At a community health meeting in 1999, a Toronto Public Health nurse kept flicking a neatly folded piece of paper to Dr. Paul Caulford, who was the new chief of family medicine at Scarborough Hospital.
In attendance were various community members describing their distinct health needs and the barriers they were coming up against. Jennifer D’Andrade, the paper flicker, persisted until she got the doctor’s attention.
When he opened the note, Dr. Caulford realized it was a $4,000 hospital bill for a 17-year-old girl who’d finally been treated for sickle cell disease, which can cause strokes, brain damage and death.
“She’d almost died in our emergency department because she’d been turned away,” Dr. Caulford told me on a Saturday afternoon as we sat inside one of the few small rooms of the volunteer-led Canadian Centre for Refugee and Immigrant HealthCare in Scarborough, Ont.
“Because she didn’t have a health card.”
Aisha (whose name has been changed to protect her privacy) had come to Canada as a sponsored refugee five years prior. But even after going “through all the channels,” said Dr. Caulford, she remained uninsured and undocumented, with no social or health insurance to her name.
As Dr. Caulford would soon learn, her case wasn’t isolated.
After conducting an unofficial study of the community, Dr. Caulford and colleagues found that thousands of uninsured and undocumented individuals were being denied access to emergency rooms and other public medical services throughout the city.
Policy allows emergency rooms not to admit people unless they are in life-threatening condition, Dr. Caulford said, but there’s no standard for what that is, meaning it’s “left up to, as usual, human behaviour” and thus bias. Depending on “what the hospital needs in its revenue stream to keep its budget going,” uninsured patients can be charged anywhere from $500 to $700 just to see a doctor.
“Every hospital is different,” said Dr. Caulford. “It’s dangerously variable.”
As a result, uninsured people — the large majority of whom are undocumented newcomers and unsuccessful refugee claimants — continue to slip through the cracks simply because they can’t pay. And when they’re finally “too sick” to be turned away, they’re slapped with gigantic bills like the one Aisha was given.
When the Canadian Centre for Refugee and Immigrant HealthCare opened later that year to try to fill the gap, they figured, and hoped, that they would close within six months to a year after the government got wind of what was happening, said Dr. Caulford.
But the centre is now in its 20th year and its clientele has grown by 400 per cent, he said, and during that time other clinics and centres have been established to help with the ever-growing list of undocumented individuals in need.
“We’ve never been busier,” said Dr. Caulford.
A dangerous situation
“Immigrants to Canada tend to arrive healthier than people who are Canadian-born,” but as time goes by their health worsens, according to a 2018 report by the Wellesley Institute.
One of the main obstacles is a three-month wait period during which most newcomers are not eligible to receive publicly funded healthcare. Five provinces — British Columbia, Saskatchewan, Ontario, Quebec and Newfoundland and Labrador — and all three territories have a version of the policy.
In theory, the policy is to ensure that individuals intend on residing in the province. In Ontario, since the 1994 law was passed, this applies to permanent residents, temporary foreign workers, and returning Canadians who have been out of the country for over 212 days.
But according to a 2006 article penned by Dr. Caulford and Dr. Yammi Vali in the Canadian Medical Association Journal, their “patients’ wait has averaged 2.1 years.”
While there are no clear numbers, an estimated 200,000 to 500,000 people living in Canada have no health insurance. Some estimates say about a quarter of a million of these individuals may be undocumented migrants, with the majority settling in Toronto.
The other half is comprised of groups such as the homeless and those who have lost their health card or had it stolen.
This is a dangerous situation to be in, especially for migrants.
For example, a report by the Women’s College Hospital, which recorded 24 health care professionals’ experiences treating uninsured and undocumented individuals, lists several ways in which their health is negatively impacted. This includes barriers to healthcare access, more severe health problems due to those barriers, and a lack of consistency in how they are treated at various points of access such as hospitals and walk-in clinics.
Fear of deportation was the main barrier for the undocumented population, followed by prohibitive costs of care.
Dr. Chetan Mehta is a Toronto-based addictions and family medicine physician and a member of Health Providers Against Poverty. In his experience, the “vast majority” of refugees come to Canada to escape political persecution and other “terrible circumstances” such as war and poverty.
“So even the idea of going to a doctor funded by the state (is) a big barrier,” he told Ricochet in a phone interview. “And by the time they show up in a physician’s office, they’re in a really, really terrible state.”
Other obstacles described in the Women’s College Hospital report were lack of knowledge among health care professionals of how to treat distinct populations, language and cultural barriers, discrimination and long wait times.
Consequently, mental health issues and pregnancy complications were the two main health problems experienced by undocumented people, according to the study’s participants.
As a volunteer at the Paediatric Outreach Program, a clinic that is separate from but operates out of the Canadian Centre for Refugee and Immigrant HealthCare, Dr. Hannah Oatley confirmed that “a vast majority of children above the age of (five) that we see struggle with mental health and/or behavioural regulation issues.”
A study by York University professor Michaela Hynie examined visits to emergency rooms in Ontario and also found dire consequences for people without health insurance. It showed they had a lower chance of hospital admission but a higher likelihood of having more serious conditions and mental health concerns, not receiving treatment, and dying in the emergency room. Further, more than a third of those without health coverage were under 16 years old.
The 2016 study noted that emergency room visits by people without insurance had risen at the same rate as increases in the number of temporary foreign workers.
The federal and provincial governments offer some band-aid fixes, but these come far too short of actually changing anything.
“Unless there’s some fundamental change in policy, I don’t think this is going to magically change,” said Dr. Mehta.
Ontario Premier Doug Ford recently cut all funding to the College of Midwives and has announced a further $1-billion in cuts to Toronto Public Health over the next 10 years — impacting services offered to undocumented newcomers during their three-month wait period, services on which they depend.
The Interim Federal Health Program offers “certain pre-departure medical services for refugees,” according to the government website.
But contributions to this program — and to the health care budget in general — are a drop in the bucket compared to the country’s more than $32-billion military budget, said Dr. Mehta, something “which is not talked about.” Even when compared to Ontario’s health care budget, he stressed, the amount of federal money allotted for all refugees in the Interim Federal Health Program amounts to “less than half of a percent” of what is allotted for insured individuals in one province alone — or about $6 per refugee.
“So we’re going to spend roughly … 150 times the sum of money than what we spend on refugees,” said Dr. Mehta, “to create war planes and arms to destroy people in other countries that will fuel our refugee crisis ultimately.”
Another doctor says “it’s the wrong message” to suggest the Interim Federal Health Program is insufficient, though he acknowledged it “could function better.”
As director of the Women’s College Hospital Crossroads Clinic, Dr. Meb Rashid treats successful refugee claimants. He said the Interim Federal Health Program, in a lot of ways, is even better than Ontario Works, the province’s social assistance program, as it “covers more drugs” and is “much less bureaucratic.”
“No one should be turned away when they have a valid certificate” for the program, he said. “We haven’t had an issue with our patients except when they don’t understand they have coverage and that there is good coverage.”
Dr. Rashid pointed out, however, that he did not deal with undocumented migrants and thus was not entirely aware of the problems they faced. But that is to be expected in a place with a patchwork approach to health care delivery.
Dr. Caulford was more blunt.
“What the fuck is going on in Canada?” he said, taking off his glasses and leaning forward in his chair. “We have an apartheid healthcare system.”
Ford also recently cut all funding to Legal Aid Ontario services for immigrants and refugees, which critics say will cause more unnecessary suffering for vulnerable people and thus cost taxpayers more in the long run.
With legal representation costing newcomers from $2,000 to $10,000, many will simply not be able to pay, according to Elisabete Rodrigues, executive director at LUSO Community Services, a non-profit organization that assists newcomers.
“Without legal assistance, many legitimate refugees will have their claims rejected and be deported from Canada to countries where they are at risk of being put in prison, tortured and even killed,” Ed Corrigan, a London lawyer who specializes in immigration law, told the London Free Press.
Legal Aid Ontario CEO David Fields said last year the organization issued about 16,000 certificates related to immigrants and refugees, which allow recipients to access legal representation. This year, the organization anticipated another 16,000 asylum claims, at a cost upwards of $22-million, plus another $5-million for projected appeal costs. Ford’s cuts mean that Legal Aid Ontario can expect to have only $13-million to $16-million, from the federal government, for refugee and immigration issues.
Combined with refugee claimant case backlogs that can take, on average, 21 months to resolve, that money will be stretched thin. Legal Aid Ontario won’t be able to cover appeals at all.
That’s trouble because, according to the Canadian Association of Refugee Lawyers and the Refugee Lawyers Association of Ontario, only 21 per cent of appeals were successful in 2018, when Legal Aid Ontario was still able to cover them.
So a “wrong decision on their case could (also) result in failed refugee claimants choosing to remain in Ontario without legal status due to serious fear of returning to their country,” the associations stated in an April 15 joint statement.
Over the past six years, Canada has held approximately 45,000 people in immigration detention, including children who continue to be detained in large numbers, with current projections exceeding last year’s total of 151.
“With the cuts,” said Dr. Mehta, “this is going to get worse.”
Populists at the ballot
Recently elected Alberta Premier Jason Kenney used to be the country’s immigration minister. Under the Conservative government of Stephen Harper — who tried gutting the Interim Federal Health Program — Kenney introduced the Safe Third Country Agreement, which denies entry into Canada to people who have been denied asylum in the United States.
With Bill C-97, the Liberals are now trying to expand the Safe Third Country Agreement and take away the right for individuals within the country to make a refugee claim. Come October, a federal election will see campaigns and trite promises roll out once again.
In a race to get votes, populist politicians will profess to care about refugees while issuing warnings about who we let in in order to appease their ever-growing far-right and overwhelmingly white fanbase.
Meanwhile, thousands of people escaping wars, abuse and other traumas will continue languishing throughout the country with zero access to Canada’s world-renowned universal health care and in government cages perpetuated by Conservative and Liberal governments alike.
This includes children.
Not so much unlike Aisha, the 17-year-old whom the system wanted to — but couldn’t — ignore.