Health care for Canada’s medically uninsured immigrants and refugees

In 1999, community health workers informed us that large numbers of immigrants and refugees lived and often worked in our Scarborough, Ont, community while being denied access to publicly funded health care.

Our inquiries uncovered empirical evidence that Scarborough’s uninsured experienced health care access inequities, health disparities, financial hardships, and delayed acculturation. Scarborough’s only community health centre (CHC) reported a waiting list of 3000 uninsured newcomers seeking access to health care.

In May 2000, an interprofessional team of primary care providers and community workers responded by establishing 2 community-based, volunteer-run health clinics in Scarborough to provide free front-line health care to this vulnerable group. We have since recorded more than 20 000 patient visits.

Our subsequent research confirmed that Canada permits large numbers of medically uninsured immigrants and refugees to reside across the country. Canada is not alone among industrialized nations with publicly funded health care schemes in struggling with this reality.¹

Faces of the uninsured

A review of our patient visits reveals that 20% of our patients are children and youth, 18% are pregnant without access to antenatal care, 60% are female, 60% are seeking care for acute medical problems, and 40% are seeking chronic disease care. A host of complex provincial and federal immigration and health care policies and regulations have led to a diverse taxonomy of Canada’s uninsured.

Ontario, Quebec, and British Columbia are the only 3 provinces that mandate a 3-month wait for health insurance for Canada’s landed immigrants. Annually, 80% of Canada’s newcomers choose these gateway provinces as their first port of call. Landed immigrants choosing Ontario constitute one-third of patients treated at our clinics.

Until the recent changes to the Interim Federal Health (IFH) Program, which are highlighted by Raza and colleagues on page 728,² Canada’s refugee claimants all received coverage upon arrival. Even before these changes, refugees making claims from within Canada experienced a 65% rejection rate, and their IFH coverage often lapsed with rejection. Some followed appeal processes without insurance. Others stayed on in Canada without status. These groups account for 50% of our patients.

Sponsored-class newcomers represent 12% of our patients. It is not unusual for them to wait several years for their provincial health care eligibility. They are not subject to the 3-month wait in Ontario.

The remainder of our patients are a mix of Canadian citizens and those whose work or education permits have expired. Most of the Canadian citizens are underhoused children and homeless youth with lost or never-obtained health cards. They lack the knowledge, the required documents confirming residence and Canadian status, or the financial means to obtain their provincial health cards. A recent report by the Toronto District School Board estimates that 13% of children and youth in schools lack health cards.³

A case from the CHC, of an uninsured sponsored youth, compelled us to open our community-based, volunteer-run clinics in 1999.

Aisha

Aisha, aged 18 years, from Grenada was attending college when she experienced another in a series of sickle cell crises and sought medical care at Scarborough’s only CHC. Her condition was beyond primary care. She was referred to the hospital emergency department. At first she refused to go, having experienced previous requests for up-front payment before receiving care. The doctor reassured Aisha that this would not happen. This was an emergency.

At the emergency department Aisha was told she had to pay $350 before they would provide care. She was told her situation was not an emergency. Not having the money, Aisha explained that her sickle cell crisis would soon leave her unconscious. It had before. Emergency department admitting staff told her that if she became unconscious, they would treat her without demanding payment first. Aisha seated herself near the triage station and waited. When she collapsed, she was taken in. After 3 days in hospital she received a bill for more than $5000.

Aisha was a sponsored youth in Canada, sent for by her father and stepmother at age 15. Her parents later separated and left Canada. Her sponsorship lapsed. Aisha was left to fend for herself without health insurance. She managed to get a part-time job, find a room to rent, complete high school, and enter college in Scarborough. Her hospital bill ended her education.

Ethical questions and practical challenges

Our patients often relate similar humiliating experiences trying to obtain health care—high costs, worsening health status, hobbled acculturation. Aisha’s story also highlights how intersecting vulnerabilities among the uninsured conspire—poverty, insufficient housing, and the growing trend toward the feminization and “pediatization” of immigration. Not all newcomers, particularly children and some groups of women, have much say in their immigration.

Providing health care to the uninsured raises ethical questions and practical challenges for all Canadians. Are Canadian political policies putting health care providers at odds with their professional and moral responsibilities to provide health care to the uninsured? If Aisha’s job was to fend for herself when her sponsorship failed, to get a job and an education, to move her life ahead, then is it not our job, when she is ill, to look after her?

Toronto’s uninsured new arrivals often take up residence in Scarborough’s “motel strip,” where many frequently occupy a single room. If a fire breaks out, would we argue for payment up front before sending the trucks? Would we send the rescued children a bill afterward? Was Aisha’s emergency different?

We frequently hear that persons are uninsured in Canada because they reside here illegally, without any status. Is this accurate? Is legality a justifiable or ethical argument for withholding health care?

Our research confirms that a substantial proportion of the uninsured we treat reside in Canada legally. In Scarborough, drug dealers routinely enter the emergency department for care when clearly illegal activities turn dangerous. What about prisoners? Has any of us paid for work “under the table” to avoid paying taxes that support health care? Where is the “legality line” to be drawn, if at all?

Sponsored persons are admitted legally. Consider, however, exploited sex trade workers brought into Canada illegally or on sham sponsorships. Or those falling ill during the 3-month waiting period while in Canada legally. Is it reasonable to argue that none of these uninsured individuals is deserving of health care access when they become ill, based solely on an arbitrary status decision?

Some argue that new Canadians have not paid into “our system.” And yet new Canadians pay tax on every purchase immediately upon arrival. This supports a health care system that we use but that they are denied access to. Our immigrants and refugees take on our “3D” work—dirty, dangerous, and difficult—injury-prone work that resident Canadians often reject.⁴ Our experiences in Scarborough confirm that the uninsured with injury and illness often delay seeking care until their provincial insurance eligibility arrives, or until they become too ill to further avoid care, in which case they face large financial debt. They end up sicker, needing more extensive and expensive care, and experience longer hospital stays in a bed-challenged health system.

Overcoming objections

In a recent review, the Ontario Medical Association called on Ontario to eliminate its 3-month wait for health care for landed immigrants.⁵ Their work and our repeated efforts seeking remedies with policy makers have always met with rejection, by all levels of government. The following are the most common objections.

Immigrants and refugees can obtain private health insurance

This is generally not an option owing to pre-existing conditions, high costs, and age-related exclusions.

In Ontario the uninsured can access CHCs, where provincial health cards are not required, for care

Ontario’s CHCs do care for many uninsured individuals, but when they were established 40 years ago, it was not with this role in mind. This role evolved by default as immigration patterns, policies, and demographic changes swelled the ranks of the uninsured. Inadequate capacity and administrative barriers limit access for many uninsured.

Providing care to the uninsured is too costly

Studies from US centres with large uninsured immigrant populations prove the opposite to be true.⁶ Health care costs and hospital use decline when accessible primary care is made available to the uninsured.

Potential solutions

Concrete, evidence-based, and cost-effective solutions do exist. Volunteer efforts, while providing some relief, lack the sustainability and generalizability to match the magnitude of the problems. We make the following recommendations:

• Eliminate the 3-month wait for provincial health insurance.

• Restore IFH coverage removed by recent federal changes and extend IFH coverage for refugees during their legally permitted appeal period.

• Remove the administrative barriers and provide health cards to all eligible Canadians, with an immediate focus on marginalized and vulnerable youth and children.

• Establish an interdisciplinary national working group with a mandate to bring forward evidence-based recommendations to address issues for the uninsured at both the provincial and the federal level.

Canada is a signatory to the United Nations’ Universal Declaration of Human Rights,⁷ which obliges signatory countries to guarantee accessible health care for all residents. Canada invites and requires immigrants to support our future prosperity. Physicians have professional responsibilities to provide medically necessary care to uninsured residents regardless of the residents’ ability to pay or their politically determined insured status. Policy makers have an equal responsibility to ensure providers are afforded the means and compensation to provide this care to expected standards. Otherwise, Canada risks an apartheid health care system.

It is past time to end the wait for health care for Canadian immigrants, refugees, and sponsored persons—for the good of everyone’s health.