Canada is known for its promise of universal healthcare. Its public health system is able to provide care at no cost to many of the people who call the country home.
In Ontario, however, the ideal of universal healthcare is far from realized. The Ontario Health Insurance Plan (OHIP) leaves some of the province’s most vulnerable people without any healthcare at all: undocumented migrants.
Undocumented and uninsured
Although the precise number of uninsured people in Ontario is unknown, there are many factors that can lead to someone being ineligible for OHIP. People experiencing homelessness, for example, are disadvantaged by the stringent ID requirements that are required to receive an OHIP card, which often require proof of permanent address.
The largest demographic of uninsured people, however, is migrants who have lost their immigration status. Estimates place the number of people without status in Canada at over 500,000. Almost all undocumented migrants in Canada come to the country via legal channels, drawn by the promise that Canada’s visa programs will offer a path to permanent residency.
Over 1.4 million of Ontarians are non-permanent residents, and the inefficiencies of Canada’s immigration system makes permanent residency difficult to attain. The backlog of applications at Immigration, Refugees, and Citizenship Canada sits at around 940,000 applications, down from over 1 million last summer, with over 200,000 international student visas set to expire in 2025. Migrants often fall out of status due to unreliable and unfair immigration policy and lack viable alternatives to living undocumented in Canada.
Sarah Shahid is an organizer with the Decent Work and Health Network and the coordinator of the Healthcare for All campaign. She explains that undocumented people “could be international students or could be farm workers who have fallen out of their status, or asylum seekers whose applications have been denied, or people who lost their immigration status for a variety of reasons and have just fallen through the cracks.”
Whatever the reason a person loses their status, they continue to contribute to the Canadian economy and to our healthcare system. According to Shahid, the healthcare, agriculture, and farming sectors are especially dependent on the labour of undocumented migrants.
Their precarity places them at greater risk for exploitation in the workplace, as they lack the job protections afforded to permanent residents. This leads to poorer health outcomes overall, since they are less likely to be able to access sick days or advocate for protections at work.
The price of care
Public health insurance works in a straightforward way: hospitals and clinics charge a fee for their services, and the fee is billed to the public provider, OHIP. Everyone in Ontario contributes directly and indirectly to OHIP through taxes, including undocumented people. But, without OHIP to cover costs, undocumented people are forced to pay large sums of money to access care.
Reporting by Wency Leung at The Local found that hospitals in the Unity Health Toronto network charged $2,458 per day for ward rooms for uninsured patients. The same article found that Sunnybrook Health Sciences Centre requests a $10,000 deposit for treatment.
North York General asks for a $6,000 pre-payment, and has rates of $780 for emergency room visits, $3,060 for a ward bed, and $4,634 for an intensive care unit bed. Leung spoke with an uninsured woman whose pregnancy-related conditions racked up an $11,000 bill, with one doctor quoting her $30,000 for a single appointment.
Such prices would be unaffordable for most people in Canada. For undocumented people, most of whom are battling precarious living conditions and poverty wages, it is virtually impossible to access care.
High prices produce an added strain on the healthcare system: since undocumented people are unlikely to risk high fees for minor symptoms, many only visit the hospital once illnesses have become severe and thus more expensive to treat. A report published by the Healthcare Network for Uninsured Clients (HNUC) found that 75.8% of uninsured survey respondents found the morbidity and severity of their illnesses to be worse (45.5%) or much worse (30.3%) when the expansion of health insurance during COVID was ended.
An easy solution
The severity of the problem—deemed a “humanitarian crisis” by some health workers—is contrasted by the simplicity of available solutions.
The COVID-19 pandemic made it clear that Ontario’s economy relies on undocumented workers, and as Shahid says, “There was a wide recognition that these workers are also the most vulnerable and most at risk.” In response to the pandemic and to pressure from the Healthcare for All campaign, the Ministry of Health implemented the Physicians and Hospital Services for Uninsured Persons (PHSUP) directive.
The program was straightforward. As Shahid explains, “There was a billing code that was put in place in hospitals so that if a migrant worker went to a hospital or an emergency room and needed lifesaving healthcare, they would be able to get it, and the hospital would use the billing code.”
During the two years that PHSUP was in place, over 400,000 uninsured clients were able to access medical care through the program. It was popular among healthcare providers, who no longer had to balance financial concerns when deciding on patient care, and among hospitals, who were guaranteed full payment for uninsured clients. Hospital administrators loved the program, since they normally have difficulty recouping costs from patients who simply cannot pay.
According to Shahid, the cost for these two years of the program was estimated at $15 million. At $7.5 million per year, this amounted to ~0.01% of the province’s $80 billion annual healthcare budget, a percentage that primary care physician Dr. Kansal described as “a drop in the bucket.” Nor does this figure account for the money saved by avoiding more serious illness through preventative care.
Despite the program’s humanitarian necessity and its support amongst all layers of the medical system, the program was cancelled in March of 2023. The Ministry of Health justified the decision by citing a reduction in COVID-19 cases, even while 2022 had been the most deadly year yet. The cancellation remains unpopular with doctors.
Fighting back
The Healthcare for All campaign is being advanced by uninsured people and healthcare professionals whose goal, Shahid says, is to present “medical evidence and economic evidence […] to highlight how expanding healthcare to migrants benefits all of us.” They are joined by groups like the Canadian Health Coalition, Ontario Nurses’ Association, the Ontario Medical Association, and the Ontario Hospital Association in calling for the immediate expansion of health insurance to all undocumented migrants in Ontario.
When the federal Conservatives cut healthcare for refugees in 2012, a broad coalition of advocates and medical professionals waged a campaign that ultimately got the decision reversed. Discriminatory and regressive decisions like cutting PHSUP can be stopped when the medical community and the general public mobilize to stop them.
The gap in access to care between undocumented migrants and people with status highlights the brutal fact that universal healthcare in Ontario is a fiction. Shahid says it plainly: “Healthcare is being treated as a privilege and not a right.”
As Ford’s government continues to cut funding to the public health system and funnel money into private clinics, public healthcare will continue to weaken. It is only by fighting for inclusive, public healthcare that Ontarians can hope to stop the Conservative’s efforts to gut public services.
The evidence is clear: a healthcare system that includes undocumented people is stronger than one that excludes them. Public health insurance for undocumented migrants is a vital part of a just and economically viable future. As Shahid says, “If any person is left behind, then all of us are unsafe.”
Send an email to your MPP to demand that the extension of OHIP to everyone living in Ontario: https://www.decentworkandhealth.org/healthcare4all/
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