Dr. Meb Rashid is a Toronto-based physician who specializes in refugee healthcare. He is a co-founding physician of Canadian Doctors for Refugee Care.
Healthcare leadership in Canada has come together to oppose the changes to our refugee healthcare system announced in April 2012 and implemented in June 2012. As physicians, we know that these cuts:
- deny services to some of the most vulnerable people in our society, whose need is dire
- are so complicated that refugee claimants and physicians alike don’t understand them
- are not cost-effective: waiting until people get sicker and need more intensive care costs money
- put all Canadians at risk: refugee claimants who aren’t getting the care they need when they are sick often end up being admitted to hospital later for more costly treatment – and sharing their untreated ailments with their communities.
- come at an enormous cost in human pain and suffering.
Before the cuts
Prior to June 2012, healthcare professionals could provide every refugee and refugee claimant, no matter where they were from or the stage in their application process, with a level of care very similar to what’s covered by OHIP here in Ontario. They could see a doctor, get diagnostic or lab tests as needed, and access a basket of services identical to social assistance recipients, including coverage for prescriptions.
All we needed to know was that a patient was in the refugee system and had a valid certificate. People whose refugee claims were not accepted, known as “failed claimants,” still had coverage for as long as they remained in Canada, right up until their date of deportation.
The process was simple, straightforward and effective.
How the cuts affect refugees and refugee claimants
The June 2012 cuts affect different groups of refugees differently and can affect the same refugee differently as he or she moves through the refugee determination system.
For instance, the federal government has created a Designated Countries of Origin (DCO) “safe country” list. Countries on the DOC list “do not normally produce refugees, but do respect human rights and offer state protection.” 1
Those refugee claimants whose country of origin is not on the DOC list can access services similar to OHIP coverage, with some exclusions, such as home care and long-term care.
But refugee claimants on the DOC list can only access coverage for diagnosis and treatment of some three dozen conditions that are deemed to be a matter of public health and public safety.
The average person has no way of knowing whether his or her symptoms are due to an illness covered on this list. This means that many patients, who are unsure of whether they are covered for a particular set of symptoms, delay seeing a healthcare provider. This can result in deterioration of their health condition and more costly care.
Furthermore, some countries on the DOC list are not safe for all their citizens. The refugees fleeing these countries include political dissidents from Mexico (Canada’s number one source of refugee claimants until 2009) and the Hungarian Roma population; Hungary was Canada’s number one source country of refugee claimants between 2010 and 2012.
Before 2012, the Refugee and Immigration Board acknowledged some of them as people fleeing persecution and requiring protection. So why are we denying them access to healthcare now?
On top of this concern, resettled refugees (those who come to Canada through government, community group or community sponsorship) are expected to comply with yet another set of complex rules and procedures.
After the cuts came into effect on June 30, 2012, for instance, government-sponsored resettled refugees retained coverage identical to what someone on social assistance in Ontario could access, and what all refugees in Canada could access before the cuts.
But those sponsored by community groups or sponsorships lost access to coverage for essential medical care through the Interim for Federal Health Program (IFPH) coverage. These individuals are not refugee claimants; they have already been accepted as people fleeing persecution and are on the trajectory to becoming Canadian citizens. Nonetheless, they can no longer access medications, emergency dental care, or coverage for prosthetics, counselling and other services. These costs now fall to their private sponsorship groups—often small organizations that are not well-resourced.
And these are only some of the cracks in the system.
The effect in practice is that the rules are so complex and difficult to navigate, refugees and refugee claimants essentially have no access to basic healthcare.
Physicians see people, not refugee status
The cuts are also inherently difficult for physicians, who tend to look at people as individuals to help, not people at a certain stage of a political process.
We see that these cuts most acutely affect the most vulnerable among the refugee community.
We see, for instance, horrific cases of people uninsured for emergency medical care…such as a woman I recently treated who had been gang-raped after she was incarcerated because someone in her family was involved in politics. After she fled and arrived in Canada she lacked insurance to cover screening for sexually transmitted infections, for ruling out pregnancy, or for getting counselling.
We see people who’ve fled the very same day they’ve witnessed family members getting shot, and don’t have any health insurance for medication to treat severe post-traumatic stress disorder.
We see acutely ill kids with no health insurance for diagnostic tests, X-rays or medications.
We see pregnant women whose refugee status changes midway through their pregnancy, leaving them suddenly without insurance, denied coverage for delivery of their babies.
Because of my involvement with Canadian Doctors for Refugee care, I’ve spent a great deal of time learning the particulars of the Interim Federal Health (IFH) program. And I can tell you, these cuts are not only inhumane, they’re also administratively impractical. In fact, most physicians simply don’t understand them.
This is because the current system requires us, before we see even someone, to know which group of refugees they belong to, where they are within the refugee system, where they come from, and sometimes even the diagnosis.
For example, clinicians who access the IFH system were sent a 17-page list of diagnostic codes that are only insured if we are ruling out one of 34 health conditions. This is preposterous. Physicians are not going to carry these lists with them to decipher which services are indeed covered.
Furthermore, one set of a patient’s symptoms may be insured, but that same patient may lose coverage if diagnosed with an uninsured condition. This would require physicians to begin to treat patients but then abandon their ethics and drop them from care if their condition becomes uninsured during the process of their evaluation.
Moreover, many of us would find it truly obscene to differentiate the care we give because of the country of origin of a patient. We can treat a child from Somalia because that child is not on a list, but then we are expected to deny treatment to a similarly afflicted child from Hungary.
Healthcare as leverage to prevent people from coming here
The government would have us all believe that these cuts only impact “bogus” refugees.
This is clearly untrue.
In my opinion, the government is using lack of access to healthcare to prevent or deter people fleeing persecution from coming to Canada, because they may not be able to get health care for themselves or a sick family member. This is reprehensible. Health care is not a tool any government should use to shape their immigration policy.
It is also not a partisan issue; it’s a matter of human rights. And evidently, the courts agree. The 2014 federal court decision demanding a reversal of the cuts makes it clear that this legislation targets those who are the most vulnerable. If the intent was to make people suffer, that intent has been met.
Canada has historically won international recognition for how we’ve treated refugees.
As a signatory to many international treaties, we have allowed a small number of the world’s refugees the opportunity to settle here when they fear persecution in other parts of the world.
If we’re changing our character as a country on this front and no longer want to comply with international treaties, we should be publicly debating this.
Until then, to use health care as a tool to leverage immigration policy is immoral.
- http://www.cic.gc.ca/english/refugees/reform-safe.asp ↩