By Suvi Mahonen
In discussion with leaders, teachers and students in the yoga community, the Director of The Yoga Institute Dr Michael de Manincor and Australian Yoga Life writer Suvi Mahonen, we examine the impact of the recent changes to the private insurance health rebate and who will be most affected.
On the 1st of April this year new government regulation came into effect that unfortunately turned out not to be an April Fool’s joke. In a bid to rein in private health costs the Federal government amended the 2007 Private Health Insurance Act, prohibiting private health insurers from offering rebates for 17 different “natural” therapies including Pilates, naturopathy and yoga.
Not surprisingly many people were dismayed by this decision, including medical practitioners, allied health professionals and many of the estimated two-thirds of the Australian population who incorporate some form of natural therapy into their daily lives . In response to the outrage that ensued – including petitions from Yoga Australia, the Australian Naturopathic Practitioners Association and a written submission to the health minister by former Federal politician and Australian Medical Association president Kerryn Phelps – the government backtracked slightly, promising a review of the legislation within a week of it coming into effect.
“Other countries around the world are moving in the opposite direction, integrating proven natural therapies into orthodox treatment with great results.”
But for now, and the foreseeable future, the decision stands, leaving thousands of Australians further out of pocket for most forms of natural health therapy, and in some cases no longer able to afford it any more, given that they no longer receive rebates from their private health insurance extras cover.
The government defends its decision, claiming that the natural therapies it no longer subsidises lack scientific evidence for their effectiveness. So is this a well- intentioned, albeit misguided, attempt by the government to reduce spending on the estimated $6 billion a year it subsidises to the private health industry? Or is this merely a cynical exercise that will have no meaningful impact on the federal deficit and health insurance premiums, and will only serve to discriminate against natural health therapists and practitioners, putting hundreds of livelihoods at risk and discouraging Australians from being proactive about their health in ways that don’t involve surgery or pharmaceutical industry medicines?
CONCERN FROM PEAK BODIES
Yoga Australia CEO Shyamala Benakovic says the government’s basis for removal of yoga and other natural therapies from the private insurance health rebates scheme is unsound.
“We strongly believe there is enough evidence that shows the benefits of yoga,” she tells Australian Yoga Life. “In December 2017 we submitted a response to the Health Minister Greg Hunt outlining key research that refuted their claim that there is insufficient evidence about the effect of yoga on health outcomes.”
She believes the decision could discourage people from turning to yoga for medical treatment and rehabilitation. “While we don’t have the data as to what proportion of people were claiming rebates from private health insurers for yoga, we do know from a RMIT University study that one in five people practised yoga for a specific health or medical reason,” she said.
Benakovic said Yoga Australia is part of the Your Health Your Choice campaign to support an Australiawide petition asking the government to reconsider its position. “We had twenty-six out of the thirty-eight health funds in Australia paying rebates for yoga,” she said. “Now none of these funds pay rebates for yoga.”
President of the International Yoga Teachers Association (IYTA) Astrid Pickup is also concerned about the changes.
“We have an ever-growing elderly population with a lot of joint and ligament problems who lose their flexibility. And when they lose their flexibility they get pain. And then they start getting trigger points in their muscles, which aggravates their pain further, so it becomes a cycle of pain that perpetuates itself”
“I feel that yoga is being discriminated against,” she says. “It is a holistic practice that moves the body, teaches people to breathe effectively and helps to calm the mind.”
Pickup believes yoga should be differentiated from some of the smaller, niche natural therapies such as aromatherapy, buteyko and iridology that health funds also no longer provide rebates for.
“I have doctors and physiotherapists who recommend their patients to my classes, so they obviously see the benefits of yoga,” she says.
Many of Pickup’s students have reported improvements in specific medical conditions after taking up yoga. One of these is a personal trainer who found that it was invaluable in helping her cope with the transition through menopause. “She said she was coping better with her symptoms and no longer suffered from hot flushes or insomnia, and her mood was stable,” Pickup said. Other students have reported significant relief from osteoarthritis, lymphodema and lower back pain.
Dru Yoga Director Noelene Francis echoes this sentiment. She says there are many cases where people have benefited significantly from the practice of yoga, including people suffering from multiple sclerosis, back pain, anxiety, depression, fibromyalgia, chronic fatigue and Parkinson’s disease.
“The criteria used by the Office of National Health and Medical Research Council to review the natural therapies was quite narrow, choosing to consider only systematic reviews completed in the past five years, only in the English language, and only seeking evidence of effectiveness for specific clinical conditions,” says Francis. “This meant that although there were a number of large randomised trials for yoga, if they didn’t focus on specific clinical conditions, they weren’t considered.”
Francis believes that abolishing the rebate for yoga will negatively impact the yoga industry.
“All our yoga teachers are small business owners and the changes may result in less people choosing yoga for financial reasons,” she said.
“People are already watching their discretionary spending on items like yoga classes, and without access to the health fund rebate for yoga it’s very likely that some people may stop attending classes altogether.”
Iyengar Yoga teacher Linda Apps says prohibiting private health insurers from providing rebates for yoga especially affects people on low incomes. “For me the disturbing thing is that this decision was based on a false premise, that is, that there is not enough scientific evidence to show yoga works,” said Apps. “But there is a lot of scientific evidence now to show that yoga is effective for a range of issues.”
She warns that the decision sets a dangerous precedent.
“It will affect the amount of research done on yoga and it makes it difficult, or impossible, to offer yoga in hospital programmes or packages of care that were previously covered by private health insurance,” she points out. “Other countries around the world are moving in the opposite direction, integrating proven natural therapies into orthodox treatment with great results.”
OUR AGEING POPULATION
Retirees may be some of the hardest hit by the changes to the health rebate. Many of them have been members of the same health fund for most of their lives and, now that they are no longer earning an income, have been relying on the rebates to help them afford activities such as yoga.
Spokesperson for The Australian School of Meditation and Yoga (ASMY) Andrew Galvin, who has been teaching yoga for 13 years, says that from a community health point of view, the decision is “a step in the wrong direction”.
One retiree, 73, said she had been regularly claiming the rebate for her weekly yoga class. “I’m part of a class of elderly students and it was a shock when we found out that yoga was no longer going to be covered,” she tells Australian Yoga Life.
She was especially dismayed by the decision, given that it was her GP who recommended yoga to help with her osteoarthritis pain. “Yoga is about making you healthier, it’s about prevention. And for me, when I’m more flexible I’m not taking painkillers,” she said.
The retired Sydney-sider wants to continue her yoga classes but admits that having to write out a cheque for $95 for the following term’s fees had made her think twice, given she will no longer receive a rebate. “When you get to this stage of life you really need to watch your spending,” she said.
Self-funded retiree Doug McPhillips, 74, agrees. He turned to yoga following his son’s tragic suicide and the breakup of his marriage.
“The rebate took the weight off retirees who were stressing over how they’re going to get by,” he said. “I was going three times a week but now I can only afford to go twice.”
As part of his healing from his personal tragedies Doug has walked the 800 km-long pilgrimage trek Camino de Santiago in Spain several times.
He plans to run events to help other people who suffer from anxiety and depression and would like to offer yoga classes as part of the program. However, he fears that no longer being able to access the rebate will discourage people who need it the most.
“It helped me a lot when I went through depression. Yoga helps you focus away from your mental state and concentrate on the physical,” he says.
Practice Principle of Surfers Health Medical Centre Dr Mark Jeffery is a clinician with more than 30 years’ experience. He says that it is unfortunate that the government has cut the private health care rebate for yoga.
“We have an ever-growing elderly population with a lot of joint and ligament problems who lose their flexibility. And when they lose their flexibility they get pain. And then they start getting trigger points in their muscles, which aggravates their pain further, so it becomes a cycle of pain that perpetuates itself,” Jeffery tells Australian Yoga Life. “Yoga, without a doubt, can help with conditions like these and has a role to play in musculoskeletal medicine.”
He believes yoga can also be an important adjunct therapy for people suffering from anxiety and depression. “The health funds need to embrace allied health and the government needs to make a stronger effort to facilitate yoga because if you can keep your patients healthy, and their mental health is good, then it ensures that their quality of life is so much better for them.”
Jeffery believes removing yoga from the health care rebate will likely discourage some patients from taking it up. “A lot of retirees simply don’t have the money,” he says.
Not everyone is as pessimistic with the changes. Yoga teacher Heidi van Maanenberg says many people were unaware they could claim the rebate until it became redundant and the changes have not affected her business. “People will come to yoga when they are ready,” she says. “It may take them longer to find us but when the physical injuries have healed, the spiritual journey always continues. I don’t think the cut in rebates is influencing the majority.”
“We recognise that the aim of the government is to only fund treatments that are “clinically effective” and that they have chosen to do this through systematic literature reviews that meet particular criteria”
John Macansh, Physiotherapist
WHAT IS THE SCIENTIFIC EVIDENCE FOR YOGA?
It is not only yoga teachers, practitioners and medical doctors that believe the rebate for yoga should continue. Gold Coast-based physiotherapist John Macansh says there is definite clinical evidence for yoga – especially for patients with lower back pain due to mobility and movement issues in their hips.
“As physiotherapists, our job is to rehabilitate musculoskeletal conditions. Preventing the reoccurrence of these conditions through therapies such as yoga and Pilates should be considered part of the rehabilitation process,” he says. But while the anecdotal and clinical evidence of the health benefits of yoga may seem compelling, the government continues to claim that there is a lack of “supporting scientific evidence” for yoga.
This is despite a 2015 report published by Holger Cramer and colleagues in the Journal of the BMC Complementary and Alternative Medicine where researchers found a total of 366 randomised controlled trials of yoga published between 1975 and 2014, many dating from the most recent decade.
And another report published around the same time in the Journal of the Australian Traditional Medicine Society found that there was “a surge in publications on yoga to mitigate disease-related symptoms in clinical populations” and that “this dramatic increase has occurred despite challenges facing the field of yoga research, which includes limitations in funding, time, and resources.”
However, some have questioned the quality and strength of some of these studies, and more detailed analysis such as systematic reviews of clinical trials for a particular medical condition would be beneficial.
From an evidence-based standpoint, caution needs to be shown by yoga enthusiasts from making overly grand statements like, “there is plenty of evidence showing the health benefits of yoga” without careful analysis of the evidence available. This does not diminish the benefits that many people gain from yoga but it would help in specifically answering questions about the research and evidence of yoga, which in turn informs health policy, and decisions about health insurance rebates.
Van Maanenberg says that it is important for there to be more accountability from the yoga world. “I think there should be some standards to adhere to,” she says. “I feel we need to step up as an industry and take some responsibility for what we claim yoga does. There are so many facets to yoga. If you are going to claim it’s going to help a certain physical aspect then I think there does need to be a standard.”
ISSUES WORTH CONSIDERING
Yoga is a whole system, a diverse way of understanding or seeing (darsana) with numerous definitions and approaches throughout history, that includes philosophy, psychology, functional anatomy, mental states, subtle energies, values, purpose, meaning and connection, as well as many different techniques related to posture and movement (asana), breathing techniques (pranayama), meditation (dhyana), and mantras. Yoga may also be taught and practised in group classes, or as a tailored personal practice.
From a research-evidence point of view, it does not make sense to talk about evidence for the benefits of “yoga”, given it is such a broad definition. Rather, it would be more helpful to be more specific, and consider the evidence for health benefits of “yoga-based interventions”, including the benefits of “yoga classes”.
The second issue to consider from a research-evidence point of view, is that systematic reviews may report a lack of evidence for the benefits of yoga due to the fact that each study uses a different approach of yoga.
While it would be a mistake to standardise yoga merely for the sake of research, as a community we need to look more carefully at the evidence for the particular yoga-based interventions for particular medical conditions, allowing for individual differences in a person-centred approach.
Of course, there are some who understandably argue that the approach of scientific research is not appropriate for yoga at all. However, if we are interested in establishing and maintaining yoga into government health policy and private health insurance rebates, then research-based evidence is essential.
Francis says that one of the best compilations of research that shows scientific evidence that yoga is of benefit is the publication The Principles and Practice of Yoga in Health Care (Handspring Publishing, 2016).
“We recognise that the aim of the government is to only fund treatments that are “clinically effective” and that they have chosen to do this through systematic literature reviews that meet particular criteria,” she says.
With a review of the legislation forthcoming, she believes it is time to issue a “call to arms” to the Australian yoga community.
“We believe that there is solid research evidence for yoga,” she says. “There is scope here for all yoga organisations and interested individuals to lobby the government and the health insurers to reconsider yoga, and especially point them to existing studies that support the clinical and cost effectiveness of yoga. We also encourage the government to support future research that assesses the effectiveness of yoga in improving health outcomes.”
Suvi is a journalist living on the Gold Coast.
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