Does government subsidy for costs of medical and pharmaceutical services result in higher service utilization by older widowed women in Australia?

Abstract

In Australia, Medicare, the national health insurance system which includes the Medical Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS), provides partial coverage for most medical services and pharmaceuticals. For war widows, the Department of Veterans' Affairs (DVA) covers almost the entire cost of their health care. The objective of this study was to test whether war widows have higher usage of medical services and pharmaceuticals.
Data were from 730 women aged 70-84 years (mostly World War II widows) participating in the Australian Longitudinal Study on Women's Health who consented to data linkage to Medicare Australia. The main outcome measures were PBS costs, claims, co-payments and scripts presented, and MBS total costs, claims and gap payments for medical services in 2005.
There was no difference between the war widows and similarly aged widows in the Australian population without DVA support on use of medical services. While war widows had more pharmaceutical prescriptions filled they generated equivalent total costs, number of claims and co-payments for pharmaceuticals than widows without DVA support.
Older war widows are not using more medical services and pharmaceuticals than other older Australian women despite having financial incentives to do so.

Full text

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RESEARCH ARTICLEOpen Access
Does Government subsidy for costs of medical
and pharmaceutical services result in higher
service utilization by older widowed women
in Australia?
Leigh R Tooth1*, Richard Hockey1, Susan Treloar2, Christine McClintock2and Annette Dobson2
Abstract
Background: In Australia, Medicare, the national health insurance system which includes the Medical Benefits
Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS), provides partial coverage for most medical services and
pharmaceuticals. For war widows, the Department of Veterans’ Affairs (DVA) covers almost the entire cost of their
health care. The objective of this study was to test whether war widows have higher usage of medical services and
pharmaceuticals.
Methods: Data were from 730 women aged 70–84 years (mostly World War II widows) participating in the
Australian Longitudinal Study on Women’s Health who consented to data linkage to Medicare Australia. The main
outcome measures were PBS costs, claims, co-payments and scripts presented, and MBS total costs, claims and gap
payments for medical services in 2005.
Results: There was no difference between the war widows and similarly aged widows in the Australian population
without DVA support on use of medical services. While war widows had more pharmaceutical prescriptions filled
they generated equivalent total costs, number of claims and co-payments for pharmaceuticals than widows
without DVA support.
Conclusions: Older war widows are not using more medical services and pharmaceuticals than other older
Australian women despite having financial incentives to do so.
Background
In Australia, an in-situ experiment in older women’s use
of medical services and pharmaceuticals can inform
health service policy on the effectiveness of alternative
models of health funding. Different models of health ser-
vice funding and charging are applied for medical ser-
vices and pharmaceuticals under Australia’s universal
health care system (‘Medicare’), and the special health
care coverage provided to Australia’s war veterans and
their widows.
Medicare ensures eligible Australian residents have ac-
cess to free treatment as a public patient in public hospi-
tals, free or low cost out-of-hospital medical and
optometric care and subsidized access to pharmaceuti-
cals. Residents may choose to pay for private insurance
for hospital and other health services not covered by
Medicare (e.g., allied health). For each out-of-hospital
visit to a general (family) practitioner (GP) (equivalent
to U.S. primary care physician) or medical specialist,
Medicare pays 85 to 100 % of the Medicare Benefits
Schedule (MBS) fee, depending on the consultation type
(MBS fees are set annually by Government), potentially
leaving a ‘gap’ payable by the patient. Many practitioners
charge more than the schedule fee; the difference be-
tween the Medicare benefit and the practitioner’s actual
charge is the patient’s eventual out-of-pocket cost. The
basic architecture of the Medicare system is shown in
Table 1 and while a minority of Australian residents
incurs some cost for health care, there are levels of
* Correspondence: l.tooth@uq.edu.au
1School of Population Health, The University of Queensland, Brisbane, Australia
Full list of author information is available at the end of the article
© 2012 Tooth et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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protection safeguarding individuals with excessive health
care needs against paying too much.
The Australian Government also subsidizes the costs
of many prescription medicines for residents through
the Pharmaceutical Benefits Scheme (PBS), also illu-
strated in Table 1. Individuals pay a maximum co-
payment per script for prescription medications listed
on the PBS, regardless of their actual cost. The level of
co-payment is lower for concession card holders such as
pensioners. There is also a PBS Safety Net to protect
individuals who require numerous medicines.
Separately, the Australian Government funds the De-
partment of Veterans’ Affairs (DVA), to provide benefits
and services to eligible veterans and their dependants for
injury, disease or death related to Australian Defence
Force service (similar to the U.S. Civilian Health and Med-
ical Program of the Department of Veterans’ Affairs
(CHAMPVA)). War widows are entitled to a war widow’s
pension and gold repatriation health card (Gold Card)
from the DVA if their husband’s death was due to war ser-
vice or other eligible defence service. With a Gold Card,
war widows are always bulk billed (meaning that they pay
nothing personally) and the benefit paid is higher. War
widows are also entitled to receive from DVA more health
services than Medicare covers for other Australians, for
example all allied health services and private hospital costs.
War widows with DVA Gold Cards are entitled to all med-
icines listed on the PBS and the Repatriation Pharmaceut-
ical Benefits Scheme (RPBS) at the concessional co-
payment rate. The RPBS includes some additional phar-
maceuticals specifically for the veteran population. Thus,
war widows are a unique group of Australian women. Re-
gardless of their own health needs, once their spouse dies
they receive their own Gold Card if they are eligible, which
entitles them to a wider range of free medical and other
health care (including treatment in private and public hos-
pitals) and a larger range of pharmaceuticals at the conces-
sional rate than other similarly aged Australian women.
Table 1 Arrangements for out-of-hospital medical (MBS) and pharmaceutical (PBS/RPBS) services in Australia for
individuals with and without DVA Gold Cards
All Australian residentsAustralian residents with DVA Gold Card
MedicareMedicare
• Medicare pays 85-100% of scheduled fee for GP/specialist
visit up to threshold (see below)
• Always bulk-billed i.e., no gap or out-of-pocket costs
• Person pays gap of up to 15% plus out-of-pocket costs
(difference between scheduled fee and GPs/specialist’s charge)
• DVA pays GPs higher fees according to its own schedule
• GPs/Specialists may accept Medicare payment (bulk billing).
This is most common for concession card holders and in areas
of lower SES
• Covers a comprehensive range of Allied and Dental
Health services
• Provides for rehabilitation appliances
• Funds in home nursing and domestic support services
• Medicare Safety Net threshold (2012 Figures):
• All Medicare card holders (Australian residents)
• Once $413.50 for gap payments has been met annually,
Medicare will pay 100% of scheduled fee
• Once $1198.00 for out-of-pocket costs for extended Medicare
Safety Net services has been met annually, Medicare will pay 80%
of out-of- pocket costs
• Concession card holders – Once minimum $598.80 for
out-of-pocket costs for extended Medicare Safety
Net services has been met annually, Medicare will pay
80% of out-of-pocket costs
PBS Co-paymentPBS/RPBS Co-payment
• General patient - $34.40 per scripts up to threshold
• $5.80 per script up to threshold of $348.00
• Concession card holder - $5.80 per script up to threshold
PBS Safety Net threshold (2012 Figures):
PBS Safety Net threshold:
• All Medicare card holders (Australian residents) - Once $1363.30
has been spent annually on pharmaceuticals listed on the PBS,
further pharmaceuticals are maximum $5.80
• Once minimum $ 348.00 has been spent
annually on
pharmaceuticals listed on the PBS/RPBS,
further pharmaceuticals are free
• Concession card holders – Once $348.00 has been spent annually on
pharmaceuticals listed on the PBS, further pharmaceuticals are free
PBS – Pharmaceutical Benefits Scheme; RPBS – Repatriation Pharmaceutical Benefits Scheme; SES - Socio-economic status.
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Research has shown that abolishing or reducing the
costs of health care leads to higher usage of health ser-
vices [1]. As financial disincentives for using health care
services are largely abolished for war widows, it might
be expected that they would also make higher use of
these services, particularly as widows often have poorer
health, higher mortality and higher use of health services
compared to partnered women [2,3]. Little research has
examined this issue.
For this paper, we hypothesized that war widows with
Gold Cards would use more medical services and phar-
maceuticals than widows without a connection to DVA.
To test this, we analysed data from a large community-
based cohort study of older Australian women.
Methods
Sample and data
The data were from the Australian Longitudinal Study on
Women’s Health (ALSWH) which involves over 40,000
women randomly selected in 1996 from the Medicare
Australia database which includes most of the Australian
population.Womenfrom
sampled at twice the rate of women in urban areas to en-
sure adequate ongoing representation as the study pro-
gressed. Three age cohorts were selected, women born
between 1973–78, 1946–51 and 1921–26 and these
women complete omnibus-style mailed surveys on their
health and social circumstances every three years (see
http://www.alswh.org.au/surveys.html).
Death Index is checked annually to ascertain deaths.
The ALSWH was chosen because it is the largest lon-
gitudinal study of women in Australia and is largely rep-
resentative of the general population of Australian
women [4-6]. The ALSWH has ethical clearance from
the University of Newcastle, the University of Queens-
land, the Australian Department of Health and Ageing
and the Department of Veterans Affairs (DVA). This
allows linkage of ALSWH and Medicare Australia data
for women who consent. For this paper, data from the
fourth ALSWH survey (in 2005) of women born be-
tween 1921–1926, then aged 79–84 years were used. In
this survey, each woman was asked whether she had a
DVA Gold Card and, if married, whether her spouse had
a DVA Gold Card. She was also asked about the sources
of income for her and her husband with options that
included all relevant DVA pensions. The women’s mari-
tal status (married, defacto, widowed, single, divorced,
separated) is asked at every ALSWH survey. Widows are
asked the date they were widowed. Only Australian-born
women who were married at Survey 1 and widowed by
Survey 4 were included.
The women were categorized as war widows with DVA
Gold Cards or widows with no connection to DVA. The
womenwerefurther categorized
rural/remoteareaswere
TheNational
bydurationof
widowhood as this is associated with health and lifestyle
changes, for example poorer mental and physical health,
higher mortality and difficulty managing on income [7,8].
Given the 3-yearly cycle of ALSWH surveys, duration of
widowhood was defined as being recent (≤3 years) or
longer (>3 years).
In the ALSWH surveys, consent is sought from all
participants for Medicare Australia (which also processes
Gold Card payments on behalf of DVA) to release link-
able claim details to the ALSWH research team. All
claims for services (including MBS/PBS/RPBS) that were
processed by Medicare Australia for consenting women
for 2005 (same year as fourth ALSWH survey) were
extracted. The outcomes used in this study were: total
cost of medical services (including gap payment made
by women); total number of claims for MBS subsidized
medical services; total gap payments; number of GP vis-
its; total costs of pharmaceuticals (PBS/RPBS); number
of pharmaceutical claims; number of pharmaceutical
scripts presented; and total co-payments for pharmaceu-
ticals. Table 2 presents further explanations about the
outcomes.
Table 2 Definitions and further explanations of the
medical services and pharmaceutical outcomes
Outcome variableInterpretation of variable and scores
Medical Services
Total costs of
medical services
Total cost of medical services for 2005
calendar year (includes Medical Benefit
Scheme (MBS) gap payment) ($AU)
Number of MBS claimsTotal number of claims to MBS for
medical services for 2005 calendar year
(additional bulk billing payments for
general medical services were excluded
from claims data to prevent
double counting)
MBS gap payment
by the women
Total amount paid by women for
medical services for 2005 calendar year
(AU$). Due to skewness this variable is
dichotomised into whether a gap was
paid (yes, no).
Number of General
Practitioner (GP) visits
Total number of un-referred visits to GPs
for 2005 calendar year
Pharmaceuticals
Total costs of
pharmaceuticals (PBS/RPBS)
Total cost of pharmaceuticals for 2005
calendar year (includes women’s
contribution) ($AU)
Number of PBS(RPBS) claims Total number of scripts dispensed
(including each repeat dispensed on one
script) in 2005 calendar year
Number of PBS(RPBS) scripts
presented
Total number of scripts presented
(irrespective of how many repeats per
script) in 2005 calendar year
Women’s contribution to
cost of pharmaceuticals
Total amount paid by women in 2005
calendar year ($AU).
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Comparison of ALSWH data with linked Medicare
data enabled women’s descriptions of their connection
to DVA to be cross-checked with the concession status
of their MBS/PBS(RPBS) claims.
Analysis
War widows with DVA Gold Cards (≤3 years or >3 years
widowed) and widows with no connection to DVA
(≤3 years or >3 years widowed) were compared on the
MBS/PBS(RPBS) outcomes, after controlling for the po-
tential confounders of age, self-reported ability to manage
on their income and self-rated health. For the continuous
MBS/PBS(RPBS) outcomes, multiple regression analyses
and selected pair wise comparisons were conducted. The
mean number (95 % confidence intervals (CIs)) of MBS
claims, GP visits, PBS/RPBS claims and scripts are pre-
sented, and the mean total (95 % CIs) costs for medical
services,pharmaceuticals
contribution to pharmaceuticals are reported. For the
MBS gap payment, this outcome was dichotomized into
whether a gap payment was made or not as the data were
skewed. Logistic regression was used for this analysis and
odds ratios (95 % CIs) are reported. Analyses were con-
ducted using SAS (version 9.2).
andthe women’sco-
Results
The fourth ALSWH survey was completed by 7158
women. Of these, 1534 (21.4 %) were married at Survey
1 and widowed by Survey 4. Of these, 999 (65 %) con-
sented to Medicare linkage. The final sample was the
730 women for whom their relationship with DVA could
be correctly ascertained and who were Australian-born.
Of these 730 women, 407 (56 %) had no connection to
DVA and 323 (44 %) were DVA Gold Card holders.
Table 3 shows selected demographic characteristics of
the 730 women. The groups differed statistically on abil-
ity to manage on available income. The strongest con-
tributor to this result was that longer-term widows
without a connection to DVA were more likely to report
having difficulty managing on their income. The groups
did not differ statistically on age or self-rated health.
Medical services: Total costs, number of claims, visits to
GPs and gap payment
No large or statistically significant differences between
the groups were found for total costs of medical services
(p=0.64), number of MBS claims (p=0.08) and visits to
GPs (p=0.21) (Table 4). Regarding gap payments, 5 to
10 % of the war widows in this study still chose to pay a
gap despite theoretically not needing to. However over-
all, these Gold Card holders were much less likely to
incur gap payments: the adjusted odds ratios ranged
from 46 (95 % CIs 21, 102) for recent widows to 76
(95 % CIs 37, 156) for longer-term widows (Table 5).
Pharmaceuticals: Total costs, number of claims, number
of scripts and amount of co-contribution
No large or statistically significant differences were
found between groups for total costs of pharmaceuticals
(p=0.33), total number of claims for pharmaceuticals
(p=0.10) and amount of the women’s co-contribution to
the costs of their pharmaceuticals (p=0.54) (Table 4). A
significant difference was found between the groups for
presentation of PBS scripts. Subsequent pair-wise ana-
lysis revealed the contributing factor to this result was
that for longer-term widows, those with no connection
to DVA presented fewer PBS(RPBS) scripts than women
Table 3 Demographic characteristics of Australian Longitudinal Study on Women’s Health participants: Grouped by
relationship to the Department of Veterans’ Affairs (DVA) and recency of widowhood
Demographic
characteristicwidowed≤3 years
n=114
n=209
Gold Card holder,
Gold Card holder,
widowed>3 years
Not DVA,
widowed≤3 years
n=136
Not DVA,
widowed>3 years
n=271
p-value
Age (mean, SD)81.1 (1.4)81.3 (1.4)80.9 (1.4) 81.1 (1.4)0.14
Self-rated heath (%)
Excellent0.9 % 4.9 %4.4 % 6.6 %0.12
Very good15.0 % 21.8 %22.2 %24.0 %
Good 53.1 % 39.8 %45.2 %43.5 %
Fair/Poor31.0 % 33.5 %28.1 %25.8 %
Ability to manage on income (%)
Easy 38.6 % 43.7 %32.1 %30.6 %
Not too bad44.7 % 46.1 %53.7 %45.1 %
Difficult sometimes13.2 %9.7 %11.2 %17.2 %0.001
Difficult always/ impossible3.5 %0.5 % 3.0 %7.1 %
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who were DVA Gold Card holders (pair wise p=0.001)
(Table 4).
Discussion
We hypothesised that war widows with Gold Cards
would use more medical services and pharmaceuticals
than women without a connection to DVA, thereby cost-
ing the Australian Government more. This hypothesis
was based on the premise that the removal of financial
disincentives would lead to higher use of services. This
hypothesis was not substantiated. DVA support reduced
the out-of-pocket costs for medical services. However
despite having access to gap free treatment, Gold Card
holders neither incurred higher total costs, nor made
more claims for medical services or visits to GPs. In-
deed, between 5–10 % of war widows in this study did
pay a gap. These findings suggest they are not making
increased use of almost free medical treatment. In an
analysis of GP visits by people aged over 70 years before
and after free GP services were introduced, Layte et al
[9] found no significant increases in number of GP visits.
He suggested that the impact of other factors such as
personal mobility, transport and information may be
more important than costs in determining frequency of
GP visits. In an analysis of factors determining use of
GPs in Australia, Zhang and colleagues further identified
issues such as social support, perceptions about the
value of good health and attitudes about health care as
being important [10].
Having a Gold Card did appear to influence use of
pharmaceuticals by war widows in a limited way. These
Gold Card holders, in particular longer-term widows,
presented more PBS(RPBS) scripts than women who
were not Gold Card holders but the total costs of their
pharmaceuticals and total number of claims were simi-
lar. Possible explanations for this finding include: Gold
Card holders made more visits to a GP – which we have
discounted; GPs wrote more scripts per visit; and/or
lower cost pharmaceuticals were prescribed. Our data
did not allow us to analyse whether GPs wrote more
scripts for the DVA Gold Card holders than women
with no connection to DVA. However, in a survey of GP
consultations (2000–2003), Britt et al [11] found that
longer consultations were more likely for patients with
a DVA Gold Card, and those who were older and fe-
male, but that the consultations resulted in fewer medi-
cations being prescribed and used. This practice by GPs
could also reflect the influence of the DVA Prescriber
Intervention and Feedback program (PFP) from 1993–
2003, and/or its successor, the Veterans’ Medicines Ad-
vice and Therapeutics Education Service (Veterans’
MATES) programs. These programs assist GPs and
veteransmanagemedicines
medication-related problems such as adverse effects or
drug interactions [12].
inorderto prevent
Table 5 Odds ratios for no MBS gap payment in 2005
calendar year for the groups defined by relationship with
Department of Veterans’ Affairs and recency of widowhood
Comparison Groups Odds ratio 95 % CIsp-value
Gold Card holder, widowed>3 years
versus Gold Card holder,
widowed≤3 years
2.090.85, 5.100.11
Not DVA, widowed>3 years
versus not DVA, widowed≤3 years
1.280.75, 2.200.36
Gold Card holder, widowed≤3 years
versus not DVA, widowed≤3 years
46.5 21.3, 101.9 <0.0001
Gold Card holder, widowed>3 years
versus not DVA, widowed>3 years
75.536.6, 155.9 <0.0001
Adjusted for age, self-rated health and ability to manage on income
Table 4 Medical Benefit Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS/RPBS) items to Australian Longitudinal
Study on Women’s Health participants by Department of Veterans’ Affairs (DVA) and partnership status: Mean (95 % CIs)
total MBS costs, MBS claims, PBS/RPBS costs, PBS/RPBS claims and PBS/RPBS scripts presented
Gold Card holder,
widowed≤3 years
n=114
Gold Card holder,
widowed>3 years
n=209
Not DVA,
widowed≤3 years
n=136
Not DVA,
widowed>3 years
n=271
p-value
MBS
Total costs ($AU: mean 95 % CIs)1213 (968,1521)1070 (904,1268)1265 (1027,1556)1166 (1006,1352)0.64
Claims (number: mean 95 % CIs)25.4 (21.7,29.6)21.3 (19.0,24.0)26.9 (23.3,31.0)24.0 (21.7,26.6)0.08
GP visits (number: mean 95 % CIs)10.6 (9.4,11.9)9.7 (8.9,10.7)9.6 (8.6,10.7)9.1 (8.4,9.8)0.21
Gap payment (% yes)9.8 %4.9 %81.3 %76.6 %
<0.0001
PBS(RPBS)
Total costs ($AU: mean 95 % CIs) 998 (816, 1220)1024 (879, 1192)1020 (845, 1231) 868 (761, 989)0.33
Claims including repeats (number: mean 95 % CIs) 38.8 (33.5,45.0)38.7 (34.6,43.3)38.1 (33.2,43.8)32.9 (29.9,36.3)0.10
Scripts presented (number: mean 95 % CIs) 15.3 (13.4,17.4)15.2 (13.7,16.7) 14.5 (12.8,16.4)12.2 (11.2,13.3)0.001
Co-contribution ($AU: mean 95 % CIs) 149 (129, 172)151 (136, 169)168 (146, 192)152 (138, 167)0.54
All analyses adjusted for age, self-rated health and ability to manage on income.
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Another possible explanation for why these DVA Gold
Card holders had more scripts but not higher total costs
for pharmaceuticals is that they do not fill all prescrip-
tion repeats, possibly indicating non-adherence. Hynd et
al [13] reported significantly less dispensing of PBS pre-
scriptions following the introduction of the co-payment
price increase in 2005, the same year our data were col-
lected. They found that pharmaceutical dispensing was
2 %-9 % less for people with ‘social security cards’ (in-
cluding age concession cards) than for the general popu-
lation. This change to the system, which would have also
impacted on Gold Card holders, might partially explain
our finding.
Few other studies have looked at similar issues. The
most relevant is an Australian Institute of Health and
Welfare [AIHW] report [14] which analyzed Australian
medical and pharmaceutical usage by veterans and war
widow(er)s who were Gold Card holders from 1997–2000
and showed that female Gold Card holders aged 70–
84 years (mostly World War II widows) had an 11 %
higher use of local medical officer/GP services than the
rest of the Australian community, matched for age. Add-
itionally, in 1999–2000 female DVA Gold Card holders
aged 70–89 years had 4 %-8 % lower use of pharmaceuti-
cals than similarly aged women in the Australian commu-
nity. The authors raised the possibility of under-reporting
of PBS claims if Gold Card holders did not use their Gold
Cards or used other non-DVA concession cards when pre-
senting scripts. We can discount under-reporting as our
complete linkage to Medicare data enabled us to cross
check the women’s DVA status and concession card status
for all claims. The AIHW report found the cost per script
to be 16 % lower for female Gold Card holders aged 70–
79 years, and, like us, could not explain this apart from
hypothesising that DVA Gold Card holders are prescribed
less expensive drugs. However, comparisons with our
study are not straightforward as the AIHW study did not
separate widows and married women, restricted the MBS
data to local medical officer and GP (out-of-hospital) ser-
vices, and used pharmaceutical use data estimated from
multiple sources because PBS(RPBS) data were incom-
plete at that time [14].
Study limitations
The findings should be considered with respect to the
limitations of the study. Only ALSWH participants who
consented to data linkage were included. While the con-
sent rates for data linkage for the two groups of women
were similar (62 % of women with no connection to
DVA versus 67 % of Gold Card holders), ALSWH parti-
cipants who consent to linkage tend to be slightly better
educated and better able to manage on their income
than non-consenters [15,16]. This potentially creates a
socioeconomic bias and underestimation of bulk billing
rates [17]. Additionally, the numbers of Gold Card
holders was relatively small, which may have prevented
some important differences being identified and limited
the number of covariates that could be used in the ana-
lyses. Our findings are strengthened by the fact that the
ALSWH is a large, nationally representative random
sample.
Conclusions and Implications
In Australia, like the United States, the government
shows its appreciation of the service and sacrifice of its
war veterans and their spouses and dependents by pro-
viding significant ongoing support for their health care
needs. This support is significant both in terms of cost
and extent. In December 2011, there were an estimated
83,562 war widows of World War II veterans in Austra-
lia, and a further 77,400 World War II veterans receiving
income support [18], many of whom will be outlived by
their wives. Our results suggest older war widows are
not using more medical services and pharmaceuticals
than other older Australian women despite having finan-
cial incentives to do so. The main implication is that the
current funding model is providing an equitable amount
and type of support and access to health services to war
widows compared to others. Given the strengths of the
ALSWH, these findings can be viewed as being broadly
representative of war widows in Australia. The extent to
which such behaviour might be displayed by other
demographic groups is unknown. Generalizations to
other countries are more tenuous but the implications
for the United States or the United Kingdom for ex-
ample, are that spouses of older veterans do not neces-
sarily exploit free services.
However, whether these results apply to policies for fu-
ture funding models is uncertain. In Australia there is
potentially an upcoming demographic of war widows of
the estimated more than 47,100 men now aged 55 years
and older who fought in the Vietnam War and who re-
ceive income support [18]. This cohort of women may
well have a different sense of entitlement and attitudes
to health service access and use than that displayed by
the older generation of war widows.
Competing interests
There are no competing interests to declare for any of the authors.
Acknowledgements
The research on which this paper is based was conducted as part of the
Australian Longitudinal Study on Women’s Health, based at the University of
Newcastle and the University of Queensland. The ALSWH (including the
salaries of LT and RH) is funded by the Australian Government Department
of Health and Ageing. The salaries of ST and CMc are paid by the Centre for
Military and Veterans Health, which is funded by the Australian Government
Department of Defence and DVA. The salary of AD is paid by the Centre for
Military and Veterans Health (40 %) and the University of Queensland (60 %).
This research project was part of a larger project titled “Needs of spouse
carers of World War II veterans before and after widowhood” funded in
2008–2011 under the Department of Veterans’ Affairs Applied Research
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Program (project #0801). This funding contributed towards the salary of RH
who conducted the statistical analyses for the project. The funding body had
no influence on the conceptualisation of the study design, collection of data
or analysis. Dr Eileen Wilson, Ms Georgina Binks and Ms Marion Springer
from the DVA provided helpful insights into the interpretation of the results
within the context of the services provided by the DVA. We thank them for
these insights and contributions to this project and manuscript. Finally, we
thank the participants in the ALSWH who provided the survey data.
Author details
1School of Population Health, The University of Queensland, Brisbane, Australia.
2Centre for Military and Veterans’ Health, The University of Queensland,
Brisbane, Australia.
Authors' contributions
LT contributed substantially to the conception and design and interpretation
of the data and was principally responsible for drafting the manuscript. RH
contributed substantially to the conception and design, data analysis and
interpretation of the data, and reviewed drafts of the manuscript. ST
contributed to the conception and design and interpretation of the data
and reviewed drafts of the manuscript. CMc contributed to the conception
and design and interpretation of the data and reviewed drafts of the
manuscript. AD contributed substantially to the conception and design,
interpretation of the data and to drafting the manuscript. All authors read
and approved the final manuscript.
Received: 5 September 2011 Accepted: 27 June 2012
Published: 27 June 2012
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doi:10.1186/1472-6963-12-179
Cite this article as: Tooth et al.: Does Government subsidy for costs of
medical and pharmaceutical services result in higher service utilization
by older widowed women in Australia? BMC Health Services Research 2012
12:179.
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