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17 Mar 2017

People subject to incarceration and youth detention in Australia are currently excluded from Medicare and the Pharmaceutical Benefits Scheme (PBS), but the AMA is hoping to see that changed.

The AMA, along with the Public Health Association of Australia, Royal Australian and New Zealand College of Psychiatrists, and Professor Stuart A Kinner, NHMRC Senior Research Fellow, Griffith University and University of Melbourne, recently wrote to Health Minister Greg Hunt and identified a mechanism by which this demonstrable inequity can be rectified, at modest cost to the Australian taxpayer.

Former Health Minister Sussan Ley had previously said that States and Territories may deliver in-prison health services through the employment of appropriately trained medical or allied-health officers, or the payment of healthcare professionals from the public or private sector. However, Ms Ley did not acknowledge the growing evidence that States and Territories are not providing in-prison health services in a manner equivalent to that available in the community, and that this has a significant impact on the health of the more than 50,000 Indigenous and non-Indigenous people released from prison to the community in Australia each year.

The situation is that prisoners and young people in detention are excluded from Medicare and PBS subsidies under Section 19(2) of the Health Insurance Act 1973 (Commonwealth). In short, the intent of this clause was to avoid ‘double dipping’, however, this is premised on the notion that the States and Territories provide equivalent health services for people in custody. Indeed, Australia has committed to the provision of equivalent health care for people in prison and youth detention, by endorsing the United Nations Mandela Rules. Rule 24 states that: 

  1. The provision of health care for prisoners is a State responsibility. Prisoners should enjoy the same standards of health care that are available in the community, and should have access to necessary healthcare services free of charge without discrimination on the grounds of their legal status.
  2. Healthcare services should be organised in close relationship to the general public health administration and in a way that ensures continuity of treatment and care, including for HIV, tuberculosis and other infectious diseases, as well as for drug dependence.

 However, in practice there are many examples of inequity in prisoner and detainee health care. The most readily apparent of these is that, despite an extremely high prevalence of mental disorder in prisoners and detained youth, psychological therapy for mental disorder in these settings is almost non-existent. Currently, most treatment is reliant on the prescription of psychiatric medications. This deviates from best practice and community standards and, because prisoners and detainees are excluded from the PBS, they are frequently prescribed psychiatric medications in a manner that would not attract a PBS subsidy in the community. As such, adherence to these medications after release from prison is likely to be poor, with the result being recurrence of psychiatric symptoms and, for some, an avoidable relapse to self-medication with illicit substances, and crime.

 As the AMA highlighted in the 2015 Indigenous Health Report Card, Aboriginal and Torres Strait Islander people are over-represented in Australia’s prisons by a factor of 13 and in youth detention by a factor of 24. Policies that discriminate against people in custody will, therefore, disproportionately impact on the health and wellbeing of Aboriginal and Torres Strait Islander people.

The letter to Minister Hunt pointed out that Parliamentary documents show that the Health Minister’s power to waive the Medicare exclusion was explicitly included in s 19(2) of the Health Insurance Act so that governments could make amendments if the exclusion was deemed to cause disadvantage. In practice, the Commonwealth has been willing to grant exemptions in cases of clear and demonstrated need. These exceptions (to Commonwealth-funded ACCHSs and the Improving Access to Primary Care in Rural and Remote Areas (s 19[2] Exemptions) Initiative demonstrate the willingness of the Commonwealth to permit access to Medicare if the ability of a health service to adequately care for the needs of a community was curtailed by the exclusion; a situation that clearly exists in prisons.

The current exemptions all share a common theme: an expressed intention to ensure that all Australians have access to appropriate and quality health care, regardless of their circumstances.

Under the Health Insurance Act, the Health Minister has the power to grant an exemption to end prisoners’ exclusion from Medicare, paving the way for rebates to be claimed for prison-based health care services in limited circumstances where demonstrable gaps exists in health service delivery. This would allow the prison system to retain the existing health service delivery model but to enhance this through access to selected Medicare items and PBS subsidies as outlined above. The costs incurred by Medicare would be minimal.

Chris Johnson and Simon Tatz

Published: 17 Mar 2017