Bogus rationale: Analysis of the government's reason for changing the Canadian Interim Federal Health Program
Recent changes introduced to the Canadian Immigration Policy have been a subject of heated debate between the conservative government and various groups that advocate for immigrant and refugee rights. Major areas of debate focus on the government asserting its right to choose who should be allowed to settle in the country on one hand and advocate groups calling for the government to respect and abide by its international obligations on the other.
One area of such debate is the change in the Interim Federal Health Program (IFHP); a temporary health insurance plan which is funded by the Citizenship and Immigration Canada to provide immigrants and refugees who are unable to pay for health care become eligible for benefits until they become eligible for a provincial/territorial or private health plan coverage.
The government's reasons for changing such a life saving and crucial health insurance plan is to reduce cost and the "extra" healthcare coverage supposedly provided to refugee claimants and to deter "bogus" refugees who come here to take advantage of Canada's "Generous" immigration policy.
However, the per capita cost for refugee claimants under the IFHP is only about 10% ($660 per year) of the average per capita cost for Canadians (CIC,2012); immigrants' health on arrival is better and decline the longer they stay in the country (Ng, 2011) and the per capita refugee load Canada hosts is lower than that of the poorest countries (UNHCR, 2011).
In this paper, I will provide a history lens on Canadian Immigration Policy to show possible reasons for the changes, their impact on health and mental health of refugees and how the rationale for changing the Interim Federal Health Program is another way to discriminate between deserving and undeserving immigrants.
Looking back at how Canada's Immigration policy has been shaped during various periods of its history enables us to put the current debate in perspective and look back to see forward. Similar to the ongoing debate, Canada's immigration policy have always been shaped by demographics, history, geography, economics and personal biases of those who are in charge of shaping and implementing it.
During the mid-nineteenth century, Canada had a "Whites only" immigration policy that primarily stemmed from the xenophobia of that period. Reflecting such bias, the Immigration Act of 1910 established the right to prohibit "immigrants of any race deemed unsuited to the climate or requirements of Canada" (Hawkins, 1991).
Such exclusionary immigration policies that primarily discriminated between deserving and undeserving immigrants had various forms. Some stated explicitly as a policy while others took a more subtle and implicit form. For example, the “head tax” on Chinese migrants in both Canada and the US began in 1885 and continued into the twentieth century with an annual head tax of $500 being applied to Chinese migrants and prohibition of Chinese women to Canada, which ensured that male migrants would not settle and raise families (Ralston, 1999).
These historical accounts of exclusionary Canadian immigration legislations and procedures clearly show explicit ways of an anti-Asiatic bias and a preference for migrants fitting an Anglo centric and Gallic norm that persisted through the early 1960s (Richmond, 1976)
Other implicit ways of restricting immigration and excluding undeserving individuals to settle in Canada have also been part of the immigration policy. For instance, in 1907, the Canadian Government reached an agreement with its Japanese counterpart that the latter would allow no more than 400 Japanese to leave the country for Canada (Mongia 1999).
Similarly, British subjects from India were prevented from arriving in (British) Canada during the early 1900s by imposing a series of restrictions, such as the "continuous journey" requirement, that were racially exclusionary, but did not explicitly name “race” or “nationality” as the basis for keeping them out for a simple reason that they were seen as being an undeserving immigrants. The continuous journey requirement meant that all Indians arriving in British Columbia had to prove “continuous passage” (travel on a single ticket from India to Canada) at a time when no such single journey existed (Mongia, 1999). Such explicit racial discrimination, however, was abolished later in 1962 when the then government established the “points system” (Richmond, 2001).
Although these changes should be given a lot of credit for shaping the multicultural demographics of the country today, the current government seems to take it's immigration policy back to the previous times when immigrants and refugees were stigmatized, excluded and discriminated against. For instance, explicitly stated Immigration messages characterize asylum seekers in a biased and stereotypical ways, suggesting that they are ‘bogus’ and are a drain on Canadian society. These beliefs, and not evidence, seem to be the primary sources of changes to policies and programs such as the IFH.
Canada is not facing "floods of refugees", as most suppose. Reports indicate that in 2010, 80% of the world’s refugees lived in the world’s poorest countries and countries like Canada had only 4.2 refugees to GDP per capita compared to Pakistan at 709.7, Congo at 475, Kenya at 247.3 and Chad at 224.5 (UNHCR,2011). As such, there was no need to tamper with such life saving and crucial public policies and programs.
The Interim Federal Health Program (IFHP)
In 2010, Canada accepted only 24,696 refugees in all classes; 11,000 fewer than the 35,776 refugees accepted in 2005. That same year, refugees in all classes accepted in Canada were about 13% of all permanent resident arrivals. Refugees accepted in 2010 were only 8% of all permanent resident arrivals, a drop of almost 5%. In 2005, the number of refugee claimants present in the country constituted approximately 0.3% of the Canadian population. In 2010 the percentage of refugees compared to the Canadian population was slightly lower at 0.28%. In 2010, 3,438 fewer refugee claimants entered Canada compared to 2005. (CIC, 2012)
While such a declining trend is seen with respect to admission of forcibly displaced persons to Canada, the number of such population is on the rise globally. According to the UNHCR Global Trends Report 2010 released in 2011, roughly 43.7 million people are displaced worldwide out of which 27.5 million people are displaced within their own country due to conflict (UNHCR, 2011).
The 1951 Convention Relating to the Status of Refugees, while not referencing health care specifically, sets out in other cases that refugees should have the same rights with regards to welfare as other nationals (e.g. public education, public relief as other nationals). Article 7 of the Convention states that, “except where this Convention contains more favourable provisions, a Contracting State shall accord to refugees the same treatment as is accorded to aliens generally.” (UNHCHR, 2007).
This suggests that a person who has the same access to healthcare as a national in a country of asylum is subject to a favourable protection situation, i.e. with regards to healthcare they are not at any particular disadvantage in the country of asylum relative to other refugees, foreign nationals, or nationals.
Given such an international provision to which Canada is party, granting refugees access to healthcare is a matter of Canada carrying out its international obligation and not charity and/or generosity. As a result of such international conventions that the country signed, it's policy has so far been consistent with implementing it. Especially when it comes to health care, where the Citizenship and Immigration Canada funds the Interim Federal Health Program (IFHP).
Refugee claimants, resettled refugees, persons detained under the Immigration and Refugee Protection Act, victims of trafficking in persons and the in-Canada dependants of these groups who are unable to pay for health care are eligible for benefits under the IFHP until they become eligible for provincial/territorial or private health plan coverage. Under this program, resettled refugees with provincial/territorial health coverage are provided with supplemental coverage for one year from the date of entry to Canada (CIC,2011).
The IFHP cost was $84.6 million in the 2010-2011 fiscal year. During the same year, 128,000 persons were covered by IFHP which means that the average IFHP cost was about $660 per refugee claimant per year. However, the current government plans to cut this budget by $20 million each year starting June 30, 2012 and this will apply to all current beneficiaries, as well as those who apply after that date (CIC,2012).
Up to and including June 29, 2012, the services covered by the IFHP for all eligible beneficiaries included basic coverage (i.e., treatments normally covered by provincial or territorial health insurance plans); supplemental coverage (i.e., health-care benefits similar to those provided through provincial social assistance plans, such as drugs and dental and vision care); and costs related to the Immigration Medical Examination (IME) (CIC,2012).
After the changes are in place, the IFHP will offer only two basic types of coverage.1) Health-care services that are only of urgent or essential nature; medications and vaccines only when needed to prevent or treat a disease posing a risk to public health or a condition of public safety concern or 2) Public Health or Public Safety Health-Care that will cover the cost of products and services only to prevent or treat a disease posing a risk to public health or a condition of public safety concern (CIC,2012).
In an effort to justify this action, Minster Kenney stated that "Canadians are a very generous people and Canada has a generous immigration system. But we do not want to ask Canadians to pay for benefits for protected persons and refugee claimants that are more generous than what they are entitled to themselves. With this reform, we are also taking away an incentive from people who may be considering filing an unfounded refugee claim in Canada" (CIC,2012).
As briefly discussed in the previous section, such changes can only be explained by the bias and attitude of those who are in charge of setting the policy. In this case, an official of a Minster capacity seems to continue perpetuate a bogus claim that refugees and immigrants are receiving more assistance than Canadians; a misperception that has been debunked by the government itself (CIC,2010)
The government already has an exclusionary policy which effectively screens out individuals who are unable to contribute to the Canadian economy due to their "excessive demand" on health care. Under Paragraph 38(1)(c) of the immigration and refugee protection act, a foreign national is inadmissible on health grounds if their health condition might reasonably be expected to cause excessive demand on health or social services (DOJ,2012).
Part 1, Division 1 of the Immigration and Refugee Protection Regulations, defines "excessive demand" as: "a demand on health services or social services for which the anticipated costs would likely exceed average Canadian per capita health services and social services costs over a period of five consecutive years immediately following the most recent medical examination required by these regulations, unless there is evidence that significant costs are likely to be incurred beyond that period, in which case the period is no more than 10 consecutive years"; Or "a demand on health services or social services that would add to existing waiting lists and would increase the rate of mortality and morbidity in Canada as a result of the denial or delay in the provision of those services to Canadian citizens or permanent residents" (DOJ, 2012)
Given such exclusionary immigration policies, the rationale provided by the Minster that protected persons and refugees add cost to the health care remains unfounded as his own policy explicitly states that individuals who have more health care needs are not allowed to come to Canada in the first place.
Furthermore, the cost of IFH per protected person per year, according to the government's own figures, was about $660 for the 2010-2011 fiscal year (CIC,2012) while the current overall per capita cost for health and social services for Canadians is about $6,141.2.(CIC,2012); clearly indicating that protected persons and refugees are not getting a better deal than Canadians as the minster suggested.
Even if the minster's wrong justifications were true, a good public policy would aim at insuring all people in the land have access to a better health care instead of finding a certain group to exclude and deny them access to health care for a mere fact that he considers them undeserving.
These biases are also clearly reflected by public statements made by the Minster who stated that he does not expect people to come to Canada and become completely dependent (CBC, 2012). Such comments are basically not true as they have an underlining wrong assumption that people who come here are unhealthy and stay the same over time. However, evidences have shown that immigrants’ health is generally better than that of the Canadian born and that it declines as their years in Canada increase.
For instance, a study based on the 1991-2001 census mortality follow-up found out that for Canada’s adult population overall, the age-standardized mortality rates (ASMRs) per 100,000 person-years at risk were 1,230 for men and 703 for women. Immigrants had significantly lower ASMRs than did Canadian-born adults: 1,006 versus 1,305 for men, and 610 versus 731 for women. However, as immigrants’ time in Canada lengthened, their ASMRs tended to rise.
The AMSRs among men were 720, 913 and 1,054 for recent, medium-term and established immigrants, respectively. Among immigrant women, the corresponding rates were 491, 546 and 637. Nonetheless, these rates remained significantly lower than those of the Canadian-born population. Such upward trends in ASMRs reflect a loss of immigrants’ health advantage over time (Ng, 2011). Given such a declining health status of immigrants, restricting access to health care remains a bad policy.
The changes introduced to the Interim Federal Health Program become of paramount importance for mental health status of refugees and new immigrants as they continue to face particular challenges that put their mental health at greater risk. They often have difficulty getting a job that matches their level of skills and education, earning a decent income, obtaining adequate housing, and face significant barriers to their seeking or obtaining help. (Mental Health Commission of Canada, 2012)
The new changes state that refugees and immigrants will receive Health-care services that are only of urgent or essential nature; medications and vaccines only when needed to prevent or treat a disease posing a risk to public health or a condition of public safety concern (CIC, 2012). This means that a refugee who suffers from depression or other similar mental illness will not be able to receive adequate treatment; further aggravating his/her condition because such condition may not be perceived to be neither urgent nor a danger to the public.
Mental health services in general are already given a lesser priority than most other services. This is clearly reflected by the fact that only one in three people who experience a mental health problem or illness—and as few as one in four children or youth—report that they have sought and received services and treatment (Mental Health Commission of Canada, 2012). Given these, the restrictions introduced to the Interim Federal Health Program will create additional barrier to an already compromised system; adding insult to an injury.
Furthermore, the changes will gravely affect refugees' and immigrants' mental health situation who are at an even more disadvantage due to their culture and the systemic discrimination they face when it comes to accessing health services in general and mental health services in particular.
For instance, a qualitative phenomenological study conducted by Martin and his colleagues (2010) indicated that lack of trust in doctors and race of doctors were among factors that were influenced by culture and discrimination that participants faced. Furthermore, Gender and language of immigrants have also been found to greatly impact their access to health care (Pottie et al, 2008) adding more barriers to refugees' and immigrants' health care access.
As indicated above, Canada's immigration policy have come a long way to abolish systemic discrimination between deserving and undeserving refuges through explicit and implicit policies. These changes in public policy have resulted in the current multicultural demographics of the country which calls for celebration.
Unfortunately, there are still possible ways by which assumptions, and not evidence, are used to shape it. This is clearly reflected by the rationales used to change Interim Federal Health Program. Evidences show that although Canada's willingness to accept and host refugees is commendable, its per capita share of such a global crisis is not comparable to other poor countries; that refugees and immigrants' health decline the longer they stay in Canada and the cost of providing life saving health programs such as the IFH is not more than what Canadian's get as most would presume.
Such changes in public policy have a grave consequence at an individual level. Tampering with an already compromised health care system where access is restricted from the very onset aggravates the declining health status that refugees and immigrants face over the long run.
Given these facts, the changes introduced to the IFH should be reversed. A rather inclusive approach should be used as a strategy instead of an exclusionary one where categorical groups are identified and become further labile to stereotyping and discrimination. Efforts have to made to identify and solve issues that lead to refugees' and immigrant's health decline over time, not worsen it. The government must be able to provide a transparent and publicly available aggregated cost data which could be comparable with similar datasets for Canadian born individuals, and last but not least, the overall immigration policy has to become bias proof.
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