On June 30, bill C-31, the Immigration and Refugee Protection Act, comes in to effect, drastically changing the access that refugees in Canada have to health care. The short name is a misleading one: rather than enhancing the protections that refugees have in this country, the bill dismantles them for many claimants, reducing their access to essential health services.
With this bill comes sweeping changes to the way Canada treats refugees seeking asylum in this country, the most notable changes being the elimination of something called the Interim Federal Health Program (IFHP), a program that provides temporary health insurance to refugees and their dependents who are not yet covered under a provincial health care plan. Effectively, the program ensured that refugees arriving in Canada were not without access to healthcare, which seems the compassionate, ethical, and all-around right thing to do. It ensured that hospitals and health care professionals had a way of being compensated for providing medically-necessary treatment to refugees and also reduced the barriers to accessing the care that new arrivals to our country needed.
The IFHP provided access to things like primary and secondary care, as well as supplementary care like vision care, dentistry, mobility aids, and pharmaceuticals. However, our government has determined that the system is inherently unfair – not to refugees, but to Canadians who already live here. How is it unfair that a refugee arriving from Somalia be given a dental exam and access to insulin, you ask? The short answer is that Canada’s health care system relies on a mix of public and private insurance schemes, where some health services are covered by provincial health plans, while others are either paid for out-of-pocket, or by a private insurer. Supplementary care – vision care, dentistry, mobility aids, and pharmaceuticals, for example – are not routinely covered by a provincial health care plan for most Canadians, but rather are covered by private insurance, often provided as an employee benefit.
So, the removal of the IFHP for refugees sought to address this inequality. Not by reforming the system to increase access to health services for all Canadians, but rather to remove them from a vulnerable group because, according to Canadian Citizenship, Immigration and Multiculturalism Minister Jason Kenney “…we do not want to ask Canadians to pay for benefits for protected persons and refugee claimants that are more generous than what they are entitled to themselves.”
That narrative has prevailed through virtually all of the government’s messages on the subject, and has served as justification for denying a vulnerable population access to things like insulin and other life-saving medications: it’s unfair to everyone else to be providing health services for these people because other Canadians don’t have access to them through a public system. That’s quite an equalizer.
The point is further driven home by a document released by Citizenship and Immigration Canada, where they provide examples of coverage after the changes to IFHP take effect. To be frank, it’s chilling. Under a heading of “Medical Emergency – Heart Attack” they provide the following scenario:
A woman has chest pain and goes to the nearest hospital emergency room where a doctor finds she has suffered a heart attack. Urgent surgery is done to install a stent in an artery. She recovers well and leaves with a prescription for medication.
Sounds good if you’re a Canadian or a protected person or a refugee from a country that isn’t one of the Designated Countries of Origin (DCO). But if you’re a Roma from Hungary, and are therefore a claimant from a DCO, what services are you entitled to in the above scenario? “None.” How about this scenario:
A doctor confirms that a patient is pregnant. She gets prenatal health services for the pregnancy. There are no complications, she delivers the baby in a hospital and then has post-partum follow-up. Prenatal, delivery and post-partum health services are considered essential services.
Refugee claimant from a DCO? No services unless you pay. Even in any of the scenarios listed on the site, consultation may be provided, but the treatment (medications) are not. Expecting a refugee claimant to be able to pay for essential medicines upon their arrival is wholly unrealistic and flies in the face of compassion. More detailed discussions on the problems with the DCO designation and other concerns with the bill (including the impact it will have on children) are available elsewhere, and are really worth a read including this backgrounder on DCOs from Citizenship and Immigration whose opening line is “Too many tax dollars are spent on asylum claimants who are not in need of protection.”
The response to these cuts has been a vociferous outcry from health professionals who provide care to refugees and immigrants. In a country known for its multiculturalism and humanitarian ethos (whether the latter is factually accurate or not seems debatable), there is a considerable community of health care professionals who have worked diligently to provide high-quality care to these communities, and who have publicly opposed these cuts. This opposition has included protesting against Ministers who have supported these cuts, including emergency room physician Chris Keefer at the Toronto General Hospital who interrupted Minister Joe Oliver announcing:
“Doctors in this country will not remain silent in light of the Conservative government’s cuts to the refugee health program…Refugees who are coming from war-torn countries, fleeing hatred, fleeing crimes against humanity, and your government is about to cut the very essential medicines, the very essential services, that these people require in order to continue living.”
The video is available here, and is really worth watching.
Paradoxically, health services are generally provided in refugee and IDP camps by NGOs or by local governments, free of charge. This in no way should mean that the services are comprehensive or even remotely comparable to what is available in Canada, but the point is this: a refugee leaving a camp in Sudan to come to Canada has access to free health care in Sudan, but not in Canada. Does this not seem backward? When a country accepts refugees, this act is grounded in humanitarianism – people escaping horrific conditions and who cannot return should be afforded asylum, and this should include access to basic health services. Recognizing that there is a need for status as a refugee recognizes the need for special protection, the unraveling of which undermines the entire system.
The second argument advanced for the removal of the IFHP is economic: it’s too expensive, costing $84.6 million in 2010-2011. While it may be true that $84.6 million is a large sum of money, it is also true that removing preventative care only shifts the burden of disease further down the pipeline. It is far cheaper to provide insulin to a diabetic than it is to treat ketoacidosis in an emergency room, or diabetic retinopathy. It is far cheaper to treat hypertension in a primary care setting (including drugs) than it is to perform open-heart surgery or treat an aneurysm. The list goes on, and anyone with a modicum of understanding of public health could tell you that the economics of prevention are sound: preventing or treating disease early on is far cheaper than dealing with its consequences.
Yet, this is exactly what removing the IFHP will do: the burden will be shifted downstream to the provinces, either as an acute emergency or as a long-term consequence of untreated disease once refugees become part of a provincial health care scheme. The economic argument is a poor one.
Finally, the argument of abuse comes in to play – people who abuse the immigration system, make bogus refugee claims, or some other assortment of claims to validate the “necessary” reforms to the immigration system. I have worked with refugees and immigrants in Canada and abroad. I have worked in multiple internally displaced persons camps, in slums, and in areas affected by conflict. These are miserable places, and to suggest that people escaping them are somehow abusing Canadian generosity or taking advantage of us is disingenuous, at best, and certainly cold and callous. As UNHCR has so poignantly stated: No one wants to be a refugee.
Fundamentally, this move is mean-spirited and devoid of any rational economic argument. It’s penny-wise and pound foolish. They are irrational and inhumane cuts to vital health services that will without doubt have drastic negative effects on the health of some of our country’s most vulnerable people. As a healthcare professional, I do not and can not support these cuts, and I am not alone.