eMJA: The price of health care for Medicare-ineligible asylum seekers in the community

Katina Kardamanidis,* Bruce Armstrong^†

* Research Fellow, Injury Prevention and Trauma Care, The George Institute for International Health, PO Box M201, Camperdown, NSW 2050; ^† Head, School of Public Health, University of Sydney, NSW. kkardATdoh.health.nsw.gov.au

To the Editor: Not all asylum seekers in Australia are confined to detention centres. Those who arrive with a valid visa live in the community. If they apply for refugee status within 45 days of arrival, they are entitled to work and to Medicare while their refugee claims are processed;1 if they apply too late, they are denied these benefits. In New South Wales in 2003 about 1500 men, women and children were in this situation, which may last from 3 months to 3 years. Asylum seekers who appeal a refusal of their application, or are released from mandatory detention with an application outstanding, are in the same situation.2 Some are eligible for the federally funded Red Cross Asylum Seeker Assistance Scheme, but, for most, access to health care is jeopardised because they are unable to pay full fees for medical services.3,4

We asked health professionals working with asylum seekers about the costs of asylum seekers’ difficulties in accessing health care. Their responses, with illustrative quotes, are divided into “tangible costs” and “intangible costs” (Box).

Some individuals and institutions sympathetic to the plight of asylum seekers give their professional time or donate money to pay for health care, but are not able to address the full range of health care needs. Obtaining access to secondary care, particularly admission to hospital, is very difficult. There is no uniform approach to charges, either between hospitals or within any one hospital on different occasions. The approach seems to depend on the decision-maker present.

Such difficulties in accessing care may lead to uncomplicated health problems developing into chronic and more serious ones. The attempt to save costs is likely to lead to higher costs in the future. The effect on asylum seekers is increased physical, psychological and social disadvantage and diminished opportunities for a healthy life.

Health professionals are faced with the dilemma of turning these people away, or aiding them without financial compensation. In either case, they cannot provide the necessary standard of care.

Although many Australians are conscious of the hardship of these people, the society as a whole seems unaware of it or of the impact that its unfairness may have on the social fabric of their communities.

If all Medicare-ineligible asylum seekers in NSW were to have the same access to health services as other Australians, we estimate that the total annual cost would be about $3.4 million.5 This is about 0.015% of the total annual recurrent health expenditure in NSW in 2000–01.6 This economic cost, some if not most of which will be spent regardless, does not justify the disadvantage created by the Australian Government’s immigration rules.

We suggest that state governments consider giving this small group of asylum seekers free access to public hospital services.

Costs of asylum seekers’ difficulties accessing health care and who bears the costs: responses of health professionals working with asylum seekers

Theme

Illustrative quote

Tangible costs

Insufficient voluntary aid to address all health needs

“We have one patient . . . with a urinary infection, and it was decided that . . . he needed a TURP [transurethral resection of the prostate], and then they realised he didn’t have any funds and they discharged him . . .”

Inconsistent attitudes of hospitals

“There’s quite a difference between different hospitals. For example, the X hospital at Y is very tough. . . . much tougher than the hospital here, on refugees. . . . They are different Area Health Services . . . it may not even be the Area Health Service directors, but the hospital manager’s idea that these people should pay.”

More costs in the long term

“I have a lot of patients with diabetes and high blood pressure . . . Now if their diabetes or their blood pressure or their cholesterol is not managed properly, then they get heart disease or strokes. So, I have a patient who has had a stroke . . . high blood pressure and so on . . . if he had [had] better access to health care, would he have had the stroke? . . . So [now], the government has had to pay . . . it doesn’t make any sense really.”

Intangible costs

To the asylum seeker (recounted by a health professional)

“If you say to someone, I really think you need to have this test, but, if I refer you, you have to pay a lot of money, so I’m not going to refer you, how does that make you feel? It makes you feel worried and powerless.”

To health professionals

“. . . if someone came in complaining about it [diarrhoea, losing weight], you would do a whole lot of checks, and with that particular lady . . . we were able to negotiate to get a couple of tests done free, and the family and she paid a certain amount of money to get some others [done] . . . if the person had Medicare, you’d take it that step further and do extra just to be 101% sure. So, there is that real ethical dilemma . . .”

To the Australian society

“. . . if people actually knew on a face-to-face level . . . what it meant to deny a newborn baby the right to health care, [or] . . . turn away someone who is extremely depressed . . . [Would they] actually be able to say ‘No, they don’t [have a right to health care]’.”

Acknowledgements: Thanks to Dr Glenn Salkeld, Associate Professor of Health Economics, School of Public Health, University of Sydney, for his help with calculating health care costs, and Dr Mitchell Smith and the nursing staff of the NSW Refugee Health Service for data collection and other information.

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