It is in the best interest of us all to have healthier “Canadian babies.” I use this term deliberately because it is at the crux of the debate around medical coverage for the uninsured.
In March 2020, the Ontario government expanded funding to allow everyone access to essential hospital care. Implemented during a health-care crisis, these measures were rolled out quickly and seamlessly. By any estimate, the program was not costly and decreased the burden on the health-care system overall. That it was needed at all was recognition of a growing population that does not have access to care. Despite this, three years later, on March 31, 2023, the funding was discontinued.
By conservative estimates, there are upwards of 500,000 people living in Ontario who are uninsured or underinsured. Reasons for this vary but include a growing number of people living at the intersections of homelessness, precarious housing, poverty, mental-health issues and addictions. Some may have documents withheld by an abusive partner or employer. An increasing number live and work here without ongoing immigration status, some because of an increasingly complex immigration system, others because of backlogs and longer processing times. Many are between applications with ever-longer waiting periods – as one permit expires, they fall “out of status” as they wait for another to be processed. In addition, an increasing number of people leaving desperate situations cross into the country illegally.
While these problems are concentrated in large urban centres like Toronto, Montreal and Vancouver, as city housing prices soar and marginalized populations are pushed out, these issues are affecting neighbouring jurisdictions and smaller cities as well.
What happens when people “fall out of status,” or are desperate enough to cross our borders without status? They wait. They pray. They consult lawyers, friends and even frauds, all while trying to build a life here. What they don’t do is go back after choosing to come here in the first place.
As often happens, it is women and children who are caught in the political crossfire. There is a growing body of research that shows people who are uninsured or underinsured access prenatal care less often and later in pregnancy. Adequate prenatal care is recognized across medicine to be associated with vastly improved health outcomes. Inadequate prenatal care is associated with higher rates of preterm birth (four times higher) and low birth-weight babies (seven times higher). The care of babies born too early and too small is among the highest of all health-care expenditures – Canada spent $8 billion in this area in 2018, undoubtedly an even higher number now. Babies born too small and too early need highly specialized medical services and often have lifelong consequences with brain and body development.
And then there is the myth that droves of people are coming here “just to have a baby.” But this is not the reality of most uninsured people. People are coming here simply to have a life and for many, having children is part of that. Do a sliver of people with wealth travel here “just to give birth?” Sure. The stark truth is that the global elite always have and always will travel for medical care. What the wealthy do not do is feign poverty – and they can afford to pay the uninsured rates.
In fact, a dirty secret known in health care is that specialists and hospitals across the country pursue the global elite to come here for surgeries and, yes, even to give birth. This is an extra revenue stream, and one hospitals do not want to lose.
Is this fair in a publicly funded system where surgical wait times are high? I cannot say. What I can say is that anger about this should not be placed on the refugee escaping persecution and violence.
Should people who come here just to deliver or those living here illegally be “allowed” to have a Canadian child? These are for public debate and ballot boxes. They cannot and should not be dealt with at the point of urgent medical care. We are health-care givers, not immigration officers.
Through the stories of four women presenting to my clinic in just one month since these cuts were implemented, I hope to show what it looks like to be pregnant and uninsured in Ontario. These health cuts are costly – not just in terms of the burden on our health-care system and already burnt-out providers, but on our sense of humanity and our fundamental Canadian values.
A suspected victim of human trafficking, she came under false pretenses from a “Canadian company” with the offer of employment, a work visa and an offer of permanent residency eventually. Young and naïve, she spent her savings and trusted others to fill out paperwork as well as to hold her documents for “safekeeping” on arrival. Her living and working conditions were nightmarish – monitored with cameras around the clock, unable to go anywhere alone “for her safety.” The circumstances of her pregnancy are unclear. I do not know what work she was brought here to do, but her “employers” paid her nothing. Eventually, she fled. Agencies involved are ensuring safe shelter and appropriate follow up, but I am tasked with the job of finding her care for her pregnancy.
With hospital rates reimplemented since the policy change, she will have to pay a minimum of $3,000-$5,000 for every night’s stay, plus the time for labour. If I can find her a midwife, she could give birth out of hospital and hope things remain low risk. However, this prospect terrifies her. Midwives are ethically bound to offer choice of birthplace; this includes home and birth centres as well as access to hospitals if that is where someone feels or is safest. Essentially, she is forced to give birth at home because she lives in poverty.
She is forced to give birth at home because she lives in poverty.
And while midwives can care for some of the population, most people cannot access a midwife. For the month this person is due, every midwife in the city is booked. Her only options are to go to the hospital when in labour or another emergency, or to give birth at home unattended – the least safe of all deliveries. These are untenable decisions, un-Canadian decisions, and ultimately costly decisions.
She is one of 11 people I have seen since the changes were announced whose only safe option is to deliver by caesarean section.
Leaving poverty and violence, she came to Canada years ago and applied for refugee status. However, like 60 per cent of applicants, the claim was denied. Also, like the vast majority of people in this situation, this family chose to stay. For the past several years, they have lived and worked here, raised their children here, all while continuing to look for avenues that would allow them to stay legally. Both parents are essential workers, again like the majority of undocumented migrants.
As a result of the policy change, she is being charged the non-resident rate of almost $5,500 per day. In addition, physician groups involved in labour and delivery have determined set rates before someone can even access a caregiver. In this case, add to the hospital bill another $6,000.
Though hospitals and doctors will not turn someone away in an emergency, during pregnancy people want access to care BEFORE an emergency. This is true across health care – it is always cheaper to treat high blood pressure than a heart attack or stroke.
For this patient, paying the required two-day hospital fee and physician fee, she will need to pay $17,000 to even have her surgery booked. This is simply not an option. Wanting this person to pay, believing she should pay, not wanting her to be in the country … These are all moot points. She is here and she cannot pay. For her, the only available option is to go into labour and present to hospital needing an emergency caesarean section. This poses the most risk to everyone involved and the most expense to our system.
With global caesarean section rates skyrocketing, more people need repeat caesarean sections to deliver safely. With current policies, many who should not go into labour will have to in order to receive life-saving surgery. Inevitably, some will arrive too late. And what about the hospitals or providers who denied care in the first place? What happens when that same patient shows up with a catastrophic outcome? This is not just a medical or legal risk, it is a risk to the mental health and well-being of health-care givers who are already exhausted. One month ago, this person and the other 10 in her situation could have booked her surgery in advance (the safest option) and everyone involved would have been compensated, including the hospital.
This patient came to me early in pregnancy when expanded COVID funding was still in place. Test results showed she was at high risk for preterm labour. I seamlessly and easily sent her to a high-risk clinic, where she had an intervention and was sent home on bedrest. With good care and some luck, she avoided preterm delivery and had a healthy baby. Had she come into care now, she may not have accessed hospital services as early; advanced payment requirements could have prevented her from accessing care at all.
While this was a “good news” story in terms of pregnancy outcome, the hospital where she delivered did not issue the baby a health card even though he is legally eligible. This is due to hospital policies and not based on actual provincial criteria. Hospitals should not be in the role of policing immigration.
The result is a baby without access to health care. While the child is eligible for a health card, the parents first need to go to Service Ontario to apply, adding additional barriers. Thus, for immediate post-birth care, a critical period, the baby will have no coverage and the parents will have to pay. This results in a lack of care in the critical early years, including important vaccinations.
A recent report from the Health Network for Uninsured Clients on the benefits of the expanded health coverage demonstrated not only the need, but the decrease in moral distress providers felt when able to provide care without worrying about payment. In a system on the edge, it is not fair to put already exhausted health-care givers in positions where they have to make impossible decisions between ethics, obligation and being paid.
This patient had an autoimmune condition diagnosed in her teens. Chemotherapy-level medication saved her life and put her in remission. Now, more than a decade later, she is married to a Canadian and waiting for her papers to be processed. She did not think she could conceive and became pregnant by surprise.
She is overjoyed and terrified. She knows her pregnancy will be high risk and her autoimmune condition could flare up, even becoming life threatening. A year ago, she could have kept the pregnancy and seen a high-risk specialist when needed. Now, I explain that every monthly or weekly visit will cost several hundred dollars. This is on top of the costs and criteria for labour and delivery mentioned above. If her condition flares and she needs to be hospitalized, her costs will be multitudes higher.
She wails with grief in my office with the realization that she may have to terminate the only pregnancy she may ever have because of the cost. Either that or go “back home” and have her child without her Canadian husband and then having to restart the entire immigration process. Is this what it should look like to be married to a Canadian and wanting to start a family?
Whether we like it or not, this problem is not going away. Canadians, especially those in large urban centres, can no longer deny that a significant portion of our essential labour force is made up of undocumented migrants. If Canadians are unaware of this, they are simply not paying attention.
Internationally, and with pride, our national identity is tied to universal health care. It is time to realize our system is no longer serving all who live here. Poverty, addiction, racial disparity and precarious housing – these problems aren’t going to disappear in the short term.
It is time for us to realize that “universal health care” is a myth for many. We decided long ago that if you live here, whether rich or poor, you deserve the dignity of access to universal health care. If this is still true, we need to fix this problem.
If it is not, what does it say about our identity as a nation and on the global stage?