Not worth the wait

Ontario imposes a three-month waiting period before newcomers can receive public health insurance. Critics say the result is people delay seeking treatment, which can make their ailments worse - and endanger the public's safety. Louisa Taylor reports

Ontario is one of only three provinces to impose a waiting period before new immigrants can receive public health insurance, and opposition to the restriction has united civic politicians, doctors, nurses and immigration settlement workers.
Newly arrived immigrants cannot get OHIP coverage for the first three months they are in Ontario. Refugees are supposed to be covered by a special federal health plan, but it is unpopular with physicians, who say it takes too long and is too bureaucratic. The result, critics say, is that newcomers delay seeking treatment until the waiting period is over, making health problems worse and in some cases, endangering public health.
Recent research suggests that most newcomers arrive in Canada healthier than native-born Canadians, but lose that health advantage over time. Statistics Canada studies show that recently arrived Canadians born in Asia and Africa have mortality rates significantly lower than those of Caucasian Canadians, but mortality rates for those immigrants who have been in Canada for more than 30 years are higher, even when age is taken out of the equation
Last month, the Ottawa Board of Health joined its Toronto counterpart, health agencies and even the Ontario Medical Association in calling on the province to eliminate the waiting period, especially when it comes to patients with tuberculosis.
Councillor Diane Holmes, chairwoman of the Ottawa Board of Health, sent a letter in January to Ontario Health Minister Deb Matthews notifying her of the board's resolution against the wait and "advocating that new immigrants who have tested positive for latent tuberculosis infection, be able to receive immediate coverage from OHIP to ensure timely and effective treatment to prevent the development of active tuberculosis disease."
Tuberculosis is contagious and a public health challenge around the world. Prospective immigrants must pass a test for tuberculosis before they are issued visas, but cases of latent TB can go undetected.
There are approximately 1,600 cases of active TB in Canada, half of which are in Ontario. Most cases are found in immigrants from countries with high rates of TB, and they are at the greatest risk of developing active TB within the first five years they're in Canada.
The waiting period applies to all new and returning residents and is intended to give the province time to confirm a person's eligibility for insurance, David Jensen, spokesman for the Ministry of Health and Long-Term Care, said Monday. "Providing an exemption from the three month waiting period for only certain groups may raise concerns about the fair and equitable application of the Health Insurance Act to other Ontario residents who also require medical care during the waiting period for health insurance coverage," Jensen said.
Only British Columbia, New Brunswick and Quebec have a similar waiting period, and Quebec makes exceptions for tuberculosis.
Dr. David McKeown, Toronto's chief medical officer of health, says if a patient tests positive for TB, OHIP will pay for the medication but patients are still responsible for other treatment costs, including hospitalization, that can add up to tens of thousands of dollars. Even if the patient doesn't test positive, he or she has to pay the cost of the initial assessment.
"The three-month waiting period should be abolished," says McKeown. "The dilemma faced by a newcomer with a bad cough is they have to decide if they're going to wait it out or do the right thing and get assessed."
The province recommends newcomers buy private medical insurance but that's not always enough, says McKeown. He cited the case of a Toronto immigrant who bought private insurance. When he was later diagnosed with TB, his insurer denied his claim on the grounds that it was a prior medical condition.
"He did the right thing for himself, for his family and for the public at large but he still ended up with a bill for $20,000," says McKeown. "It's a particularly clear example in my mind of how the three-month waiting period isn't working."
Jensen points out that immigrants are welcome to seek treatment at community health centres, which are funded by the province. But one of the most vocal groups calling for an end to the waiting period is the Right to Health Care Coalition, which represents 30 community health centres, hospitals, settlement agencies and others. Jack McCarthy, executive director of Somerset West Community Health Centre and a member of the coalition says community health centres don't have the resources to cope with all the uninsured who come through their doors.
"I have a budget of about $66,000 for the non-insured this year and I'm going to blow that budget by $20,000," says McCarthy, who is also head of the health committee of the Ottawa Local Immigrant Partnership, a planning group working on ways to improve the integration of immigrants. "That includes the homeless and people who are noninsured for other reasons. We do the best we can but the resources are very limited. God help them if they need to go to hospital. We can't cover any acute care costs."
The Ontario Medical Association studied the issue last year in response to reports from member physicians, says Dr. Stewart Kennedy, association president. They found that it's not just patients with tuberculosis who are caught in the wait for insurance.
"Many emergency physicians were facing landed immigrants with no OHIP coverage," says Kennedy, a family physician in Thunder Bay. "They were uncomfortable turning anybody away from the emergency department. Some of their needs were acute - things like diabetes and chronic diseases, best managed in a family practitioner's office."
The OMA released a paper last year saying that the three-month wait fails to save taxpayers money, while endangering public health.
"It's supposed to save money but it's not, because there's a spike in OHIP billings after the three months and medical cases get more acute," says Kennedy, citing a 2004 study in the Canadian Journal of Public Health. "It just made common sense - if it's not saving any money, why have it?"
The waiting period is also intended "to create a disincentive to persons moving to Ontario briefly only for the purpose of acquiring insured medical services without the intending to make Ontario their primary place of residence," says Jensen.
McKeown isn't convinced.
"Governments say they are concerned about medical tourism, but really, I don't think anyone is going to go through the very long and complex process of immigration just to get three months of medical coverage," says McKeown.
In 2011, the Citizen's Louisa Taylor won a fellowship from the Canadian Institutes of Health Research that allowed her to research and write about immigrant health in Nepal, India, the United States and Canada. "In my work I often hear about the 'healthy immigrant effect,'" says Taylor. "The idea that newcomers get sicker when they move here seems like an alarming trend in a country built on immigration. This fellowship was my chance to find out what we know about it and what it means for health care."
"Unhealthy Welcome" runs in the Citizen until today.
New Canadians, old assumptions: The challenge to Canada's health-care system.
Margins to mainstream: Frontline practitioners break new ground.
Lost in Translation: Overcoming the language barrier.
Reaching Out: Bringing health to newcomers.
See videos, slideshows, graphics and links to more information at unhealthywelcome

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