Should I have public or private surgery? Medicare vs health insurance

If you’ve been told you’ll need surgery in the near future and you have private health insurance, you might be wondering whether it’s better to go to a public or private hospital. In 2024-25, around 67% of elective surgeries in Australia were done in private hospitals. While being treated in a public hospital is free under Medicare, there may be long waits to be seen by a specialist and then to have your surgery – and you can’t choose who treats you. Going to a private hospital generally means faster treatment, the choice of doctor and – if the hospital allows it – your own room, but it might also mean out-of-pocket costs. 

Here are the 3 factors to consider when deciding between public or private surgery.

1. Timing 

Surgery that’s urgent or considered an emergency will be done in public hospital without delay. But for non-urgent or planned surgery such as cataracts or knee replacements, if you have Hospital Cover you may have the choice whether to go private or public (if there’s a private hospital in your area). Timing will be an important factor in your decision. Consider:

• What are the average public wait lists for the procedure? Your surgeon can give you an estimate for your local area, and you can check Australian Institute of Health and Welfare average wait lists for common procedures in recent years. For example, around 50% of Australians who had cataract surgery in 2024-25 waited more than 106 days.  

• What are the wait times to see a specialist in the public system to schedule your surgery? According to 2025 ABC data, the wait time for this “hidden” wait list for public outpatient clinics can be as long as 6 years in some parts of Australia. Your GP might give you an indication of timeframes when they refer you.

• How much is your health issue affecting your quality of life? If it’s holding you back significantly, you might prefer to go private and get your procedure done sooner rather than later.

• How important is it to choose your date and time? In the public system you won’t get any input into when your surgery happens, but in the private system you may have some say in the proposed dates and times.

• How long is the waiting period on your Hospital Cover policy? If it’s a new policy, you may have to wait up to 12 months for pre-existing conditions before you can claim. If the expected public wait list is less than that, it might be best to go public.

2. Your policy and insurer 

While you can choose to pay for private hospital treatment yourself (i.e. without using health insurance), this is very expensive – especially if there are complications. If, however, you want to have your surgery privately under Hospital Cover, you should check:

• Does your policy definitely cover the procedure? It’s a good idea to phone or email your insurer to confirm.

• Have you served the waiting period?

• Are there any restrictions on what your insurer will cover?

3. Costs 

Treatment in a public hospital is free under Medicare. However if you have your surgery done privately, you may face out-of-pocket costs, also known as Gaps. Your doctor will give you a breakdown of costs including the Gap that applies for their services, and for other surgeons or specialists that will be involved in the procedure. You should consider:

• Can you afford the excess?

• Will any co-payments apply? Check your policy.

• Is the hospital one of your insurer’s Agreement Hospitals? If not, you may have to pay a Hospital Gap.

• Does your surgeon have a Gap or no-Gap arrangement with your insurer? If not, you might face a higher Medical Gap.

How do I lower my Gap?

Why do I have to pay out-of-pocket costs?

Public or private surgery – the takeaway 

Deciding whether to have your surgery done in a public or private hospital comes down to a weighing up of the timing, costs, your health needs, your lifestyle and your budget. Make sure you take your doctor’s advice into account.

Want to change your policy?

You can change to a different Hospital Cover policy at the same tier or lower without needing to serve waiting periods again. This might be a good option if you want to change to an insurer who has a Gap or no-Gap agreement with your doctor or preferred hospital – but make sure you check cover with the insurer before you switch. To compare your policy with others and find one that suits your needs better, use the healthslips.com.au calculator, which unbiased comparisons of every policy in Australia. It’s fast, free and you can search anonymously.

Compare your current policy or look for a new policy on the healthslips.com.au calculator.

How do I switch health insurance policies?

healthslips.com.au does not provide general or personalised advice. Your particular circumstances are likely to impact the accuracy, completeness and relevance of the information or results. Take this into account before making a decision and talk to an expert for financial advice.  

Trudie McConnochie

Writer and Researcher

Knowledge is power – that’s the guiding principle behind everything Trudie writes, and it’s a philosophy she brings to her work at healthslips.com.au. By breaking down complex information into easy-to-understand blogs and stories, she aims to empower Australians to make the best choices and an informed decision around private health insurance.

Trudie understands firsthand some of the complexity of private health insurance having moved to Australia from New Zealand and having to navigate a vastly different public healthcare system and health insurance structure.

Trudie holds a Bachelor of Communication Studies (journalism major) from the Auckland University of Technology.

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