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.

Advertisements

BC And Drug Coverage (Revisited)


Canada's Source for HIV and Hepatitis C information

CATIE.CA

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.

Happy (belated) Anniversary!


First AnniversaryI meant to finish this up yesterday, but somehow the time just simply got away from me.

December 22, 2011 was the date upon which Ms. Marlene Edmond of the Citizenship and Immigration Canada visa office in New York City, NY, USA officially rejected my application for permanent residency.

Thus, on this the first anniversary date (plus one) of the rejection I am looking back.  Things have changed dramatically in the past year.

When she has to refuse an application I wonder if she worries if she has made a mistake.  Perhaps in a case such as mine she doesn’t – though the subsequent events suggest to me that in fact the rejection – or at least the procedure leading up to that rejection – was a mistake.  I have no idea if such cases are ever reviewed internally at CIC to see if they are actually “doing things correctly” or not. I do know that it seems like once they lose a case, they bend over backwards to correct whatever the fundamental flaw was in the original process.  Still that doesn’t guarantee that the application will be granted.

In Ms. Edmond’s case, my opinion is that her mistake was in not pushing back on the medical officer’s decision.  That even a casual reviewer – let alone an immigration officer of her many years of experience – would look at this and say “wow, how can you reach a conclusion that someone is inadmissible when they have multiple overlapping plans for payment that don’t require on personal promises to pay and cover 100% of more than 4x the estimated current cost?” suggests to me that she should have been asking that question.

Or perhaps another way of looking at it Ms. Edmond: if you were going to reject me simply because of the policy of British Columbia, why did you ask me to submit anything to you in the first place?  I could have saved the thousands of dollars I spent in responding to the fairness letter and you wouldn’t have needed to waste your scarce resources on reviewing that response.   Indeed, looking back at it now, I find it difficult to see how a Federal Judge wouldn’t have asked that question – and therein concluded that there really was no “individualized assessment”.  After all, the decision simply required referring to the provincial policy.

In Sapru, the Court concluded that the immigration officer could not “fix” the poor decision of the medical officer.  In my case, the Medical Officer Hélène Quevillon really didn’t have any other reason in her original written notes to indicate this was related to me – it really was about BC’s public funded drug policy.  Ms. Edmond didn’t even go as far as the officer in Sapru did – she certainly didn’t push back on Ms. Quevillon’s determination and there is absolutely no indication that she reviewed that decision, especially in light of her duty to do so under the Sapru decision.  She certainly didn’t try to invent additional rationale for reaching the decision.  Thus, she acted more like a rubber stamp – with even less “value add” than was the case in Sapru – a case in which the Court overturned CIC’s decision.

So while I seriously doubt that Ms. Edmond will ever review her decision in my case, if I could communicate directly with her I would say that I am disappointed – not in the outcome, but rather in her execution of the process.

I am quite fortunate – I had the drive and resources available to challenge her decision.  Most people in such a position likely just walk away from the decision.  That is why it is so important that people like Ms. Edmond do their best to ensure their decision is fair and equitable.

In the interveningyear, I’ve had the honour to assist several people with their cases, and one is a case similar to mine: a federal skilled worker application in which the spouse was found to be HIV positive.  The medical decision is still pending – they have now furthered it once again, because the test results indicate that without treatment this individual does not require treatment under current guidelines in their intended province.  Of course, if they were coming to BC it would be easier – CIC could just reject them, since the provincial policy is to provide treatment to everyone, regardless of their lab results.  It saddens me to see how difficult this is for people – leaving their lives hanging in the balance for months and years.

So Ms. Edmond, it’s been one year now since you wrote that rejection letter.  Even now as I read the closing (“thank you for your interest in Canada“) I feel a certain degree of bitterness with the snide nature of that closing line. Canada deserves better – it deserves immigration officers and medical officers that remember there are real people behind those files.

While I didn’t win the victory I really wanted, I have managed to achieve sufficient victory for me to be satisfied with the outcome.  I hope both you and Ms. Quevillon do your very best for Canada now and in the future.

Merry Christmas!

 

The importance of a credible plan


Cerebal PalsyPeriodically I read decisions as they come out of the Courts regarding medical inadmissibility.  This case (De Hoedt Daniel) was heard here in Vancouver – I wish I’d been there to hear the arguments.  While the finding of excessive demand medical inadmissibility was upheld, the judge had some unusual words to say.  For anyone dealing with issues of medical inadmissibility there are valuable lessons in this case: be prepared, present a credible plan.  The shape of a possible plan just isn’t enough.  Indeed, this is the same lesson as Companioni – your plan must be real enough to convince a CIC officer.

Of course, even so, such a plan is not a guarantee of success.  They turned down my plan – even though it was a real, in place plan.  The final rationale offered for rejecting my plan (“we weren’t convinced that the plan would work for medication available for free from the province”) was created after-the-fact and failed on even a cursory analysis – the plan included a non-discretionary plan.  I also verified that the insurance would cover the medications by actually filling prescriptions – although that was done after the rejection.  Had the visa office expressed that concern, it would have been easily addressed. They didn’t do so however – they just rejected.

Here is the interesting comment at the end of the decision (an obiter dictum):

It is recommended by the undersigned that the number of well-intentioned individuals, organizations and entities, having come forward to assist the Applicant with the care of the said child, begin the process again and that the Canadian authorities give priority to that process, recognizing the time and effort that has already been given to the voluminous documents accompanying the application for permanent residence by all involved, including the specific individuals and entities in Maple Ridge, British Columbia.
It would seem that a viable plan requires the preparation of a practical commitment on paper to ensure that it is acknowledged and understood as such by the authorities who would then make their decision thereon.

This is an essential point for anyone involved in a fairness response: your plan needs to be real, it needs to be concrete and it needs to be clear to the decision maker that it overcomes the initial concern of excessive demand.

I cannot stress this enough: you must have a credible plan.  It needs to be in-place, workable and it must address the cost concerns – remember, this is all about money. That’s the issue you must address.

Ideally, anyone in this situation (dealing with a fairness letter regarding medical inadmissibility) should keep this point in mind: have a clear plan.  Make it concrete and real.  If it is hypothetical or the visa officer has any doubts about the viability of the plan, it will likely be rejected.  Better to do the up-front work and overcome the objection before it makes it before the court.

Decision time


 

So I am now faced with a very difficult decision, one that pits my personal interests against my sense of duty and obligation to others.

I’ve been forced to really carefully review my current situation and attempt to determine what is my best course forward, because the decision I make now has potentially long-term consequences for me and for others in the future.

So where am I right now.  At the present time I technically have four different applications ongoing with respect to some aspect of my immigration status in Canada.

The oldest is my original application to be an immigrant to Canada in the Federal Skilled Worker category.  I applied in that because I seemed to be qualified.  I don’t think I fit the typical skilled worker model – I wasn’t looking to go to work for an existing company.  I’m already established in my field, I’ve written books, I give lectures and talks, I work with companies all over the world. Thus, no matter where I live, I bring my skills and my customers with me.  I actually made the decision to apply back in 2006.  Had I not waited three years to do so, none of this would have happened, because I’d have been done in 2008, even with the 18 month processing time typical at that time.

But I didn’t – I applied in June 2009.  By the time they got around to doing my medical I tested HIV positive and while not an “automatic” failure to qualify for FSW, based upon the rejection I did receive it is for all intents and purposes an automatic failure for anyone planning on immigrating to British Columbia.  The attorney I was using at the time basically gave up on me at that point, once I received the follow-up medical request.  I hadn’t thought much about this honestly, until my conversation with my current attorney – but it did profoundly impact my willingness to trust anyone else, something I had not seriously thought about until after my conversation with my current attorney on Friday.

I’m the one who found my current attorney.  I did so by finding the Companioni decision and then looking through other decisions.  There are only a handful of attorneys with serious experience in medical inadmissibility and mine seems to specialize in the HIV cases. I’d been preparing the path to a solid response for quite some time.  Being an American I’m used to the idea of buying private insurance – indeed, it’s one of the very first things I did once I moved up here to work, which is quite fortunate because I wouldn’t qualify for personal private insurance any more.  I organized a group insurance policy as well and worked with my employer to set up a Personal Health Savings Plan (PHSP), which is a form of “health savings account”.  Thus, by the time I started working with my current attorney I’d put together all the fodder necessary to present a strong, credible, and current plan.

Behind all of this is my own fundamental distrust of the very paradigm that one must assume is true in order to create such a strong, credible, and current plan.  While I’m sure it marks me as a heretic, I find mounting evidence that the model of pharmaceutical intervention is deeply flawed.  I did write up a document to that effect and I even circulated it to my attorney and he did so to the expert who wrote up the report for me.  There was some feedback on it, but it was essentially negative – no surprise coming from someone who is deeply plugged into the current paradigm.  But the model for medical inadmissibility here doesn’t allow you to refuse the preferred treatment paradigm, no matter what the basis: religious, moral, philosophical or even scientifically based.  So while I can (and did) point to papers that say “um, this treatment paradigm doesn’t really work the way we’re telling people it works” (much like the article in the Guardian to which I linked earlier) that isn’t a winning strategy – and I did want to win.

Of course, in parallel with all of this I have the growing relationship with my now husband.  I’ve had previous relationships, and I was even married for quite some time, but this time my feeling is I’ve really found something quite special and that feeling has only grown and intensified.  When I received my fairness letter in early April 2011 it was actually upsetting, even though I had expected it.  I was very grateful for his strength and support and that was the final push and I asked him to marry me.  He agreed instantly.  We married six weeks later, after a week of actual planning – we literally were at breakfast (Dim Sum) and I said “so, you busy, because if you aren’t how about we get married?”  We didn’t get married that morning, but we did pick up our marriage licence.  We spent some time online looking at wedding bands and found several we liked at a local jewelry store, which is where we went the next day after he got home from work.  After looking at over a dozen different bands we narrowed it down to three.  He wanted me to pick, but I said, no, you pick one, and I’ll pick one and then we’ll figure it out from there.  We picked the same ring.  Even more amazing, they just happened to have two of those rings in stock.  Given that usually they have to order these things, it was surprising.  I’ll just say that it lent it that magical sense.  I contacted a wedding commissioner here, found she was available on the date we wanted (one week from getting the licence) and so we booked with her, made arrangements for two close friends to accompany us.  The day was an amazing spring day – sunny, bright, warm.  A true rarity in Vancouver in spring.  I even won the lottery that day!

The deadline for the initial submission was a Sunday, May 27.  My attorney indicated he had asked for an extension, but I’d not heard anything back, so I sent a copy of the document I had written, along with a cover letter saying that my attorney had asked for an extension and I wanted to make sure something was on file.  I also indicated that I’d been married, since I’m under an ongoing obligation to do so.

When the marriage certificate came in mid-June, I forwarded a copy to my attorney (although it turns out it was forwarded to my previous attorney, not my new attorney) and to CIC in NYC.

So, we submittted the mitigation plan.  My attorney did an excellent job of clearly laying out the issues and pointing to the case law, and my hat is off to him. When I noticed the change on the online CIC tracking system (to “decision made”) I was initially elated, thinking that this meant we were done.  But as I read a bit more and considered it a bit further I began to realize that it was most likely a rejection – my FBI clearance letter would have been expired by then, along with my medicals, both of which have a one year expiration date.  Thus, if they had decided to move my application forward, they would have ordered new medicals and a new FBI clearance letter.   Of course the rejection letter was sent to my attorney.  Since I was in NYC  – working in the same building as the Canadian Consulate – I tried to get a copy but they refused to even give me a copy.   So I had to wait until he returned from vacation to find out what was going on.

I still remember that early conversation and the questions without clear answers.  I even went so far to consult with a second attorney about one burning question: is it possible I might be rejected at the border?  Nobody really knew.  As a foreign national I do not have a legal right to enter Canada – it is discretionary and thus any border officer could look at my information and say “you’re inadmissible”.   I know this is not not a rational thought, but I am deeply in love with my spouse.  The thought of being forced to live apart is not a pleasant one for me.

So I studied and filed for a Temporary Resident Permit.  That’s my second oldest active application. Nobody knew if I was inadmissible, so asking for one would answer the question.  There were three possible outcomes:

  1. I’m not inadmissible and hence do not need a TRP;
  2. I’m inadmissible and am eligible for a TRP;
  3. I’m inadmissible and not eligible for a TRP

Of course, after everything that has happened since then I think (1) is the most likely outcome, but (2) is still not entirely unreasonable.

I’d also moved along with my spousal application.  That is my third application and I’ve talked about it (and these others) extensively.

The most recent is my work permit renewal. That’s just so I can remain in Canada while we sift through all of this.

Wow… so my situation is this – to move forward with the Judicial Review application I have to make sure my application is withdrawn.   That means sending my withdrawal letter via FedEx to them in LA (versus ahem, mailing it to them, a process that looks like it’s led to the loss of that letter).  But that raises the likelihood I will have to deal with the temporary inadmissibility issue.

A win on the Judicial Review will send my application back to CIC for reconsideration, which will mean going through the process again: a new medical, a new fairness letter, a new response to the fairness letter, etc.  At least another year.  Thus, the only “gain” here might be the positive legal decision.  But will it move the “state of the case law” forward enough to justify the personal inconvenience.

What I’d do most likely is just withdraw the application once it was returned to CIC.  That would make processing the spousal application simpler.  Ah, but I’ve been told that the spousal application is all but done – so there’s no reason to try and make it simpler, since it’s already over.

Thus my decision: do I declare a symbolic victory and move on with my life, or do I continue the fight?

Not an easy decision.

 

 

British Columbia and the Optional Nature of Health Care


 

Chopped Care CardSince my surprise on Friday I’ve spent a bit of time going over various materials.  One large project I’ve undertaken is to start reviewing all the relevant case law.  I’m doing this by researching the various decisions, including the Supreme Court of Canada (one decision), the Federal Court of Appeals (three decisions), and the Federal Court of Canada (100+).  This is a lot of material to review, so I’m not really ready to start covering it here, but I will be – if for no other reason than to provide those who follow with a bit of a starting point in analyzing the material.

I also looked through the copy of my “immigration file” and found an interesting piece of e-mail recorded within the computer notes.  To be honest, it probably should not have been included, because it looks to be privileged communications (attorney/client).  However, the ATIP folks review everything before they send it out, so someone reviewed it and decided it wasn’t sensitive.

The applicant identified above has filed a judicial review application challenging the refusal to grant him a PR status on the basis of his medical inadmissibility. He is challenging this finding suggesting that fairness was breached in that his case did not benefit from a personalized assessment as established by Hilewitz . Could you please look at the attachments and confirm that the documents he has now introduced in his application before the Court, were also provided in support of his application for PR .

Your comments are appreciated. Of particular interest is whether or not he presented evidence to demonstrate that he could opt of British Colombia‘s publicly funded Medical plan.

It was this last paragraph that caught my attention as I was reading through this, because indeed, we did not present this information to the visa officer – why would we?  Based upon the fairness letter, they asked about costs, not about BC’s coverage of those costs.  While my attorney wrote up the letter to CIC regarding my case, I’m the one that had picked him based upon my own reading of the Companioni decision – I essentially used this as a check list for a well-formed plan.

Had the original fairness letter stated “Alternative payment plans will not be considered because BC pays 100% of the cost…” I would not have wasted my time presenting a plan to provide 100% coverage of the costs.  instead, I would have argued “BC does allow an opt-out scheme”.  The government will argue that the judge should not consider this because it was not before the visa officer at the time of the decision.  However, it does underscore the fact the fairness letter itself was deficient because it did not clearly establish this concern of the officer.

At any rate, after thinking about it for a while i realize the government is in a trap of their own construction.  By noting that they are aware of BC’s policy for payment for this particular class of drugs, which is not described on the BC MSP website or the Fair PharmaCare website, it would suggest they are familiar with subtle nuances of the BC medical services plan.  Yet now they seem to be arguing that they don’t really know much about the provincial health program and it was my obligation to educate them about their own program.

How can you both be responsible for administering a program and simultaneously arguing you are not responsible for being knowledgeable about it?  That would seem to run counter to natural justice – CIC is only responsible for knowing those bits of policy that allows them to reject you, particularly if you are someone with a disability.

The original letter doesn’t mention British Columbia’s policies at all.  To pull this out at the end as part of the final rejection is indeed unfair because it never gave me an opportunity to respond.

It does seem to bolster the separation of powers argument as well.  It is not good policy to allow CIC to “cherry pick” which parts of provincial health policy they have to understand.  In Deol [2002 FCA 271] the court rejected the idea that CIC had to advise an applicant of a program that might have been beneficial to the applicant:

As for the visa officer’s alleged unfairness in not drawing Mr. Singh’s attention to Manitoba’s bonding program, Muldoon J. noted that visa applicants have the burden of establishing that they meet the qualifications for admission. Accordingly, the visa officer was not under a duty to advise Mr. Singh how he might overcome the “excessive demands” hurdle by drawing to his attention a program offered, not by Citizenship and Immigration Canada or any other federal agency, but by the Department of Health of the province of Manitoba. He also noted the paucity of evidence about the program, including its availability to Ms. Deol.

This does not say the visa officer was not under an obligation to understand the laws of the province, although it does imply this.  But it does help strengthen the separation of powers argument – if CIC isn’t required to understand provincial health care law, why are they making decisions based upon it?  How is this fair to the applicant?

I am feeling somewhat upbeat at this point.  It would seem that CIC does not have a good track record when it comes to medical inadmissibility cases.  I don’t have a complete number yet, but by the time I’m done I will.  Right now though it is clear that CIC loses more cases than they win in this area – the Federal Court often finds their decisions come up deficient.

I’m hoping to tip that count a bit more.