Failing those in need 

“I’m OK, but I don’t know what I’m going to do,” my patient says.

As a resident physician. I hear these words often. Helping patients with uncertainty and anxiety around illness and disease is a central part of my job.

My patient, a man in his 50s from South America who came to Canada seven years ago, is an undocumented migrant – a person with “no status” – who says he is afraid to return to his home country because of persecution. He works as a day labourer to support his family. He is hospitalized because of newly diagnosed kidney disease and likely will need dialysis.

“We’re going to try to help you.” I say, waiting for the interpreter to translate my words to Spanish, though I’m not sure there is much I can do.

“Thank you, doctor.” He says in English and shakes my hand. I can barely meet his eyes.

—

Though it is unknown how many undocumented migrants live in Canada, the federal government estimates it may be as many as 500,000, with 15,932 deportations occurring in 2023. Most live in major population centres such as the Greater Toronto Area, and work in a shadow economy composed of caregiving, construction, housekeeping and other jobs that offer little or no worker protections and no access to health care.

Health care for undocumented people living in Canada is fractured. In all provinces, in most instances undocumented patients will be expected to pay to access the health-care system, including emergency services. Ontario and Quebec provide access to non-emergency services through a variety of community health centres and clinics. During the COVID-19 pandemic, Ontario provided funding for medically necessary hospital services via the Physician and Hospital Services for Uninsured Persons (PHSUP) program. The program ended in March 2023, leaving thousands without coverage – and one man with a hospital bill for $90,000. A recent report from the Health Network for Uninsured Clients found that post PHSUP, clients lost access to care, including dialysis and cancer treatment. The report found that patients are presenting later and in worse condition due to fear of costs.

This was the case for my patient. Months of worsening symptoms, tiredness, shortness of breath, and chest pain finally lead to him being evaluated at a clinic. He was diagnosed with severe kidney disease and was told to go to the emergency department because he might need dialysis.

Dialysis or renal replacement therapy is a lifesaving and sustaining treatment for people living with end-stage kidney disease. Dialysis is expensive. Provincial insurance plans are billed up to $60,000 per year, per patient for the 30, 000 Canadians receiving treatment. It is not known how many undocumented migrants receive dialysis in Canada but as for all other services, patients would be expected to pay. Data from the United States suggests that most undocumented patients rely on “emergency only dialysis,” often presenting to hospital with life-threatening symptoms. Emergency-only dialysis is associated with higher risk of death, hospitalization and a worse quality of life. It is medically inferior to the usual schedule of three times weekly dialysis and is a major ethical issue for physicians. In Canada, no such provision to cover the cost of emergency dialysis for undocumented persons exists in any jurisdiction. Patients would be expected to pay, every time, even if their life is threatened. Outpatient dialysis for undocumented persons in Canada may be accessed for around $1,000 per treatment, an unrealistic option for most.

Outpatient dialysis for undocumented persons in Canada may be $1,000 per treatment, an unrealistic option for most.

Patients may be told to go back to their country of origin or otherwise try to gain status in Canada through a refugee claim, a process that can take years, with no guarantee of success. There are concerns about the current policy making it difficult for health-care practitioners to meet appropriate and ethical standards of care. The HNUC report noted that health-care workers described increased feelings of burnout and a negative impact on their mental health. An article in the Canadian Medical Association journal from 2019, “Some doctors unsure how to handle undocumented patients,” discusses how physicians may be unaware of institutional policies as well as alternative programs that exist for non-resident patients to receive general medical care like community health centres and clinics for refugee and undocumented persons. The Canadian Medical Protective Association (CMPA), the mutual medical defence organization for Canadian physicians, has specific guidance on what to expect in terms of legal protection when treating uninsured patients or people without status/non-residents in Canada. Clearly, there is uncertainty at all levels of how to best provide care for these vulnerable patients.

The HNUC report recommends several key policy changes aimed at expanding health care for the uninsured:

• Make OHIP available to all residents to alleviate barriers for access to care.
• Reinstate, expand and make the PSHUP program permanent.
• Educate health-care providers and learners on the ways and means of providing health care to uninsured residents to better meet their needs During the recent provincial election campaign, all parties made promises to spend billions to create a more robust primary care network. Though there is an attitude and understanding among Ontarians regarding the importance of access to care, questions remain about how to best promote that access for all people living in Ontario. It is an issue that must be addressed as this problem likely will worsen in the years to come as desperate migrants flee the United States to come here.

In the end, my patient’s kidney function improved, avoiding dialysis. For now. He was discharged in stable condition with a plan for affordable or cost-free follow-up. Despite this, he is faced with the costs from this hospital stay. I worry he may be reluctant to present in the future, especially without a clear plan for his care. I think of him and the hundreds or thousands of patients like him who I haven’t met yet. Canada needs a comprehensive plan to help the most vulnerable among us, otherwise they will fall through the cracks.