Even with her teenage brother in extreme pain, his knee swollen from a bad fall and looking like a melon, Luna Garcia’s family hesitated to take him to hospital.
Instead, they waited a day to see a doctor, acting only when the suffering became excruciating for the 15-year-old — all because the undocumented Toronto family feared hospital staff would ask for their immigration status and demand fees upfront that the family couldn’t afford.
But thanks to the Ontario government’s temporary measure to extend health care to uninsured residents during the pandemic, there was none of that. Garcia’s brother got the medical attention he needed and avoided lasting damage to his knee.
Health-care providers say that during the pandemic they saw first-hand the improvement in the care of the uninsured. They now hope the “milestone changes” will stay.
“As a front-line provider, I have seen many patients access urgent health-care services, life-saving treatments at times, that they would otherwise either have been denied or felt afraid seeking,” said Dr. Ritika Goel, a Toronto family physician.
“We have seen the benefits of these changes and we want for them to be made permanent.”
However, as many pandemic-driven health policies have been either relaxed or scrapped, advocates in Ontario fear that the province’s interim health coverage for the uninsured will be next on the chopping block.
Prior to the start of the pandemic in Canada in March 2020, advocates say about half a million children and adults in Ontario were without public health insurance at any given time. They included new immigrants, returning Canadian citizens caught up in the three-month waiting period, temporary foreign workers between contracts, international students and non-status residents.
To reduce barriers to access health care during the pandemic, the province has not only relaxed eligibility to include the uninsured, but also removed the three-month waiting period for OHIP coverage.
Goel is part of a coalition of front-line health professionals and community groups that has launched a petition to urge the province to make the existing directives a permanent program to ensure universal access to health care services for all Ontario residents. They have planned a rally at Queen’s Park next Wednesday.
“Many things during COVID have been unpredictable. What we know is that the pandemic has unearthed so many inequities, including that between people who have health insurance and those who do not. We worry that many of the social benefits that have come through in this time are being rolled back,” said Goel.
“But it’s in the interest of the government and the people of Ontario, health-care providers and the health-care system to ensure access for all people living in Ontario.” (Campaign organizers say Quebec and British Columbia also made health care more available to the uninsured during the pandemic, to lesser extents.)
She said the interim directives have been hugely beneficial for health-care providers because they are dealing with fewer of the preventable complications which result from delays in care.
A recent study in Canadian Journal of Emergency Medicine interviewed health-care providers and recommended the most effective way to improve the care of uninsured patients would be to make permanent the temporary extension of medical coverage to uninsured patients enacted during the pandemic.
“In this post-COVID world, we now have an opportunity to learn from our experiences and build a more equitable (emergency department) system together,” said the study by a team of University of Toronto medical school researchers.
The report cited stigma and bias, lack of privacy over immigration status, unclear care pathways, and access to post-emergency department care among the key challenges facing uninsured patients in accessing care.
Those were exactly some of the reasons for the delay in sending Garcia’s brother to St. Michael’s Hospital after his injuries in a June 2021 soccer game. Instead, initially, the family just put ice and applied compression to his joint, fed him painkillers and hoped the swelling would go down.
“If we had immigration status then, we probably would have gone straight to the emergency,” said Garcia, originally from Spain, whose family had been without status since 2015 after her father’s work permit renewal was refused. They were only granted permanent residence earlier this year on humanitarian grounds.
“That’s the good thing about this special program. And hopefully it will not stop and be permanent, because things happen and people get hurt and need access to health care regardless of their status.”
Dr. Irfan Dhalla, a vice-president of Unity Health Toronto, said that in the course of the pandemic, his network’s hospitals — St. Michael’s, Providence Healthcare and St. Joseph’s Health Centre — have seen patients coming to them earlier, instead of showing up in a health crisis.
“It’s very clear that the policy has been of enormous benefit to people who are living in Ontario and who in many cases have been really keeping things going during COVID,” said the general internal medicine specialist, who oversees the hospitals’ care experience and equity.
“We quite rightly turned some of our attention towards essential workers during the pandemic and ultimately health care as a human right.”
Dhalla said the care for the uninsured throughout the pandemic has been about one per cent of the total hospital spending and “across virtually every health condition, there is evidence that prevention improves health and let people live longer and better lives.” (The provincial Ministry of Health didn’t provide the Star with information about the amount it has spent reimbursing physicians and hospitals for services provided to uninsured Ontarians during the pandemic.)
Toronto pediatrician Dr. Shazeen Suleman said that before the pandemic, she would see uninsured children coming into her office only when they were “acutely unwell”; sometimes she would have to refer them to emergency.
She said that conditions such as asthma and even chronic illnesses like diabetes benefit from community physicians monitoring patients’ conditions so they don’t have to show up in hospital only when they are in crisis.
“We’re still in COVID and to turn back the clock at this point is going to have disastrous outcomes. We hear every day about how our system is at its breaking point and to then add another extra burden of having individuals come in at death’s door will be disastrous,” said Suleman.
The interim policy has also simplified the administrative work for health-care providers and alleviated their stress and burnout, Suleman noted, saying that in the past “I might have been one who was trying to rack my brains (about) how to get care for someone who didn’t have insurance. Now it’s opened up.”
Although the uninsured already had access to government-funded midwifery even before the pandemic, midwife Shezeen Suleman (no relation) said the special measures to extend coverage have made it “fluid and seamless” to provide best care for patients.
Before this directive was put into place, a big chunk of her time spent with uninsured clients was figuring out how they were going to actually pay for delivery at a hospital.
“If somebody is entering into my office and they end up being hypertensive and they’re uninsured, that assessment needs to take place at the hospital,” she said.
“If they couldn’t pay the additional $300 or $500 fees for triage and would forego that assessment, that can really spin out and lead to really poor outcomes for people and in its worst case, death.”
The Toronto midwife, who also does abortion work and care for women who suffer miscarriages, said that during the pandemic she has been able to make clinical decisions, alongside clients, based on the clinical facts of a patient’s case and not financial considerations.
“In my past, I would have to bring that into conversations with people, like (saying), ‘You need to know that when I’m sending you to the hospital to have your diabetes checked, you’re going to have to pay $300,’” said Suleman.
“Invariably, there will be people that say, ‘No, I can’t do that.’”
In a response to the Star’s inquiry, the Ontario Ministry of Health said there are no changes to the eligibility the uninsured at this time and officials will communicate in advance if changes are planned.
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