Data collection

Data analysis

Interviews were transcribed, translated and accuracy-checked. All personal identifiers were removed. Data were inductively coded [32] by a coding team of trained community researchers, trainees, and coordinators, most of whom had lived in/migration experience. Coding was managed using NVivo v12 (QSR, AUS) and the team maintained a detailed study codebook. Data analysis drew on an inductive content analysis approach. We initially used content analysis to generate a set of initial codes to organize the data and describe key features. As interviews were conducted, the coding team iteratively adapted the coding scheme using analysis of initial transcripts and collaborated to establish a shared understanding of codes and their definitions. The second stage of analysis involved the first three authors reviewing codes pertaining to access to health services for women, focusing on emerging themes related to health insurance coverage. As the emergent analysis revealed that participants’ narratives frequently used the language and framing of ‘rights’ to critique and describe their experience with BC’s health insurance and services, during the final stage of analysis we drew on conceptualizations of the ‘right to health’ [14] to analyze participants’ perspectives on health insurance coverage, as well as its health and social impacts (e.g., unmet needs for care, discrimination, cost). Preliminary results were shared with im/migrant women participants and community partners (e.g., community advisory board meetings, partner meetings, and virtual sharing of plain-language materials and infographics), who were invited to provide feedback on the findings and their perceived accuracy, relevance, and implications to inform data interpretation as it progressed.

Participant characteristics

Among 78 im/migrant women participants, the median age was 31 and the median duration since arrival in BC was 1.59 years. Primary regions of origin were Latin America and the Caribbean (Table 1), followed by the Eastern Mediterranean and Africa. Three-quarters of participants spoke Spanish, with 21.8% (n = 17) speaking Farsi, Dari, and/or Turkish and 9% speaking Tigrinya, Amharic, and/or Arabic. The majority had experienced multiple im/migration status changes since arriving to BC/Canada; at the time of interview, 37.2% of participants were either a permanent resident or citizen, while the remainder had more precarious immigration status (e.g., undocumented, work or student permit, tourist, or refugee claimant/asylum applicant). Providers had a range of professional roles and represented various places of origin and languages spoken (Table 2).

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Table 1. Im/migrant women: Participant characteristics (N = 78).

https://doi.org/10.1371/journal.pgph.0001131.t001

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Table 2. Service providers: Participant characteristics (N = 10).

https://doi.org/10.1371/journal.pgph.0001131.t002

Findings

Following arrival to BC, im/migrant women commonly faced ongoing and severe barriers to health insurance coverage and health care—in stark contrast to common discourse framing Canada’s health system as providing access to health care, regardless of ability to pay, Our analysis identified the following five themes which describe various dimensions of im/migrant women’s access to and experiences with public health insurance coverage: 1) Ineligibility for public health insurance–which in BC is tied to immigration status and requires a mandatory waiting period following arrival (3 months)—resulted in serious negative impacts related to unmet needs for sexual and reproductive health, preventative, and curative services, and negative health consequences. 2) Women for whom health services were covered by insurance (e.g., women without insurance and in some cases, those requiring care not covered by MSP) described the economic burden of care to be unaffordable, unpredictable, and deeply stressful for families. 3) While becoming eligible for public health insurance (typically through immigration status changes) often improved access to care, women often received confusing, contradictory and incomplete information about health insurance that led to gaps in care for those affected by status changes. 4) Ineligibility for health insurance and the exclusion from systems of care this engendered was perceived as a form of discrimination amongst im/migrant women. 5) In response to these structural barriers, narratives highlighted the crucial role of community-based supports for minimizing harm and navigating exclusionary immigration and health systems. Below, we expand on these themes.

1) “A migrant doesn’t receive benefits”: Ineligibility for public health insurance and unmet healthcare needs

Of the 78 im/migrant women, almost three-quarters (n = 57) arrived in Canada without permanent residency and as a result experienced varying periods of precarious im/migration status that would have impacted eligibility for public health insurance in BC. For example, arriving as a visitor to Canada, changes in employment resulted in status gaps, reliance on employer or school for status, or periods of no status after rejected status claims. The remainder of the sample experienced some privileges associated with landed permanent residency, but experienced discrimination at the point of healthcare access (see theme 4—Discrimination, invisibility, and exclusion from care), and specific gaps depending on provincial regulations such as the three month wait period [28].

Participants overwhelmingly described the ways in which exclusion from government-funded public health insurance contrasted with their expectations when coming to Canada, which some identified as an infringement of their basic rights:

They treat us like…we don’t have rights…The most important thing in a family is to feel healthy, to feel well, and we don’t even have that (Latin American woman, 3 years in BC)

Such policy structures that failed to address the realities of im/migrants with precarious status in BC were often seen as placing im/migrant women and families in a state of limbo between their places of origin and destination–ineligible for coverage and unable to access affordable care in either setting.

As a result of being ineligible for public health insurance, im/migrant women faced high unmet needs for hospital, specialist, and primary care services. These included sexual and reproductive health (SRH) services such as contraception, STI testing, prenatal care, labor and delivery care, preventive check-ups, and treatment for ongoing and emergency conditions. Particularly severe impacts were faced by pregnant women, who were often left completely excluded from coverage, since pregnancy is considered a pre-existing condition for which private insurance companies will not provide coverage. As a result, participants faced gaps in prenatal care. Many did not receive standard-of-care (e.g., early and regular prenatal visits), with numerous women reporting their first prenatal visits as late as six or seven months into pregnancy–a violation of both maternal and child health rights [14]. These concerns were particularly alarming given that participants’ experiences of pregnancy were often associated with complex, traumatic health needs or obstetric emergencies, thus adding financial stress at an already-stressful moment:

In the moment when your labor is not going as planned, in addition to that emotional pain that you feel when you realize that your labor is not going to be as you wanted, you have the worry about the fact that you know that everything is not going to cost $1000 (CAD), you know that it is going to be around $10,000 (CAD). I don’t know what hurts more. (Service provider)

As a result of policies excluding them from public health insurance coverage, women often described feeling powerless to protect the health of themselves and their families and expressed desperation that no one would fall ill; such concerns were compounded by the gendered nature of caregiving. Participants commonly described immense concern about the cost and burden of falling ill while being uninsured. Those who had only dealt with minor health issues since arriving expressed profound relief, recognizing that they would not have been able to access care had they faced more complex needs. As one participant explained:

When I felt that I was beginning to get sick I would tell myself that I didn’t have a right to get sick, I would say “shake it off, you can’t get sick”…thank goodness nothing else happened to me. When the hospital bill arrived I said, “no, I won’t get anything else”. (Latin American woman, 5 years in BC)

2) “For me, that’s a fortune”: Prohibitive costs of care and economic burden

High out-of-pocket costs for healthcare not covered by BC’s public health insurance program posed a prohibitive barrier to care that shaped access to care and types of care accessed, and in some cases resulted in foregone care altogether. High and unanticipated costs represented an extreme economic burden and source of stress for families. In many cases, accessing care meant forgoing other essential needs (e.g., food, housing); in cases where families could not pay their bill, some reported having collection agencies come after them after giving birth in a hospital.

Many participants described concern regarding a lack of clear information provided to im/migrant women and families regarding what the cost of care would be until arrival at the point of care, or in some cases, after services were delivered. Clinics and physicians in BC are allowed, and it is common practice, to charge fees for “uninsured services” that are much higher than the insured rate. Despite the College of Physicians and Surgeons of BC recommending that its’ members consider what is “reasonable” and what a person can afford, there are no established guidelines for routinely covered services.

Cost considerations restricted women’s agency in accessing types and modalities of care related to SRH care (e.g., prenatal care, labor and delivery, contraception, ultrasounds) and resulted in unmet or delayed access to preventative check-ups and lab visits. For example, some participants noted that they would have rather given birth in the hospital, but opted for homebirth to avoid prohibitive costs. For participants who delivered in-hospital, high hospital fees resulted in pressure to leave quickly, sometimes in poor condition, and in many cases earlier than they felt was appropriate. One woman paid $15,500 [CAD] for a caesarian delivery and left hospital before full recovery to avoid additional costs. Another uninsured woman described multiple instances during which she was advised to go to the hospital during her pregnancy–because she began to bleed while pregnant–but left after being informed of the prohibitive costs:

I went to emergency and just for going into the hospital they wanted to charge me $1000 [CAD], and I got nervous and left, because I didn’t have [the money]. With only my husband working, rent, I mean, honestly…(Latin American woman, 4 years in BC)

In addition to the challenges faced by uninsured women, both insured and uninsured women faced cost-related barriers to services that are not covered by public insurance (e.g., medications). For example, while many participants from Latin America described accessing sexual health screenings or low/no-cost contraception (e.g., oral contraception, surgical) in home countries, upon arrival to Canada, these services were prohibitively expensive for many. While some provinces do cover select prescription medications for individuals who are already enrolled in public health insurance—requiring that many Canadian citizens hold private health insurance for any non-covered prescription medications—barriers were greatly exacerbated for uninsured im/migrants. This was largely due to the two-step process to accessing prescriptions necessitated by a gatekeeper model that requires patients to visit a primary care provider for diagnosis and prescription, which must then be filled and paid for at a pharmacy, with added costs at each step for those without insurance. As a result, contraceptive health care choices were restricted, and many women and their partners were forced to use whichever method was offered for free or forgo contraception entirely. These logistical barriers and challenges caused confusion and anguish for participants, particularly for those used to healthcare all being under one umbrella in home countries.

3) “It was an improvement for us”: Impacts of becoming eligible for health insurance

For women who recently arrived to BC or experienced periods of precarious status, becoming eligible for public health insurance often dramatically improved access to care. This was typically achieved following immigration status changes or the end of the mandatory waiting policy after moving to BC. Due to the stress and costs associated with being uninsured, becoming eligible for public health insurance was accompanied by peace of mind and improved access for women and their families, including formerly uninsured children:

We did the papers for our residency and they gave my husband a work permit. Immediately we got insurance for my son so that he could have access to healthcare. (Latin American woman, 3.5 years in BC)

It was an improvement for us…here, without being legal it’s hard…with immigration status it’s different, and you can access several supports. (Latin American woman, 1.17 years in BC)

Despite the potential for status changes to improve access to healthcare coverage, women and service providers reported confusing, contradictory and incomplete information about health insurance that led to gaps in care for those affected by status changes. Those newly eligible for public health insurance described facing additional confusion and barriers associated with the 3-month waiting period for health insurance coverage [28,33]. For example, one woman did not receive any prenatal visits during the wait period, because she was turned away for not having proof of insurance and did not know she could pay out-of-pocket. She later miscarried and does not know the cause. Others thought they could access care during this wait period—since there was no mention of cost at the point of care—but were later sent unexpected bills.

Additionally, there have been changes to Canada’s Interim Federal Health Program (IFHP), which grants temporary health insurance and other social benefits to refugees and refugee claimants [34]. Both im/migrant women and providers found the administrative hurdles and changes to the IFHP to be confusing and difficult to navigate; for example, knowledge of coverage and specific services covered, cost, billing procedures, and acceptance of IFHP by different providers were all described as unclear and challenging to navigate. Whereas refugee women largely expressed concern that they felt ‘in the dark’ regarding how, where, and when they could use IFHP and the implications of being unable to effectively access care under IFHP for themselves and their families, providers focused more on the administrative challenges this posed, expressing concern about the impact this had on their clients.

It wasn’t until my boy got sick that the lady from the Church told me that with that paper [IFHP] they were not going to charge me anything and they will take care of my son. But I didn’t know the paper was useful for everything. I didn’t know. (Latin American woman, 1 year in BC)

They [providers] need to know, OK, this person has federal coverage, and then [patients] need to know which providers they can go to, including obstetricians that they might need, that are registered under Blue Cross, Federal Health, so that they don’t get billed, so it’s…yeah. This confuses me, and I’ve been doing this for seven years, so how do folks know this? It’s really, really difficult. Lots of barriers. (Service provider)

These challenges often persisted long-term, with some women recalling that they did not realize they were eligible for health insurance and therefore did not seek out health services, even long past the point where they first became technically eligible for health insurance coverage.

I don’t think we had a family doctor until like two years that we were in Canada…Cause nobody really would, like- I think they charge for it before, no?…Can you get a family doctor if you don’t have, your, like PR or citizenship or something? (Latin American woman, 11 years in BC)

4) “They will leave you to die? Because you’re not from here?”: Discrimination, invisibility, and exclusion from care

The multiple ways in which im/migrant women and their families were excluded from care resulted in feeling ‘invisible’. Women struggled to identify where they could access services “as a human being here, regardless of status” (Latin American woman, 1 year in BC). Providers concurred that the needs of im/migrants–particularly those who are uninsured—are infrequently acknowledged in front-line health care settings, and as a result, staff are often unsure and under-resourced to appropriately support these patients.

Experiencing the impacts of structural racism, xenophobia, and gender inequity built into health and immigration systems and policies, experiences of poor treatment or being unable to access services at the point of service delivery were perceived as deeply discriminatory and unjust by im/migrant women:

[It was] racism. Because for a health service it shouldn’t matter if you’re from…well, I know that obviously not all of us can enjoy the privileges of, like, those from here, Canadians, but they also don’t have the right to push you aside. If you get sick, they will leave you to die? Because you’re not from here? (Latin American woman, 4 years in BC)

The experiences of undocumented women and mixed-status families highlighted the ways in which administrative procedures in clinics and other health service delivery settings–such as asking for proof of health insurance coverage–were often deeply-fear provoking and resulted in avoidance of care. In an alarming number of cases, participants recounted xenophobic experiences in clinics and hospitals that created significant mistrust and fear that accessing care would result in negative immigration consequences:

If you go to a health centre and they say…”Why are you in this country if you don’t speak English? Why are you here?”…yes, going there, I perceived that they would not open their doors and I felt a lot of fear. It was practically that, by asking for medical attention it was a button to be sent home instead of to receive medical attention. (Latin American woman, 6 months in BC)

[At the hospital] they started to question us, to ask us for papers… what we did was better to get out quickly…we were afraid, I mean, because as soon you get out of the hospital you see a lot of police officers…and when they start questioning you, “let me see your papers”…well, what option is left but to leave… [even though] my hands swell, my face swells…no, I can’t go to the doctor.(Latin American woman, 5 years in BC)

5) Supportive role of community-based organizations

Despite these immense structural inequities, supports provided by community-based organizations and im/migrant-friendly providers who supported them were essential for reducing harm and supporting system navigation. Local community-based, non-profit organizations–particularly those staffed and led by im/migrants—played a crucial role in connecting women to low/no-cost healthcare, and provided essential socio-economic supports (e.g., food, economic assistance). In many cases, these efforts were successful in advocating for reduced or no-cost services (e.g., pregnancy care).

Related to the pregnancy I cannot complain… [Community Based Organization] helped me a lot, a lot, a lot. With the hospital, they treated me well. I was checked by the doctor. For me, thanks to [Community Based Organization]…my baby is doing well. I had a place to give birth… I had no problems related to that. I have not gotten sick; I have not had to go to the hospital. Now, [my baby can] go to the doctor, because [Community Based Organization} helped me get [his medical card], if not, I wouldn’t have been able to. (Latin American woman, 8 months in BC)

Providers and participants alike spoke of these efforts being under-resourced and under-prioritized by the government. One provider blatantly acknowledged that while there was an official understanding in their healthcare setting that all im/migrants have the right to access care, in practice “there are still no answers for how to treat people without [public health insurance].” Another participant discussed the gaps created by the defunding of Vancouver’s only refugee health clinic:

I had a medical need and I went with my kid to a walk-in clinic where they had told me that they see you without a problem, but when I arrived there, it was closed. They closed it because the government stopped the funding for that clinic, so they closed it. (Latin American woman, 5 years in BC)

Participants discussed the need for increased awareness and protective policies that support the needs of communities who are made invisible by current health and immigration systems. As one recently arrived woman noted, making the experiences of this population more visible and advocating for their needs were described as important steps towards this:

It is like a hidden community from the government…[the community should] fight more so that the government does not discriminate or…focus so much on the person’s status when offering services (Latin American woman, 6 months in BC)

Strengths and limitations

As im/migrants with precarious status are under-represented and often entirely absent from population-based and epidemiological health research, a strength of our work is generating unique insights regarding lived experiences with health insurance and impacts on health and human rights for this population in BC. As sampling focused on representing a range in experiences among recently arrived im/migrant women facing precarious circumstances, findings may not represent the vast diversity of experiences of im/migrants in BC or elsewhere. To ensure rigor in our interpretation of data, we maintained a detailed study codebook; employed “member-checking” with participants; and sought analytic consensus among multiple coders. Finally, our community engaged research approach helped to ensure the relevance and accuracy of our findings to the local community and supported meaningful and trusting relationships with participants and community members.

Conclusion

In contrast to common perceptions of Canada’s health system as ‘universal’, participant narratives highlighted the ways in which ineligibility for public health insurance coverage resulted in unmet needs for essential sexual and reproductive health care, preventive care, and curative services among im/migrant women, children, and families. Additionally, ineligibility for public health insurance resulted in negative impacts including a high economic burden, and perpetuated experiences of discrimination, invisibility, and exclusion from systems of care amongst im/migrant participants. Expanding health insurance options to cover all residents and decoupling health insurance eligibility from immigration status are recommended, alongside implementation of local-level ‘Sanctuary’ policies, which would reduce access barriers, better reflect principles at the foundation of ‘universal’ health systems and meet global commitments to uphold the right to ‘health for all’.