Private Healthcare vs. Medicare

If you are an Australian citizen, you are eligible for Medicare, so you don’t NEED private health care. This in itself could be a reason why you may never bother going for private health care. But there must be something pulling a respectable number of Australians out of free health care and into private health care, paying for the privilege of the best private health funds Australia has to offer. Maybe the benefits are better with private health care. Nevertheless, it would be valuable to line up the pros and cons of each service to get a gauge on which one better suits you and your family.


What Medicare Does Cover:

This section has been split into two parts because if you have a specific need that must be present in your private health cover (dental treatment, for example), then you’ll want to know whether Medicare covers it. Perhaps, from this list of cover benefits, you will realise that Medicare caters to everything you need, and the few compromises you would have to make (which we will delve into later), do not faze you.

Let’s begin with what Medicare DOES give you:

  • Consultation fees for not only doctors, but specialists too
  • Optometrist appointments, including eye tests
  • Illness-related examinations and tests (required for health), such as x-rays and pathology tests
  • Some surgical procedures performed by approved dentists
  • Specific treatment for Cleft Lip and Palates under the Cleft Lip and Palate Scheme
  • Specific items for allied health services under the Chronic Disease Management Plan
  • Some services under the Enhanced Primary Care (EPC) program

A handful of these are slightly vague, as they state “some”, so it is advisable to delve further into this and get specifics breakdowns of what is and is not covered, likewise with the dental cover too. These small caveats may be petty now, but could be a huge deal breaker if one of these procedures were specific to your needs and not on the Medicare benefits list.

That being said, there are many areas of medical care which is covered under Medicare.

What Medicare Doesn’t Cover:

Although Medicare covers a multitude of medical services, there are some things it doesn’t cover, such as:

  • Examinations for life insurance, superannuation or memberships for which someone else is responsible (for example, a compensation insurer, employer or government authority).
  • Ambulance services
  • Most dental examinations and treatment
  • Most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services.
  • Acupuncture (unless part of a doctor’s consultation)
  • Glasses and contact lenses
  • Hearing aids and other appliances
  • Home nursing

If you do your research around the type of private health insurance Australia has available, you can find a plan which will cover these areas that Medicare does not. You will pay a premium for them, naturally, but you will know that should you need one of these services, there is no uncertainty to what you have access to.

Waiting times

The best health insurance Australia has on offer heavily relies upon the quality of its waiting times. With a growing population showing no signs of slowing down, the health care industry is being stretched more and more every year. Seeing as the majority of Australian citizens will be with Medicare, it is natural to assume the waiting times for this service will be far longer. The private healthcare Australia has to offer should make its shorter waiting times a key benefit of joining up.

Furthermore, not for profit private health care providers are known to team up to share doctors, nurses and hospitals across their members, opening up availability even further. Having private health insurance provides the ability to “jump the queue” to access a range of elective procedures in private hospitals. But this comes at a price for all patients. With Medicare, you may have to wait longer, but it will be at a reduced rate. Although, that encourages food for thought, as even if you are with Medicare, your operation may not be entirely free.

People with private health insurance are likely getting services ahead of people without insurance but with greater need. The private patient who gets their orthopedic or cataract surgery within weeks rather than months will very often end up with substantial, unexpected out-of-pocket costs.


One of the positives of the Medicare system is that it has a multitude of facilities all over the country. You would not need to go far to find a hospital or GP practice under Medicare to cater to your needs. Australian health insurance companies simply cannot provide the same number of facilities.

As a member of a health fund AU based, you may find yourself in a Medicare-run hospital, which is where many people on private healthcare get their wires crossed. They may expect the same levels of care they would get privately in a public hospital; benefits such as choosing their doctor, or a reduced waiting time. Be aware that you may lose these privileges in this scenario. Even if you have private health care, this is a scenario you could be lumbered with.

Choosing Your Doctor

Australia health funds prize themselves on being able to boast a shopping list of doctors. With Medicare health care, you are allocated a doctor based on availability. You may get a different doctor each time you visit, regardless of how far apart your appointments are. A private Australia health fund gives you that peace of mind where you know who will be seeing you. This factor is important to those with recurring visits to the doctor, and those with sensitive subjects they wish to discuss. It makes sense to have the same person to discuss these issues with each time.

Whether you compare health insurance Australia wide, health insurance Victoria, or health insurance WA, the private health funds Australia provides will have these key attributes over the public Medicare system:

  • Reduced waiting time
  • Choice of doctor
  • More chance of private facilities
  • Less crowded

These differences may seem quite obvious, and when you are fit and well, could even appear unimportant, but if you are waiting for that knee surgery to get walking comfortably up those stairs again without pain, there is a good chance, that if it is not life threatening, you could be waiting a year for that operation. But with private health care, you can have your knee is shipshape form in no time. It is these differences which encourage people to make the transition.

Paying your way (for higher earners)

If you are a high-income earner, you are encouraged to take out private health insurance because you are requested to pay a 2% levy to help fund Medicare and the National Disability Insurance Scheme. If you choose not to opt for private health insurance, you pay a tax penalty called the Medicare Levy Surcharge. Upon reaching 30, for each year private health insurance is not taken out, the levy increases by 2%, another reason to consider a private health plan.

Whether you choose to stay with Medicare or go private, the decision should be based on the best interests for yourself and your family if they are in the plan too. Use this as your inspiration to make your choice, and you’ll be just fine.