What will happen to Ontario’s uninsured? Experts weigh in

It’s an incredibly challenging decision that the government felt it had to make. In Canada and specifically Ontario, the health-care system took a very serious hit during COVID. A lot of the weaknesses in the system became very, very evident. As Canadians, we’ve all grown up on this wonderful story about our great health-care system – and it has been a very excellent system. There are still great pockets of expertise and wonderful, talented frontline health-care workers. But what’s very clear is that the system is in serious trouble.

Without serious changes in how that money is spent and how services are delivered, it won’t be a good system anymore. All governments across the country are facing real challenges in terms of how they allocate their resources. That was one of the challenging decisions that the provincial government felt it had to make. It had changed the policy during COVID. At that time, it was an all-hands-on-deck situation to try to manage and contain a pandemic. Now that we’re not in the critical stage that it was, the government felt it was necessary to go back to the original policy so that residents, citizens, legal residents and legal immigrants would be the priority. That doesn’t mean that there aren’t a lot of programs and other funding that’s helping to support people who have been excluded from that category. But it’s been a challenging decision and not easily made at all.

This change is already having an impact. As midwives, we have it built into our contract to look after people that are uninsured and pregnant. That’s a fairly unique position to be in as health-care providers – I still get paid regardless of the insurance status of my patient.

Where my contract doesn’t carry me forward is with the facility-fee portion of what happens when my clients seek care in hospital. That might be for labour and birth, but it also might be to get assessed for things to prevent them from developing emergencies.

Just today, we had a patient from a Latin American country who is here undocumented with her partner living in incredibly precarious housing after being swindled by her landlord. She is calling in with signs of pyelonephritis, which is a fancy way of saying an infection in the kidneys of the birth parent. That condition will present as a 10-out-of-10 pain and difficulty peeing. The reason we care about that, aside from the fact that it’s terrible to have those sensations in your body, is because pyelonephritis can also lead to preterm labor.

This person is in their 20s and only a few weeks pregnant – way too early to be heading down that course. If she had paged me on March 28, I would have said to her, “I want you to meet me immediately at labour and delivery triage at the hospital. I’m going to do a full assessment and get you sorted out.” She would not have had to pay the facility fee, nor the obstetrician, nor the labs for the tests we’d have to run. Today, my conversation with her is, “I’m really worried about you. For me to assess you at the hospital, it’s important that you know that you will most likely be receiving a bill. The bill will be between $300 and $400 just for the facility fee.” I know that for her that $300 is not nothing.

We are going to start hearing stories that I think none of us are going to feel very proud of as Canadians.

In early March, we had a client that came to our care for what she thought was the beginning of a miscarriage. It turned out that she was having signs of an ectopic pregnancy, which is when a pregnancy forms outside the uterus. It can be a life threatening condition if it’s not immediately caught and dealt with.

She paged us in the night describing 10-out-of-10 pain. She needed to get herself to a hospital right away but she was really reluctant to go. Her midwife was able to tell her ‘When you get there, you will not have to pay anything, I promise you. There’s a Medical Directive in place where the Ministry of Health is covering the health care for uninsured people right now.’

She had a ruptured ectopic pregnancy, which means that the pregnancy was in the fallopian tube. It burst and she needed emergency life saving surgery. If we weren’t able to tell her that day that she would not have to worry about that financial burden, she might not have gone. This is where my mind goes when I think about this program being pulled.

We are going to start hearing stories that I think none of us are going to feel very proud of as Canadians. Really tragic stories – and I’m not being hyperbolic. This is literally what I see in my practice every day. The program we’ve had for the past three years needs to be made permanent.

When the policy was changed in 2020, it was made clear that it was a temporary measure driven by COVID issues. Borders were being closed; movement between provinces was being restricted. It was an uncertain time and ensuring everyone had access to treatment for medically necessary services was important both for the individual and from a public health standpoint.

Now, three years later, we are reverting back to the original policy. This should have been foreseen and anticipated by hospitals and physicians. The factors that lead to the temporary change no longer exist, so why would the policy continue?

Has anything significantly changed in the intervening time that would make the previous policy no longer valid? Arguably no. Are there still homeless who are unregistered in the system? Yes, but their numbers have not grown substantially. Are we seeing an increase in medical tourism? Perhaps, but most of these people have some form of insurance. Are there other factors driving up the number of uninsured seeking service? Nothing substantial.

The factors that lead to the temporary change no longer exist, so why would the policy continue?

Prior to 2020, the policy on uninsured patients was working with little pushback. It frankly was a very minor cost in the grand scheme of hospital budgets. Is the policy perfect? Probably not, but it was working.

So, if nothing substantially has changed, the original policy was working and the special conditions that required invoking a new policy no longer exist, why would we not expect to revert to the original policy? In other words, what is all the fuss about?

Anytime someone believes something has been taken away from them there is an outcry. This is no exception, but there is no reasonable expectation that reverting to the original policy should have any impact. Despite this, some will beat drums and claim this as another example of health-care mismanagement in an attempt to use it to advance other social causes such as saving the homeless. The facts remain, this change should not have any significant impact on hospitals, physicians or those they serve.

The program that was created during the pandemic was an opportunity to really have universal health care in Ontario. What we’re going to return to is two-tier, unequal health care.

Those of us that are advocating for a permanent program are very concerned that we are returning to a situation in which uninsured people are incentivized to delay seeking care, wait until they develop complications, causing more burden to the system.

There’s a lot at stake. With the removal of this policy, I think we will again see pregnant women being asked for cash while in labour or delaying seeking health care and delaying seeking prenatal care until the point of being in labour. This was a regular occurrence in the past. I think we will see children and elderly people being turned away for what is perceived as not emergency care. We will see people avoiding hospital care with heart attacks and strokes. We will see people with life-threatening conditions being denied surgeries.

We know that anybody who is uninsured and living in Canada, particularly some of the most vulnerable people in our communities, will be disproportionately impacted in their ability to access safe, effective care when they need it.

Ultimately, we know that it can be devastating for people. That should be concerning for all of us in terms of the value and meaning of our health-care system, and what that implies about what kind of care we provide for those who are most in need. We saw such a change in the degree of access and the outcomes of that access for some of those folks when compared with before the pandemic (when we didn’t have these kinds of supports in place).

What we are doing is ultimately downloading the cost just a little bit further down the road.

Beyond that, I think it’s really important to look at the other parts of the system that will be impacted. Any decision in any policy change has impacts that reverberate to all players and all providers in Canada’s public health-care system.

We know that individuals who are already structurally marginalized and who have complex medical, mental-health and substance-use related conditions will present with more acute conditions and with increasing duress when they’re not treated in a timely and proactive way. This will have a much greater impact on individuals, their families and the health system itself.

What we are doing is ultimately downloading the cost, beyond the human impact here, into a greater cost just a little bit further down the road.

When I look at the full impact of the value that was brought to people, communities, system performance with a lens of health economics, I can’t see what is driving the decision to make this adjustment. What is the actual policy goal?

I would hope in our health-care system that for various life-threatening or serious injuries this change will have no impact at all; that, in those cases, people will still get treatment regardless of insurance status.

But for people who reside in Canada and are not able to access care for minor ailments – that could be for minor chest pains or infections – if they don’t have the ability to access care, then their health will decline. That’s why we provide early, free care service – because it prevents serious health effects from coming about. Those serious health effects are very expensive in the health-care system.

I don’t know what the conversion rate is from refugee and immigrant applicants to permanent residency and citizenship. If it’s five per cent, we’re not going to have to live with those consequences very often. But if it’s 60, 70 or 80 per cent of those applying who become citizens, then these are future Canadian citizens and we should really treat them as such. We’re not just responsible for their health in this period while they wait to have their documents reviewed and approved. We’re going to be responsible for their health over their entire lifespans. That’s the basic business case here.

Fundamentally, from a human-rights perspective, I also think that as long as someone is inside your borders, you have an obligation to care for them and ensure that their health does not decline because you didn’t manage a condition that you could have easily managed.

This is going to be very detrimental and fatal to our community.

Migrant members are contacting us and some of them are pregnant and need to be able to give birth in hospitals in the safest way possible. Without insurance, they’re being asked for $15,000 up front to be able to do that. Who has $15,000 on hand? Especially when we’re dealing with a housing crisis and an affordability crisis. Migrants already don’t have access to benefits, a social safety net, and most oftentimes don’t even have control over their work or the ability to be paid wages they deserve and need to live a life with dignity.

This is what we’ve seen before; we’re expecting suffering and death.

They’re dealing with so much already, and then to have to now be able to cough up thousands of dollars. People are going to be giving birth at home in unsafe ways. Some of them might have to get out loans or ask for financial assistance and get themselves into debt – and in other cases, people are going to die.

We’ve seen this happen before. Not just in my work with Migrant Workers Alliance for Change, but I’ve been an advocate for access to health care for over a decade. This is what we’ve seen before; we’re expecting suffering and death.

We’re calling for this program to be reinstated and extended immediately.

Ending the program will disproportionately affect our most vulnerable and marginalized populations. This includes newly landed immigrants, migrant workers, and temporary foreign workers. It also includes a significant number of Ontarians who do not currently have an OHIP card, but do not have a fixed address to receive it in the mail, nor access to the documents required to apply for another card.

Regardless, all of these patients deserve the same access to health care as all other Ontarians. We know through the Ontario Medical Association that physician services billed through the program was around $5 million per year, which is a miniscule fraction of the billions allotted to the province’s health budget.

But this program also allowed uninsured patients to access health care earlier, likely preventing costly hospital admissions or invasive interventions, ultimately saving the province money in the long run. It also meant that these patients didn’t have to choose between paying for health care or paying for their rent, food, and other basic necessities – a decision that no one should be forced to make. Timely access to health care saves lives and prevents complications, and at the end of the day, it should be based on need and not ability to pay.

OHIP coverage will revert to the previous days when uninsured patients paid out-of-pocket. Ideally, patients requiring elective care (i.e., non-life-threatening) should return to their home countries for care. However, uninsured patients often stay in Ontario for care due to various factors (e.g., patient anxiety, established family/social support system, lack of trust in their home country’s health-care system, etc.). Hospitals may consider their care case by case (e.g., considering hospital resource capacity and patients’ ability to pay upfront). As our system is not set up for private health care, there is no standardized fee schedule or process to see uninsured patients.

This is different for emergency department visits. Unlike elective care, the uncertainty of diagnosis, treatment plans and urgent nature does not allow payment upfront before service provision.

It would be great if the government could look into different categories of uninsured patients (e.g., multi-year student permit, open work permit, parent and grandparent super visa, short term tourist visa) and set eligibility to consider some funding for unplanned hospital services. Setting a standardized fee schedule for uninsured patients may also be beneficial to ensure equitable care. In addition, strict regulations for providing elective care should be in place to rule out medical tourism.