One of the most vulnerable populations in Canada are refugees. Refugees are people in need of protection based on a well-founded fear of being persecuted (UN). Under the framework of the Immigration and Refugee Protection Act in 2002, refugees invited by the Government of Canada or some private groups typically arrive sicker due to the priority placed on resettling vulnerable refugees who need urgent protection (Arya et al., 2012).
Refugees have high chronic disease rates, often divergent from the general population because of differing disease exposures, vulnerabilities, social determinants of health, and access to healthcare services in their country of origin, during, or after immigration (Swinkels, 2011). There is evidence that refugees are twice as likely to encounter difficulty in accessing care and had a notably lower self-reported health status compared to other immigrants entering Canada (Government of Canada, 2019, October 15)(Newbold, 2009).
For more than 50 years, the Federal Government has funded comprehensive health insurance coverage for refugee claimants through the Interim Federal Health Program (IFHP), which included medications, vaccines, periodic health assessments, psychological services and dental care (Government of Canada, 2019, August 19). Using the Ecological Model for Health Promotion framework, public policy plays a notable role in this multi-level framework. As per McLeroy (1988), the use of successful healthcare policies has a dramatic effect on the health of a population.
In 2012, the Government introduced changes that significantly reduced the level of health care coverage available to many such individuals, and all but eliminated it for others unless they posed a public health and safety risk, for instance, had Chicken Pox or HIV. An increase in refugees coming to Canada, leading to an increase in healthcare costs with the annual cost to the IFHP program ($84.6 million) was cited as the rationale for the significant change to this policy (Citizenship and Immigration Canada, 2012). The cuts were projected to save $100 million over 5 years. (Bakewell et al., 2018).
Although these benefits were re-instated fully in 2016, the negative impact of on the chronic health of refugees had already taken place. In the public inquiry in to the IFHP, the Ontario Health Minister accused the Government of Canada of abdicating its responsibility towards some of the most vulnerable in society (Canadian Doctors for Refugee Care v. Canada, 2014). The Interim Federal Health Program was neither a popular or a successful health policy change as it downloaded the costs to provinces, was determined to be unconstitutional, and negatively impacted the chronic health conditions of refugees.
The reduction in coverage caused significant backlash amongst healthcare groups and refugee advocates, arguing that this would result in reduced access to care for an already marginalized population (Eggertson, 2013). Following both a public inquiry in whether the IFHP was constitutional, they found that the changes were “cruel and unusual punishment” and determined the changes to be unconstitutional (Canadian Doctors for Refugee Care v. Canada, 2014), which caused a partial re-instatement in 2014.
One of the notable changes was to create a “country of origin” list where refugee claimants were unlikely to face persecution, such as Mexico, Poland or Hungary. The intention of this list was to counter potential abuses of the refugee system since they are generally considered safe and respect human rights (Government of Canada, 2019, May 17). Hungary contains a large Roma population that has faced historical persecution (Canadian Public Health Association, n.d). When there was a reduction in the coverage with the IFHP, this caused a lot of confusion and panic not only in the Roma community, but amongst other refugee groups and healthcare providers (Barnes, 2013) (CPHA, n.d). This led to system barriers and confusion for both the refugee and healthcare provider. A loss of benefits to those who actually qualified under the changed IFHP was found due to misunderstanding of the new requirements (Barnes, 2013).
The changes in the IFHP caused refugees to avoid seeking medical care, especially primary care, until they required emergency treatment (Canadian Doctors for Refugee Care v. Canada, 2014). Refugee claimants arrived in emergency rooms with exacerbated conditions, such as diabetes and mental health conditions, that could have been more cost-effectively treated at earlier stages (Piccininni & Kwan, 2020). Along with reducing their primary health care services (e.g. family doctors, nurse practitioners, midwives), many also lost access to medications that helped control chronic conditions, such as inhalers to control asthma (Stanbrook, 2014).
Child refugees were also impacted by the reduction in the IFHP. The Emergency Department visits at Toronto’s Hospital for Sick Children demonstrated that the proportions of refugees presenting to the ER after the cuts significantly decreased, yet there was a doubling of the admission rate of refugee children from 6.4% to 12.0% (Evans, 2014). The top reason for admission was the chronic disease of sickle cell anemia. According to Dr. Rummens, an expert witness at the IFHP inquiry this suggests that there may have been a delay in seeking help for some of the children – a phenomenon that has been identified in research regarding uninsured adult populations (Canadian Doctors for Refugee Care v. Canada, 2014).
The reduction of primary care physicians was also a barrier to follow up after Emergency Department visits. A higher proportion of patients were advised to follow up with their family physician (67.2% compared to 41.8%) before the IFHP changes, but fewer patients had a primary care physician. Before the cuts to the IFHP, 30% of refugees had primary care physicians whereas after changes only before cuts compared to 20.4% afterwards (Bakewell, 2018). This led to a gap in care where patients either had to have follow in the Emergency Department, or they never came back and were potentially missing the follow up required for their condition.
This shift in the level of healthcare access from primary care to emergency care led to an overall increase in healthcare costs due to the cost of treating chronic conditions. This exacerbated future refugee healthcare needs and only download federal costs on to the provincial healthcare system (Evans et al., 2014). This cost shift was demonstrated at the Hospital for Children where 93% of ER bills submitted to their insurance company went unpaid, whereas pre-IFHP changes had only 54% of bills going unpaid (Evans, 2014) and University Health Network reporting nearly $800,000 in uncollected refugee costs (Piccininni, 2020). Ontario had to step in to create their own Ontario Temporary Health Program (OTHP) to bridge the gap and fund health care services. As of January 1, 2014, all refugee claimants and failed refugee claimants had funded access to basic medical care, including coverage for medications, subject to an income test. It’s questionable if there was realized actual savings for Canadian taxpayers since the cost of care was downloaded to the hospitals and the provinces and the Federal government never had a follow-up study.
In 2013, thirty percent of refugees who were impacted by the changes in the IFHP have become permanent residents (Immigration and Refugee Board of Canada, 2013). This group is now covered by the healthcare that they were previously denied and now Canadians must cover the costs of chronic disease that potentially could have been prevented with more timely care. Of note, there was an acceptance rate of twenty percent in the “country of origin” list that had no coverage at all (Immigration and Refugee Board of Canada, 2014), demonstrating that this was a false assertion by the Government that these countries were safe from persecution and this policy change was not thought through or based on actual data.
The significant change to the IFHP coverage in 2012 was a policy failure that was not proven to save Canadian taxpayers money, and ultimately negatively impacted the chronic conditions of refugees. It is now four years after the re-instatement of the IFHP, but the current policy does not support all of the chronic health issues that refugees face and barriers to care still exist. Good health policies matter to the chronic health of vulnerable refugees and should continue to evolve by improving access to health. This should be done through multi-disciplinary teams and modernizing the IFHP to also include improved coverage for priority chronic diseases, such as mental health and pre-natal care, in consultation with who know their care the most – their primary care physicians, not politicians.
References
Arya, N., McMurray, J., & Rashid, M. (2012). Enter at your own risk: government changes to comprehensive care for newly arrived Canadian refugees. Canadian Medical Association Journal, 184(17). https://www.cmaj.ca/content/184/17/1875
Bakewell, F., Addleman, S., Dickinson, G., & Thiruganasambandamoorthy, V. (2018). Use of the emergency department by refugees under the Interim Federal Health Program: A health records review. PloS one, 13(5), e0197282. https://doi.org/10.1371/journal.pone.0197282
Barnes S. (2013). The real cost of cutting the Interim Federal Health Program. Wellesley Institute. www.wellesleyinstitute.com/wp-content/uploads/2013/10/Actual-Health-Impacts-of-IFHP.pdf
Canadian Public Health Association. (n.d.) Serving refugee populations – Toronto Roma Community. https://www.cpha.ca/serving-refugee-populations-toronto-roma-community
Eggertson L. Doctors promise protests along with court challenge to refugee health cuts. Canadian Medical Association Journal. 2013; 185(7) doi: 10.1503/cmaj.109-4430
Evans, A., Caudarella, A., Ratnapalan, S., & Chan, K. (2014). The cost and impact of the interim federal health program cuts on child refugees in Canada. PloS one, 9(5), e96902. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4014561/
Government of Canada (2019, October 15). Statistics and Open Data. http://www.cic.gc.ca/english/resources/statistics/menu-fact.asp. Government of Canada. (2019, August 19). Interim Federal Health Program Policy. https://www.canada.ca/en/immigration-refugees-citizenship/corporate/mandate/policies- operational-instructions-agreements/interim-federal-health-program-policy.html
Government of Canada. (2019, May 17). Designated Countries of Origin Policy. https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/claim- protection-inside-canada/apply/designated-countries-policy.html
Immigration and Refugee Board of Canada. (2018, July 3). Refugee Protection Claims (New System) by Country of Alleged Persecution – 2014. https://irb- cisr.gc.ca/en/statistics/protection/Pages/RPDStat2014.aspx
Immigration and Refugee Board of Canada. (2018, July 3). Refugee Protection Claims (New System) by Country of Alleged Persecution – 2013. https://irbcisr.gc.ca/en/statistics/protection/Pages/RPDStat2013.aspx
McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health education quarterly, 15(4), 351-377. https://www.researchgate.net/profile/Kenneth_Mcleroy/publication/20088489_An_Ecology_Pe rspective_on_Health_Promotion_Programs/links/0d1c84f972a1e3f12d000000/An-Ecology- Perspective-on-Health-Promotion-Programs.pdf
Newbold, B. (2009). The short-term health of Canada’s new immigrant arrivals: evidence from LSIC. Ethnicity & health, 14(3), 315-336. https://doi.org/10.1080/13557850802609956
Swinkels, H., Pottie, K., Tugwell, P., Rashid, M., & Narasiah, L. (2011). Development of guidelines for recently arrived immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions. Canadian Medical Association Journal, 183(12), E928-E932. https://www.cmaj.ca/content/183/12/E928.full
Stanbrook, B. (2014). Canada owes refugees adequate health coverage. Canadian Medical Association Journal, 186 (2) 91. https://doi.org/10.1503/cmaj.13186
The UN Refugee Agency (1951). Convention and protocol relating to the status of refugees. Office of the United Nations High Commissioner for Refugees. www.unhcr.org/3b66c2aa10.html