Health care for refugee claimants: Impact of Interim Federal Health Program (IFHP) cuts

1
Health care for refugee claimants Impact of
Interim Federal Health Program (IFHP) cuts

• Janet Cleveland, PhD
• Centre de recherche
• CSSS de la Montagne/McGill University

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What is a refugee claimant (asylum seeker)?

• A person who flees to another country and asks
  for asylum because she has serious reasons to
  fear that, if sent back to her country of origin,
  she would be persecuted because of her ethnicity,
  religion, sexual orientation, gender, political
  opinions or similar reasons
• To be accepted as a refugee, the claimant must
  convince the Immigration and Refugee Board (IRB)
  that
• She has suffered severe mistreatment (e.g.,
  rape, torture, beatings, death threats) and would
  be in danger if sent back
• She cannot obtain protection from the
  police/courts in her own country
• She would not be safe anywhere in her own country
  (i.e., moving to another part of her country was
  not a solution)

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Refugee claimants in Canada

• About 20,000 claimants per year
• Currently claims process takes 2 years
• Acceptance rate about 40
• During the process, the claimant is entitled to
• Temporary work permit
• Social assistance (same criteria as citizens)
• Health care Interim Federal Health Program
  (IFHP)
• No provincial health insurance until accepted as
  a refugee

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Anti-refugee discourse and policy

• Federal Conservatives discourse
• Refugee claimants presented as bogus, illegal,
  taking advantage
• Federal policy changes
• New law (C-31) that will
• Speed up processing of refugee claims
• Increase detention of refugee claimants
• Limit the rights of refugee claimants from
  countries designated as safe by the Minister of
  Immigration (Designated Countries of Origin or
  DCOs)
• Cuts to IFHP Rationale
• Not give refugees better coverage than Canadians
• Decrease pull factor, deter asylum shopping
  and bogus claims
• Save money

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Interim Federal Health Program (IFHP)

• BEFORE June 30, 2012
• Full health care coverage for all refugees and
  claimants
• Refused refugee claimants covered until
  deportation
• AFTER June 30, 2012
• 3 main types of IFHP coverage (baskets of
  services)
• Expanded Health Care Coverage
• Health Care Coverage
• Public Health/Public Safety Health Care Coverage
• Provinces partial coverage of services/meds not
  covered by IFHP (varies between provinces)
• Unchanged
• Managed by Medavie/Blue Cross

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Expanded Health Care Coverage

• Who?
• Government-Assisted Refugees (GARs) first year
  in Canada
• Often from refugee camps, recognized as refugees
  before arriving
• Persons recognized as trafficking victims
• What?
• All medical ( doctor/nurse), diagnostic,
  hospital services
• Medications (same as social assistance
  beneficiaries)
• Many supplemental services, e.g., basic dental
  and eye care, psychotherapy, physiotherapy, long
  term care
• Before June 30, 2012, all refugees and claimants
  had this coverage

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Health Care Coverage

• Who?
• Privately Sponsored Refugees first year in
  Canada
• Refugee claimants (unless from Designated
  Countries of Origin)
• Starts with recognition of eligibility to make a
  refugee claim
• Refused claimants lose this type of coverage
  after exhausting all appeals against the
  negative IRB decision
• But still qualify for IFHP until deportation
• What?
• All medical, diagnostic, hospital services EXCEPT
  elective surgery, rehabilitation and long-term
  care
• Medication NOT covered EXCEPT for conditions that
  threaten Public Health/Safety
• Infectious diseases on the federal Public Health
  Agency list
• Psychotic states involving a danger to others

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Public Health/Public Safety Coverage

• Who?
• Refugee claimants from Designated Countries of
  Origin (DCOs)
• Refused refugee claimants, from the moment they
  exhaust all appeals against the negative IRB
  decision until deportation
• Humanitarian and Compassionate applications,
  Pre-Removal Risk Assessments not appeals
• What?
• NO coverage of any medical services or
  medications (not even emergency care) EXCEPT for
  conditions that threaten Public Health/Safety
• Infectious diseases on the federal Public Health
  Agency list
• Psychotic states involving a danger to others

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Designated Countries of Origin (DCOs)

• C-31 will give the Minister of Immigration power
  to place a country on the DCO list if
• Low acceptance rate of refugee claims from the
  country, and
• Democratic country with independent, effective
  judicial system
• Federal Cabinet decides when this provision (s.
  109.1 of the Immigration and Refugee Protection
  Act) will come into force (probably end of 2012)
• If refugee claim was made before s. 109.1 comes
  into force
• Claimant retains Health Care Coverage even if
  her country is placed on the DCO list
  (grandfather clause)
• If refugee claim is made after s. 109.1 comes
  into force
• Claimant has only Public Health/Safety Coverage
  for medical services received after her country
  is placed on the list

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No health care coverage

• Refugee claimants waiting for a determination of
  their eligibility
• Refused refugee claimants who stay in Canada
  after their deportation date (non-status)
• Individuals with a temporary visa (e.g., student
  or visitor visa)
• Individuals who stay in Canada after their
  temporary visa has expired (non-status)
• Permanent residents 3-month waiting period after
  arrival in Canada before qualifying for
  provincial health insurance

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Provincial coverage

• Québec
• RAMQ on arrival for Government-Assisted Refugees
  (GARs) and Privately Sponsored Refugees (PSRs)
• Social assistance same supplemental coverage for
  refugee claimants as for citizens (medications,
  basic dental care, etc.)
• If employed access to Québec Prescription Drug
  Insurance
• Refused refugee claimants medical services
  covered until deportation date
• Ontario
• OHIP on arrival for GARs and PSRs
• Social assistance same supplemental coverage for
  refugee claimants as for citizens (medications,
  basic dental care, etc.)
• Community Health Clinics nonprofit clinics,
  offer medical care and midwives services
  regardless of migration status

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Provincial coverage (cont.)

• British Columbia
• Provincial insurance within 3 months for GARs and
  PSRs
• Social assistance same supplemental coverage for
  refugee claimants as for citizens (medications,
  basic dental care, etc.)
• If employed access to BC PharmaCare coverage 3
  months after obtaining work permit
• Alberta
• Provincial insurance within 2 weeks for GARs and
  PSRs
• Adult Health Benefit (low income)
• Medications for chronic diseases and for pregnant
  women
• Basic dental and eye care
• Child Health Benefit (low income)
• All essential medications
• Dental and eye care
• Temporary grant to Calgary Refugee Clinic for
  other meds

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In practice chaos!

• (False) perception that claimants no longer have
  coverage
• Complicated system lack of information from
  governments
• Confusion who is entitled to what?
• Failure to renew IFH document no coverage
• Some procedures pre-authorization required
• Billing problems
• Confusion about reasons for refusals
• Lengthy delays
• Québec for refused claimants, two-step billing
• Results
• Many clinics refuse all refugee claimants
• Many doctors demand cash upfront
• Even hospitals may demand that claimants pay cash
  upfront or sign undertaking to pay before
  providing services

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Examples of problems accessing health care

• Ontario
• Obstetrician demands 3000 to continue care for a
  refugee claimant, 36 weeks pregnant
• 32-week pregnant refugee claimant with lower
  abdominal pain ER asks to sign undertaking to
  pay leaves without being seen
• 1-year-old child of Roma claimants, fever,
  refused at several clinics before receiving care
  at a volunteer clinic
• Québec
• Refused claimant falls and breaks nose ER
  demands 735
• Covered by Québec, but forgot to renew IFH
  document
• Refused claimant on dialysis hospital
  interrupted treatment until informed that Québec
  will cover her care

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Conclusions Impact of IFHP cuts

• Direct negative impact
• (Almost) no medical services for
• Refused refugee claimants (except in Québec)
• Refugee claimants from Designated Countries of
  Origin (after coming into force of s. 109.1 IRPA)
• (Almost) no medications for
• All refugee claimants and Privately Sponsored
  Refugees
• Mitigated in part by provincial programs
• Increased difficulty accessing care to which they
  are entitled
• All refugee claimants
• Especially persons needing long-term care
  pregnant women, people with chronic conditions