Australia must get Medicare into its 132 prisons

Politically, it is a moral abomination that Medicare – which Australia touts as 'universal' – is denied to its incarcerated citizens, some of our most vulnerable people.

Medicare ensures the highest quality of healthcare available to the general population. Only the rich can afford better healthcare. The poorest and most vulnerable individuals are found in Australia's 132 prisons. They comprise the lowest income base — most are unemployed, the majority with significant physical and/or neurological impairments. Many come in and return to homelessness, housing insecurity and crushing poverty.

Aren't existing health services in prisons adequate?

The incarcerated are the only Australians denied Medicare. The argument that they have alternative medical services is not true. I will explain.

The infirmaries in gaols are poorly resourced and understaffed. Many are without physicians. What's on the inside of gaols is not equivalent to health services available on the outside. Access to health services on the outside is at the discretion of Corrective Services. The majority of those incarcerated still endure delays or indefinite access to health services once released.

In terms of rates, deaths in custody, particularly of young ages, are an abomination. These deaths are mostly preventable deaths — but don't signify the health disparities and discrimination that I argue are killing people. Those who survive the health discrimination and inadequacies of prison life, in general, come out of Australian prisons worse than they went in.

Medicare in prisons would have most certainly kept many people alive who suicided or died before their time from undiagnosed ailments or from poorly treated conditions and preventable complications.

Medicare in prisons can ensure onsite bulk billing physicians can diagnose or refer patients to specialists. This is the least of what should be guaranteed in prisons. We've got to fight for prisoner rights, prisoner health rights, the right to the dignity of good health — assistance that should be denied to no one. We've got to fight for the vulnerable in Australian prisons like never before. As a society, we should not continue condemning people to bleaker and more troubling futures. 

Medicare in prisons would ensure physicians 24/7 can craft healthcare plans and mental healthcare plans where required. Do we not want to improve the lives of our most vulnerable? Doing so would make people leaving prison more employable, less likely to re-offend and give them the opportunity to be positive role models for their families. They can leave prison in better primary health than when incarcerated. They are validated; they matter. They are employable if in good health and, therefore, less desperate.

It is my experience, in general, that people come out of prisons in worse condition than when they commenced the situational trauma of incarceration. Medicare in prisons will go quite a way to reducing the Australian prisoner population. 

Prisons need to be transformed from punitive to restorative settings. Medicare in prisons is a major way forward to this. I see prisons where hearts break in the breasts. Prisons without Medicare savage the flesh. In the mad blasphemous squat that is a cell, life’s brief light can be extinguished. 

Nearly 42,000 prisoners (persons in custody) are denied Medicare. Therefore, Medicare is not "universal" as is touted. Before continuing further, I argue no legislative reforms are needed to pass both Federal houses of Parliament. The solution is as simple as only requiring the Federal Health Minister to issue an exemption to the exclusion of the gaoled from Medicare. Concomitant reform to legislation can be pursued to better guarantee in perpetuity of Medicare in prisons. 

I remind you — Medicare is denied to prisoners, old and young, to children as young as ten. Oftentimes filled with tears, unseen weeping, unmasked sorrow withheld within until the perishing.

In addition, the incarcerated, in effect, are denied access to the Pharmaceutical Benefits Scheme (PBS) and the National Disability Insurance Scheme (NDIS), with disastrous impacts. The exclusion of Medicare in prisons makes it near impossible for the incarcerated to access the PBS and the NDIS.

It is established and self-evident that nearly all of Australia’s prisoners are comprised of people living in the lowest quintile of income. Additionally, they also comprise the quintile of the weakest primary and secondary health.

The Australian Labor Party argues Medicare is universal and, at times, has included in its national policy platforms a promise to end the health discrimination of the incarcerated. It is yet to uphold this promise.

I have seen too much unaddressed preventable physical and mental suffering among the incarcerated. I recount prisoners who complained for months and years of pain because those who were meant to heed did not. They were not referred but given paracetamol. Their cancers spread.

Medicare is a health funding stream that should be accessed by every Australian to ensure rapid access to vital services. It is intended to make healthcare accessible to our poorest Australians. It makes no sense that Medicare is not available to the incarcerated. This discrimination is the worst of classism, making vilified lepers of the most vulnerable.

How would Medicare change prisons?

I have met with several premiers around the nation and have attempted the nutshell introduction:

"Please consider advocating to the Commonwealth for Medicare in prisons. The introduction of Medicare in prisons will improve health outcomes and employability; will reduce prison incidents and inroad prisons as restorative."

If we can provide Medicare, in its fullness, in gaols, then (generally) people will leave gaol in better health — physical and mental. This will reduce reoffending rates, reduce the prisoner population and make society safer and more harmonious — restorative beliefs that will ripple out and deliver other positive societal narratives.

For a decade, the Australian Medical Association (AMA) has advocated for prisoners to retain their Medicare rights.

In its 2023 position statement, the AMA calls on the Commonwealth Government to:

'Ensure people in custodial settings retain their entitlement to the Medicare Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme (PBS) throughout all stages of the custodial cycle to ensure access to appropriate healthcare and treatment.'

Furthermore, the AMA also insists the quality of healthcare has an indisputable impact on the "rehabilitation" of the individual.

Thus, the AMA calls on health service providers in custodial settings to:

'Commit to actively working towards decreasing criminalisation and recidivism rates by detecting individuals with health issues that could put them at risk of imprisonment while in the community and working.'

State and territory governments were made responsible for the provision of healthcare in prisons. But equivalencies of healthcare between prisons and society in general just do not exist.

The Commonwealth Health Insurance Act (1973) includes a clause to prevent "double-dipping" of medical services. It assumed states and territories would fund equivalent access to health services and build internal health systems in prisons. They do not.

The Federal Government has the immutable opportunity to strive for its "leave no one behind" claim. More than half a million Australians – one in 50 – have been to prison. Poor health marginalises people into unemployment and underemployment. The ALP argues that all Australians "have a right to the best possible health”.

There is no worse discrimination than health inequality. Many readers will find it hard to believe health rights such as Medicare and the PBS are denied to Australia’s 40,000-plus incarcerated adults and to nearly 1,000 incarcerated children. There has been a long silence about this life-threatening inequality. When will we speak of this cruel unfairness and call for a love of one another?

Societies' grossest concrete jungles are the prisons where in my view, the affected are maltreated as once were "lepers" — held captive to demonisation and ceaseless cruel harassment.

There is nothing redemptive about prisons. Simply, prisons need doctors, clinicians, nurses, health resources and a capacity equivalent to what's on the outside for the incarcerated to access emergency care within most hours, where it's life-threatening — near immediate healthcare on the inside, ambulatory assistance to external supports such as hospitals as fast as would be the case in general on the outside. These are not difficult propositions. The encumbrances occur because there is a lack of political and moral will. 

Where is the will?

If we ensure health dignities in prisons, we will make prisons safer for everyone and potentially life-changing settings. I am a prisons abolitionist, but if prisons are to blight Australia, let them at least not be settings where people are demonised, vilified, invalidated and hardened to the bleakest of selves.

Some of our restorative works and transformational projects in adult and children’s prisons allowed us to witness the effects of health inequalities and the impacts of no Medicare. Seemingly, there is an endlessness of horror stories of untreated infections that have led to amputations and, worse — death.

With the cognitive criminal age of responsibility still at ten years old, gaoled primary school-aged children are denied Medicare.

I also believe every prison should have a general practice physician on-site, who, with Medicare, can bulk bill. Prisoners have a higher prevalence rate of co-morbidities than the general population, higher rates of disabilities and acute mental health conditions — and First Nations prisoners have even higher rates. One in six First Nations people living has experienced incarceration.

Prisoners are nearly three times as likely to have acute mental health conditions compared to the rest of Australians and up to 15 times as likely to have a psychotic disorder. First Nations prisoners once again are hostage to higher rates.

With First Nations individuals making up nearly 30 per cent of the national prisoner population, as well as having a higher susceptibility to health issues, healthcare "catchups" in prison are a missed opportunity. Incarceration is cruel and barbarous, and there are kinder and gentler ways, but while prisons remain, they must ensure healthcare equality.

Half a century has passed and Medicare (Medibank in its first iteration) has not been universal throughout Australia. All it will take is moral and political will. The Federal Health Minister has the power to immediately include Medicare for prisoners. Simple amendments to the relevant subsection of the Health Insurance Act 1973 passed through Parliament can guarantee universality in perpetuity.

I urge everyone to reflect on the trembling that is prison life and of undivided caring. Let us not wage war on one another and move us from shadows to the light, rise beyond chains, bars and wires, prejudices and demonisation and turn our eyes to each other. Let not the unfairnesses of the world harness us. Let not the good and bad luck we are born into divide us.

Once again, I urge the state and territory corrective services to interrupt their silences and prayers – to speak out publicly – and contribute to collective consciousness universalisms. To advocate on behalf of the hearts and souls within their care.

Everyone must stand up for what is right for one another; we must neither leave anyone behind nor hold anyone back. Prisons leave people behind. Not having access to Medicare in prisons holds people back, guaranteeing the worst possible outcomes.

Many of the incarcerated cry out for help till death do part. Coronial inquests cannot absolve or atone.

Think about this. So many people, in effect, without doctors, diagnoses or treatment plans.

The majority of prison deaths in custody are preventable — the majority of preventable deaths in prison custody are the young. Individuals who should be enjoying the best of health in the bloom of lives, but they are old before their time, with ailments and degenerations decades too soon.

Medicare in prisons would have kept many of those deceased alive. It would have ensured correct diagnoses, care plans and mentoring, which would have improved mental well-being. Medicare in prisons would give prisoners the voice and advocates they do not have — the diagnoses and doctors they need, which would guarantee access to expeditious adequate healthcare. Think about this. So many people, in effect, without doctors, diagnoses or treatment plans.

Coronial inquests scream loudly of people who took their lives — young and old, who self-harmed multiple times, who attempted suicide multiple times, who relentlessly cried out for help, who, after ten attempts, finally took their life.

These people were not assisted with clinical support or seen by doctors but were isolated and hovelled in cells — best assessed by guards or staff limited by dangerous protocols that did not include mandatory access to medical and psychiatric specialists.

It is an abomination that they were not effectively heard, seen, or supported. The way forward is not rocket science. Once again, I am describing an indicting lack of political will.

What can you do? 

It breaks my heart that we have to keep beating the drum about what's right, what should be universal. How many times do we have to pose the fact this is life and death? How many times do we have to argue these are our most vulnerable and marginalised Australians — many who never had a chance from the beginning of life?

In the month ahead, I will be in the ear of Prime Minister Anthony Albanese and first up, I will raise the need for Medicare in prisons, pleading for the ending of the worst health discrimination in Australia.

Meanwhile, Australia needs you – each one of you – to call relentlessly for the introduction of Medicare to Australia's 132 prisons. We need a multitude of voices.

Gerry Georgatos is a suicide prevention and poverty researcher with an experiential focus on social justice.

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