Mr. Chair, thank you for inviting us to appear before the committee today.
Immigration, Refugees and Citizenship Canada, or IRCC, appreciates the committee's decision to undertake this study.
Canada's medical admissibility policies and guidelines play a critical role in the immigration system. As a result of the increasing number of migrants to Canada and the health risks associated with migration, there is an ongoing need to assess the health status of immigrants. This screening identifies health and safety risks and helps reduce impacts on Canada's health and social systems.
As the committee is aware, under the Immigration and Refugee Protection Act, permanent resident applicants and some temporary resident applicants may be refused admission to Canada if they have a health condition that would pose a risk to public health or public safety or would place an excessive demand on health or social services, which are mostly administered by provincial and territorial governments.
Health admissibility is determined through a two-stage process.
First, applicants undergo an immigration medical examination, including any supplementary tests, which are performed by a third party physician designated by IRCC. The department then performs an assessment of the examination's results to reach a decision on whether an individual is medically admissible. The department also notifies provincial and territorial public health authorities of the arrival of individuals who may require ongoing medical surveillance and follow-up for conditions such as inactive or previously treated tuberculosis.
In general, individuals are found to be inadmissible for public health reasons if they have a highly communicable disease that could have a serious impact on other persons living in Canada. Active tuberculosis and untreated syphilis are considered dangerous to the public, for example.
A finding of danger to public safety considers whether a foreign national's health condition could create a danger to the health or safety of persons living in Canada. This may include certain medical health conditions that could result in unpredictable or violent behaviour, such as sociopathic disorders.
In terms of the excessive demand provision, although the specific requirements have changed over time, there has been some form of screening for immigrants to Canada to minimize impacts on health and social services for most of our history. Currently, under the Immigration and Refugee Protection Act, this provision applies to all applicants for permanent residency, with the exception of convention refugees, protected persons, and some members of the family class—for example, spouses, partners, and direct dependents. Excessive demand also applies to some applicants for temporary residency, where these are eligible for provincial or territorial services.
The objective of the provision is to strike a balance between protecting publicly funded health and social services and facilitating immigration to Canada, while also supporting humanitarian and compassionate objectives in Canada's immigration policy.
Excessive demand considerations are determined by a departmental officer, usually referred to as a visa or immigration officer. These officers consider the assessment of an applicant's immigration medical exam by a departmental medical official, as well as projected health or social services needs, the cost of those services in Canada, and the effect on wait-lists.
This entails reviewing the medical diagnosis and prognosis, the required services, the costs for services in the intended jurisdiction of residence, and, in the case of social services or prescription medication, the ability and willingness of the applicant to pay out of pocket. If the individual's anticipated costs are expected to be above the average per capita cost of publicly funded services over five years, which is $33,275 as of January 1, 2017, then the individual may be found inadmissible.
No specific health condition will result in an automatic rejection of an applicant. Each decision is made on an individual basis.
The provision has been found by our courts not to violate the Charter of Rights and Freedoms, as it does not exclude persons based on a specific health condition. Rather, the decision is made according to an individual's likely demand on Canada's health and social services.
Of the approximately half a million medical exams performed annually by IRCC in recent years, only 900 to 1,000 applicants, or 0.2% of all applicants, received a finding of excessive demand by a medical officer. This includes about 200 to 300 individuals needing special education services.
The health inadmissibility provisions are designed, in part, to reduce impacts on Canada's publicly funded health and social services systems. We recently undertook a cost-benefit analysis, using data from 2014 arrivals.
The conclusion from the cost-benefit analysis was that the excessive demand provision results in avoided costs for provincial-territorial health and social services on the order of $135 million over five years, for each year of decision. That amount represents 0.1% of all the provincial and territorial health spending in 2015.
As you may know, IRCC has undertaken a fundamental review of the excessive demand provision. As part of this review, we launched consultations with provinces and territories in October 2016. Departmental officials also engaged stakeholders, including disability advocates.
The results of these discussions, together with consideration of public perspectives, judicial decisions, media reports, and internal departmental analyses, will inform the development of options to be presented for decision by the government.
As recently stated at a federal-provincial-territorial meeting of his counterparts, “...with the cooperation of the provinces and territories, I'm pretty confident that we will arrive at a place where we can both live up to the need to protect our health and social services from excessive costs, while also treating people fairly and including individuals with disabilities.”
In summary, I will say that IRCC's medical screening program takes a risk-based approach that balances the facilitation of immigration with the protection of federal, provincial and territorial health and social services.
Once again, Immigration, Refugees and Citizenship Canada appreciates that the committee has chosen to undertake a study of the immigration medical screening policy.
Thank you very much.
We look forward to answering your questions.
Yes, we can provide additional details in that area.
To be clear, the assessment does not do a cost-benefit analysis on an individual basis. It is an assessment based on the results of the medical examination and supplementary testing, from which a medical officer assesses the severity of the illness and the degree of service that would be required to treat it, which then forms the initial medical recommendations that are given to a visa officer.
At that point, however, as part of a procedural fairness step, individuals are able to prepare a mitigation plan to identify if they are able to offset the costs that are related to things that can be paid for here in Canada.
In other words, under the Canada Health Act, if individuals cannot pay for medically necessary treatment, individuals who are applying to come to Canada can say that they would be able to offset the costs of prescription drugs or of other social services that can be provided through the market. To the degree possible, this is a way of identifying their ability to make a contribution to offset those costs.
Other countries have considered approaches that use something more resembling a cost-benefit analysis—specifically, Australia—but they found that it was unworkable because it involved too many unsupportable assumptions as to what an individual's employment trajectory or income would be over the years following their arrival, so they abandoned this approach.
I thank the officials for their presentation to the committee.
Mr. Chair, I have a series of questions. I know we're limited in time, so I'm going to put these questions on the record and ask the officials to undertake to provide answers to the committee with respect to them.
I think what's underpinning all of this is one of the most important questions, and that is the information and the evidence the officials can provide to us on how the government sets the current cost threshold for excessive demand. I don't believe that anyone is disputing the information provided by the Canadian Institute for Health Information, but I would like to get to how this figure is being derived. To that end, Mr. Chair, I would like to ask the officials for the following information.
First, how does IRCC set the cost threshold for excessive demand, particularly for social services? It is my understanding that the government uses a figure of $356 for what it spends on social services per capita each year. Where did that figure come from, and is that the correct figure?
Does the current review aim to more clearly define the social services considered when setting the threshold for excessive demand? If yes, how will this be accomplished and accounted for to ensure transparency?
What about applicants who have been denied in previous years for amounts very near to this threshold? We have heard about the number of people who are being assessed in this context. How many people were denied? For those who have been denied, if their threshold was very close to this amount, does IRCC intend to launch a proactive review of these cases or at least provide an avenue for applicants to reapply without incurring additional costs?
We have seen major inconsistencies, at least anecdotally, in how applications involving medical inadmissibility are reviewed and handled, depending upon the medical officer or the immigration office responsible for a particular file. In some cases, medical officers failed to provide any sort of cost estimate to applicants in procedural fairness letters when stating that applicants may be deemed inadmissible, an apparent violation of existing case law, specifically in the Sapru v. Canada 2011 case, which requires that applicants be provided with cost estimates during the procedural fairness process so that they may put forward a reasonable challenge to the government's claims.
To that end, do the officials acknowledge that there are problems in terms of how applicants are handled by one officer or office versus another, and that these problems include significant inconsistencies in how medical officers review the anticipated costs of care in Canada?
Also, has IRCC's review of medical inadmissibility included a review of these inconsistencies? If yes, what efforts has IRCC undertaken to ensure medical officers are aware of and adhering to existing case law regarding procedural fairness?
The Canadian Bar Association has recommended that the processing of cases involving medical inadmissibility be centralized in Ottawa so that these more complicated cases can be given the care and attention they deserve. I wonder whether or not the officials agree. If yes, what is being done to make this happen? If not, why not?
We understand the provinces are being consulted on a range of possible policy changes, including the possibility of expanding groups of persons exempted from these provisions, something that is currently limited to refugees and protected persons. Is this true? If yes, what groups is the government considering for exemptions from medical inadmissibility and excessive demand provisions?
Also, disability advocates from across Canada have spoken out against these provisions, saying that medical inadmissibility discriminates against people with disabilities, forcing them to go through a process that able-bodied persons do not have to. Do the officials and the government acknowledge that this policy unfairly discriminates against persons with disabilities?
Specifically what I'm talking about is the process of forcing people with disabilities through a separate and segregated process of medical review, by virtue of the fact that they have a disability. This, to me, is a textbook case of discrimination, and the outcome, whether admitted or not, is irrelevant, in that the person with disabilities is discriminated against prior to these decisions ever even being made.
To that end, does IRCC intend to make persons with disabilities, particularly dependent children of economic applicants, exempt from these provisions? If yes, what disabilities will be exempted, and how will the government determine the list of exempted disabilities and conditions?
There are the usual conditions that an officer has in making a decision.
As I spoke earlier, they're looking at the response to the procedural fairness letter that was sent out. The family may dispute the medical condition, the prognosis, and bring their own specialist reports to bear in relation to the condition and the expected health and social services the individual may need over the next five years. For the social services side, then, after the Supreme Court decision in Hilewitz and De Jong, they can present one of their mitigation strategies for not having the same impact.
For example, if someone is going to be employed in Canada and the employer has a health care plan that will cover expensive prescription medications, that could be a mitigation plan. The officer would take that into account and say that expensive medication is covered off by their health care plan, so they find they're not medically inadmissible.
Generally, then, on the temporary resident permit, humanitarian and compassionate grounds are powers that officers have all the time, as does the minister.
Could I get those numbers from the officials? If you can undertake to provide that information to us, that would be greatly appreciated.
I have two specific cases I'd like to bring to the attention of the officials just by way of a snapshot of the examples.
One is the publicized case of Mercedes Benitez. She made her application in 2010. She has been waiting seven years for it to be processed. Her case involves a son who has an intellectual disability, so it's not TB or anything like that. Her application has been in process for seven years.
I have a case of another individual, Monica Mateo. She made her application in 2012. It's been five years since she made the application, and again it's not a contagious disease or anything like that with respect to her daughter. In fact, in her case, her employer has even offered to cover all expenses related to her daughter if there were excessive demands determined. Her employer has submitted her bank statements for verification. They are still waiting.
There is something wrong with our system in the way we are treating such individuals.
When the officials say that this is not an issue around discrimination and that people's rights are not being violated in accordance with our charter, the question I want to put to the officials and to the government is this: is not the process you are making people go through because of their disability deemed to be a violation of our charter? Any other person would not have to undergo this process. Only people with disabilities have to undergo this process. That is the argument the associations working with people with disabilities are advancing.
I'd like to have the officials comment on that.
Thank you very much, Mr. Tabbara.
I'm trying to wrap my head around this, so thanks for teaching us.
There's a category of “a danger to public health”. If someone comes forward who could be a danger to public health, their application could be delayed, in which case they would receive treatment, or it could be denied outright, presumably.
Then there is “a danger to public safety”, and again, if it could be treated, it'll be treated, or they could be rejected.
Then there is this third category of “excessive demand on health or social services”. Under that we have a couple of different interrelated definitions. One is being above the average health care cost threshold. The other one is the demand on health or social services that would add to existing wait lists and would increase the risk of mortality or morbidity.
I'm trying to see how this could be quantified. Do you have particular metrics that you use, and how do they interplay? In the data structure you use to assess applicants, are there particular fields within that data structure that go into whether or not this person is going to increase wait times or increase morbidity or increase mortality? Are there particular line items within the data structure for the applicants that go on these things together, and would it be easy for the department to assess family by family, rather than individual by individual, or maybe just exclude the children altogether?
I know it's a long-winded question, but maybe we can talk a little about how this data is presented to the department and stored.