The Healthcare Divide – Episode 4

Hundreds of thousands of people are living in Canada without health coverage, according to one estimate. So what happens when those people get sick, or hurt, or pregnant? We touch down at Doctors of the World’s Montreal clinic, to get an idea of what it’s like for migrants living in Canada without health insurance. 

Penelope Boudreault, director of national operations and strategic development, Médecins du Monde Canada

Thatiana Hernandez

Dr. Baijayanta Mukhopadhyay, family doctor and author

The Healthcare Divide

Episode 4 – Uninsured: How Universal is Canada’s Healthcare System?

Thatiana Hernandez (via translator) My husband and I looked on Marketplace and for $30 we found a heart monitor to be able to listen to our baby. If I wasn’t going to have ultrasounds, I wanted to know that the baby was okay, and I wanted to know that their heart was beating.

Dr. Alika Lafontaine Canada’s healthcare system should provide equal access to everyone. But in reality, it’s a system of haves and have nots. I’m talking to the people who have experienced inequities first-hand, and those who are working to create change. 

Dr. Baijayanta Mukhopadhyay A health care system that works for the most vulnerable is a health care system that will work for everyone.

Dr. Alika Lafontaine In this episode, we’ll challenge a belief of many Canadians: that Canada’s healthcare system is universal. We’ll explore the barriers migrants and refugees face when accessing care, and how many end up with no access at all.

I’m Dr. Alika Lafontaine, an Anesthesiologist and the first Indigenous physician to have led the Canadian Medical Association. From the Canadian Race Relations Foundation…this is The Healthcare Divide.

About 17 years ago, Penelope Boudreault started working with Doctors of the World in Montreal. The organization provides healthcare for people affected by social inequality or those living in vulnerable situations. At the time, she wasn’t focused on migrants.

Penelope Boudreault I start as a nurse in the streets, so proximity work, going to outreach and, well, reach out to a population that were living in the street,s using drugs, sex workers. So all people that didn’t have access to health care services or an access that was difficult or not adapted to their reality. We were used to work with population that were living in the streets, having difficulty to access the system, but they were allowed to have access to the system. So they had access to a RAMQ. It was sometimes lost, not renewed, that they didn’t want to go, they didn’t felt welcome in the system, but they could go.

Dr. Alika Lafontaine RAMQ is Quebec’s public health insurance plan. A few years into the job, Penelope started to see people in a different type of situation coming to her for help.

Penelope Boudreault Around 2009, undocumented migrants that were coming to me in the street with my backpack. I was used to like do STI screenings or for STI or treatment or wound that were caused by the life in the streets. But the reality of the migrants that were coming to me were really different. So they had lots of chronic diseases. They were pregnant. They had mental issues linked to their reality of the immigration process. So their needs were much bigger than what we were able to give at Doctors of the World at that time.

Dr. Alika Lafontaine Health access is just one of many issues migrants face, part of a complex web of barriers that can include serious issues like exploitation, lack of cultural safety, discrimination, and workplace violence. Recognizing their need for support, Penelope and her peers went looking for advice. 

Penelope Boudreault And everybody just told us, you are nurses, you are doctors. Please just give some health care services.

Dr. Alika Lafontaine In Canada, resettled refugees, refugee claimants, and certain other groups are eligible for temporary healthcare coverage under the Interim Federal Health Program, or IFHP. But they may not know they’re eligible, or they may struggle to access care for other reasons: language barriers, discrimination, or just a lack of knowledge about how the system works. And that’s not only on the patient side. One survey from 2016 found that 39% of healthcare workers were unable to answer a single question about the program correctly. Studies have also noted that some clinics won’t take patients covered by the IFHP because of the paperwork required to get reimbursed. If people are undocumented, they’re not eligible at all.

Penelope Boudreault So we started the first clinic and it was kind of hidden because we were scared with immigration. We were scared that we’d just like ask people that with no document or with no situation here that might be looked at by immigration or, so we didn’t want to put them in trouble. So we just did this like really, we we rent a clinic outside of the hours, at night, and then we see people. They were calling us. And then we make appointment and we were not talking about the clinic.

Dr. Alika Lafontaine You know, as I’m listening to you, I think about how as Canadians, we sometimes think of ourselves as so much different than immigration problems in the US. We think, down in the South, people get rounded up if they don’t have papers or other things and are sent out of the country. But we have a much more human-focused approach to immigration. But it sounds like those same sorts of fears are there for folks who are in need of healthcare services.

Penelope Boudreault We think that we are an open land for immigration. We are in some ways. But the process is so long and so complicated that just only the process makes people vulnerable because it takes so long to have papers. And by that time there is not that many status that you can have. And I’ve heard through those years, everybody that needs healthcare services in Quebec are allowed to go to the hospital. Allowed, it’s a thing, but you need to have the money to pay for it. And you won’t enter the hospital if you don’t have at least, just to be pass the triage at the entrance of the emergency, you need $500, $600. So it’s not accessible. So the reality is we have people coming in Montreal. Majority of them didn’t walk through the border. Majority of them did arrive in Quebec with a status, with a paper. But like when they tried to make some changes in their status, it takes so long that they can fall through the cracks. And if they get sick, then they get in trouble because they don’t have access and it’s too expensive.

Dr. Alika Lafontaine Doctors of the World’s Montreal clinic is no longer a secret. They have weekly walk-in hours, and openly advertise their services. They’re also vocal advocates for better access to healthcare.

Dr. Alika Lafontaine What changed for the care that you provide to come out from those hidden places and, you know, take the place that you’re in right now where when you talk about migrant health, you know, yours is a voice that’s almost always at the table?

Penelope Boudreault I think, for once, the notoriety. Because now nobody know, like, lots of people and recognize us, public health and we get money to do what we are doing right now. So we, the reality and the needs are acknowledged. So it was kind of normal for us, not being just a care provider because, as well, we realized that we would not be able to answer everybody. So we need to participate in the transformation of the system. And then with the peers now that have themselves been through that, we are stronger and able to to talk about the reality and make changes. I remember the day that we told ourself, if immigrations come to the clinic, if the the police come to the clinic, we will get out in the media and we will talk about the reality of those people that are living in Montreal with no services. And that the best that we are able to do is to come get them when they’re sick and put them in jail? It wouldn’t look too good.

Dr. Alika Lafontaine People come to Doctors of the World for all kinds of reasons. As Penelope said, some are undocumented migrants, but some have other barriers to accessing healthcare.

Thatiana Hernandez  Mi nombre es Tatiana Hernandez, como ya saben. Yo soy Colombiana…[fades under]

Dr. Alika Lafontaine This is Thatiana Hernandez. She’s speaking to us through an interpreter.

Thatiana Hernandez (via translator) I don’t speak French, I speak English. But for an interview like this, I don’t feel confident as an expert. I have two personalities. In Spanish, it’s a wonderful, lively personality. And in English, I’m very shy.

Dr. Alika Lafontaine Thatiana came to Canada from Colombia with her husband and three-year old daughter, because they were worried for their physical safety.

Thatiana Hernandez (via translator) We had a family business running restaurants in the beautiful city of Bucaramanga. We came to Canada for security reasons. We experienced what in Colombia is called fleteo, which is when we were followed. And they determined that we handle cash and then we are threatened with attacks if the money is not handed over. And so because of risks to our lives, we decided to look for more opportunities. We had big expectations for Canada. We thought it was a great place to raise a family. We knew about the cold and we thought that that might be a barrier, but we knew that we would forge forward. We didn’t have much information about health and education, but we felt that we wouldn’t run into problems as immigrants. 

Dr. Alika Lafontaine Thatiana came to Canada on a student visa, something that required her to have private health insurance.

Thatiana Hernandez (via translator) I did have private insurance at the time, but it only covered emergencies. It was very difficult for you to prove that it was an emergency. Also, you had to pay up front and then prove that it was an emergency and they would reimburse you. So if you didn’t have the money upfront, you couldn’t access care.

Dr. Alika Lafontaine Shortly after she arrived, she found out she was pregnant. 

Thatiana Hernandez (via translator) I wasn’t feeling well. I think it was due to the first month of my pregnancy. And so I asked Carlos if he could get me a pregnancy test. So I found out that I was pregnant through a home pregnancy test, and I knew that I needed ongoing care throughout my pregnancy. In my country, when you’re pregnant, you go to the doctor every month throughout your pregnancy. You call them, make appointments, and have questions answered really easily. So I consulted with a friend about how to do that here, and she said that the insurance wouldn’t cover me until I was 12 weeks along. It was kind of a catch-22 where I didn’t know when I would be 12 weeks pregnant. And how could I know that without seeing a doctor? Then later on in the pregnancy, I noticed some bleeding that alarmed me, and after consulting with my husband, we decided to go to La Salle Hospital to emergency room. Because of Omicron, my husband couldn’t accompany me, so he stayed in the parking lot with my daughter and I went in with my mask and everything to the triage. They took my blood pressure. They took my vital signs. And then they sent me to accounts payable. And it was there that I learned that being seen would cost me $1700. And so I left because I didn’t have the money. I remember being in my kitchen and just falling apart. I didn’t know if I was losing my baby or if I was sick. And I was telling this to Carlos, and he said, with $1700, you could go to Colombia, you could get checked, they could run tests, and you could fly back. It would be crazy to spend $1700 on some bleeding. We couldn’t spend that crazy amount of money. So I was asking around and what people told me was to exaggerate the condition at the hospital so that I would be treated, and then settle on a payment plan with them. But I didn’t want to become indebted with a huge debt to the hospital. I just wanted to have my pregnancy monitored in a dignified way and I wanted to know how many weeks I was at. So my husband and I looked on Marketplace and for $30 we found a heart monitor to be able to listen to our baby. If I wasn’t going to have ultrasounds, I wanted to know that the baby was okay, and I wanted to know that their heart was beating. 

Dr. Alika Lafontaine It was then that a friend told her about Doctors of the World. She called the clinic.

Thatiana Hernandez (via translator) I said that I wanted to speak to somebody in Spanish and a lovely Mexican woman helped me over the phone. She put me through to a social worker who would communicate to me through WhatsApp. Her name was Morgan, and she was the first person who really made me felt like my pregnancy and my baby mattered. I eventually got an appointment with a volunteer doctor and through Morgan on WhatsApp and the doctor, they kept asking me in the evening texts, how is your baby doing? And setting up my first appointment. 

Dr. Alika Lafontaine When it was time for her to give birth, she had just graduated, which meant she was eligible for a postgraduate work permit…and to get on Quebec’s public health insurance plan.

Thatiana Hernandez (via translator) But the process of getting a post-grad work permit and then the health insurance card is a tedious process that takes about four months. And I was running against the clock.

Dr. Alika Lafontaine Doctors of the World helped her through the process.

Thatiana Hernandez (via translator) And after a number of calls, somebody was able to deem me a priority case and process me. But babies are supposed to arrive after 40 weeks, and my baby arrived after 41 weeks and one day.

Dr. Alika Lafontaine Her healthcare card arrived on a Thursday. The baby came on Saturday.

Thatiana Hernandez (via translator) So everything happened at the time that it was supposed to. I think this was a great gift to me. And it gave me the opportunity to have a calm birth. After the birth, I received a bill, which I wasn’t required to pay, and it would have cost $12,000.

Dr. Alika Lafontaine Many of the details of Thatiana’s story—the uncertainty, the language barrier, the stress of being turned away from a hospital in a time of desperation—are shared by others. But for those who are without status, there’s also a fear of deportation. Penelope hears this all the time.

Penelope Boudreault We’ve been following some pregnant women. Until the end, even if we know that their situation is really difficult and even like they have difficulty to eat, sometimes they won’t even tell us because they’re scared that somebody will take their kid. They’re scared that somebody will come and check their house. They don’t know and they don’t trust. So we need to understand and be really open to receive and wait for the people to be ready to talk about that. At Doctors of the World, we see all the same problems that you would see in any walk-in clinic. So lots of chronic diseases. As people don’t have access to prevention care, it’s diseases that will, like diabetes, high blood pressure, but it’s been on and on for years. So the reality is, when they come to us, it’s because they feel really bad, because they really have a real need that they need to address.

Dr. Alika Lafontaine So it sounds like there’s a lot of hidden problems because of the situations that these folks find themselves in. How much demand do you think’s actually hidden? I mean, since opening the clinic, you probably have had an outpouring of people who are accessing services. But what do you think the real need is out there?

Penelope Boudreault I think the real need is huge because we are really small clinics. Two nurses, two social workers. And we have, like right now, it’s a triage over the phone. We will get 40, 50, 60 phone, maybe over that like some people are not admissible to our services. Lots of them are refugee claimer, so they have access to the system. So our job is to tell them you have access. The access is not perfect, but you do have access to healthcare services. But let’s say on that 20, 30 per cent are admissible to our services. And then we have a walk-in clinic on the Thursdays. Here, maybe there will be 30, 40 person at the door. And we could see maybe ten, 12. So all of the other one, we are not able to see them. And that’s only the person that are coming to us. And even the person that are coming to the clinic, we have like, if we’re talking about cancer, we don’t do surgery here, we don’t have access to lots of things. So even if they do have access through Doctors of the World, we can’t address everything.

Dr. Alika Lafontaine So take the patients who are unable to access your services and have to turn to paying out of pocket somewhere. For those folks, how much does something like a basic checkup cost?

Penelope Boudreault It’s really expensive. Lots of places, they won’t be able to go anyway because some clinics just won’t accept to see people that don’t have a card or don’t have a doctor in the clinic. It’s difficult for the population and like all the population to have access to that are a doctor. So if you don’t have a RAMQ or the coverage for refugee claimer, it’s even harder. So lots of time they will have to go to the emerg, which will cost them 400, 500, 600, just to get in. Then you see the doctor and everything that you will have to do, blood test, any exam, you will have to pay before. If it’s not an ambulance that bring you to the emerg because you had a car accident and you are not talking, then you will get the services before. But if you walk in the hospital, you will have to pay before you get your services.

Dr. Alika Lafontaine There is an exception for kids. In September 2021, with the help of Doctors of the World, a new law was passed in Quebec that allows children whose parents have a precarious migratory status to access healthcare.

Penelope Boudreault It’s new. Before that, even the kids didn’t have access to healthcare services. So lots of families told me, my kids is, like, having fever. It’s been two or three days. The medication doesn’t work. It’s like 40 and I’m really scared. What should I do? I want my kid to be better, but I need to decide if I pay $400, $500 just to see the doctor and it’s nothing. And then I don’t have the money to feed my kid. So that’s the reality of lots of immigrant people here in Montreal. 

Dr. Alika Lafontaine Are there any patient stories that have stuck with you over the years?

Penelope Boudreault So many. I remember, but this it’s a long time ago, when I was in the street and we had those first story in 2009, the man came to me and he was like, all broken with the broken bones and everything and he said, I can’t have access to the follow up to the hospital because it’s too expensive. And then I was asking him what happened. He was working on a construction site and he fall down. So he was just all broken. And then he said that he remember he was in a kind of coma, but he remember hearing the nurses and the doctor walking around him and saying well, he should be dead. We don’t understand how he could survive that. He’s all broken everywhere. It’s thousands of dollars, like $10,000 per day, that he’s costing to the hospital. He will never be able to pay for that. And he was like hearing that. And then, when he woke up from the coma, he said that, as soon as they could, it was a long time ago but still, they put him outside of the hospital with no follow up, nothing. And then I see this man in the street, like, saying that he want to live, he want to continue, but now what he’s going to do with his situation? He doesn’t have access to, like, no services to help him out getting better. How is he going to work in this situation? 

Dr. Alika Lafontaine Governments across Canada suspended a lot of the system-centered approaches that I think made life more difficult for patients like precarious migrants. When you were in the middle of the pandemic, were there any changes that made it easier to get care for patients?

Penelope Boudreault Unfortunately, no. The reality for the population was more difficult. So they had job. They lost them. They had job at night. Then we have the curfew. So people were hidden to make sure that they were not seek or find by the police. And then we had the government that was saying, so if it’s COVID-related, people can get care. So if you have COVID, you can go to the emerg or to the hospital and you will get the care that you need to. But then lots of people had to prove that it was that, so it was not that easy either. So the situation, the reality, with the rent, with the work, with the money, with the food, people were scared because they didn’t want to get sick. If you get sick because of COVID, you don’t have access to healthcare services, even if on paper COVID was covered, but it was not like, never that easy. Even to have access to the vaccination, it was complicated. We tried to have a card because then they had to identify themselves. And then but then having papers for someone with immigration issues, it’s complicated. So it was even more complicated.

Dr. Baijayanta Mukhopadhyay I mean, I think the entire healthcare system is struggling. A healthcare system that works for the most vulnerable is a health care system that will work for everyone.

Dr. Alika Lafontaine This is Dr. Baijayanta Mukhopadhyay.

Dr. Baijayanta Mukhopadhyay I’m a family doctor who works mainly, for the past ten years, mainly in Eeyou Istchee, which are the Cree territories of James Bay in Northern Quebec, in what’s known as Northern Quebec. Also Treaty 3 and Treaty 9 territories in Northern Ontario. But also, Montreal is home, or has been home for the last two decades or so, and I work with undocumented migrants, migrants of precarious status, queer and trans youth in the city, as well, and unhoused people, as well, in the city. I think that’s one of the things that, especially in conversations in the last few years, about when we’re thinking more about structures and processes and social dynamics that affect people’s access to care, that’s one thing I really feel like I want to tell people, because people often get lost in, oh, but I’ve had such a hard time getting to see my doctor, but I’ve had like a hard time with this process and the wait time’s been so long.’ And I think I really want to tell people is that, if the system works for people who have no access to any sort of social support at all, it probably means that you would be okay. You know, as in, from your positions of much more privilege, often, you would probably be okay because the system is able to care for those who have none. And that’s something I feel like maybe we’ve lost a little bit after the first waves of COVID-19. I think maybe we’ve lost that perspective a little bit.

Dr. Alika Lafontaine In 2017, Dr. Mukhopadhyay wrote an essay for CBC titled, “As a doctor, I call Canada’s bluff on, quote, ‘universal’ health care.”

Dr. Baijayanta Mukhopadhyay I think we have this myth in Canada that, oh, well. It’s solved. We’ve solved that problem. For most people, that’s actually not true. You know, a lot of health care that we need, like our teeth, for example, our eyes, you know, to be able to see isn’t covered. So that’s one thing. But for medical care, which most of us presume is covered, that we don’t have to pay to see a doctor, that there is no financial barrier to see a doctor. That’s actually not true. We have a universal public health insurance system. We don’t have a universal health service. And an insurance system implies that you’re insured, that you have access to the insurance. And in Canada, we’ve decided that you have to have certain type of paperwork to be eligible for this insurance. And that paperwork is often a citizenship document of some sort, either a birth certificate or a document that says you’re a citizen, a naturalization certificate, or a certain type of visa. And that’s how we’ve decided who has access to health care or not. It does not mean everybody here in this country has access to health care, and especially as our migration system is pushing people to more and more precarity, we’re moving towards temporary forms of migration, we’re pushing more and more people into these precarious social situations where they may not have access to healthcare. And certainly there’s a vast number of undocumented migrants, people who end up in the country, but who do not have the paperwork to say they can live in this country that do not get access to healthcare.

Dr. Alika Lafontaine So I imagine that people’s minds immediately go to a place that these are folks that snuck into the country. You know, folks that are here illegally. Before we circle back to talking about access again, like what actually happens? Like, who are these people? How did they come into these situations? How did they arrive at a point where they don’t have access to funding their health care through government mechanisms anymore?

Dr. Baijayanta Mukhopadhyay There’s a whole range of stories, there’s a whole range of pathways to being undocumented. One very common way is people apply for refugee status in the country and as a refugee status kind of winds its way through all the tribunals and courts, you know, they end up having a life here. They end up kind of working, going to school, meeting partners, having kids. And eventually one day some government body decides, actually, no, you can’t stay here. And by that time, their life is here, so people end up not leaving. Other times, it can be people who are under kind of temporary migrant visas. The complications of which type of visa you’re on, what sort of access to social services you might get, can be so difficult to decipher. And sometimes they’re dependent on your employment status. And if you change employer, you quit your job, you lose access to a whole bunch of benefits. So there’s a whole range of ways people end up in these situations. It usually is not criminal. And even for people who enter a country without permission, it’s actually not a criminal act to do that, you know? And I think people fleeing for security to feel safe, fleeing violence of all forms, including structural forms of violence, it’s not a crime to want to protect yourself. And I think that’s really important to underline in these conversations.

Dr. Alika Lafontaine So now you’re one of these patients who either knows or has yet to realize that they don’t have coverage for insurance and you’re presenting to the hospital or to a clinic to receive care for something that you believe you need care for. Can you walk us through, you know, a couple of different scenarios, maybe one scenario where you’re presenting with something that’s fairly serious. You’re having chest pain and you maybe are having a heart attack or something like that. Or you’re having something that’s maybe a bit more common, but less life threatening. Lots of patients across Canada have hip pain or knee pain or other things that could lead to something much more nefarious. How did those experiences differ as they navigate the healthcare system?

Dr. Baijayanta Mukhopadhyay If you’re presenting to a clinic, a walk-in clinic, say, because you have knee pain, it’s kind of unlikely you’ll even get past the door, actually, because probably from the get go, you’ll be asked for your provincial health insurance card or you’re a federal refugee claimant. If it’s a clinic that knows, and some clinics don’t know, you’ll be asked for your federal refugee health insurance papers. And if you don’t have either of those, you’re not going to get an appointment, you’re not going to get seen. You might be said, well, if you pay us a certain amount of money, then sure, you’ll be able to see the doctor. So that’s actually the easier one because like, if it’s something that is not life threatening or an immediate emergency, you probably won’t be able to do that unless you have that disposable cash. For an emergency, it’s a little bit different. So emergency rooms are under the obligation to treat anyone who shows up, essentially, even if they don’t have an immediate ability to pay or their care isn’t covered immediately. That’s not always the way it works, but that’s in principle how it’s supposed to work and most emergency rooms will follow that. But it’s very likely, say, you do have chest pain and you do end up having a heart attack and you’re admitted to the hospital for a few days, it’s very likely that you’ll receive a bill from the hospital afterwards. And people are aware of that. And so even that concern that they might end up getting a bill often prevents people from showing up at the emergency room, which, of course, has disastrous consequences for their health. And I think what strikes me most and what’s really hard sometimes is, if only you’d come sooner. The stories that I think about most, it’s not even like, oh, well, you would have lived longer or something like that. It’s just the amount of suffering. For how long people suffer. That’s really hard for clinicians to swallow. Like for anybody to swallow.

Dr. Alika Lafontaine We both know, and anyone who’s worked in health care knows, good will’s not a sustainable model for health care, you know? How would you redesign what’s going on as a provider? Beyond simply just funding everyone who’s undocumented. You know, you talk about a lot of things that I think are lessons that we could learn just in treating patients generally.

Dr. Baijayanta Mukhopadhyay Just to be clear, I think funding everybody’s healthcare is an important thing! But beyond that, sometimes it’s hard to articulate, like…sometimes it’s a feeling and it’s hard to articulate what that feeling is. One of the things I feel is really important in Canada, and I think I’ve read critiques about this in various places, is that we have such an institutional model of care. That’s part of the perversities of our funding mechanisms, where a lot of money gets channeled through hospitals because that’s how our health insurance system works, or even that we have to go to a doctor’s clinic to get care. That’s one thing that I feel like we could think about redesigning or reimagining and thinking about care as something that happens more in people’s neighbourhoods. In the early days of COVID-19, there was lots of sort of thinking about what that looks like while people were in lockdown, like how do we make sure that people on our block are actually cared for? And I think that has a very different feel than like, oh, to get care, I need to go to this big, scary building that’s got a lot of fluorescent lighting and smells funny and people might not speak my language.

Dr. Alika Lafontaine if you’re looking to reframe how governments and maybe even Canadians see this whole issue, what do you think’s the most important message to get across that we’re maybe not paying attention to right now?

Dr. Baijayanta Mukhopadhyay Our belief that our health system is kind of inherently magnanimous and sort of giving is just false. That’s not how it works. And it’s been a tool of colonial control. It’s advanced colonial control just within these lands and these territories alone. So that’s one thing, and the fact is that it’s possible to imagine other systems, like, countries like Spain, for instance, decided that undocumented migrants wouldn’t get access to care. And then a few years later reversed that decision, saying, actually, that doesn’t work. So it’s possible to make different decisions. The UK, before decades of austerity actually decimated the National Health Service, you could get care. Like, it didn’t matter what your status was in the UK. And you actually can still get access to. If I’m not mistaken, you can still get access to your family doctor if you’re undocumented in the UK. So it’s not that radical to be able to think of something that’s that’s different.

Dr. Alika Lafontaine From Penelope’s point of view, success would mean that Doctors of the World could shut down their clinic.

Penelope Boudreault That was a goal since the beginning. I was talking over those years, we are working to disappear. We don’t want to be a system outside the system. The care, health care services are better in the system, but then, 17 years ago, I have to admit that I don’t know. So many things need to change and the cracks are big and when we are going to start to see people that need like, yeah, the migrant with precarious status, but people living in the street, people using drugs, Indigenous in the streets of Montreal that don’t have access to a real care services, or if they do have access, they face racism, discrimination. And this is another reason not to go to the system and not to get the healthcare services that your in right to have, you’re entitled to have. I think that we need to realize that even. There’s lots of things that needs to change in the system to make sure that everybody is have access. So a big change of mind for the migrant, not seeing migrants as people that want to come here and use their services. If they could have their work permit and pay for their taxes and everything, they would. It’s just that the system, the immigration system is just putting them in that situation. And we’re a rich country. We are able to have people coming here and they make their life here. But if we do make their life, well they are arriving so complicated. We put them in the vulnerable situation.

Dr. Alika Lafontaine Today, compared to who you were back in 2009, do you have more or less hope that things have gotten better?

Penelope Boudreault Depends on the day. Sometimes it’s hard not to see that sometimes things are getting worse and the system is not better. And it’s not treating people better. And there’s still more and more people that don’t have access or their rights or not respect. So this is hard. But lots of times when I feel myself going in that, I just try to go back and just see all the bright things, all the people that do believe in. And we are invited and doing things with so many like amazing person that do change a little bit of things. So all of us together. So I prefer seeing that side and seeing that even like, if things are moving really slowly, they do move. They do move. Straight forward. Not behind. We’re not going back. And we are more people. We are getting stronger.

Dr. Alika Lafontaine Thatiana and her husband are now working on qualifying for permanent residency. 

Thatiana Hernandez (via translator) We’re doing all that is asked of us, and we think that it will bear fruit in the end. We’re hoping to be able to get our permanent residency. We’ve been working on that since 2020 and we would like to have that be one less thing to concern us. But we’re hoping that this will all bear fruit in the end and we’re so happy.

Dr. Alika Lafontaine And the baby?

Thatiana Hernandez (via translator) Beautiful. So beautiful. He’s doing well. He started daycare. We found a daycare three weeks ago. He cries a lot. He’s in a transition period.

Dr. Alika Lafontaine Last year Canada welcomed over 405,000 newcomers—the most ever in a single year. The Canadian Government, supported by Provinces and Territories, continues to set aggressive targets: 465,000 permanent residents in 2023, 485,000 in 2024, and 500,000 in 2025. There is a strong economic imperative for this; with a negative birth rate and worsening availability of workers across many fields, the competition for migrants is an ongoing issue for countries across the world. In Quebec, at least 50,000 people live without any medical insurance. According to a 2016 report by the Wellesley Institute, an estimated 200,000 to 500,000 people live in Canada without health insurance. This is a conservative number, equivalent to the population of Halifax. Migrants and refugees make up a sizable part of these numbers. It’s a fact that access to healthcare is one of the most important social determinants of health. Lack of access can have dramatic impacts, especially for pregnant women and for people with serious or chronic illnesses. As a physician I cannot, as a matter of law and ethics, deny care to a patient who is in an acute life-threatening situation. But I can turn away a patient for preventative care, forcing them to wait while their function and quality of life deteriorates. It’s an impossible choice left to patients and providers. But only governments have the power to find the actual solution.