What do you do when you cannot afford to go to the doctor?
Patients in the Huon Valley in southern Tasmania are grappling with this question after their local clinic stopped bulk-billing.
The sudden loss of bulk-billing was "a big hit for a rural community", said Sam Black, one of the clinic's patients.
"I can't afford to pay for a doctor's appointment. I called around other practices in the area and no-one is taking on new patients or they don't bulk-bill.
"If I can't afford the gap after Medicare, I certainly can't afford the drive to Hobart."
The stress for the community is being mirrored around the state and the country as practice after practice makes the decision to end, or limit, bulk-billing.
"Bulk-billing is nearly non-existent in rural Tasmania," said Australian Medical Association Tasmania president John Saul.
Medical bills add up when you're chronically ill
In 2017 Ms Black had a virus that led to meningitis.
"I was bedridden for the first couple of years [after the virus]. I've been living in chronic pain ever since," she said.
Ms Black's complex health needs mean lots of trips to the GP, and before the practice ended bulk-billing she was going every two weeks.
"I'm on a medication that I can't have repeat scripts [for]," she said.
Because Ms Black is on a health-care plan she can get her scripts filled five times for free, but after that she does not know what she will do.
Both of Ms Black's daughters have conditions that need ongoing support, and she is not sure how she is going to pay for it.
'Quite a shock'
Another patient, Alanna Emmett, also has chronic health conditions and is the single parent of two daughters, one of whom has asthma.
"Thankfully I've been bulk-billed for the majority of their lives. To have that suddenly taken away was really quite a shock," she said.
The end of bulk-billing at the local clinic has also had consequences for Ms Emmett's university studies.
She is undertaking a Bachelor of Midwifery and needs to have a series of medical checks before she can begin her pracs.
Ms Emmett has previously moved around the state, and has her name at a few practices.
She hopes they still bulk bill, but it will mean quite a drive to get there.
"In emergencies … the [local clinic] Cygnet Family Practice is the easiest place to go," she said.
Privately bill, or close
Ending bulk-billing is not something general practices do lightly.
"It was a desperate decision and was made with much heartache, but we just could not continue to provide a service with the current Medicare rebate," said Kerrie Duggan, co-owner of the Cygnet Family Practice.
"Our philosophy is kind, holistic health care, but it can't be free. We've absorbed costs for as long as we can," she said.
"But it's come to the point now that if we didn't introduce private billing, we would have had to close our practice and we would have no services for the 2,000-plus patients that are on our books.
"This will see an increased number of people seeking help at emergency departments, often later in their illness or injury where complication and poorer health-care outcomes will be a consequence.
"Our emergency departments are already overcrowded with people who don't need emergency care but urgent care, which has historically been provided by general practices."
Ms Black understands the decision, but wishes the community was given more warning.
"Now we have to scramble to figure out what we're going to do about important referrals and our important medication," Ms Black said.
"People on low incomes can't have sudden surprises like this."
While Ms Duggan and her team discussed having a transition period they decided it was not possible.
"We didn't have a choice, we either started more private billings or would close — it was that urgent," she said.
Emergency funding 'needed now'
Dr Saul said general practitioners were being put in an untenable position.
"The bulk-billing rebate now is only $39, it's impossible to make ends meet and provide quality medicine at that rate."
When Medicare was introduced, the rebate was "the equivalent of about $75 in real terms today," he said.
"We're now over 100 days in [with the new government] and we've seen no traction. We need emergency funding and we need it now."
In a statement, Health Minister Mark Butler said primary care was in its worst shape since Medicare began, and the government was committed to investing almost $1 billion in general practice and strengthening Medicare.
For Ms Black, the stakes are high.
"My health and wellbeing was already suffering, and I don't doubt for a minute it will worsen significantly, all due to practices going private," she said.
