White Coat Black Art

Pay-as-you-go health care: Uninsured people in Canada face sky-high bills, delays in treatment, doctors say

Most Canadians are secure knowing that they benefit from universal health care. All you have to do is walk into a clinic or hospital and you will be treated. For an estimated 500,000 people who live and work among us, it’s a different reality.

An estimated 200,000 to 500,000 people in Canada live without health insurance, says report

Canadian Centre for Refugee and Immigrant Healthcare manager Libery Andaya consoles Grace, who was diagnosed with stage 3 cancer. Grace came to Canada legally in 2001, but lost her job and status shortly after. (Dr. Brian Goldman/CBC)

Originally published on Jan. 17, 2020

Updated Sept. 27, 2022:

Grace, who was diagnosed with stage three breast cancer, received her first chemotherapy treatment in late January 2020, according to Dr. Paul Caulford. He said Grace was responding well to the treatment.

But this past summer, Grace died from heart failure. "She succumbed peacefully, without pain," said Caulford.

And Renata, 4, was offered a  free speech-language test after pediatrician Dr. Anamaria Richardson was contacted by a speech-language pathologist after the show first aired in 2020.

In a Scarborough, Ont., clinic, a woman receives test results with news no one wants to hear: she has stage three breast cancer.

But along with the prospect of chemotherapy, radiation and a mastectomy, she's also facing a bill in the thousands, because she doesn't have health insurance.

CBC Radio is calling her Grace because she fears she may risk being deported if her identity is revealed. She came to Canada legally in 2001 as part of the live-in caregiver program, but lost her job — and her status — before she could complete it.

"I feel like it's ripping me apart," she said. "I have to put [on] a brave face just like nothing happened."

Grace first detected a lump last August. She paid hundreds of dollars for a mammogram and ultrasound at a walk-in clinic — but without a financial guarantor, couldn't afford a biopsy to get a diagnosis.

I thought, Oh my God. Will I die of the bill, or will I die of the sickness?- Grace

In the meantime, she was prescribed antibiotics and Tylenol for the pain.

The Canadian Centre for Refugee and Immigrant Healthcare (CCIRH) agreed to do the diagnostics at no cost to Grace.

The clinic's volunteer oncologist who delivered the news told White Coat, Black Art host Dr. Brian Goldman she's likely looking at treatment at a cost north of $10,000.

According to a 2016 report by the Wellesley Institute, an estimated 200,000 to 500,000 people live in Canada without health insurance.

They could be landed immigrants living in Ontario, Quebec or B.C., which mandate a three-month waiting period before provincial health benefits kick in. They could also be temporary foreign workers who remained in Canada after their contracts ended, refugee claimants or people seeking asylum.

Paul Caulford looks after a child at the Canadian Centre for Refugee and Immigrant Healthcare. (Canadian Centre for Refugee and Immigrant Healthcare)

Veteran family doctor Dr. Paul Caulford, who works at the CCRIH clinic, calls the 500,000 figure a "conservative estimate."

"Health equity is the issue here. As physicians … we try our best to create health equity access, to reduce the health disparities that happen within our population," he said.

'Greener pasture' on hold

For the last 18 years, Grace has been working under the table at factory and babysitting jobs, keeping herself afloat and sending money to her family back home.

She would have been able to apply for permanent residency after working for 24 months over three years in the then live-in caregiver program. But she says she lost her job and status after being "hunted" by her abusive husband.

"I came here looking for a greener pasture; that someday I can take my children here," she said.

An oncologist holds Grace's hand while delivering the diagnosis. (Dr. Brian Goldman/CBC)

A health scare in 2012 landed her in the emergency ward. She came out with a new pacemaker and a bill in the tens of thousands. She's paid most of it out of her own pocket.

"I thought, Oh my God. Will I die of the bill, or will I die of the sickness?"

A 2013 report by the Toronto Board of Health characterized the medical charges billed to uninsured residents as "inconsistent," and noted that they often don't know how much they will be charged before treatment.

"Key informants note that hospitals often bill uninsured residents at rates substantially higher than OHIP rates, resulting in exorbitant charges that they cannot afford," the report said.

Confusion over interim health program for refugees

Caulford is calling on Ontario to waive the three-month wait period for OHIP coverage for people applying for immigration status in the province. 

"Ontario has an obligation under international law to ensure that all residents can effectively access essential health care services," the province's human rights commissioner wrote in a July 2019 letter to Health Minister Christine Elliott.

Caulford also says it should be mandatory for health-care practitioners and agencies to enrol in the Interim Federal Health (IFH) program, which offers limited health coverage like dental and vision services for refugee claimants and asylum seekers.

In 2012, the Conservative government made cuts to the program, but the Federal Court ruled those cuts violated the Charter of Rights and Freedoms.

Doctors and other health-care providers protest the former Conservative government's cuts to refugee health-care benefits in Halifax in 2013. The Liberal government reversed the cuts in 2016. (Andrew Vaughan/Canadian Press)

The Liberal government reversed the cuts in 2016, and in July 2019 announced a $283 million infusion in response to the surge of asylum claims in the last few years.

Caulford says the 2012 cuts led to confusion about how IFH actually works, and that many physicians refuse to enrol as a result, even today.

"Right now, we see patients with their IFH … go to a walk-in clinic for an infection, and the walk-in clinic won't see them. They'll charge them $100 or $150 to be seen," he said.

White Coat, Black Art reached out to Health Minister Patty Hajdu's office for comment. 

The request was forwarded to the Ministry of Immigration, Refugees and Citizenship, which responded in part by noting that "publicly funded health insurance is a provincial responsibility."

'I think it's so unfair'

In Vancouver, pediatrician Dr. Anamaria Richardson is worried about four-year-old Renata, who arrived illegally with her mother from Mexico three years ago. They met at Watari, a counselling and support service community for the city's Latin American community.

Richardson says Renata is non-verbal, and may have autism spectrum disorder. Because her condition isn't life-threatening, diagnostic tests or treatment aren't available without payment, which the family cannot afford.

Renata's mother, who does not speak English, told Richardson she worries that getting even routine medical care puts them at risk of being deported.

"Two years ago she needed to take Renata to a consult with a doctor, and she said it turned into just an immigration questionnaire," said Richardson. "I think it's so unfair."

She says she understands why some Canadians might object to coverage for non-citizens, especially when health-care budgets are strained. But she believes capacity exists for patients like Grace and Renata.

"I understand that it is a very costly venture. However, we live in a country that has so much, and I feel like we need to at least bring light to the issue," she said.

'A lot of faith'

The CCRIH clinic operates on private donations and a small amount of money from the provincial government.

"It runs out about five months into the year ... we're going on fumes for about seven months," Caulford said.

Doctors, nurse practitioners and other health-care providers volunteer their time to work there, donating the small government stipend they receive back to the clinic to help keep it afloat.

During a visit earlier this month, Caulford says he was alarmed at how dramatically Grace's tumour has grown since the fall.

"As a physician, we see so much. [But] I just stepped backwards when I saw this thickened, inflamed, red … warm, hot mass that was eight centimetres that started out at two to three centimetres in October," he said.

Caulford speaks in studio with White Coat, Black Art host Dr. Brian Goldman. (Sujata Berry/CBC)

Promisingly, a CT scan funded by donations revealed that while the cancer spread to her lymph nodes, her bones, lungs and liver are clear.

Caulford has reached out to several doctors about Grace's situation, and two breast surgeons have offered to waive their fees to help with treatment.

He hopes to start chemotherapy soon with the donations they've gathered already and hopefully raise more — "on a lot of faith."

But he wishes it didn't need to come to this.

"Grace has been working here for 20 years. ... When does she become Canadian enough for us to care enough, without being too judgmental?"

Written by Jonathan Ore. Produced by Sujata Berry.