The proposed Interim Federal Health Program cuts (discussed furtherhere) have not only motivated individual physicians to action, but also mobilized groups of health providers nation wide. On May 11, physicians across Canada held protests, an occupation and issued press releases in an effort to catch the Minister responsible, Jason Kenney’s ear.  More recently, the Canadian Medical Association, College of Family Physicians of Canada, Royal College of Physicians and Surgeons, Canadian Nurses Association, Canadian Pharmacists Association, Canadian Association of Optometrists, Canadian Association of Social Workers and Canadian Dental Association sent a joint letter to the Minister requesting that the planned IFHP cuts be rescinded. A full list of media coverage is below.

Medical groups slam plan to cut refugee health coverage– Ottawa Citizen (May 18, 2012)

Refugee health reform assailed– CMAJ (May 18, 2012)

Refugee health cuts are bad for all of us– Hamilton Spectator (May 17, 2012)

They aren’t all ‘bogus’ refugees, as portrayed by Kenney– Winnipeg Free Press (May 17, 2012)

Why cutting health care for asylum-seekers makes no sense– Globe and Mail (May 15, 2012)

Canadian doctors occupy government offices over healthcare cuts- Guardian (May 12, 2012)

Doctors fight for refugee health care– Hamilton Spectator (May 12, 2012)

Physicians occupied MP’s office over cuts to refugee health care– Toronto Star (May 11, 2012)

Doctors stage sit-in over refugee health care costs– CBC News (May 11, 2012)

Doctors demand changes to proposed refugee health policy– CBC News (May 11, 2012)

Doctors protest refugee health cuts– CBC News (May 11, 2012)

An attack on vulnerable refugees- Ottawa Citizen (May 9, 2012)

Cuts to refugee health insurance dangerous, inhumane, doctors say– National Post (May 7, 2012)

Doctor worries federal cuts could harm refugee health– CBC News (May 3, 2012) 

Jason Kenney, Minister of Citizenship, Immigration and Multiculturalism, has been a very busy man as of late. In less than five months, he has sought to redefine Canada’s threshold for asylum seekers and to tighten the handshake that welcomes them to their new home. For those in the medical community providing care for and advocating on behalf of refugee patients, these efforts have caused considerable consternation. After a closer inspection of Bill C-31 and the more recent overhaul of the Interim Federal Health Program, it is not a stretch to see why.

Bill C-31 or theProtecting Canada’s Immigration System Actwas first introduced to Parliament in February 2012 with the intention of clamping down on ‘bogus’ refugees, speeding up claimant processing times and reducing government costs. Stretching a healthy fifty-six pages, C-31’s most objectionable provisions related to health include:

• Automatic detention of asylum seekers for up to one year without review if deemed to land via an “irregular arrival.”
• An embargo on permanent resident applications and family reunification for five years after arrival.
• Conditional permanent residency with the possibility of a later revocation.

As a group ofOntario based physicians pointed out in a Toronto Star column, prolonged detention of refugee claimants leads to increased risk of suicidal thoughts, post-traumatic stress disorder and self-harm. This comes in addition to incubating infectious diseases and exacerbating chronic ones. Public outcry has led Kenney to amend this portion of the bill, granting review of detention at 14 days and 6 months. But the remainder stays unchanged. Delayed family reunification will still serve to weaken already fragile social supports and health, while revocation of already granted residency will still lead to social isolation, slow improvement of language skills and poor mental health.

In addition to the above reforms, C-31 also builds on the 2010 Conservative led legislation, Bill C-11, or theBalanced Refugee Reform Act.It divides refugee claimants into two categories: those from ‘Designated Countries of Origin’ (or DCOs) and those not. The stated aim of DCO policy is to deter abuse of the refugee system by those who come from countries generally considered ‘safe.’ One would expect a panel of experts to make such a crucial distinction – but not according to Minister Kenney. Bill C-11 contained no parliamentary oversight, but created a panel of public servants to make recommendation to the Minister. C-31 goes one step further, eliminating this provision and granting the Minister unilateral authority to deem which countries are considered ‘safe’ and which are not.

The DCO distinction is not an esoteric one. It has direct and very harsh implications for more recent reforms to refugee health services provided under the Interim Federal Health Program (IFHP). These changes do not require legislative reform; no Parliamentary vote or committee review is required. Their scope (though not their consequences) requires only the approval of Prime Minister Harper's Cabinet.

Like C-31, the stated aim of the IFHP change is cost-savings.It currently costs the Canadian government 84 million dollars annually – the Harper government is aiming for a reduction of 20 million. To achieve their ends they are leaving no category of refugee unaffected, even rolling back services for those who are government sponsored on recommendation from the United Nations High Commission on Refugees (UNHCR).

For these refugees, ironically deemed ‘protected persons’ in government releases, pre-reform benefits equate approximately to those available under most provincial social assistance programs. Post-reform changes will bear little resemblance to this, with health coverage available only for conditions deemed to be of an ‘urgent or essential nature’ or those to ‘prevent or treat a disease that is a risk to public health or a condition of public safety concern.’

What does that mean in practice?A ministry briefer illustrates a few examples. Come Canada Day, a protected person can be assessed for coronary artery disease by a physician, but their statins and anti-hypertensives will not be covered. A protected person will still be able to see a nurse or physician for a diabetic assessment, but will receive no coverage for insulin. For protected persons, many vaccines don’t even meet these new thresholds. All of these examples are significant changes from current policy. For claimants from the newly created DCO category, the news is even worse. Coverage has been completely eliminated for prenatal care, labour& delivery, as well emergency services. Every DCO acute myocardial infarction will go unfunded.

Kenney has defended these reformson grounds that asylum seekers should not enjoy a level of government funding that Canadians themselves don’t receive. Physician and advocates have responded with both moral and economic arguments.Andre Picardhas pointed out that it is exactly the vulnerability of refugees that necessitates broader health services.Dr. Mark Tyndallhas also provided a reality check - the real challenge is connecting refugees with unfamiliar preventative services and primary care, not stopping ‘abuse.’A Hamilton Spectator health provider Op-Edhighlights that according to the Ministry’s own data, refugee claimant’s per capita health costs are only 10% of Canadians, a number that is expected to rise with cuts to prevention.

Jason Kenney’s stated ends are to strengthen Canada’s refugee selection process and to save government dollars.  But by choosing a path ignoring evidence contrary to his means and by adopting a hostile stance to those on refugee health’s frontlines, he risks doing just the opposite. Bill C-31 and the IFHP reforms come into force in less than 6 weeks. Minister Kenney, you still have time to change course. July 1^stdeserves to remain a celebration for Canadians already here and for those that have yet to come. 

As the newest member of theOpen Medicineblog team, you can expect posts from me that focus on the intersection of health and elected politics. If I had started posting some months ago, you might have seen stories onthe 2014 health accord, the health scandals in Alberta/defection of Raj Sherman and the recent ICES report on primary health care reform in Ontario. While I can't always promise to strike an impartial tone, you can look forward to posts that seek clarity in often messy situations.

When not blogging forOpen Medicineor Tweeting via@DanyaalRaza, you can find me in the midst of a Family Medicine Global Health& Vulnerable Populations Fellowship at the University of Toronto. My first set of posts will focus on this area - specifically, proposed reform to refugee health care in Canada.

I look forward to hearing your thoughts on each post, and the opportunity to respond to each of your posted comments.

Happy reading,

DR