Reviewing the OHIP Three-Month Wait:

Feature OMA Policy Paper Reviewing the OHIP Three-Month Wait: an unreasonable barrier to accessing health care Summary The Ontario Health Insurance Plan (OHIP) covers a wide range of medical services, including primary and emergency care, as well as laboratory tests and imaging to aid in diagnosis. This insurance is available to most Ontarians. If an individual moves from another province, that province s health insurance covers the individual during this wait period. For most refugee claimants to Canada, the Interim Federal Health Program (IFHP) is available, and, although not perfect, is designed to facilitate medical care at no cost to these patients. For legal immigrants coming to Ontario from another country, and for returning Canadian Citizens, it is a different story though. Both groups face a wait of three months for OHIP coverage. The legal immigration process is rigorous and involves meeting a set of strict criteria that include such things as wealth, opportunity for employment, family support and health status. Acceptance as a landed immigrant does not, however, bring with it immediate health insurance coverage; as a result, medical care is often a problem. The OMA s examination of this issue included a literature review and interviews with physicians in a variety of different types of practice who regularly see immigrant patients. We have found that this OHIP wait-period does in fact delay care, and can result in negative medical impacts for the individual and, in the case of an infectious disease, that individual s family and the people he or she comes in contact with. Although this three-month wait was implemented by the Ontario government in 1994 as a cost-saving measure, we have found no evidence to suggest that this delay actually saves the health system any money. The data demonstrate that people without health insurance tend to go to hospital emergency departments for care, and sometimes they wait longer than advisable to seek medical treatment. 1 Those who wait and save up their medical appointments until they receive coverage can compound costs, especially if illnesses worsen. In fact, in our examination of the three-month wait for OHIP, and its impact on returning Canadians, newcomers, families, physicians, and society at large, the OMA has found no reason to restrict newcomers or returning Canadians from full health insurance coverage upon their arrival in Ontario. 13 Introduction The three-month waiting period for OHIP applies to new legal immigrants to Ontario, but also to returning Canadians who have been living outside of Ontario for more than 212 days in the calendar year. 2 For Canadians moving from another province, health insurance is provided by the home province for the duration of the threemonth wait. Canadians returning from abroad are in a similar position to new immigrants, insofar as they are responsible for gaining private health insurance for the duration of their wait period. There are some exceptions to this rule for example, in some cases, people who have been living abroad for purposes of employment, education, and charitable work are not subject to the threemonth wait period if they meet certain provisions. 3 This paper will focus on investigating the challenges that the three-month wait presents to patients, physicians and society as a whole. April 2011

The OHIP wait period and healthy new immigrants New immigrants are defined here as people who have recently moved to Canada for the first time and who are not refugees or permanent residents, but who are in the country legally, with the full sanction of the federal government. Each year, Canada allows 220,000 to 260,000 new immigrants into the country. Ontario accepts approximately 40% of Canada s immigrants. 4 These thousands of new Ontarians do not qualify for OHIP coverage until three months after their date of arrival in Ontario. The majority of these immigrants are actually healthier than nativeborn Canadians; according to data from Canada s National Population Health Survey, short-stay immigrants (those who have been in Canada for less than 10 years) have fewer chronic illnesses and less disability than either native-born Canadians or long-term immigrants. 5 Factors that contribute to their better health status may be the rigorous health screening during their immigration application, or the fact that the majority of applicants come from countries where the population is more active and has a typical diet that is lower in saturated fats, sodium, and cholesterol than the typical Canadian diet. After approximately 10 years, immigrants health converges with the Canadian average level of health, meaning that their health status erodes gradually to the level of native-born Canadians. 6,7 Even though they are typically healthier than the Canadian population, health insurance is crucially important for those new immigrants who are pregnant, have an accident, or get sick upon arrival in Canada. The Ontario government, immigration advocates like Settlement.org, and immigration agencies encourage people to buy private insurance prior to arriving in Canada to cover the wait period. However, this is often either not purchased, unavailable, or the coverage is insufficient. A 2008 parliamentary report pointed out that private insurance is often denied, and if gained, it is not comprehensive. 8 In Ontario there are provisions intended to provide some care to new immigrants. The provincial government identifies Community Health Centres (CHCs) as a place where new immigrants can access care. CHCs offer limited primary care health services for free to immigrants and other uninsured individuals, although wait lists can significantly reduce access. Midwifery services are also made available by the provincial government to pregnant women without OHIP coverage. Importantly however, diagnostic tests that are a necessary part of health care, including tests for pregnant women before and after the birth of their child, are not covered at all for uninsured individuals. People who are involved in serious accidents, or who suffer a serious health event and are taken to emergency departments, do receive immediate care, but follow-up appointments or tests may not occur because of their inability to pay. Hospitals will try to recover costs of treatment rendered from the patient directly, or through private insurance if they have it. It is often the case that neither the treating physician, nor the hospital, can recover these costs. There is anecdotal evidence that the wait time for OHIP coverage can also be much longer than the stipulated period. While the wait for new immigrants is set at three months, Dr. Paul Caulford, who has published articles on this issue, found that the average wait time for people at his clinic was 2.1 years. 9 Another physician reported that for some immigrants at their tuberculosis (TB) clinic, OHIP coverage is gained quickly, while others wait a year or more. Under Section 11 of the 1990 Ontario Health Act, access to public health insurance is a right of each resident of the province. Barriers to care for new immigrants In the experience of some physicians, the barrier to health care for immigrants without OHIP is significant. According to Dr. Caulford, the number of people he sees who have private health coverage is small, and most new immigrants (as well as people who are in the process of applying for residency, and a handful of Canadians who have lost their OHIP cards) do not have any coverage. Other physicians report treating uninsured patients free of charge, and not pursuing payment because of the delicacy of the issue, and being aware that a patient or family cannot afford to pay. One physician that we interviewed explained how uncomfortable it was asking an ill patient at the bedside how they intended to pay for the services the physician has just rendered. This physician felt that being put in the position of having to ask that question about payment was well outside the fundamental principle of medicine, which is to care for the sick. We were told that many primary care clinics will not see uninsured patients because of confusion surrounding coverage. Emergency departments, as a rule, do not turn sick people away. Emergency physicians and physicians working in specialized clinics (TB clinics, for example) see a high number of uninsured patients, and often receive no compensation for treating them. Although some uninsured immigrants do not seek care when medically they should, others will resort to using emergency departments for their relatively minor health needs. Emergency departments are an expensive part of the health-care system, and, in Ontario emergency departments are often already crowded with patients. Emergency physicians reported that they see immigrants for ongoing non-emergency care because these patients cannot get care elsewhere. Immigrants rely on emergency departments for treatment that would be more appropriate at a walk-in clinic or other primary care access point, like care for a minor infection, or getting a prescription for birth control. 10 Physicians also reported seeing patients in the emergency department who had unmanaged chronic illness, such as diabetes or high blood pressure, but who had not been assessed and were not being treated because they did not have access to care. This use of emergency department (continued on p. 16) 14 April 2011

(continued from p. 14) resources means unnecessary costs for the system; not only are people misusing this part of the health-care system, which is not well suited to their complaint, but they may get sporadic and inconsistent care for conditions that require regular and ongoing physician attention. Uninsured immigrants who forego follow-up care can negatively impact their own health as well as that of others. A physician who works at a TB clinic said that a common problem is that immigrants cannot afford to pay for the follow-up care they require after mandatory visits to the TB centre for testing and initial treatment. Patients often miss the follow-up appointments and delay seeking care until they have OHIP coverage. 11 It is difficult to obtain detailed information about the health needs of immigrants when they arrive in Ontario. Evidence suggests that visits to physicians are highest in the fourth month after people immigrate to Ontario, and that the number of claims filed decreases steadily over time from this point. 12 This supports the perceptions of the physicians mentioned above, as it implies that people who are not covered for the first three months of residence in Ontario wait to see physicians until their health cards are issued. It does not appear that the health system saves any money by waiting three months to provide OHIP coverage, as visits to physicians increase significantly in the fourth month of residence. The health care needs of new immigrants Certain otherwise healthy individuals will still require essential care within their first three months in Ontario. For pregnant women, routine prenatal care and postpartum care (if they give birth in the first three months) are required. Immigrants who are injured in accidents require emergency care. Any person suffering an acute health event, such as a stroke, a heart attack, or acute appendicitis, also requires immediate attention and treatment. Finally, any contagious illness that is a public health concern requires immediate medical intervention as well. New immigrants most often seek care at emergency departments and CHCs, though these facilities are often stretched for capacity and some CHCs often have difficulty providing primary care when it s needed. The 2008 Parliamentary report stated that services at CHCs can be inconsistent, and people are often turned away due to long waiting lists. CHCs are also concentrated in larger cities; there are 54 CHCs in Ontario, 20 of which are located in the Greater Toronto Area. An additional 6 CHCs are located in Toronto s commuter communities between Oshawa and Hamilton. Only 5 CHCs serve the communities north of the Windsor-Ottawa corridor. 13 While the majority of immigrants settle in the larger centres, there are immigrant families throughout the province who may not have access to a CHC. These people must be kept in mind when thinking of provincial solutions to access to health care for new immigrants. Clearly, access to CHCs is difficult for new immigrants, and CHCs are not currently meeting the needs of this group. Level of care offered in other provinces Since 2001, Quebec has had a three-month waiting period for new immigrants for coverage with provincial health insurance, the Régie de l assurance maladie du Québec (RAMQ). For people in this waiting period, medical care related to pregnancy (including childbirth and termination), conjugal or domestic violence or sexual assault, and infectious diseases that may be of public health concern, are provided free of charge. 14 Other types of health services received during the three-month period are not reimbursed by RAMQ. Nunavut, Yukon Territory and Manitoba currently have a three-month waiting period in place for newcomers from within or outside of Canada, 15 and British Columbia has a waiting period that consists of the balance of the month of arrival plus two months. 16 New Brunswick rescinded its threemonth wait for health insurance for returning immigrants and Canadians in February 2010, though new immigrants still have to wait three months. Alberta, Prince Edward Island, Newfoundland, Saskatchewan, Nova Scotia and the Northwest Territories all provide immediate full provincial health insurance coverage to new immigrants upon establishing residence. Selective insurance coverage It is clear that the provinces have taken different approaches to the issue of delaying health insurance coverage. If Ontario followed Quebec s lead, immediate coverage would be provided for three types of patients: pregnant women, people suffering from infectious disease, and victims of violence. They all require timely care, and the impact of not providing this care is felt by these individuals, their families, and society as a whole. If implemented in Ontario, Quebec s model would improve care and likely relieve some pressure on emergency departments. However the categories that Quebec has chosen for coverage are somewhat arbitrary. While public and political perceptions are often at play in policies such as this, there are no medically sound reasons to include the treatments that Quebec has chosen to insure over other types of patients and procedures. Injuries sustained in violent attacks (covered in Quebec) are no more serious than injuries sustained in an automobile collision, for instance. In fact, there is no medical argument for inclusion of injuries due to violence over acute medical events, such as a heart attack, stroke, acute appendicitis or other serious illness. There may be some medical argument that infectious diseases are in need of coverage because of their link to public health, or that care during pregnancy should be covered because the baby will be entitled to full coverage after a birth in Canada anyway, but it would be difficult to argue that they are medically more important than other health-care needs. It would also be a great moral challenge to claim that the good health of 16 April 2011

these individuals is more important than that of others. In terms of health, there is no benefit to waiting to provide health insurance to new immigrants until after three months are up; the three-month time period itself is arbitrary. Whether a person has an infectious disease, an urgent health event, an accident, or a chronic illness, the best possible outcomes will be achieved when the person seeks medical care as quickly as possible. Conclusions and recommendation In February 2010, the government of New Brunswick dropped the threemonth wait for provincial health insurance for returning immigrants and Canadians. The Health Minister, Mary Schryer, stated that Removing the three-month waiting period is the right thing to do...our government recognizes that removing this barrier will enhance access to health-care services for immigrants and citizens who return home. 17 New Brunswick s government has noticed that this wait time imposes costs and challenges on people trying to make the province their home, but hasn t gone far enough to remedy this situation. The three-month wait poses a barrier for new immigrants as much as it does for returning immigrants and Canadians. Many groups in Ontario would benefit from the removal of the three-month waiting period for OHIP coverage. New legal immigrants and returning Canadians would all benefit greatly by having a major barrier to accessing health care removed, along with the stress and potential financial burden. There are no medical reasons to support keeping this three-month wait, and many medical reasons to support its removal. Further, evidence suggests that any immediate savings gained by not providing insurance for newcomers is subsequently depleted by the over-use of emergency departments and people seeking care sometimes with more advanced stages of an illness or an unmanaged disease, upon receiving health insurance coverage. Physicians and the health system would benefit by the removal of the wait period as it would allow physicians to treat returning Canadians and new immigrants like they treat everyone else, and would allow people to seek care at appropriate health-care delivery points, rather than continuing to resort to emergency departments. Finally, society at large would benefit from providing immediate OHIP coverage to newcomers insofar as this would remove the costs which discourage people from seeing physicians for infectious diseases, like tuberculosis, and other illnesses of public concern. For the reasons stated above, the OMA considers that there is no medically valid reason to maintain a three-month waiting period for OHIP coverage for returning Canadians or new immigrants. The OMA thinks that Ontario should take the cue from New Brunswick s government and recognize that the three-month wait for OHIP poses an unreasonable barrier to accessing health care, and challenges to those delivering that care. It is the OMA s hope that Ontario will respond to the evidence that we have presented, and completely remove the three-month waiting period for OHIP coverage. Appendix: The Interim Federal Health Program It is important to highlight that the situation surrounding people claiming refugee status is complex and separate from the questions of health coverage for other groups. Those claiming refugee status are eligible for coverage with the Interim Federal Health Program (IFHP) which covers emergency and essential care. For these people, there are many barriers to effective care through the IFHP. First, gaining refugee status is a lengthy process, so admission to the IFHP can take some time. Once a person qualifies for IFHP, it does not mean that he or she automatically accesses care. Physicians experiences with the program vary widely. Physicians must do a large amount of paperwork for reimbursement of services, and once submitted, the processing can take a long time. Some physicians receive payment promptly, while others have waited six months or more for reimbursement. There is also a challenge in that some services which are covered by 17 April 2011

OHIP are not covered by the IFHP, while other services are covered but at a lower rate. The IFHP is a federal system and does not mesh easily with provincial insurance plans. Some physicians suggested that harmonizing the services covered by the IFHP with provincial coverage would make the IFHP easier to work with. Hospitals are more likely to accept the IFHP certificate than family or afterhours clinics because of greater human resources for paperwork and greater familiarity because of patient volumes. Anecdotal evidence suggests that, like uninsured new immigrants, refugees in the IFHP over-utilize hospital emergency departments. Notwithstanding these challenges, since refugees make up a separate group of newcomers to Canada than immigrants, and because they face a different set of challenges with a federal care system, this brief has not included them in the discussion of the three-month wait for OHIP coverage. References 1. M. Khan, et al., Highlights: February 12, 1. Khan M, Lalani M, Plamadeala C, Sun E, Gardner B. Highlights: February 12, 2010 research conference on healthcare for the uninsured and undocumented. Toronto, ON: Wellesley Institute; 2010 Apr. Available from: http://www.womenscollegehospital.ca/programs/pdfs/feb%202010%20 Uninsured%20Conference%20final%20 report.pdf. 2. Ontario Ministry of Health and Long-Term Care. OHIP coverage waiting period. [fact sheet]. Toronto, ON: Ontario Ministry of Health and Long-Term Care; 2009 Apr. Available from: http://www.health.gov. on.ca/english/public/pub/ohip/pdf/wait. pdf. 3. Ontario Ministry of Health and Long-Term Care. Longer absences from Ontario. Toronto, ON: Ontario Ministry of Health and Long-Term Care; 2009 Apr. Available from: http://www.health.gov.on.ca/english/ public/pub/ohip/pdf/longer.pdf. Accessed: 2011 Mar 31. 4. Citizenship and Immigration Canada. Facts and figures 2009 immigration overview: permanent and temporary residents. [Internet]. Ottawa, ON: Citizenship and Immigration Canada; 2010. [Last modified: 2010 Aug 19]. Available from: http://www. cic.gc.ca/english/resources/statistics/ facts2009/index.asp. Accessed: 2011 Mar 31. 5. Beiser M. The health of immigrants and refugees in Canada. Can J Public Health. 2005 Mar-Apr;96 Suppl 2:S30-44. index.php/cjph/article/view/1494/1683. 6. Beiser M. The health of immigrants and refugees in Canada. Can J Public Health. 2005 Mar-Apr;96 Suppl 2:S30-44. index.php/cjph/article/view/1494/1683. 7. Cairney J, Ostbye T. Time since immigration and excess body weight. Can J Public Health. 1999 Mar-Apr;90(2):120-4. index.php/cjph/article/view/1150/1150. 8. Elgersma S. Immigration status and legal entitlement to insured health services. [PRB 08-28E]. Ottawa, ON: Parliamentary Information and Research Service, Library of Parliament; 2008 Oct 28. Available from: http://www2.parl.gc.ca/content/lop/ ResearchPublications/prb0828-e.pdf. 9. Caulford P, Vali Y. Providing health care to medically uninsured immigrants and refugees. CMAJ. 2006 Apr 25;174(9):1253-4. Available from: http://www.cmaj.ca/cgi/ reprint/174/9/1253.pdf. Accessed: 2011 Mar 31. 10. Sylvain M. Caring for the uninsured: securing medical care can be a real problem for immigrants and refugees - as well as their doctors. Medical Post 2005 Nov 1;41(37):1. 11. Elgersma S. Immigration status and legal entitlement to insured health services. [PRB 08-28E]. Ottawa, ON: Parliamentary Information and Research Service, Library of Parliament; 2008 Oct 28. Available from: http://www2.parl.gc.ca/content/lop/ ResearchPublications/prb0828-e.pdf. 12. DesMeules M, Gold J, Kazanjian A, Manuel D, Payne J, Vissandée B, McDermott S, Mao Y. New approaches to immigrant health assessment. Can J Public Health. 2004 May-Jun;95(3):I22-6. Available from: http://journal.cpha.ca/index.php/cjph/article/view/507/507. 13. Ontario Ministry of Health and Long-Term Care. Health services in your community: community health centre locations. [Internet]. [about 20 screens]. Toronto, ON: Ontario Ministry of Health and Long- Term Care. [Last modified: 2009 Jun 15]. Available from: http://www.health.gov. on.ca/english/public/contact/chc/chcloc_ dt.html#forest. 14. Régie de l assurance maladie du Québec. Arriving in or returning to Quebec. [Internet]. [about 2 screens]. Quebec City, QC: Régie de l assurance maladie du Québec. [Last modified: 2009 Nov 11]. Available from: http://www.ramq.gouv.qc.ca/en/citoyens/ assurancemaladie/arriver/ext_can.shtml. 15. Manitoba Health. Are you covered?: Questions and answers about health care coverage: Am I eligible for coverage? [Internet] [about 1 screen]. Winnipeg, MB: Manitoba health. Available from : http:// www.gov.mb.ca/health/mhsip/#eligible ; Association franco-yukonnaise. Yukon health insurance card. [Internet] [about 1 screen]. Available from: http://www. afy. yk. ca/ secteurs/ main/ en/ index. php?location=p379-yukon-health-insurance-card. 16. British Columbia Ministry of Health, Medical Services Plan. Eligibility and enrolment: all residents of B.C. must enroll with MSP.[Internet] [about 7 screens]. Victoria, BC: British Columbia Ministry of Health. Available from: http://www.health. gov.bc.ca/msp/infoben/eligible.html. 17. CBC News. N.B. waives waiting period for health coverage. [Internet] [about 1 screen]. Toronto, ON: CBC; 2010 Feb 26. Available from: http://www.cbc.ca/ health/story/2010/02/26/nb-healthcoverage-immigrants-military-1133. html?ref=rss#ixzz0ggewhu8h. Accessed: 2011 Mar 31. 18 April 2011