FROM JUNE 2023 ISSUE OF WEST END PHOENIX

Mr. Zhang* huddles next to the landline phone inside the Parkdale Queen West Community Health Centre as I sit nearby. He is listening to an English-Cantonese translator. The office phone has been placed on speaker so he can hear the translator, who could be anywhere. Zhang knows some English, but to chat about his health and his life as an uninsured and undocumented migrant in Toronto for the past 25 years, the translation service provided support.

I ask Zhang, a native of China, how he copes as a man in his early 80s with no health care, in a country that prides itself on what it claims is universal access. Or rather, I ask the unnamed translator to ask him that. His thin frame is bent over the phone looking as though it could snap at the wrong angle. He nods as the translator speaks.

Zhang wears a light tan jacket and a long-sleeve button-up shirt underneath despite the May weather outside, and pats my hand gently when I shake it.

But the warmth he exudes diminishes slightly when he speaks of the difficulties of old age in Canada without health insurance.

“I always worry that no doctor is going to take care of me,” says Zhang, who pulls his surgical mask back up over his nose as he speaks. “I have nothing. I have no medical card, and the only thing I can do is, sometimes, I will get some Chinese medicine, my herbal tea, to eat or to take.”

Zhang is a client of the Parkdale centre, which sits in the northeast end of Little Tibet, bordering Liberty Village. It provides services to more than 1,900 patients across Toronto who, like Zhang, don’t have health insurance.

Diana Da Silva, co-chair of the Health Network for Uninsured Clients in the Greater Toronto Area, says the majority of people who are uninsured do not have permanent immigration status. They include temporary foreign workers, international students or visitors, and undocumented or stateless people. Many within these categories face barriers to accessing a legitimate residency status, which impacts their ability to get health insurance. Such barriers can include mental-health issues that make filing documents difficult, uncertainty about the process, increased fees, language requirements and fears of deportation by engaging with the process.

The Toronto-based advocacy group Health Network for Uninsured Clients cites figures from the Wellesley Institute, a research and policy think tank that estimates there are half a million uninsured people living in Canada. At least half of the country’s undocumented people live in Toronto.

Da Silva notes that migrant workers who live on farms or who provide care in the homes of their employers can be barred from accessing health care or applying for permanent status.

“Temporary foreign workers who have a work permit should be able to get OHIP, but if they are living on farms where there are no doctors and no Service Ontario nearby, they won’t be able to get a health card,” she says. “Employers do have a history, in the past and present, of controlling workers, who are at the mercy of those who hire them”.

The Parkdale centre helps connect uninsured patients with doctors who provide care for free, or it pays for treatment itself. Some of the centre’s clients are dealing with serious health issues, including ongoing cancer treatment, says executive director Angela Robertson. And there’s concern that a client could face deportation if they are undocumented and seek care, she adds.

Robertson is clear that community organizations can shoulder only so much. Ontario provided what it deemed medically necessary care to uninsured patients at the outset of the pandemic, for the first time ever, by reimbursing hospitals for the cost. A report released in March by the Health Network for Uninsured Clients found that the program improved health outcomes for uninsured patients, reduced wait times and decreased the administrative burden on the system. It also paid doctors who sometimes offer these services for free.

The network recommended that the province make the change permanent. Instead, Queen’s Park cancelled the program at the end of March 2023.

Community-care providers and advocates told the West End Phoenix that the cancellation is unacceptable. And the problem isn’t fading with the decline of the pandemic, as Canada’s current immigration policies can make it difficult for migrants to attain permanent status, due to the increase of temporary work permits to meet growing labour demands, leading to more uninsured patients.

The Health Network is calling for the program to be reinstated immediately, or for OHIP to be provided to all. Not providing care only exacerbates the issue, as residents who are uninsured often wait until a health problem has progressed to a more serious stage before interacting with the healthcare system, says Da Silva. “In order to have a universal health-care system, we need to ensure universality and include everyone who works and contributes here.

“Canada is composed of a large percentage of immigrants and migrants,” she continues, “and they are the ones carrying this country forward. In a fair society, everyone needs to access health care.”

Zhang arrived in Canada in January 1998 after his sister, who lived in the Toronto area, phoned to encourage her single brother, who had no other family, to come and stay with her. She said she would take care of him. But after he arrived, Zhang found that getting a work permit in Toronto was impossible. He was already retired, unsure of what he could do, and for him, dealing with the paperwork without strong English skills was daunting. Zhang never obtained one. Health care, then, was impossible.

“I personally don’t know how to set up all that kind of insurance,” he says. “My sister is old now and in a senior-care centre, and that’s why nobody could help me. That’s the reason I’m feeling frustrated.”

Currently, in order to obtain an OHIP card, an individual who isn’t a citizen or permanent resident, or who is applying to be one, must have a valid work permit or be classified as a refugee or another type of protected person. Authorization is available for those in Canada due to emergency circumstances, such as refugees from Ukraine.

Zhang fit none of those criteria. After living in Canada for decades, he became homeless when his sister was placed in an old-age home. That was three years ago. He was admitted to a service centre for refugees, where he met a doctor who connected him with the Parkdale facility. Community health workers found him cheap, subsidized accommodation. He shares a house with four other people, each of whom has their own room. It costs him $182 a month.

But the fear of becoming sicker, especially at his age, is a pressing concern. He’s trying to create a savings pool, in case that happens. Though Zhang won’t say, the Parkdale centre said he likely has an under-the-counter job. “Because I have no insurance,” he says, “sometimes I need to save money in order to make ends meet.”

“Insurance should be given to all residents of Toronto,” he continues. “It would be very nice if the government could help me; it would make my life a lot easier.”

Those who are undocumented or whose documents have expired contribute to Canadian society in a variety of ways and need to benefit from the health-care system, argues Da Silva. “These folks live, work and contribute to our communities...and rely on makeshift, uninsured clinics that are underfunded, overburdened and can only provide minimal primary care.”

While the province would not disclose the cost of the uninsured program while it was running, she says, her organization estimates that it would have been hundreds of millions of dollars. But factors that may have escalated the cost included running it during the pandemic, and the fact that those accessing it may have waited years or decades for care that had therefore become more expensive.

A flash of frustration crosses Roberto’s face. His worn hands are woven together on the table as he speaks sternly in Portuguese to the translator on the phone.

I ask the translator if he is speaking Brazilian Portuguese instead of Roberto’s native continental Portuguese, which is pronounced with more hard consonants. The Parkdale centre had taken pains to ensure the correct translator was on the phone, and we were delayed trying to find someone who understood the differences.

The translator says abashedly that he used a Brazilian accent, which has annoyed Roberto. He won’t do that again, he assures me.

Roberto is 60 years old. He looks down while he speaks, his Steelers baseball cap shadowing his face. In 1998, he arrived in the Toronto area to visit his brother from Portugal. He liked Canada and wanted to stay, spending many years working in construction, but without proper work permits. Roberto tells me he paid taxes.

But in 2005, he developed a lung condition and had to pay for treatment out of pocket. Then, in 2022, he underwent heart surgery and also began having issues with his legs that he was not able to elaborate on with the translator, with the result being that he could no longer work. Roberto also developed diabetes.

The Parkdale centre’s support, along with Ontario’s funding for uninsured patients during the pandemic, helped him deal with these issues. And he doesn’t understand why the provincial program was discontinued. “I’m not old yet,” he says. “I still have some years left. But the work that I used to do one or two years ago, this is no longer possible since my legs, they get stuck.”

Roberto has been in Canada for more than two decades. And people like him who work in low-wage, essential jobs like construction are given temporary immigration status and face more difficulties in getting that status renewed, which impacts their health insurance, said Marshia Akbar, the Canada Excellence Research Chair research lead in Migration and Integration at Toronto Metropolitan University.

Too often, those who do essential work like Roberto struggle to access health care as they have to rely on their employer to provide them with insurance. And they often jump from job to job, as the work is precarious, Akbar says. Some allow a temporary work visa to expire, leaving them undocumented and without health insurance.

“There are many ways in which groups of migrants who do not have permanent residency are very vulnerable,” she says. “There are some clinics that provide healthcare services to undocumented migrants...but it’s so limited. It’s not enough to cover all these groups.

“The group that struggles the most are the low-skilled workers,” she continues, “who do not have enough pathways to get their status.” She explains that Canada’s goals around retaining highly skilled immigrants often overlook those who provide essential services, including food production, construction and care services. “We need them. There’s a labour shortage in these sectors.”

Six months ago, the Parkdale centre helped Roberto apply for immigration status, which has not yet been granted. “What made me go ahead with this,” he says, “was basically the fact I have this heart issue, and I’m not able to work. If it is not approved, well, I will put a rope around my neck, as some might say.”

Roberto feels strongly that those who work hard to contribute to Canada should have more chances to get citizenship and health care. “Life should be easier for us.”

*The West End Phoenix is withholding the names of the uninsured patients interviewed for this story because of the sources’ vulnerability and the backlash they fear due to their immigration status.

This health series is supported by the Joe Burke Fund for Social Justice Reporting, which was created in memory of Joe Burke, the late social justice advocate and lawyer.