“Why are you collecting payment from me? The social worker told me not to worry because the government is covering,” said the tourist after initially agreeing to pay his medical bill before admission. As a former hospital administrator responsible for patient billing, there was nothing I could do but trash the $45,000 hospital invoice, ultimately at the expense of Ontario taxpayers.
Historically, the Canada Health Act (CHA) and Ontario’s Health Insurance Act have restrictive criteria for “medically insured” persons, ensuring that only people legally entitled to reside in Ontario could enjoy the Ontario Health Insurance Plan (OHIP). This criterion leaves half a million people with precarious legal status, including undocumented migrants, temporary workers, visa overstayers and tourists, excluded from OHIP.
But this criterion changed after COVID-19 hit Ontario.
Ten days after COVID-19 was declared a pandemic crisis by the World Health Organization (WHO), the Ontario government subtly released a policy to expand OHIP coverage for all uninsured patients in response to an open letter from more than 650 medical students and professionals, encouraging uninsured patients to seek care when presented with COVID-19 symptoms.
However, while this immediately reduces the administration costs of screening the patient’s ability to pay, the directive lacks clear definitions of “uninsured patients” and “medically necessary” services. The ambiguity has left Ontario hospitals with differing interpretations of “eligible medical expenses” and the illusion of free health care for all, even beyond the care for COVID-19. Examples include treating swollen knees from a bad fall and surgical care for Stage 1 thyroid cancer. Meanwhile, these medical expenses come out of Ontario taxpayers’ pockets.
“No eligibility criteria. No ID or proof of residency is required,” says an emergency department (ED) registration clerk at a Markham-based Hospital. “Suppose you declare yourself as an Ontario resident. In that case, you can walk in and out of a hospital facility at no cost.”
Meanwhile, at a Toronto-based ED, an uninsured patient registration form was openly placed at the registration desk for anyone without OHIP. Once completed, patients will not need to pay for their medical expenses.
The new “OHIP for All” policy has led to potential abuse of our already strained health system.
In my experience, ED clerks seldom perceive their roles as “gatekeepers” to ask about uninsured patients’ financial status (i.e., self-pay, by work or travel insurance), partially due to the lack of training to consider the health system from a funding perspective. Primarily, they are trained to take OHIP cards from Ontario residents and have no idea how to deal with uninsured patients. The lack of clear roles and responsibilities in the new “OHIP for All” policy has therefore led to potential abuse of our already strained health system.
We have seen fraud and medical tourism before. In 2009, Radio-Canada featured a non-resident Lebanese woman who faked her stay in Canada while exploiting the Canadian citizenship application process to access Quebec’s public services, including medical care. So, the investigation went, Quebec taxpayers continued to subsidize wealthy medical tourists.
The “OHIP for All” decision also unintentionally benefits travellers who were ready to pay for their care before entering Canada. An example is an international student who was diagnosed with thalassemia (genetically born disease) and is ready to pay for monthly blood transfusions. Under the new policy, not only could this non-resident enjoy free health care, but also enjoy equal priority to Ontario taxpayers for limited blood supplies, day transfusion rooms and health-care staffing services.
Is this fair to Ontarians?
Looking at Ontario’s past ED services usage, the volume of uninsured medical patients doubled between 2002-2011. They comprise 6 per cent of total ED patients and are more likely to be categorized as having the highest medical severity.
Thanks to Premier Doug Ford’s drastic cut to Ontario’s health-care spending, Ontario ranks last in provincial health-care spending per person among Canadian provinces. In fact, before COVID-19, Ontario had already reached its capacity to meet public demands. The situation worsened after COVID-19 with more than 80 ED closures and 2.5 million diagnostics, and more than 400,000 surgery backlogs. Notably, some Ontario hospital executives, clinicians and health-policy experts commented that these disastrous outcomes might stem from systemic inefficiencies, limited infrastructure capacity and staffing shortages.
In 1994, Ruth Grier (former Minister of Health) successfully revoked OHIP coverage for temporary residents, including foreign workers, their families, and international students. By redefining “residents” under the Health Insurance Act, 1990, it saved Ontario taxpayers $48 million annually. In fact, one pre-COVID study showed that 82.8 per cent of Canadian medical professionals viewed health care as a privilege for law-abiding taxpayers and considered those with precarious legal status as “undeserving” of free health care.
In 2022, as the World Health Organization forecasts an end to the pandemic after almost three years, there is no reason visitors cannot return home for care. Is the government going to demote our health system back to the 1990s, further depriving Ontario taxpayers of proper care?
As Grier emphasized, “Nobody in Ontario will be denied urgent care by an Ontario hospital or community health clinic due to their OHIP status.” But considering the already strained health-care system post-pandemic, more sustainable solutions to address uninsured patients are needed rather than continuing “OHIP for All.”
Firstly, clear policies are required to clarify emergency services with less reliance on subjective clinical judgment, promoting care standardization across Ontario. Secondly, a uniform fee schedule and billing process for different residency statuses (e.g., uninsured residents vs non-resident-visitors) should be developed given the different billing schedules for non-OHIP patients across Ontario hospitals (see Halton Healthcare, Queensway Carleton Hospital and Scarborough Health Network). Thirdly, just like in pre-COVID times, hospitals should resume asking for pre-authorized payment before admission and discharge, which would necessitate adequate staff training to clarify roles and responsibilities.
Otherwise, we are placing the medical expenses of non-residents on the shoulders of Ontario taxpayers.