HHSA 2023-24 PRE-BUDGET SUBMISSION

Expanding access to affordable hearing health care for vulnerable Australians.

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About us 
Founded in 2019, the Hearing Health Sector Alliance (the Alliance) is unique in the hearing sector, consisting of 17 national peak bodies and organisations representing practitioners, consumers, researchers, service providers, and manufacturers working in the hearing health sector.

The Alliance aims to elevate the priority of hearing health and hearing loss in the minds of policy makers, advocate to maximise access to hearing health care within Australia, and for Australians to receive the very best hearing health care and support. The purpose of the HHSA is to represent the hearing health sector in Australia to government.

The Alliance’s vision is: 
(i)    all Australians value their hearing
(ii)    all Australians who are deaf or hard of hearing live well in the community
(iii)    Australia has a world class hearing health system.

2023-24 Budget Proposals
a)    Expand the Hearing Services Program to provide affordable access for vulnerable Australians of working age on low incomes
Cost: $25.3 million in the first year with lower ongoing annual costs
Benefit cost ratio: 12.3:1
ROI: Very significant 

b)    Fund hearing screening for all children of refugees and any hearing services through the CSO to ensure equitable access to hearing services and continuity of care.  This initiative should be accompanied by a program of research (including data collection) and consultation with affected communities, their advocates and hearing experts to determine the optimal model for service delivery.
Uncosted

c)    Develop and implement a national plan, led by the Department of Health and Ageing, in partnership with state and territory jurisdictions, Aboriginal and Torres Strait Islander Health organisations and Alliance members, that:

• provides resources to conduct hearing assessments for prisoners who have never received such an assessment, including young people in juvenile detention; and

• ensures access to the Hearing Services Program.

Uncosted​

Overview
Hearing is immensely important to health, personal and financial well-being.  Hearing loss is deeply personal and individuals are the primary participants in managing their physical and mental health, and communication needs. 

An estimated 3.6 million – one in six Australians – experience hearing loss.  By severity, 66% had mild hearing loss and a third had moderate to severe hearing loss.

While hearing loss is often associated with ageing, hearing loss affects people throughout the life course.  
The Hearing Services Program (HSP) and National Disability Insurance Scheme (NDIS) support many Australians with hearing loss who would otherwise struggle to self-fund their hearing care.  Some groups of vulnerable people, however, are ineligible.  Access to hearing services and appropriate treatment can be difficult and is often unaffordable for:

• people of working age on low incomes

• children of refugees

• prisoners.  

Two Parliamentary Committee inquiries into hearing services in Australia expressed grave concerns about inequitable access to affordable hearing care.  

The 2010 report of the Senate Community Affairs Committee, “Hear Us: Inquiry into Hearing Health in Australia”, proposed broadening eligibility based on an income test and developing a national plan with State and Territory jurisdictions for prisoners to access hearing assessments and hearing services.  

The 2017 report of the House of Representatives Standing Committee on Health, Aged Care and Sport, “Still waiting to be heard”, recommended expansion of Hearing Services Program’s Community Service Obligation to people of working age on low incomes.

Key issues
People of working age on low incomes 
In 2019-20, one in 10 Australians (246,800) of working age (26-64 years) had diagnosed hearing loss.  The impact of this is reflected in the significant economic costs of hearing loss, estimated to be $20 billion in 2019-20.  Productivity losses (reduced taxation revenue) contribute $16.2 billion to this total, largely due to reduced employment of people with hearing loss [HCIA 2020].

People with under-treated or untreated hearing loss have a lower likelihood of being employed compared to their hearing colleagues.  This arises through disadvantages in job-seeking or self-selection out of the workforce.  Absenteeism and reduced performance at work (presenteeism) are also associated with hearing loss [HCIA 2020].  In 2019-20, the estimated cost of reduced workforce participation was $12.6 billion in 2019-20.

Addressing hearing loss at an early stage may provide lifetime social and economic benefits including preserving remaining hearing, study and workforce participation leading to longer term well-being [HCIA 2020, p 21].

There are compelling health benefits too – for the individual, society and the economy.  The World Health Organisation (WHO) recognises hearing loss as a leading, modifiable, risk factor for dementia [WHO, 2019].  As the risk of cognitive decline increases with the onset of hearing loss at a younger age, treating hearing loss earlier in life and stage of hearing loss can reduce the risk of cognitive decline and dementia.  
Unaddressed hearing loss of people in mid-life (45-65) is a greater risk factor for dementia than alcohol, traumatic brain injury, obesity and hypertension combined [HCIA 2021].  Managing hearing loss is one of 12 actions recommended to prevent or delay the onset of dementia.  This includes the use of hearing aids for hearing loss and protecting ears from excessive noise exposure [Lancet, 2020].  

Younger people are also at risk of hearing loss.  According to the WHO, up to 50% of young people in high income countries like Australia risk hearing loss through unsafe recreational listening – on personal devices, at music venues, bars and nightclubs. Young people exposed to loud sounds in social settings are three times more at risk of hearing loss than those with no exposure.  Noise induced hearing loss is irreversible [WHO, Make Listening Safe Listening]. 

One cost benefit analysis assessing the benefits of reducing dementia symptoms relative to the total cost of hearing aids produced a ratio of 30:1 [HCIA 2021].

Children of refugees
Children with hearing loss whose families are waiting for Australian citizenship or permanent residency are ineligible for the HSP.  

Many have left countries with high rates of chronic otitis media.  Research shows that rates of chronic suppurative otitis media are much higher in refugee populations than in the wider Australian community.  Untreated otitis media can lead to life-long hearing loss. Some refugee populations are also at higher risk of developing hearing loss due to exposure to extreme noise during conflict situations in their country of origin.

Becoming proficient in English is critical to successful settlement for refugees. Even mild hearing loss and a small delay in the diagnosis and treatment of hearing impairment can result in a life-long reduction in children’s language and communication skills.  Vulnerable parents are less likely to be equipped to make an informed decision about the future healthcare needs of their child [Benson 2012].

The Community Service Obligation (CSO) element of the HSP is designed to address the needs of children and people with complex hearing needs.  It offers an immediate channel for access to hearing services for this small and vulnerable population.  

The Alliance recommends hearing screening for all children of refugees and any hearing services required be funded through the CSO to ensure equitable access to services and continuity of care.  This initiative should be accompanied by a program of research (including data collection) and consultation with affected communities, their advocates and hearing experts to determine the optimal model for service delivery.

Prisoners
Aboriginal and Torres Strait Islander peoples experience high levels of ear disease and hearing loss from a very early age. 

Aboriginal and Torres Strait Islander peoples are considerably overrepresented in police custody, in both the juvenile and criminal justice systems of Australia [ABS, 2019].

Prisoners have higher rates of hearing loss than the general population and hearing loss is over-represented in Aboriginal prisoners in all jurisdictions [House of Representatives Standing Committee on Health, Still Waiting, 2017].  This leads to acute hearing needs that are currently poorly serviced [Krieg, 2016].

This situation is reflected in the youth justice system where Aboriginal children make up 54 percent of those in juvenile justice systems [O’Brien, 2021] and constitute 80 percent of those with significant hearing issues when tested [Senate Community Affairs Committee, Hear Us, 2010].

High rates of hearing loss among Aboriginal and Torres Strait Islander people contribute to communication difficulties. In turn, this exacerbates problems in interactions with law enforcement and criminal justice [House of Representatives Standing Committee on Health, Still Waiting, 2017].

Prisoners with untreated hearing loss face the vicious cycle of social disadvantage, incarceration and recidivism.

In keeping with a recommendation of the Senate Community Affairs References Committee in 2010, the Alliance urges the Government to partner with state and territory jurisdictions, Aboriginal and Torres Strait Islander organisations and Alliance members to develop and implement a national plan that:
(a)    provides resources to conduct hearing assessments for prisoners who have never received such an assessment, including young people in juvenile detention; and
(b)    ensures access to the Hearing Services Program.

Costing
Deloitte Access Economics costed the expansion of the HSP to Australians with hearing loss of working age on low incomes for the Hearing Care Industry Association (HCIA).  Full details are available in HCIA’s 2020 Hearing for Life report.

An upfront investment of $25.3m to provide free access to hearing services to 13,523 Australians on low incomes may result in 60% of this group obtaining employment in addition to substantial well-being gains.  
The potential productivity gains and increased taxation of increased employment, valued at $311.7 million, would deliver a projected overall benefit to cost ratio of 12.3 to 1.
This represents the initial cost of expanding the HSP in the first full year. Ongoing funding, at lower levels, would be required for new HSP entrants under expanded HSP eligibility and for ongoing rehabilitation, maintenance and/or replacement of devices.  Benefits, similarly, would continue to accrue over subsequent years.  
No costing is available for funding hearing screening and services for the children of refugees and prisoners ineligible for the HSP and NDIS.  The Alliance believes the costs would be small with significant lifetime benefits for beneficiaries, society and the economy.

References
Australian Bureau of Statistics (2019). National Aboriginal and Torres Strait Islander Health Survey 2018-19 Canberra: Australian Bureau of Statistics. https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples/national-aboriginal-and-torres-strait-islander-health-survey/latest-release 
Benson, J & Mwanri, L (2012). Chronic suppurative otitis media and cholesteatoma in Australia’s refugee population.  Australian Family Physician, 41(12)
HCIA (2020). Hearing for Life – The value of hearing services for vulnerable Australians, https://www.hcia.com.au/hcia-wp/wp-content/uploads/2020/02/Hearing_for_Life.pdf
HCIA (2021). Dementia, Hearing Loss and Hearing Care: Saving Australia’s Minds, https://www.hcia.com.au/hcia-wp/wp-content/uploads/2021/12/Dementia-Hearing-Loss-Hearing-Care.pdf
House of Representatives Standing Committee on Health, Ageing and Sport (2017).  Still waiting to be heard. Report on the Inquiry into the Hearing Health and Wellbeing of Australia. https://www.aph.gov.au/Parliamentary_Business/Committees/House/Health_Aged_Care_and_Sport/~/link.aspx?_id=09014C27B7F84C7EAF6848C0D7F77E8E&_z=z
Krieg, A, Guthrie, J Herbert Levy, M & Segal, L (2016).  “Good kid, mad system”: the role for health in reforming justice for vulnerable communities. Medical Journal Australia, 204 (5) https://doi.org/10.5694/mja15.00917
Livingston, G et al (2020).  Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet, 396: 413–46. https://www.thelancet.com/article/S0140-6736(20)30367-6/fulltext
O'Brien, G., & Trudgett, M. (2020). School House to big house. The Australian Journal of Indigenous Education, 49(1), 98–106. https://doi.org/10.1017/jie.2018.13  
Senate Community Affairs References Committee (2010). Hear Us: Inquiry into Hearing Health in Australia. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Completed_inquiries/2008-10/hearing_health/report/index
World Health Organisation (2015-2020). Make Listening Safe resources released over several years available at https://www.who.int/activities/making-listening-safe
World Health Organisation (2019).  Risk reduction of cognitive decline and dementia: WHO guidelines, available at https://www.who.int/publications/i/item/9789241550543

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