2051. Ageing and health costs
Many believe our ageing population is a crisis in the making—that aproportionately small working age population will find it hard to support aproportionately large older population; and that the costs of providing healthcareservices to a much larger older population will prove prohibitive in the longer term. The upward pressure on health costs applied by an ageing population results bothfrom the fact that older people tend to have a greater need for health services andthat they use those services more often than other age groups. The other majordrivers of rising health costs are the increasing cost and availability of new healthtechnology, as well as burgeoning consumer demands and expectations. Consumersincreasingly expect and demand the latest and the best, whether it be the latestmedical/surgical advance, or the latest blockbuster drug.
Growing older is accompanied by an increasing incidence of non-fatal diseases ofageing and chronic degenerative diseases. These include arthritis, diabetes, heartdisease, cancer and dementia. Such diseases can severely impact on the quality oflife and independence of older people. They also bring with them markedlyincreased utilisation of health services—medications, doctor consultations, hospitaladmissions, and so on—and significantly higher health costs.
The relationship between a person’s age and the amount spent on health services hasbeen clearly demonstrated in two recent studies undertaken by researchers at theAustralian Institute of Health and Welfare. Mathers et al. (1998), in their study of the health system costs of diseases and injury in Australia in 1993–94, found that, Australia’s Ageing Population: Fiscal, Labour Market and Social Implications per capita, health system costs rise with age for both males and females,particularly from the mid-50s (see Figure 5.1). Figure 5.1: Health system costs per capita by age group and sex, 1993–94
15–24 25–34 35–44 45–54 55–64 65–74 The study shows that health system costs per capita in 1993–94 rangedfrom a minimum of $800 for males aged 5–14 years to $7,500 for femalesaged 75 years and over, close to a ten-fold difference. The other feature ofthe results, shown clearly in Figure 5.1, is the cost peak for females duringtheir reproductive years.
More recently, Gibson and Goss (1999) have disaggregated the variouscomponents of healthcare to demonstrate how the amounts spent on thosecomponents—hospital, nursing homes, medical services andpharmaceuticals—vary with age.
Figure 5.2: Health expenditure per person by age by area of expenditure,

Both studies show the significant increase in spending on health servicesthat occurs after age 50. Gibson and Ross show this to be the caseparticularly with spending on hospital and nursing home services. Whilethe data for both these studies are somewhat dated, the findings areunlikely to have changed in the decade that has passed. The Institute hasadvised that up-to-date estimates of per capita health system costs will beavailable shortly.
Australia’s Ageing Population: Fiscal, Labour Market and Social Implications One disease of old age recently the subject of research in Australia is dementia.
Access Economics (2003), which undertook the study for Alzheimer’s Australia,shows that more than 162 000 Australians currently suffer from dementia, with asmany again likely to be experiencing the early stages of the disease. As thepopulation ages, Access predicts that by 2041, 500 000 Australians will have adiagnosis of dementia. Moreover, the cost of dementia (both direct and indirect) isprojected to grow from the present 1 per cent of GDP to more than 3 per cent by2050. Access predicts that neuro-degenerative diseases such as dementia willreplace systemic degenerative diseases such as heart disease and cancer as the majorcause of death and disability in the early decades of the twenty-first century. Propermanagement of these diseases is essential to ensure their costs do not get out ofhand in the future—more of this later in the chapter.
The Intergenerational Report
The combination of an ageing population and higher health spending on the elderly provide the main impetus for the projected growth in Commonwealthhealth spending over the next 40 years, as set out in the Government’s first Intergenerational Report (IGR), released at the time of the Budget in May 2002.
Currently the Commonwealth funds close to half of total health spending inAustralia. In 2002 this amounted to $30.7 billion out of a total health spend of $66.6 billion (AIHW 2003). The major health and aged care programs the Medical Benefits Scheme (MBS), which provides patient subsidies formedical practitioner services, optometry, diagnostic imaging and pathology; • the Pharmaceutical Benefits Scheme, which provides subsidised pharmaceuticals to patients, so as to ensure all Australians have affordableaccess to cost-effective medicines; • public hospital services, through contributions to state governments; • contributions to residential aged care provided, mainly by non-government organisations and community care services delivered by state and territorygovernments; • a 30 per cent rebate to Australian taxpayers to subsidise the cost of private • financial support in many other areas including medical research, public health, indigenous health services, health information management, health safety andquality, as well as health workforce development and infrastructure.
Treasury projections suggest that Commonwealth spending on health will increasefrom around 4 per cent of Gross Domestic Product (GDP) in 2001–02 to 8.1 percent of GDP by 2041–42. Figure 5.3, taken from the IGR, shows that spending onthe PBS is projected to grow most rapidly, from its present share of 0.6 per cent ofGDP to 3.4 per cent by 2041–42. Less rapid rates of increase are expected for theMBS (from 1.1 per cent of GDP to 1.8 per cent in 2041–42) and hospital andhealth services (from 1.2 per cent of GDP to 1.6 per cent in 2041–42).
Australia’s Ageing Population: Fiscal, Labour Market and Social Implications Figure 5.3: Projected growth in components of Commonwealth health spending
Medical Benefits Pharmaceutical Hospital & health Source: Intergenerational Report (2002) These cost projections have led the Treasurer, Mr Costello, to identify the PBS asthe most significant area of future spending pressure in the Commonwealth Budget.
In a recent speech to the Queensland Press Forum (2003), Mr Costello drewattention to the fact that the cost of the PBS has increased by 60 per cent in thepast four years to its present level of $4.5 billion. He said ‘it is vitally importantthat we make certain that the PBS is sustainable, because the reality is that the realcost of a number of commonly used medicines puts them out of reach of manyAustralians’. This sentiment is echoed in the IGR, which argues that ‘ongoingsound management of the PBS will be required to keep long-term growth in theScheme sustainable, to allow governments to continue providing access to affordablemedicines for all Australians’.
Contrary to widespread perceptions, there are several reasons to believe thatAustralia’s ageing population does not constitute a crisis in the making. Health costs and the size of the aged population
First, international experience suggests otherwise. Kinnear (2001), for example, hasshown there is little association between health costs and the size of the agedpopulation in a selection of countries. Countries with a significant proportion oftheir population aged over 65, such as Japan (16.2 per cent), Finland (14.7 percent) and Germany (16.6 per cent), have relatively low levels of health spendingrelative to GDP of 7.6, 7.4 and 10.6 per cent respectively. This contrasts with theUnited States, where health spending is relatively high (13.6 per cent of GDP),while the population aged over 65 is a relatively low 11.9 per cent. This result isconfirmed in a recent study by Castles (2001), who shows there is an ‘almostcomplete lack of correspondence’ between population ageing and levels of healthcare costs. There is, however, evidence of a relationship between the size of the agedpopulation and spending on aged care services—which is hardly surprising giventhat such services are targeted exclusively at older people. The main drivers ofrising health spending are new medical technology, the cost of new drugs, risingconsumer demand, rising prices and the overall growth in population numbers. Australia’s Ageing Population: Fiscal, Labour Market and Social Implications Older but healthier
Second, while people are living longer, they are generally healthier thanprevious generations. We cannot, and should not assume that the elderly oftomorrow will be an economic or social burden on society due to poor health.
Indeed, the opposite may well be the case. Kinnear (2001) puts it well: … the vast majority of older Australians enjoy healthy, activeand independent lives, with 93 per cent living in private homesand only 7 per cent in residential care. Only 3.5 per cent ofpeople over 65 require public assistance for daily living. Evenfor those over 80, only one-third require help with self-careactivities. This view is supported by a recent AIHW publication (2002), which providesevidence that many older people have a positive view of their health. AIHWrefers to data from the 1997 National Survey of Mental Health and Wellbeing of Adults conducted by the ABS, which found that 70 per cent of Australians aged 65 years or older rated their health as either good, very good or excellent,while 30 per cent reported their health as fair or poor. Self-rated health has been found to work well as a measure of health status. Furthermore, it seems older people typically adapt to the limitations and increasing prevalence ofdisability and illness that age brings. It seems they also adjust their expectations of health and wellbeing with advancing age.
The hazards of prediction
Third, it is worth bearing in mind that ‘prediction is very difficult, especiallyabout the future’ (Neils Bohr). We only have to step back in time to remindourselves of the incredible changes that have occurred in health services andtreatments in the past few decades. As Gibson and Goss (1999) observe: the nature of health care 50 years ago was hugely different tothe nature of health care today, and the nature of health care in50 years time is likely to be hugely different again. Thesedifferences are likely to be not only the incrementalimprovements in treatment, but differences in terms of thenature of the illness, the medications, the surgery, thediagnostic and therapeutic technology, the health care systemand indeed the broader context of society itself. Take medications as an example. In 1964 (the first year for which detailed drugutilisation statistics are available from the Commonwealth Department ofHealth), the most frequently prescribed medicines on the PBS were analgesics,antihistamines, sulpha drugs, barbiturates, early anti-hypertensives and a rangeof antibacterial antibiotics. Today, the most commonly prescribed medicines (none of which were availablein 1964) are Salbutamol (for the treatment of asthma), Frusemide (diuretic),Simvastatin (serum lipid reduction), Enalapril (anti-hypertensive), Ranitidine(peptic ulcer treatment), Budesonide (asthma preventative) and Thyroxine(thyroid hormone). Also high on the list are analgesics such as paracetamol anda range of different antibiotics. The point of this comparison is to highlight the hazards of predicting the Australia’s Ageing Population: Fiscal, Labour Market and Social Implications future, particularly beyond the next five or ten years. Even population projectionscan be subject to substantial error. Twenty years ago, the ABS suggested thenumber of people aged 65 and over in Australia would be 1.7 million in 1996. Thisturned out to be 20 per cent short of the actual figure in that year, an error of half amillion people (MacDonald 1966). Recognising the benefits
Fourth, the pessimistic view of the future that often accompanies evidence ofAustralia’s ageing population reflects a heavy emphasis on cost, with little or norecognition of benefits. While it is certainly the case that we can expecttechnological improvements and medical/ pharmaceutical advances to continueunabated, and for the costs of those innovations to continue to rise, we should notoverlook the benefits that these advances bring in terms of better quality of life,extended life expectancy, avoided hospitalisation, early return to work and to providing a productive contribution to the community, and so on. As Freund The pessimistic view and Smeeding (2002) argue in their excellent examination of the many issues involved in estimating the future costs and benefits of healthcare expenditures of the future that often for and by the aged in the rich nations of the world, there is much hope, and perhaps not so much despair as some of the literature suggests, when one considers future outlays for health care and their relative costs and benefits in an ageing society. Inother words, with some distributional exceptions, the glass is more than half full and we should welcome cost effective medical advances which directly and substantially improve the well being ofolder generations. Freund and Smeeding refer in particular to the recent work of Lichtenberg in the United States, who has estimated empirically the impact of medicines onmortality, morbidity, hospital use, medical care utilisation and overall healthexpenditure. His findings underline the crucial importance of recognising thebenefits as well as the costs of innovation. He shows, for example, that a great dealof the increase in life expectancy is due to new drugs, and that life expectancy hasincreased over time with pharmaceutical innovation. Lichtenberg’s analysis of datafrom the 1996 MEPS (Medical Expenditure Panel Survey) also shows: • that replacement of older by newer drugs results in a reduction in mortality, • that while newer drugs cost more, this is more than offset by a lesser frequency of dying, fewer work days lost, less hospital utilisation and an overall reductionin total health care expenditure.
Time until death not age since birth
Fifth, longer life expectancy does not necessarily imply higher health costs. Rather,since severe disability and high health costs tend to be concentrated in the finalyears of life, the more relevant consideration is time from death and not time frombirth. This certainly holds true if rates of disability remain stable or improve overtime. Results from the 1998 ABS Survey of Disability, Ageing and Carers (reportedin AIHW 2000) suggest that the proportion of the population with ‘a profound orsevere core activity restriction’ increases with age, with the young-old (those aged65–69) experiencing low levels of disability—7.8 per cent of men and 9.2 per cent Australia’s Ageing Population: Fiscal, Labour Market and Social Implications of women. These proportions increase with age, however. For example, for thoseaged between 80 and 84 years, 24 per cent of men and 36 per cent of womenreported a profound or severe core activity restriction. As to whether there has beena reduction in disability rates among the elderly over time, the results are somewhatequivocal, with recent OECD figures suggesting disability reductions (see Kinnear2001), while recent Australian data show no such reductions (AIHW 2002). Other reasons for rising health costs
Finally, it is worth restating that the ageing of the population is but one of anumber of factors contributing to the rise in health costs—and a relatively smallcontributor at that. Analysis by AIHW (1998) suggests that during the period1983 to 1995, only one-fifth of the real annual increase in health spending was dueto Australia’s ageing population. Of greater explanatory significance were: • the increasing use and cost of medical technology; • the increasing use and cost of pharmaceuticals;• increasing consumer demand for health services; • choices (both private and public) about spending on health relative to other Others have reached similar conclusions, both in Australia (Richardson and Robertson 2000) and overseas (Williams 1990; Fuchs 1998; Strunk andGinsburg 2002).
The previous section has provided argument and evidence as to why we shouldbe sceptical of the crisis outlook for our health system which predicts the healthcosts of an ageing population will prove unsustainable in the long term. Rather, thechallenge is one of proper control and management of future health care costs andthe development and implementation of appropriate policy responses. These includepolicies to encourage sustained economic growth, maintenance of an appropriatepublic/private balance in our health system, and, perhaps most important of all,maintaining a healthy and productive health workforce.
The importance of sustained economic growth
One of the keys to our ability to afford and manage the future cost of health care issustained economic growth. The IGR (2002) is somewhat pessimistic on this front.
It projects that over the next four decades economic growth will ‘slow relative tothe outcomes achieved over the past decade, reflecting lower productivity andemployment growth rates’. Slower employment growth will flow from lowerpopulation growth and a falling rate of overall labour force participation. Treasurypredicts real GDP growth will decline from average annual rates of 3.4 per cent inthe 1990s to below 2.0 on average in the 2030s. Productivity growth is central to determining the level of long-term economicgrowth. The IGR projects productivity to grow at 1.75 per cent per annum, thelong-term average for the past 30 years. This is substantially below the average rateof 2.25 per cent experienced in the 1990s, even assuming a rate of 2 per cent into Australia’s Ageing Population: Fiscal, Labour Market and Social Implications the future would add a further 9 per cent to the level of per capita income inAustralia. Furthermore, improving labour force participation rates beyond thoseassumed in the IGR would add further fuel to economic growth, again by as muchas an additional 9 per cent in GDP per capita in 2042. Combining the effects ofhigher growth rates in both these variables would result in GDP per capita beingalmost 20 per cent higher in 2042 than the base case used in the IGR projections. It is interesting to note that these revised projections have been generated byTreasury in its 2003/04 Budget Papers (Statement 4: Sustaining Growth in Australia’sLiving Standards) one brief year after the release of the IGR. Also of note are recentpronouncements by both the Treasurer (2003) and the Prime Minister (2003), whostress the importance of productivity improvement and increased labour forceparticipation. The Prime Minister, for example, believes maximising labour forceparticipation, particularly for the elderly, to be Australia’s principal economic Dowrick and Day, for There are others apart from Treasury who do not share the IGR’s pessimistic example, argue against outlook for Australia’s economy. Dowrick and Day (2003), for example, argue against the ‘ageing pessimists’ who are alarmed at the implications of the ‘ageing pessimists’ demographic change. In particular, they challenge the view that the living who are alarmed at the standards of future generations will be adversely and unfairly affected by the increase in the dependency ratio—the ratio of the dependent elderly implications of demographic population to those of working age, which is expected to double by 2040.
change … They argue that Dowrick and Day argue that the size of the increase in costs associated with ageing, which the IGR estimates will require an additional 5 per cent of GDP the size of the increase in to be raised in taxes, is trivial relative to the expected 100 per cent rise in real incomes that will occur by 2040. This is due largely to the educational costs associated with ageing attainment of younger Australians, which will drive strong productivity is trivial relative to the growth and hence strong economic growth into the future. expected 100 per cent 4.2 The public/private mix
Managing the transition to an older population is to be preferred to radical rise in real incomes that short-term policy solutions introduced in response to crisis scenarios. This view will occur by 2040. is strongly advocated by Kinnear (2001), who suggests policies should be targeted at containing the factors that more heavily influence rising health the need for an increasing emphasis on public health and primary careinitiatives that recognise the importance of health promotion and illnessprevention strategies to the overall health of the population as a whole andto older people in particular; and • the need for an appropriate balance between public and private health provision which recognises that shifting costs from the public to the private purse isunlikely to control health-related costs of population ageing over the long term.
This latter point is taken up by McAuley (2002) in his critique of the IGR.
McAuley is critical of the Commonwealth’s move to shift the growing burden ofhealthcare costs off-budget through, for example, widespread participation inprivate health insurance and a commitment ‘to minimise the tax burden transferredto the next generation’. McAuley argues that the likely consequence of theCommonwealth reducing its involvement in health and aged care funding would behigher overall health care costs in 2042. ‘In health care there are tremendous Australia’s Ageing Population: Fiscal, Labour Market and Social Implications benefits in concentrating purchasing power in one fund holder, preferably agovernment agency’. Benefits include more effective cost control and universaland affordable access for all sections of society to quality health services. An obvious example of this is Australia’s Pharmaceutical Benefits Scheme,which provides universal access for all Australians to subsidised prescriptionmedicines. In place for more than 50 years, this scheme has effectively kept alid on drug prices in Australia to such an extent that the prices of medicines onthe scheme are well below world average and less than half those in the UnitedStates. Recent research by the Australia Institute (Lokuge and Denniss 2003)has shown that removal of PBS price controls and a resultant move to pricelevels similar to those in the United States would add an extra $2.4 billion tothe cost of the scheme (presently around $5 billion). Co-ordinated policy response
Another important strategy for handling the growing demands on our health system resulting from an ageing population is the need for co-ordinated policy responses for particular disease states and health issues. This approach is nowevident in government thinking, with, for example, the establishment of National Healthcare Priority areas such as diabetes, asthma and mental health. A good example of a disease state that requires strategic thinking is dementia, management of which Access Economics (2003) identifies as an overwhelmingpriority for health care in the twenty-first century. Access identifies five pillars for a future national strategy to tackle dementia: 1. A significant investment in research for cause, prevention and care.
2. Early intervention through improvement in diagnosis, and the provision of cost-effective pharmacotherapies.
3. Comprehensive provision of support, education and respite services, in place in the community as far as is optimal.
4. Quality residential care, appropriately financed, that is centred on the person with dementia and their family/carer.
5. Provision for special needs, including people with younger onset dementia, people from culturally and linguistically diversebackgrounds, indigenous Australians and people in rural and remote areas.
With regard to point 2, the report highlights concern about current restrictedaccess to affordable medicines for dementia. The rigid authority restrictions forthe three treatments of choice—Aricept, Reminyl and Exelon—prevent earlyaccess to these medicines at subsidised PBS prices. They also exclude patientswith forms of dementia other than Alzheimer’s disease. Other research quotedby Access Economics suggest such cost-cutting measures are counter-productiveand rather than reducing overall health costs, have been found to increase themby 30 to 50 per cent. Indeed, one researcher has concluded that ‘rising drugscosts are, in general, part of the solution, not part of the problem’. A healthy and productive health workforce
We know from population projections that the number of older Australians is Australia’s Ageing Population: Fiscal, Labour Market and Social Implications set to grow rapidly in the coming decades. Not only do we need policies in place toensure these people remain healthy and productive for as long as possible, but alsowe need a skilled and well co-ordinated health workforce, working productively inan effective health system, to service the health needs of an ageing population. Thiswill not be possible if health professionals continue to desert their chosen careers, as they have in the recent past. Doctors, nurses, pharmacists, physiotherapists, allied health professionals and evenvolunteers are all signalling with their feet that the personal costs are too high andthat the incentives, financial and otherwise, are too weak to keep them in the healthindustry. Innovative policies are required to prevent: • expensively trained young people from leaving their chosen profession, older professionals from leaving, forced out by the personal costs and between the future • decisions being made to restrict the health services being offered and to reduce the risks and costs of participation.
(as defined by Without a well-trained, well-paid and committed health workforce with access to the latest health technologies, we cannot hope to maintain an effective demographic factors healthcare system. Absence of an effective healthcare system will inevitably undermine our attempts to maintain a healthy and productive older Choice in public policy
of health services is Finally, it is worth stressing the importance of choice in public policy, a point a complex one. well made by Gibson and Goss in their 1999 paper on the impact of our ageing population on health spending. They argue that the relationship between the future demand for healthcare (as defined by demographic factors suchas the ageing population) and supply of health services is a complex one. They arecritical of models which posit a direct relationship between the two, such that anincrease in demand will inevitably result in an increase in supply and hence to anunsustainable level of health spending. They point out that supply in healthcare,and in aged care in particular, is largely determined by public policy, and publicpolicy is determined by societal choices—‘it is not exogenously or technologicallydetermined’. This is an important point, and one which should always be borne inmind when we are attempting to predict the future, a hazardous pastime, as wehave seen earlier. It also helps to underline the importance of proper planning as thekey to managing our future and the challenges posed by Australia’s ageingpopulation. Australia’s Ageing Population: Fiscal, Labour Market and Social Implications References
Access Economics (2003), The Dementia Goss, J. (1992), ’Health Care for the Elderly—Costs Epidemic: Economic Impact and Positive Solutions and Some Institutional Issues’ in Economic and for Australia, Canberra, March.
Social Consequences of Australia’s Ageing Australian Bureau of Statistics (2003), Population Population, EPAC Background Paper No. 23.
Projections, Australia, 2002–2101, Canberra.
Howard, J. (2003), Prime Minister’s Address to the Australian Institute of Health and Welfare (1998), Business Council of Australia, Sydney, October.
Australia’s Health 1998, Canberra, AIHW.
Kinnear, P. (2001), ’Population Ageing: Crisis or Australian Institute of Health and Welfare (2000), Transition?’ Discussion Paper No 45, The Australia Australia’s Health 2000, Canberra. AIHW.
Australian Institute of Health and Welfare (2002), Lokuge, K. and Denniss, R. (2003), ’Trading in our Older Australia at a Glance, 2002 Third edition, Health System? The Impact of the Australia—US Free Trade Agreement on the PBS’, The Australia Australian Institute of Health and Welfare (2003), Health Expenditure Australia 2001–02, Canberra,AIHW Health and Welfare Expenditure Series No 17.
MacDonald (1996), ’Demographic Trends and TheirImplications for Social Policy in Australia’ Issues in Castles, F. (2001), ’Population Ageing and the Public Sector Change Lecture Series, Centre for Public Purse: Australia in Comparative Perspective’Australian Journal of Social Issues, 35.
Public Policy, The University of Melbourne,September.
Commonwealth of Australia (2002), IntergenerationalReport, 2002–03 Budget Paper No. 5.
McAuley, I. (2002), ’Australia in 2042: Here’s Whereto Send the Nursing Home Bills’ Consuming Costello, P. (2003), Address to the Queensland Press Forum, Brisbane, 12 September.
Dowrick, S. and Day, C. (2003), ’Australian Mathers, C, Penm, R, Carter, R. and Stevenson, C.
Economic Growth: Why Bill Gates and the Ageing (1998), Health System Costs of Diseases and Injury Pessimists are Wrong’ National Institute of in Australia 1993–94, Canberra, AIHW, Health and Economics and Business Public Lecture, 14 May.
Freund, D. and Smeeding, T. (2002), ’The Future Richardson, J. and Robertson, I. (2000), ’Ageing Costs of Health Care in Ageing Societies: Is the and the Cost of Health Services’ paper presented Glass Half Full or Half Empty?’ prepared for UNSW to a Productivity Commission Forum on ’The Policy Seminar on ’Ageing Societies, Responding to the Implications of the Ageing of Australia’s Population’. Strunk, B.C. and Ginsburg, P.B. (2002), ’Ageing Fuchs, V.R. (1998), ’Health Care for the Elderly: How Plays Limited Role in Health Care Cost Trends’ Data Much? Who Will Pay For It?’ Working Paper No.
6755, National Bureau of Economic Research, Bulletin, Centre for Studying Health System Change, Gibson, D. and Goss, J. (1999), ’The Coming Crisis Williams, A. (1990), ’Population Ageing: Burden or of Australian Aged Care: Fact or Fiction?’ Australian Benefit?’ Public Health Association of Australia Journal of Ageing, 18, Supplement.
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It is only fitting and proper for the medical examiner’s office to express its thanks and

PRESS RELEASE Joshua A. Perper, M.D., LL.B., M.Sc. Chief Medical Examiner March 26, 2007 It is only fitting and proper for the Medical Examiner’s Office to express its thanks and appreciation to Chief Charlie Tiger and the Seminole Police Department, including Detective Katheran Frank, for their valuable and continuous cooperation, professionalism and their thorough investigat

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