On November 1 the axe fell, splitting nigh in half the number of Medicare-funded sessions for clients of psychologists.
Until five years ago, Medicare’s mental-health cover was restricted to services provided by medicos, mostly psychiatrists. Psychologists didn’t count, as they’re not required to be medically trained.
In 2004, Ian Hickie, executive director of Sydney University’s Brain and Mind Research Institute, co-authored a report, ‘Not for Service: Experiences of Injustice and Despair’, which documented the failings of the Australian mental health system.
In response to the report and to growing community outrage about the broken mental health system, the Howard government launched a $5 billion set of reforms. Howard’s optimistically named ‘Better Access’ initiative addressed one of the most intransigent problems in mental healthcare, namely that a significant proportion of suffering goes undiagnosed and untreated. Healthcare providers have always had difficulty accessing certain groups in the community — particularly youth, men, and residents of rural, remote or disadvantaged areas.
Better Access saw Medicare begin funding up to 18 psychology consultations per year. Clients of psychiatrists, on the other hand, already had access to at least 50 funded sessions per year.
By all accounts, the Better Access initiative outdid even its own name. Highly popular from the start, its client numbers increased by 20 per cent per year.
"Why this startling demand?" wondered Professor Ian Hickie. Despite co-authoring the report that stirred John Howard into action on mental health, Hickie — together with other influential psychiatrists such as Patrick McGorry — opposed the Better Access initiative from the start. Hickie concluded that its popularity could mean only one thing: over-servicing by psychologists. Despite the documented success of Better Access, the hymns of praise sung by its consumers, and zero evidence of over-servicing, the government, under pressure from critics, gutted Better Access, slashing the maximum yearly allocation of sessions from 18 to 10.
The cuts to Better Access will affect an estimated 87,000 clients each year, plus any number of people who might be on the verge of seeking psychological help.
According to the Federal Government’s evaluation of the results of the first three years of Better Access, the vast majority of its clients who required more than 10 sessions in any given year — that is, the clients affected by the cuts — had initial diagnoses of severe depression or anxiety, including post-traumatic stress disorder. In other words, the clients having close to half their funding ripped away are those who needed it most. Public mental healthcare required a "fresh start", said Hickie, breathtakingly insensitive to the damaging effect of the cuts on these vulnerable clients.
Fixing a busted system, apparently, entails breaking something else that works.
The success of Better Access can be measured partly by the dint it has made in previously unmet need. The government’s evaluation shows that one million of the initiative’s two million clients were new to the mental healthcare system. In other words, a million people with previously unmet needs were treated under Better Access in its first three years.
Faced with this clear evidence of the initiative’s success, Hickie had nowhere to go but the equity argument. Better Access, said Hickie, has failed because it provided twice as many treatments to high-income than low-income clients. There’s no denying that the better resourced citizens get the better healthcare. But the better resourced get better everything. There’s no denying the structural inequities in the health system — and the education system, and the labour market. You name it, if it’s structural, it’s inequitable. The system is not so much trickle down as siphon up.
Even so, the government evaluation of Better Access, in direct contradiction to Hickie’s claim that it had failed disadvantaged groups, shows that the initiative was taken up by these groups at the fastest rate of all. Between 2007 and 2009, for example, use of Better Access by young people nearly doubled, and increased by nearly three-quarters for those living in the most disadvantaged and remote areas.
In summary, the evaluation showed that all groups in the community were using Better Access more each year, "with the biggest increase for those who have traditionally been the most disadvantaged".
The most striking irony of the 1 November cuts to Better Access is that, for many clients, the maximum 18 funded sessions weren’t enough. Take someone dealing with the long-term effects of trauma — having access to funded therapy once every three weeks is much like getting no more than one decent affordable meal a day. And now the 18 have been slashed to 10. A starvation diet.
Why the vast disparity in funding between clients of psychiatrists and psychologists — now roughly five funded sessions to one? Is it because the psychiatric establishment insists on seeing this issue as a turf war? Surely this issue is actually about choice: a client’s right to choose between different types of publicly funded mental healthcare.
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