Social Policy in Ontario

A Scarborough clinic for those with no health insurance

Posted on December 12, 2011 in Health Delivery System

Source: Toronto Star — Authors: Noor Javed

TheStar.com – Published On Mon Dec 12 2011.   Noor Javed, Staff ReporterPublished On Mon Dec 12 2011.   Noor Javed, Staff Reporter

In the decade she has worked at the volunteer health clinic for the uninsured, the one story that Toronto public health nurse Jennifer D’Andrade can’t seem to forget is that of a man named Jose.

Maybe it’s because of how hard she tried to get the failed refugee claimant from Guatemala into a local hospital for chemotherapy to stop his esophageal cancer from spreading.

Maybe it’s because D’Andrade knew that if he had OHIP, Jose might have been “salvageable.”

Maybe it’s because she knew that clinic director Dr. Paul Caulford was holding the 42-year-old in his arms when he died last year in the east-end apartment he shared with his brother. They use Caulford’s office in the evenings

“There was a reasonable chance he would have survived,” says D’Andrade, sitting in a patient assessment room at the Scarborough Academic Family Health Centre at Markham and Ellesmere Rds., out of which the volunteer clinic operates. “But he had no insurance, no money, and no one would take him in. So there was nothing we could do.”

This is just one story. D’Andrade has hundreds like it. Stories she has accumulated from a constant stream of patients who have been coming to the free, walk-in Community Volunteer Clinic for Medically Uninsured Immigrants and Refugees — the only one like it in the GTA — over the past 11 years.

For almost all the patients she sees, the Scarborough clinic is their only option short of the emergency room. In most cases, they have found out about it from the signs posted at the local OHIP office. When they arrive, they are almost always immensely grateful.

“As long as we can keep them in the clinic, we’re happy,” says D’Andrade. “It’s when we have to go to a hospital or get a referral for a specialist that it gets tricky and it becomes all about money. Then you don’t know how things will turn out.”

Care for the uninsured in the GTA occurs largely under the radar — administered through an uncoordinated mix of community health centres, emergency rooms and free clinics. But an increasing number of front-line health-care workers and advocates are pushing for better access to care for the uninsured, amid concerns the patchwork system in place is not only unethical and costly to the system but is putting the lives of the most marginalized and vulnerable at risk.

“In Canada, we live with this notion that everyone has health insurance,” says Michaela Hynie, associate director of the York Institute for Health Research and a psychology professor at York University. “So our biggest problem is that most of us don’t even know that the problem exists.”

In Ontario, the uninsured fall into four major groups: new immigrants and those returning to the province, who have to wait three months for their health insurance to kick in; refugees and those who have been denied asylum; people who have lost their documentation, such as the homeless and mentally ill; and those who are in the country illegally.

Accurate numbers of how many people are living without insurance in the city are hard to find. The Scarborough clinic sees around 1,200 patients a year. Hynie conducted a study of emergency rooms from 2007 to 2008 and found that more than 5,000 people who had registered had no insurance. But these numbers don’t account for the estimated 30,000 to 100,000 undocumented workers who are believed to live in Ontario, or the more than 50,000 permanent residents who will immigrate to the province this year and spend three months without health care.

But Caulford says quantifying the problem makes little difference at the policy level. He believes lack of action comes down to a lack of political will.

“Over the past 10 years, things have gotten worse,” he says. “Our volumes are up and there has been no policy change. The truth is that most politicians see the issue of giving health care to the uninsured as political suicide. I have had politicians say to me, ‘I want to do something, but I don’t know how to spin it.’ ”

In Ontario , the emergency room is the great equalizer. It is the one place in the health system from which no patient can be turned away, which makes it an entry point for most of the uninsured.

But it’s not cheap for them. At some hospitals, registration can cost upwards of $350. If a hospital stay is required, charges of between $1,000 and $2,300 per day — or even more — can apply, depending on the treatment. Many people can’t afford to pay, forcing hospitals to absorb the cost. But there are exceptions. D’Andrade says she can recall one man who paid back his bill to a Toronto hospital in instalments of $5 every two weeks, because that was all he could afford.

“The problem is that by the time people get to emergency, they are in need of more serious and acute care,” says Hynie. “These are conditions or illnesses that could have prevented. But because of high costs, or other fears, many of the uninsured leave before even getting treatment.”

Provincially funded community health centres are the only arm of the health system that receives financing to see the undocumented. While they are serving a need in the community, many workers in the centres say they are underfunded, restricted to caring for people in the neighbourhood, and in most cases are so full they have had to close waiting lists to new patients.

A Toronto Central Local Health Integration Network (LHIN) task force is trying to assess just how much it costs hospitals when an uninsured patient comes to emergency.

Downtown hospitals are seeking solutions to questions such as: how do they convince the province to fund those who are underground, undocumented and here illegally?

“There is that notion that people will cheat the system if we were to make health care truly universal,” says Hynie. “But there is no proof of that. If we believe that health is human right, then to argue that some people deserve human rights and others don’t on the basis of citizenship or poverty is problematic.”

The easier fix, advocates agree, is the elimination of the three-month wait for landed immigrants. Last week, the Right to Health Care Coalition, made up of more than 80 groups, and Toronto’s Medical Officer of Health, Dr. David McKeown, took their case to eliminate the three-month wait period to Queen’s Park.

“These people have been approved, and they have gone through all the proper channels,” says Bob Gardner, the director of policy at the Wellesley Institute, a think-tank focused on advancing urban health and health equity. “You could say it’s even fraudulent to invite people to Ontario and then say to them when they get here, by the way, don’t get sick for a few months.”

Ontario, B.C and Quebec are the only provinces that make new immigrants wait three months for health care. But Quebec alone does offer coverage when it comes to domestic violence, maternal care and infectious diseases. The Ontario Ministry of Health introduced a three-month wait period for all new immigrants and returning residents in 1994, on the grounds it allows officials time to confirm a patient’s resident status.

The policy, which saves Ontario $90 million a year, is a way to protect the health-care system from abuse, says Health Minister Deb Matthews.

“We are not looking at changing the three-month wait period at this time,” she says. “It’s important that when people come to Canada, they know that they won’t have health insurance for three months, so they should get insurance before they come.”

Try explaining the government policy to the “almost-citizens” such as Raj Gupta and his wife, Pallavi.

On this blustery Tuesday evening, the recently landed immigrants are happy they have found the Scarborough clinic, where they have brought 2-year-old Arnav, who has had a high fever for three days.

“For elders, it is okay, we can resist,” says Pallavi. “But with a child, you can’t take a risk.

“I feel like I won’t be able to breathe until the three months are over.”

The Guptas arrived in Toronto in October, aware that they would be without health care for three months. They bought insurance, but that covers them only for emergencies. So Raj went to Scarborough General to find out how much it would cost him if he needed to bring in his son.

“They told me its $300 for registration,” says Gupta, a family physician in India, who found out about the free clinic at the local OHIP office. “If you call the ambulance, it is $250 more. Once the doctor comes, he will charge $100, and other examinations are extra. And if you need to stay a night, it’s another $1000.

“It would cost me less to send both of them back to India where they could get care right away. If it wasn’t for this clinic, we might have done just that.”

The clinic started in May 2000, with D’Andrade and Caulford seeing patients in basements and community centres twice a week. They would bring in tackle boxes filled with gauze, needles and syringes.

Over time, they applied for funding from the Ministry of Health and Long-Term Care and received $100,000. It’s just enough to cover the cost of diagnostic and lab tests for patients and a small stipend for the eight physicians who rotate through to cover the two-days-a-week clinic. Many of the drugs and supplies are donated, as is the time of nurses, volunteers and the pediatric doctors who come to the clinic to treat children one Saturday a month.

Some advocates say the walk-in concept of the Scarborough clinic offers a “brilliant model” that could be adapted in different communities. But D’Andrade notes that in its current form — built on the generosity of volunteers — it isn’t sustainable.

With proper funding from the province, however, it would be a cost-effective alternative to sending patients to the emergency department, she contends. Yet there has been little willingness on the part of Queen’s Park to even consider it.

“It’s frustrating,” she says. “Maybe they haven’t looked into the eyes of the people we see and see how legitimate their issues are, and how much they have struggled to make it here. Now that they have made it here, the least we can do is help them.”

< http://www.thestar.com/news/article/1100059–a-scarborough-clinic-for-those-with-no-health-insurance >

Tags: Health, immigration, poverty, standard of living

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