International comparisons show that Australians enjoy relatively good access to healthcare services. But increasingly this access is price sensitive and, as out-of-pocket costs grow, a growing group of people - those most in need of healthcare - are missing out.

There is mounting evidence of what is called the inverse care law. Inverse care means that people with the most means and whose needs for healthcare are usually less, consume the most care, whereas those with the least means and greatest health problems consume the least.

It goes against the grain, and our belief in the universality of Medicare, to realise that government spending on health services benefits the rich more than the poor and that the availability of good healthcare tends to vary inversely with the needs of the population served. But the data hold this to be true.

Australians living in rural areas and lower socio-economic suburbs are less likely to have access to essential services such as preventive, dental and mental healthcare, their costs to see a specialist are often prohibitive, and their primary care is too often limited to short consultations despite higher rates of chronic conditions. Some aspects of decreased access can be charged to the tyranny of distance and workforce mal-distribution, but the reality is that access to timely and appropriate healthcare is really only ''universal'' for those who can afford to pay.

By international standards, Australian out-of-pocket costs are high and comprise almost 20 per cent of the nation's total healthcare expenditure. Older Australians with a number of chronic conditions may need to spend as much as 16 per cent of their income on their healthcare. While government incentives have helped improve GP bulk billing rates in many areas, the constraints that the Medicare reimbursement level once imposed upon the fees charged by specialists have long disappeared, the final knell being the introduction of the inflationary Extended Medicare Safety Net.

Every year the federal budget trims this program at the margins to try to control government costs, while the benefits of the safety net accrue disproportionately to the better-off and the gap between Medicare reimbursement and doctors' charges grows.

Ironically, at a time when policy and budget people alike are looking to rein in healthcare costs by keeping people out of hospital, a major perverse incentive in the system means that acute care in public hospitals is free once you are sick enough to need it, but there are costs for primary care to keep you well and for specialist treatment.

There is another important aspect of access that must also be considered and that is around access to health and wellbeing. This is the ultimate goal of any health system. It is less about providing affordable medical services and more about taking prevention activities to where people live, work and play.

The drivers of the chronic illness burden borne by individuals and society and the resultant costs to the healthcare system are risk factors such as obesity, lack of exercise, smoking, abuse of alcohol and risky behaviour. These are not readily addressed by doctors, nurses and prescription pads, and arguably, ''medicalising'' these problems ensures that many people will never reach out for help or guidance.

The challenge for governments and policymakers is to simultaneously invest in wellness through prevention and the treatment of illness by improving access to health and healthcare. The ubiquity of Medicare, the Pharmaceutical Benefits Scheme and public hospitals should not blind us to the inequities around us. The evidence for these is starkly presented in every report on population health status and the availability and use of health services, if only we would see it.

Dr Lesley Russell is a senior research associate at the Australian Primary Health Care Research Institute at the Australian National University.