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

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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 midwive’s services regardless of migration status

12. 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

13. 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

14. 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

15. 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