Challenges for Medicare and universal health care in Australia since 2000

To the Editor: People incarcerated in Australia are uniquely excluded from Medicare, although this exclusion is not widely understood or studied. In their article discussing challenges for Medicare in Australia since 2000, Angeles and colleagues explicitly excluded coverage of groups that lack Medicare access, including people in prisons.1 They did, however, note the lack of success in addressing the vast health inequities faced by Indigenous Australians.1 Australia is currently failing to meet its Closing the Gap targets to reduce the number of Indigenous adults and children in custody.2 Indigenous people continue to be massively over‐represented in Australian custodial settings, where they are further disadvantaged by exclusion from Medicare. Despite years of advocacy from a diversity of stakeholders, most recently reflected in the 2023 Australian Medical Association position statement on health care in custodial settings,3 this remarkable inequity has persisted.4

Under the United Nations Mandela Rules,5 Australia is obliged to provide community‐equivalent health care in custodial settings. However, it is clear that health care in Australian prisons is not equivalent to that available in the community.6 Currently, incarcerated people are not provided with certain treatments as they are considered too expensive without Medicare rebates; this exclusion puts them at a higher risk of long term illnesses.6 There is good evidence that improving health care in custody not only improves the health and wellbeing of people who experience incarceration but also reduces re‐offending.7 Ending the discriminatory exclusion of people in custody from Medicare is therefore important to multiple Closing the Gap targets, pertaining to both improving health and wellbeing (target 1) and reducing Indigenous incarceration (targets 10 and 11).2

Just as there have been attempts to address Indigenous health inequities through policies such as the Closing the Gap Pharmaceutical Benefits Scheme strategy,1 there is a similarly strong case for allowing people in prison to access Medicare‐funded services. As a first step, the Aboriginal and Torres Strait Islander Peoples Health Assessment (item 715) and mental health services available under the Better Access initiative could be made available in prisons, to provide much‐needed funding support for targeted services in the areas of greatest need. In our efforts to Close the Gap, Indigenous Australians who experience incarceration must not be left behind.