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July 24, 2013

Cuts to interim federal health program for refugees unfair and unjust

Edward C. Corrigan

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"Today, as yesterday, a nation is judged by its attitude towards refugees." Elie Wiesel, Nobel laureate, Globe and Mail, July 7, 2012.

We need to remember these wise words and recall that Albert Einstein was once a refugee that was forced to flee Germany. At this same time Canada was refusing to accept Jewish refugees from Germany. Many thousands of refugees have been forced to flee their homes and were granted the protection of Canada and have made a valuable contribution to this country.

Today, Monday June 17th, 2013 is the second National Day of Action in support of refugee claimants in Canada who have been cut-off the Interim Federal Health Program. Demonstrations are taking place in virtually every major city in Canada protesting these unfair and draconian cuts to some of the most vulnerable people in Canada, refugees who have been forced for one reason or another to flee their homeland and to come to Canada seeking the protection of this country as refugees. From Victoria to St. John’s Canadians, and especially those in the medical profession, are raising their voices protesting against this injustice.

On June 30th, 2012, the Conservative Federal government of Prime Minister Stephen Harper and Citizenship and Immigration Minister Jason Jenney made cuts to important health care services for refugees. Due to these cuts many refugees living in, Canada will no longer qualify for coverage for necessary medications such as insulin. Some refugee claimants will also be denied access to physicians unless their condition is deemed a threat to public health or safety. Among other health care services to be cut for some or all refugees are: prenatal care for pregnant women, child care and access to mental health care.

Before the cuts, the IFHP provided refugee claimants and refugees with coverage similar to that of low-income Canadians, including medical and hospital care, medications and certain other services such as basic dental care. Since the cuts, most refugee claimants and refugees have lost access to so-called “supplemental” health services and the vast majority of medications.

The Interim Federal Health Program (IFHP) has been in existence since 1957 and is administered by Citizenship and Immigration Canada. IFHP paid for basic health care for refugee claimants and refused claimants until they were removed from the country or became eligible for provincial health care. Without consultation, Minister Jason Kenney abolished the program in June, 2012, and replaced it with a program that denies basic, emergency, and life-saving medical care to thousands of refugee claimants who have lawfully sought Canada’s protection.

Owing to the secretive process of rolling out an opaque and complex set of rules, health care providers, insurers and patients have been left in a state of confusion. Many patients fear asking for health care and some physicians simply refuse to treat any refugee claimants.

Dr. Meb Rashid, a founding member of Canadian Doctors for Refugee Care, has stated that, “Some patients cannot be treated unless their health condition is a threat to Canadians. It is far below the standard any physician would hope to provide his or her patients. Ultimately these reductions will cost the health care system as much or more in emergency care and have already caused a great deal of suffering.”

“It is also far below the standard any democratic country should provide for refugee claimants or any other human being under their jurisdiction,” added Lorne Waldman, president of Canadian Association of Refugee Lawyers and lead counsel on the case going to the Federal Court of Canada. Waldman adds, “These cuts are inconsistent with the Canadian Charter of Rights and Freedoms and Canada’s international obligations under the UN Refugee Convention. Worse than that, they are mean and callous. People with severe medical conditions are being put at risk; they are suffering unnecessarily for the saving of a pittance.”

Many organizations, and most of the national Medical Organizations in Canada, have severely criticized these attacks on refugee health care in Canada.

Last year on May 11th, 2012 doctors in cities across the country, many of whom treat refugees on a daily basis, organized demonstrations, press conferences and public events to protest these cuts to refugee health-care. These protests included a sit-in at a federal cabinet Minister's office in Toronto by more than 50 physicians. Following an overwhelming positive response from the medical community and public at large, a number of physicians came together to launch Doctors for Refugee Care.

In response to the outcry on June 29th, 2012 the federal government made partial revisions to its planned cuts that maintained services to some refugees, specifically those who are classified as Government Assisted Refugees. However, other groups of refugees still were suffering from cuts to important health benefits.

These cuts to different types of coverage, depending on refugee category and country of origin, are discriminatory and arbitrary, and deprive many refugees of essential health care.

Refused refugee claimants and claimants from “Designated Countries of Origin” are now only covered for conditions that affect public health or safety, such as contagious diseases. Even emergency care for life-threatening conditions is no longer covered.

Quebec and Manitoba are the only provinces so far that have decided to compensate for the federal cuts, through a program that covers medication as well as medical and hospital care for all refugee claimants, including refused claimants and claimants from Designated Countries of Origin. However, the Quebec government does not cover the basic dental care, vision tests, rehabilitation services and psychological treatment previously covered by the IFHP.

Ontario hospitals absorb health costs to treat refugees

As the Toronto Star reported, on June 8, 2013 “One year after Ottawa cut refugee health funding, Ontario hospitals and Toronto-area refugees are picking up the tab.”

Hospitals in Greater Toronto are hardest hit by the changes, made effective by the federal government last June, since the majority of refugees are destined for this province.

The University Health Network — which includes Toronto General, Toronto Western and Princess Margaret hospitals, along with the Toronto Rehab Institute — expects to foot a total $800,000 bill this year for services delivered to the uninsured in its emergency rooms alone.

As Critics have warned the federal government’s cuts to refugee health costs would simply be downloaded onto the provinces and individual hospitals, since they are obliged to treat patients in emergency cases and recoup fees later.

“What we are seeing is what we had anticipated,” said Dr. Meb Rashid of the Canadian Doctors for Refugee Care.  Anecdotally, he said uninsured patients are delaying seeking treatment, end up in emergency departments with more serious conditions and generate higher costs to the health system, he said.

“It’s an absolute mess.”

Minister Kenney has claimed that the reforms will save taxpayers $100 million over five years.

“There are a number of patients in the system, who were covered by the (federal) program, are no longer covered but for whom treatment must continue or death would result,” said Gillian Howard, at Toronto’s University Health Network.

“We recognize that some hospitals and other health-care facilities have been assuming health care costs that would otherwise have been borne by the federal government . . . I continue to call on the federal government to reverse their decision,” Ontario Health Minister Deb Matthews in an emailed statement to the Toronto Star.

“In the meantime, we continue to consider options available to the provincial government to mitigate the effects of this decision.” Said Minister Matthews.

At most hospitals now, patients must provide valid health insurance for elective care or prepay the fees.

“The ability to pay will not be a barrier to care and we will continue to serve the refugees living in our local catchment area,” said Dr. Ted Rogovein, chief of staff at St. Joseph’s Health Centre.

He added however: “St. Joseph’s does not have the capacity to provide services to all refugees in the GTA and so expects other hospitals to care for refugees in their local areas.”

Dr. Paul Caulford, of the Scarborough clinic for the uninsured, said “Taxpayers are still on the hook,” he said. “The federal government has essentially downloaded the responsibility onto the shoulders of service providers, turning us into the police force to police the system, making us the bad guys.”

Opposing Refugee health cuts: 50 prominent Canadians sign declaration demanding an end to ‘suffering’

Nearly 50 prominent Canadians are “heartbroken” that Canada won’t care for sick kids, pregnant women.

Dr. Vincent Lam, a Toronto physician as well as a Giller Prize-winning author, found the fellow prominent Canadians he contacted quick to join in signing a declaration calling on the federal government to restore health care funding to all refugees in Canada.

About 50 prominent Canadians —  Life of Pi author Yann Martel, Margaret Atwood, Rohinton Mistry, Kiefer Sutherland and former Governor General Adrienne Clarkson and her husband John Ralston Saul — have signed a declaration asking Ottawa to reverse its cuts to refugee claimants’ health care.

The declaration, released on June 13, 2013, says “refugees arriving in Canada — many of whom are fleeing war, violence, or famine — often come with little more than the clothes they are wearing. Access to basic health services is guaranteed to them under the Charter; care has been provided because it is the right thing to do. Now, due to these cuts, many refugees — future citizens of this country — are being denied services.”

The declaration calls on Ottawa to “reverse these health cuts and restore our country’s humanitarian tradition of providing care to refugees.” ADVOCATES LOSE CASE FOR REFUGEE BENEFITS

Churches in Manitoba were forced to take Citizenship and Immigration Canada to court for cutting health benefits for refugees they had sponsored. The Church groups said Ottawa walked away from signed sponsorship agreements and left church groups and individuals who had sponsored refugees on the hook for medical bills. The case was lost primarily due to a technicality that the evidence did not demonstrate harm to individual refugees. As noted above the Manitoba government stepped in to cover the refugees' supplemental health benefits that the federal government took away.

WHAT ARE THE LEGAL ISSUES?

Canada has a long tradition of providing basic health coverage to refugees

Since 1957 there has been some form of a federal insurance program, has historically provided temporary health, vision and dental insurance to all refugee claimants and resettled refugees, up until the time they were either accepted as refugees and were eligible for provincial health care, or if not accepted, until they had exhausted their legal options to remain in Canada.

CUTS ELIMINATE MOST FEDERAL HEALTHCARE BENEFITS FOR REFUGEES—EVEN IF THEY ARE CHILDREN

On April 5, 2012 the federal government passed an Order-in-Council to make drastic cuts to the health benefits paid by the federal government to refugee claimants. These changes were made without advance notice or consultation with the provinces or health and immigration stakeholders. The cuts came into effect on June 30, 2012, including the following:

  • Refugee claimants have coverage for medical services, but no longer have federal coverage for vision care, dental care or prescription medications—even life-sustaining ones such as insulin. This rule even applies temporarily to privately sponsored refugees—people who Canada recognizes as being in need of protection.
  • Refugees from countries that the Minister has designated as safe (“Designated Country of Origin” or “DCO”), such as Mexico and Hungary, as of Dec. 15, 2012 receive no medical care at all, unless their condition poses a public health risk or security concern for Canadians.
  • Refugee claimants whose claims have been rejected can only obtain medical care where their condition poses a public health or security concern. Even where the person cannot be removed from Canada, due to a government-issued moratorium on removals to particularly dangerous countries like Afghanistan or Iraq, she or he has virtually no health coverage despite being able to work legally in Canada.

CUTS TO REFUGEE HEALTHCARE HAVE SIGNIFICANT NEGATIVE IMPACTS

The changes to the healthcare coverage for refugee claimants are significant for a number of reasons:

This is a dramatic cut to the basic level of health coverage to some of the most marginalized and vulnerable people in Canada (sometimes, a claimant’s health problems are directly related to the persecution they suffered in their home country);

People are likely to suffer significant health risks under this new policy;

Refugees have had federal health insurance coverage for 55 years; these cuts mark a major shift in Canada’s tradition of universal health care and its humanitarian treatment of refugees;

The changes were imposed without consulting provinces, the public or direct stakeholders;

The changes will result in a significant downloading of costs onto the provinces and onto individual physicians who provide certain emergency services free of charge;

The complexity of the changes, coupled with the lack of consultation, has made it difficult for the medical community to understand the cuts, and to accurately inform patients about their coverage;

The average annual cost of the Interim Federal Health Program was about $552 per refugee claimant;

Ironically, the cuts may well increase government health costs in the long run as emergency care generally costs much more than the preventive care which is being eliminated.

LEGAL CHALLENGE ALLEGES REFUGEE HEALTH CARE CUTS ARE UNCONSTITUTIONAL

The legal challenge has now been filed at the Federal Court of Canada on behalf of three patients who have had critical health care denied to them since the government cut health care coverage for refugees in June of 2012.

The cuts to refugee health care are also being challenged by two public interest groups who bring additional expertise and resources to the fight: Canadian Doctors for Refugee Care, a group of doctors who treat refugees across the country, and the Canadian Association of Refugee Lawyers (CARL), a national organization of lawyers and academics who are concerned with refugee law and policy.

The challenge argues that the cuts to refugee health care violate the fundamental human rights of refugees, as protected by the Canadian Charter of Rights and Freedoms, without any lawful justification.

THE CUTS THREATEN THE RIGHTS TO LIFE AND SECURITY OF THE PERSON IN SECTION 7 OF THE CHARTER.

The Supreme Court of Canada has already made clear in the Chaoulli decision that denying medical care can increase the risk of medical complications and cause severe psychological stress that threaten the security of the person and can even lead to death, in violation of section 7. The government has not clarified its reasons for these cuts. Assuming that the goal of the cuts is to discourage fraudulent refugee claims, there is no evidence that these cuts will have that result. Accordingly, the government’s decision to cut health care benefits is arbitrary and unjustified.

THE CUTS AMOUNT TO CRUEL AND UNUSUAL TREATMENT, CONTRARY TO SECTION 12 OF THE CHARTER.

These cuts reduce or deny basic and life-sustaining health coverage for refugee claimants, likely causing significant and unnecessary pain and suffering to refugee claimants. The changes to the refugee health care coverage are inconsistent with international practice; numerous European countries provide more comprehensive healthcare coverage to refugee claimants than Canada.

THE CUTS DISCRIMINATE AGAINST REFUGEES FROM CERTAIN COUNTRIES, AND DISCRIMINATE AGAINST PEOPLE BASED ON THEIR IMMIGRATION STATUS, CONTRARY TO SECTION 15 OF THE CHARTER.

For the first time, the type of health care coverage provided to a refugee depends on their country of origin. The federal government’s changes to refugee health care insurance deny medical assistance to people from certain countries, such as Mexico and Hungary, which have been designated as safe by the Minister, while providing care to refugees from other countries. The cuts to refugee health care also discriminate on the basis of immigration status by denying basic health care to individuals residing in Canada on the grounds that they are seeking refugee protection. This arbitrary division violates the equality provisions of the Charter of Rights and Freedoms.

THE CUTS ARE INCONSISTENT WITH CANADA’S INTERNATIONAL LAW OBLIGATIONS.

Under the Convention on the Rights of the Child and the Convention Relating the Status of Refugees, Canada is obliged to provide basic health care for refugees and children. The cuts do not comply with those obligations.

There are many heart breaking stories as to how these unfair cuts have harmed refugee claimants, including children. The cost of maintain this Federal Interim Health Program is only $552 per refugee claimant or put another way around 0.59 cents per Canadian. 

It is clear that these cuts are directly contrary to Canada’s humanitarian and compassionate obligations and Canada’s obligations under International law.  It is also a lie that these cuts will save money for the tax payer. The truth is that these expenses are being passed on to the doctors and hospitals who treat these refugees and to the provincial taxpayers. In the end will undoubtedly cost Canadians more money due to the failure to treat many medical problems early on and before they become serious medical issues the costs will be borne by our doctors, hospital emergency wards and by the provincial healthcare systems. The refugees will suffer from a lack of adequate health care.

There is no cost saving to support this unfair cut and it will most likely cost the taxpayer much more money in the long run. It also will have severe impact on the lives of refugees and their families who have been cut off from this long standing health care coverage. It is time to end this heartless attack on many of the most vulnerable in Canada, refugees and their families and including their children.

Edward C. Corrigan is a lawyer certified as a Specialist in Citizenship and Immigration Law and Immigration and Refugee Protection by the Law Society of Upper Canada in London, Ontario, Canada. He can be reached at or at (519) 439-4015.

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