Reverse “Cherry Picking”

I’ve had this thought for some time, and I’ve explained it in conversations but never posted it here.

The current process of determining when something is “excessive demand” is to take the medicals for every person in the family and then picking the one that has a condition requiring treatment and using that to declare the entire family is inadmissible.

I’m having a difficult time how this seems fair to a reasonable person.  The numeric value is computed as an average over the population.  So, how do you take the average of one group and the worst case of a second group and make any reasonable determination on such basis.

Instead, I would suggest this is a form of reverse cherry picking – you pick the worst sample of the group and then discard the entire group.

My suggestion: if you find yourself in this situation, make the argument.  Get someone at IRCC to explain why this is fair.  I’d suggest that what makes more sense is to compare average to average between groups.  So a family with three children, one of whom needs special education services, would be evaluated as a family.

Perhaps I’m wrong here.  I’m interested in hearing people’s opinions on this.



Happy Anniversary!

Today marks the 3rd anniversary of my refusal letter.  It’s amazing to me that it has been that long: I really had to think about it this morning to confirm the length of time, as I’d originally thought it had only been two years.

I continue to learn more about medical inadmissibility in Canada – it continues to impact real people, often in surprising cases.  I have been able to help several people through the gauntlet.  By far the most successful path through is to demonstrate that the actual medical treatment required falls below the excessive demand threshold – it’s surprising how often CIC medical officer’s just say “it’s expensive” and foist the burden of computing costs back onto the applicant.

As for me, well I’ve turned my eyes towards the citizenship process.  With the impending changes to the process I either must apply now (and face a 3 year wait to chat with a Citizenship Judge) or wait until sometime in 2018 to apply (and face a 2 year wait…)  Life continues to be interesting.

For those of you dealing with Canadian excessive demand medical inadmissibility I wish you the very best.  While I’m not nearly so active these days, I do continue to answer questions and leave this blog as a (hopefully useful) resource for those facing it.

I do hope to read one of these days that the Federal Court has struck down A38(c)(3).  Maybe because it violates the separation of powers between Federal and Provincial governments, maybe because it violates the various UN agreements to which Canada is signatory, or because it violates the Charter rights.

Whatever the reason, it will be nice to see the morally repugnant scheme struck down.  And maybe – once I have citizenship – I’ll be more public and vocal in the political process for reform in the system.  As a permanent resident I have to worry about the criminalization of protest in Canada – after all, it only requires one brush with the law and permanent residency can be revoked.  And since permanent residents remain so by the grace of her majesty’s government it’s generally best to remain “below the radar”.

Best wishes for all in 2015!

Defending Healthcare: A Different Perspective

Positive Living I recently read an article under the banner “Fighting Words” entitled “Defending healthcare“.  The authors in that article threw down an interesting jingoistic saying.

Right now, there’s a legal attack before the courts that could turn Canada’s medicare system into the type of system found in the United States.

I understand the authors’ desire to inflame passions and press forward with their point, but of course I thought of the benefits that the US system has over the Canadian system when it comes to those that Canada deems to be “medically inadmissible”. The Canadian Healthcare system covers most people in Canada but in exchange for this universal coverage the Canadian system systematically refuses anyone with certain medical conditions entry into the Canada.  Indeed, the very disease of most interest to the authors and readers of this magazine (HIV positive people) is the one disease that Citizenship and Immigration Canada refuses as a matter of policy. I’m sure there are folks who understand that the written policy is to perform an individualized assessment of people.  But pragmatic experience in helping people with medical issues has taught me that in fact HIV is one of those conditions that are refused as a matter of course. Thus, while the authors view their healthcare system as being a wonderous thing, my perspective is that is is the fundamental justification of a morally bankrupt system intent on classifying anyone with HIV (or Down’s Syndrome, etc.) as being an unmitigated drain on society. The US system does not discriminate in this fashion.  The US immigration system is not tied into the costs of the US healthcare system.  The Canadian immigration system is. And it continues to get worse.  Essentially, anyone immigrating to BC would automatically be excessive demand because the province pays for all drugs (albeit in exchange for your agreement to enter the UBC research study.) Once Canada permits pre-exposure prophylaxis (PReP) not only can a disease condition be used to refuse someone entry into Canada, but even being at high risk could theoretically be used to justify the same thing. While I don’t post too much here anymore, I continue to communicate with people trying to find their way through the medical inadmissibility system.  Recently I communicated with someone who was given a fairness letter without any cost estimates at all. Just the blanket assertion that their treatment was expensive and paid for by the public healthcare system. I must admit, I was incensed at it.  Why?  Because the persons treatment was the only treatment that doesn’t exceed the threshold.  It’s all generics (Neverapine, Lamivudine and Zidovudine).  Using the Quebec published numbers, the cost was something like CAD$2,500 per year. So much for “individualized assessment”.  Hence my claim that, like it or not, it leads to systematic refusal of people with specific health conditions.  Like HIV. If you want a better health care system, stop using it to discriminate against people that want to come here but cannot because they might use it.  At least come up with some mechanism that balances inputs from outputs. In the meantime, pardon me for disagreeing with this blanket rosy self-congratulatory claim of superiority.  It rings hollow.

BC And Drug Coverage (Revisited)

Canada's Source for HIV and Hepatitis C information


In my previous post about prescription drug coverage in British Columbia I did not really go into detail about the evidence supporting my argument that the province does not cover drug costs for HIV specifically.

In this post I’d like to rectify this oversight.

First, each province has a governmental website dedicated to explaining the coverage provided by provincial health care. In BC, it is Fair PharmaCare that provides coverage for some prescription medications. The BC website includes a drug formulary that describes the drugs covered by the provincial plan.  British Columbia has a separate panel that actually reviews drug information as part of the process of being added to this formulary and after careful scrutiny recently that program has been renewed.  While I did not check every single drug for HIV available, I checked those that are commonly prescribed (e.g., tenofovir, efavirenz, raltegravir, ritonavir) and the once-per-day treatment options (Atripla, Complera, and Stribild).  None of them are listed in their formulary.  Further, that formulary explicity states that they do not describe drugs covered by the BC Centre for Excellence in HIV/AIDS. This group is a non-governmental research group with funding from a variety of sources, including the provincial government.  The web page for the therapeutic care given explicitly states:

The Drug Treatment Program (DTP) is an innovative research and treatment program designed to ensure that all medically eligible persons living with HIV in British Columbia have access to free antiretroviral therapy.

Established in 1992, the DTP currently provides nearly 5,500 patients with access to life-saving drugs.

One of the foundational programs of the BC-CfE, the Drug Treatment Program is funded by the provincial government (PharmaCare) to distribute anti-HIV drugs based on guidelines generated by the Therapeutic Guidelines Committee. Information from all participants is entered into a database, providing data for clinical and virological outcome studies of patients receiving antiretroviral therapy.  This database acts as a registry of all HIV-treating physicians in the province, as well as an “early warning system” to alert government about the trajectory of the disease.

Thus, the data from patients working through this program is used to further the research goals of this group.  While one could claim (as CIC does) that this constitutes “free drugs” in fact it does so for the express purpose of using the participants as guinea pigs in the research being done by this organization.

Further, this group limits the therapeutic options that are available to participants.  In this published list a surprising number of drugs listed are subject to restrictions.  For example, my own doctor said the therapeutic option he recommended would not be approved by the Centre for Excellence – and normally he can’t prescribe this specific therapy precisely because it won’t be approved.  When I looked at that list, all but one of the drugs he prescribed to me are listed as “Certain restrictions apply”.

So “free” can also mean “therapeutic options in the best interests of the research group, not the patient”.  That’s the nature of a research study – it’s primary focus is in collecting information about the subject under study.  But I suspect most patients want to pick the best therapeutic option for them personally, not the one that forwards the interests of a research study or group.  Of course, some people do choose to enroll in research studies (e.g., clinical trials) in exchange for something: lower costs, otherwise unavailable therapeutic options, etc.

As an aside, notice that all the Centre for Excellence web pages are actually maintained by the University of British Columbia.  While that’s a public educational institution, it’s not one that is generally associated with the provincial health care system and operates as an independent organization.

So, for anyone else facing this situation in the future, do your homework. Regardless of the province where you intend on landing, don’t assume that the medical officer knows the provincial rules.  It’s quite possible that he or she is just making it up, based upon her or his own misconceptions.  For example, in my case the medical officer stated:

This applicant’s medical condition is likely to require treatment that is expensive and publicly funded in B.C.  Although he has private insurance, antiretroviral medications are covered 100% by the provincial drug plan in the Province of Britsh Columbia with no payment from private insurance.

She completely misunderstood the BC plan.  It isn’t funded by the provincial drug plan directly.  It’s funded indirectly through a research study: you must accept loss of privacy and you must be willing to accept treatment options that advance the research effort and are not necessarily the best options for you as a patient.  In my case I had private insurance to cover the best therapeutic option.  Why would I choose an option that wasn’t best for me?

From my interactions with others caught in this quagmire of excessive demand, it really does seem clear to me that it’s more about reinforcing biases against people with disabilities, despite Canada’s obligations to the contrary.  Ah, but that’s topic for another blog post.

BC and Drug Coverage

Fair Pharmacare
I recently did some analysis of the BC health care coverage for prescription medications for treating HIV. To my surprise, it would appear that none of them are covered under the provincial prescription drug plan.

Why did I find this surprising?  Because this is the very basis of the decision by CIC to refuse my original application.  But the teensy detail they failed to mention (and I hadn’t fully grasped) is that in order to obtain “free” medications in British Columbia you must enroll in the grand medical/social experiment.  In doing so your detailed medical information is provided to the Centre for Excellence for whatever use they deem.

Further, as it turns out, the Centre for Excellence maintains a strict policy with respect to treatment options.  So if your doctor thinks you would be better served by a different treatment option than the ones permitted she probably won’t even mention it to you because she knows it won’t be permitted by this group.

Thus, gaining access to this “free treatment” isn’t part of the health care policy, but rather it is in exchange for agreeing to be a guinea pig in this large medical experiment.  It seems to be a harsh basis for a refusal simply because there is a research group that will permit you to trade your medical privacy (so they can obtain something of value from it) in exchange for “free medication”.   That sure looks more like the normal arrangement for medical experiments.

Thus, it would seem that CIC’s position is that if there’s someone out there that obtains governmental funding for doing research and you might be willing to exchange something of value (your right to the best treatment option for you specifically and your medical privacy rights) for something that might also be helpful to you, then you’re just ineligible to come to Canada in an economic class – well, at least for British Columbia.

I wish I had known about the nuances of how the system worked several years ago, because this would have been a rather interesting conversation: anyone who doesn’t want to participate in the experimental study group has no coverage.  None of the drugs I checked were covered by Fair Pharmacare, which means they don’t count against the cost limit ($10k maximum, lower amounts based on income).  Thus, they cannot create excessive demand.

And if someone does wish to participate in the experimental study group they can do so – but it’s a standard commercial exchange.  The study group does receive governmental funding, but those funds are used as a quid-pro-quo for something else of value.

Lee v MCI

MP Jason Kenney of the Conservative Party fiel...

Citizenship and Immigration Canada has been doing some major revisions to their website of late.  One area in which things are more interestingly laid out is the area dealing with medical issues, in particular, medical inadmissibility due to excessive demand.

I’m familiar with most of these cases, but I’d never reviewed the oldest of them: Lee v MCI.

Why is this important?  Because in the Lee decision, the court overturned the refusal because the officer failed to consider the applicant‘s request for a Temporary Resident Permit (TRP).  That request was a bit informal from what the record indicates.  Yet it reminded me that in our own original response to the visa office we asked they consider a TRP.  This was never addressed by the visa officer, nor was it raised in the application for leave and Judicial Review we filed.  In my case it didn’t matter (we obtained leave anyway) but it’s important for people going through this process to keep in mind they do have the option to request they be granted a TRP and to raise this as an issue in any legal challenge, as there is case law on-point here.

So if an officer has a concern about something in your plan – for example, perhaps she or he isn’t sure your insurance will cover the cost of prescription drugs – rather than blanket refusing you, she or he could grant a TRP for a period of time, say six to twelve months, with the understanding that in that time the applicant should be able to confirm that the insurance plan is working as intended.

Or let’s revisit Companioni – where the judge was concerned that their plan was inchoate.  To create a viable plan essentially required they be in Canada – after all, even my own plan was viable only because I was already in Canada.  Everything was set up and ready to go.  So to get out of the “chicken and egg” issue here, a TRP could allow someone to come to Canada for a short period of time – a year, for example – and set things up so she or he could show that they really wouldn’t be a burden.

After a year, the applicant could go back and apply for an extension, pointing out that the plan is working and the applicant is not a burden.  If that’s the case, the TRP can be extended again.

After three years of this, the applicant becomes eligible for permanent residency as a member of the “permit holder’s class“.  The medical inadmissibility concern is no longer an issue to CIC – but an officer had two opportunities to review the file and verify that the applicant really was complying with the terms and conditions of the application.

This underscores one more approach that a motivated applicant can pursue.