“These reforms (to refugee health coverage) allow us to protect public health and safety, ensure that tax dollars are spent wisely and defend the integrity of our immigration system all at the same time.”—Immigration Minister Jason Kenney, June 27, 2012
When refugees or asylum seekers arrive in Canada, they receive basic health-care coverage and access to supplemental services such as pharmaceutical, dentistry, and vision care. But beginning on June 29, under reforms to the Interim Federal Health Program, this coverage will be scaled back. Way back. The biggest change is that refugees who are brought to Canada or who arrive here from countries the government considers “unsafe” will lose their supplemental health care benefits, such as the drug coverage. As well, rejected refugee claimants who are waiting to go home and those who arrive from countries the government has declared “safe” will basically lose all access to health care, unless their condition poses a risk to public health and safety.
Health professionals across the country are incensed about the changes, saying they amount to an inhumane, public-health disaster. Our Immigration Minister, Jason Kenney, maintains that this is a cost-cutting measure that will lead to $100 million in savings over the next five years, not to mention that the changes will actually protect public health and safety and deter health tourists from gaming the system.
Leaving impassioned rhetoric aside, Science-ish wanted to consider the evidence for refugees and health tourism, and what happens when you take health-care coverage away from people. Unfortunately, there wasn’t much: these reforms, it seems, are more ideology-based than rooted in good evidence.
Dr. Merrick Zwarenstein, senior scientist at the Institute for Clinical Evaluative Sciences, noted that the paucity of experimental studies speaks to a wider problem concerning our evidence for policies: it’s poor. “There’s a complete contradiction between how we decide what drugs work and how we decide on what policies and programs work,” he said. With the drugs, we use science, testing them with randomized controlled trials to try to get unbiased answers about their effectiveness. Not so with policies. We may do follow-up studies or track outcomes, but we usually don’t bother with randomization.
He thinks there are a few reasons for this, the major one being the lack of political will. “Policymakers are elected and promoted not on the basis of whether a policy works, but whether a policy is popular and electable,” says Dr. Zwarenstein. “So they are less interested in outcome, which often occurs years down the tracks after they have moved on.” Plus, he added, “Citizens are partly to blame because we don’t insist on a society in which we make the best use of the resources we have. We make decisions often on ideological grounds, when often these are not ideological questions. These are questions of pure pragmatism.”
The refugee health example is a case in point. Those who study evidence-informed policy making suggested looking to the U.S., since they’ve done some of the most robust experimental studies on the impact of moving people with no health-care insurance to coverage. This could be similar to the situation many refugees find themselves in when they arrive in Canada. One ongoing study in Oregon, which looks at citizens who are randomly assigned to health insurance, found that the insured spent an average of 25 per cent more on health care than the uninsured. So, it seems, leaving people without coverage could save on upfront costs, as Minister Kenney suggested.
Still, the insured in the Oregon study reported feeling healthier and happier than those who did not get coverage. They were less anxious about their well being, and there was a sharp decline in their medical debt and medical bills being sent to collection agencies. In other words, they were both more financially and physically sound. This left Katherine Baicker, an economist on the study, to note: “It’s up to society to determine whether it’s worth the cost.”
Our federal government grappled with the question of coverage for refugees and asylum seekers, and determined that it wasn’t worth the cost. Dr. Zwarenstein suggested that while other countries—including the U.K. and the U.S.—are moving to answer policy questions with the same rigour as pharmaceutical ones, Canada lags behind. At a time when we know more about the effects of drugs on our bodies than policy changes on our collective well being, the decision to chip away at the Interim Federal Health Program was made on the basis of political and ideological grounds. We should do better, especially with questions that determine who gets to live and who dies.
Science-ish is a joint project of Maclean’s, the Medical Post and the McMaster Health Forum. Julia Belluz is the associate editor at the Medical Post. Got a tip? Seen something that’s Science-ish? Message her at email@example.com or on Twitter @juliaoftoronto