Surjit Sodhi* is 24 years old, lives in Mississauga, Ont., and has a $250,000 hospital bill. He came to Canada from India in 2012 to study computer engineering, and five years later, he landed a job with a security company in Toronto. In June of last year, he started bleeding consistently from his gums. Then a debilitating fatigue set in. “I thought it may be general weakness,” he says. Sodhi had some health coverage through his employer and was able to see a dentist, who prescribed antibiotics; one morning, he took his medicine and fell asleep. He woke up five days later in the hospital, where a doctor gave him some bad news: He had been diagnosed with aplastic anemia, a bone-marrow disease that makes people extremely susceptible to bleeding and infection. Then a social worker gave him some more bad news: He had no health insurance. The coverage he had through work did not apply to critical illness or hospital admissions.
Sodhi is among up to an estimated half-million people living in Ontario who do not have access to OHIP, the government’s health insurance plan for the province’s residents. In theory, people who are uninsured are expected to pay for health care themselves, and they can be charged more than the standard OHIP fee for a given service. In practice, some services are funded for uninsured people—immunization and some prenatal care, for example—but these are in scarce supply and fall far short of comprising comprehensive care. “It’s a patchwork response,” says Rebecca Cheff, researcher at Wellesley Institute and co-chair of the Health Network on Uninsured Clients. “The care someone is able to receive will vary greatly, based on where they enter the system. And it will vary regardless of what their needs are.”
How does this patchwork system play out in the lives of people who need health care? And who winds up paying for the shortfall?
Why are people uninsured in Ontario?
For most uninsured people, lack of access is tied to immigration status. The advocacy group OHIP for All broke down the numbers for 2015: Among those without insurance were nearly 89,000 newly landed permanent residents (who go without OHIP for three months); some 85,000 temporary workers (who similarly go at least three months without OHIP, and longer depending on their work situation); and almost 54,000 international students (both post-secondary and younger), who have no access to OHIP at all. There were also an estimated 250,000 people living in Ontario who did not have official immigration status in Canada, and thus also had zero access to OHIP. (Refugee claimants, for the most part, have health insurance from the time they arrive through the Interim Federal Health Program.)
Those without status—for example, people who come in as visitors and stay without applying to become residents—have never been insured for health coverage. But in 1994, many more people joined the uninsured ranks when the provincial government removed access to OHIP from temporary residents (including international students) and introduced a three-month wait period for newly arrived permanent residents, temporary foreign workers, and Canadians who had been out of the country for more than 212 days.
The rationale for these changes was to ensure that those receiving health care in Ontario were actually living there, as opposed to “medical tourists” taking advantage of the system. At the time, it was estimated that the changes would save the province $48 million annually, though OHIP for All argues that the Ministry of Health has “not demonstrated the effectiveness” of these policies at “deterring medical tourism” or at producing cost savings to the system.
“The idea [behind these changes was] establishing residency for immigrants,” says Ritika Goel, a Toronto family physician and a co-founder of OHIP for All. “Anybody who has immigrated to this country, as I have, knows that it is actually a pretty extensive process to be able to get landed immigrant status. So the idea that you would need three months to establish residency doesn’t make a lot of sense.”
Goel also notes that over the past 15 years, there has been a huge spike in the numbers of people coming into Canada as temporary foreign workers (between 2002 and 2012, the number went from 101,098 to 338,221). TFWs are also subject to the three-month wait for access to OHIP, and may never receive or may lose access if they only work part-time or have a gap between contracts.
Immigration status is not a factor for all those without access to OHIP. People with precarious housing or who have addictions or mental health issues may also have difficulty obtaining or maintaining a health card due to an inability to prove residency in Ontario or to present a health card to providers. And, although babies born in Ontario to parents who lack access are, for the most part, automatically eligible for an OHIP number, a new report from the Wellesley Institute has found that they do not always receive one at the hospital, as newborns typically do in the province.
What services exist for people who don’t have health insurance?
The province has made some allowances for uninsured patients. Community Health Centres, for example, have a mandate to serve people who don’t have access to OHIP. “It’s a tacit acknowledgment that those persons are here with us,” says Paulos Gebreyesus, executive director of Regent Park Community Health Centre in Toronto. “The Ministry provides for this as a little bit of a safety net, but it’s not advertised, it’s not promoted.” CHCs receive “historical” allotments (they haven’t changed in at least a decade, says Gebreyesus) based on the percentage of their clientele who are uninsured, and the monies are designated for specific services: diagnostic testing, for example, and referrals to specialists. Access Alliance, a CHC in Toronto’s northwest corridor, uses some of its uninsured allotment to run a walk-in clinic specifically for uninsured patients. However, the funding cannot be used to cover hospital “stay” fees, which run into the thousands per day (and for which people who have OHIP are not charged). CHCs provide primary care to people who don’t have insurance, but this is wrapped into providers’ salaries and is only available to a limited number of patients, based on capacity.
The province also provides some funding for prenatal care through midwife services, which Ontario midwives negotiated in their 2014 collective bargaining agreement. These services include some diagnostic testing and referrals to obstetricians for consultation, but are limited to women with uncomplicated pregnancies and do not cover any time spent in hospital.
Some health services are municipally funded. In Toronto, where the majority of uninsured patients live, public health departments provide immunization, testing for sexually transmitted infections and counselling, dental care, and some pre- and post-natal counselling. But these services are also limited. People who are HIV-positive can receive case management specific to HIV, for example, but not primary care or medications.
There are also providers who serve uninsured patients on a completely volunteer basis, such as the Canadian Centre for Refugee and Immigrant Health Care, which is based in Scarborough, Toronto’s northeast corridor, and which runs a number of clinics—pediatric, dental, chiropractic, women’s health, and primary care—free of charge for people who have no health insurance.
Who pays for the shortfall?
Some of the costs that result from the system’s patchwork response to uninsured patients are “hidden.” For example, says Sophie Bart, clinical director at Regent Park CHC, she and others at the organization spend a lot of time on the phone with finance departments and specialists’ offices at hospitals, asking them to lower or even suspend fees to clients who can’t afford to pay. “There’s some goodwill, and some of the hospitals will reduce the rate they charge, but sometimes we’re paying the absolute maximum,” says Bart. She points out that these negotiations not only eat up staff time, but can also hold up care. “I have a situation right now where the client needs ongoing care and the specialist will no longer see them until they are able to clear their balance. So that’s also a negotiation with the client to try to figure out what they might be able to cover.”
Other administrative costs that fall to CHCs include the work typically done by OHIP: paying patients’ bills. Gebreyesus says there is “no added consideration” for this extra aspect of patient care. Bart notes that some health care providers won’t accept uninsured patients, even when CHCs affirm that they will cover their bills, and this also adds to CHC clinicians’ workload, as they spend a great deal of energy trying to figure out where they can refer patients. Plus, all through the year, CHC staff try to calculate how much they can afford to spend on a given patient’s needs, based on their limited pot of funds. A CHC where Gebreyesus previously worked used three-quarters of its annual uninsured budget on one client for a round of (happily, successful) chemotherapy. “The CHCs generally try and pool our non-insured resources,” says Gebreyesus. “Last year, a sister CHC had a surplus and we were running a deficit, and we were able to, thankfully, get some support.”
A more troubling apparent result of the “patchwork” response is that some uninsured patients wait to seek care until they are too sick not to, whether because they’re afraid of the bills, or of deportation, or both. A 2016 analysis comparing Ontario emergency department visits by insured and uninsured patients over a nine-year span found that uninsured patients were 43 percent more likely than insured patients to be triaged as severe. They were also more likely to leave the ED without treatment (insured, 3.1 percent vs. uninsured, 5.4 percent) and to have died on arrival or in the ED (insured, 2.8 percent vs. uninsured, 3.7 percent). Children under age 16 comprised more than a third of uninsured patients presenting in the ED, and both children and young adults without insurance were more likely to present with ambulatory care sensitive conditions, suggesting that they may not have been receiving primary care, as ACSCs (asthma, for example, or pneumonia) can typically be treated on an outpatient basis.
When people go untreated or under-treated, everyone loses. For Surjit Sodhi, a bone marrow transplant is the best course of treatment—it could potentially cure him. But he is not eligible for this procedure without OHIP, and receives blood transfusions to try to alleviate his symptoms. He frequently winds up in hospital with infection; that’s how he racked up his massive hospital bill. “They’ve already spent too much money on me,” says Sodhi. “I’m receiving calls from collection agencies. I cannot go to work; I cannot see my future. I’m just 24 years old, and everything is dark in front of me.”
The push for change
A number of groups have advocated for improved care for uninsured people, and to some effect. When the Harper government clawed back benefits available to refugees through the Interim Federal Health Program in 2012, the health sector mobilized in protest, and the Ontario government created a temporary relief program; eventually, the cuts to IFHP were overturned by the federal courts. In 2013, Toronto elected to become a sanctuary city, which allows non-status residents to use any municipal service—including the police—without fear of being reported. While this may not seem to relate directly to health, the freedom to come forward as the victim of a crime, for example, might prove a significantly protective factor. As Gebreyesus points out, lack of health insurance is one of myriad barriers a person without status might face. And at the same time, he says, “having non-insured status is in itself almost a medical condition. The multiplicity of vulnerability because of the legal limitations of [non-insured people’s] rights definitely increases their risk of a shorter life and an increased burden of disease.”
Other groups like the Right to Healthcare Coalition and the Health Network on Uninsured Clients have lobbied for an end to the three-month wait for new immigrants. CHCs like Regent Park want to see the Ministry mandate a more streamlined system in which hospitals help to fund the care of uninsured patients. The group OHIP For All sees access to health care as a human right, and wants everyone who is living in Ontario with an intention to stay to be provided with insurance. “At the end of the day if you need health care and you don’t have OHIP, it doesn’t matter what the reason is that you became uninsured,” says Goel. “It doesn’t matter that you’re a new immigrant in the three-month wait, or you’re undocumented, or you’re a temporary foreign worker. The solution here is access to OHIP.”
In the fall, shortly after being diagnosed with aplastic anemia, Surjit Sodhi applied for permanent residency on compassionate and humanitarian grounds. His parents, both in their 60s, have come to Canada from India to be with him, as has his sister, who is hoping to be his bone marrow donor. They are living on donations from relatives and some money from Sodhi’s father’s business, which is temporarily shuttered. Immigration recently requested his medical records from the hospital. “My doctor has written a letter that says I have no other options than staying and getting treatment here.” And so he waits.
*Name has been changed to protect privacy