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.

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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.

Schedule F: The Chain Link Fence to Keep Sick People Out of Canada


Permanent Resident CardI recently was discussing the issue of the cost of drugs inside versus outside Canada. One of the side-effects of the strong controls present in the Canadian system is that it forms a fence around Canada further making immigration for someone with a medical condition challenging.  This is because of the way the existing law is written.

The cost of certain drugs is much lower outside Canada.  While we can discuss the relative merits of this, such as this recent Forbes article or this recent book on the topic, the bottom line is that the cost of drugs in Canada is high – in some cases as much as 10x higher than the same drugs are from a reputable manufacturer (Cipla, Teva, etc.) in a different country, such as India, where patent rights differ.  One thing that makes this even more difficult in Canada is the blanket prohibition of the importation of certain drugs, currently on a list known as Schedule F, though this is in the process of being replaced by a similar scheme that makes it easier for Health Canada to manage the list.

The purpose of the list, however, is to prohibit the importation of certain drugs into Canada unless one is a doctor, a pharmacist or a hospital.  A patient may bring in a 90 day supply for personal use – but that doesn’t allow the drugs to be shipped.

So, how does one get around this?  Well there are a few options:

  • You can find a sympathetic doctor willing to receive the medications – essentially to serve as the “importer”.  This can be tricky, as some doctors are not willing to accept the potential liability of these non-Canadian approved drugs.  Still, some doctors are a bit more sympathetic.  It can be difficult to find such a doctor. One good thing about the new regulations is that they would extend the importation ability to anyone with the legal right to prescribe in the province.  Here in BC, for example, naturopathic doctors have prescription rights for many things and thus would be allowed to import drugs in some of these cases.  That increases the potential pool of doctors willing to assist.
  • You can arrange for delivery to the US border and then pick up a 90 day supply every three months.  Services like Kinek charge a modest fee for receiving a package for you in the US.  The US has an exception to the importation ban when the drugs are for personal use, which makes it easier to import them into the US.  Then you can bring them into Canada under the 90 day personal use exception.
  • You can try to find a Canadian pharmacy willing to sell the drugs to you.  For example, here in BC there’s a pharmacy in Surrey (Blue Sky Drugs) that indicates they will ship to Canadian addresses; whether this constitutes importation by a Canadian pharmacy or not is something that I will admit is definitely not clear.
  • You can “take your chances”.  This is what people who don’t have to worry about immigration do.  In my experience these services will reship anything that doesn’t arrive.  This is definitely a grey area, as they are exploiting the fact that CBSA cannot police every package and thus only a small fraction are actually seized.

For someone trying to convince CIC that they have a credible plan this situation can be problematic: some officers at CIC know about Schedule F and can use it as a means to refuse someone from being granted permission to immigrate.  In that case the best thing is to find a sympathetic doctor willing to allow shipments of the meds to them.  The doctor might be more willing if they know the drugs are coming from a foreign charity (NGO) rather than an internet pharmacy;  the patient may need to sign a written release indemnifying the doctor in case the drugs provided are ineffective or contaminated – after all, the doctor has no way of being able to verify the veracity of the drugs any more than the patient.  Were I trying to come to Canada and had a foreign NGO willing to provide me with expensive (or overpriced – depends upon your perspective) drugs, I’d be happy to indemnify a doctor willing to help me get into Canada in the first place!

Of course some types of drugs are worse than others.  In January 2013, Gilead reported they had a 76% profit margin.  AIDS Healthcare Foundation has been calling for moderation of their prices, but at the present time that’s the way the system works – the laws protect the companies’ profits not the health and well being of the actual patients.  For those wishing to immigrate to Canada this creates a real barrier to entry.

Canada in turn only looks at a few diseases very closely.  I personally know of people with heart conditions (requiring multiple surgeries and hospital stays after coming to Canada) who disclosed their conditions but were not subjected to the “excessive demand” fire drill.  But this is what the Canadian public has decided to do.  Immigration is always fraught with this sort of problem – a deep-seated xenophobia.  That’s hardly unique to Canada, sadly.

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 Never Ending Story


While my own journey through the quagmire of Medical Inadmissibility has come to an end (at least for now) I am glad to be hearing from those who are going through the process.

I have been surprised when I read the posts of people who are in a similar situation to mine and the vitriolic comments in public forums about them – either that or often a complete lack of response.  It is clear to me that this is a poorly understood area, with a dearth of empathy or understanding from those not impacted by it.

One recent positive step has been that CIC has published new information about the medical examination process.  This includes new forms, new processes and links to a sample from the “Panel Physician Handbook” – apparently the final handbook is not yet complete.  The information there is useful, especially for people trying to understand the initial part of the Canadian Immigration medical examination process.

Landing: The Close of One Chapter


I’m writing this a week after the event. Indeed, even now it’s still a bit of a euphoric shock.  The images isn’t my landing stamp, but it’s very similar and it doesn’t have any specific identifying information.

USPS finally managed to deliver the letter.  A day late.  But it was a relief to know that they hadn’t lost it.

Thus, my company’s US office finally received the paperwork on Friday October 12.  Since I couldn’t see the paperwork, I couldn’t know 100% that they had issued a COPR. The person in the US office who put it into a FedEx envelope said “it looks like they returned the documents you sent to them.”  After all this time I must admit, I was still not 100% convinced this was going to happen, that something would “go wrong” at the last moment.  No PR, work permit rejection and – of course – I’d abandoned the challenge on my original PR application rejection before the Federal Court of Canada.  Even knowing that it was a paranoid fantasy doesn’t mean that the thought didn’t run through my head.  This in spite of the fact that my last ATIP report had been returned to me just days earlier, with complete information on it.

Case Analysis FOSS: Application for PR denied due to medical inadmissibility December 2011 (HIV Positive). Development of Relationship: Second marriage for PA, USA citizen had valid status in Canada – expired 2012/09/03. Met in 2008 via the internet, communicated   via the internet for several months prior to meeting in person in 2009. PA and sponsor continued to see each other  on a regular basis, engaged and married in 2011 cohabitation from 2010/11/15 to 2012/01/23. Eligibility:  Photos of relationship provided, copies of e-mails also provided as evidence of communication. Relationship appears to be genuine. Admissibility: FBI Clearance
provided, RCMP screening submitted. Based on  information provided, further review required due to previous inadmissibility. RPRF- Paid

Note: emphasis added.

So while I think the review might have been timely, I suspect it was pushed to the front in order to get it done quickly – and thus provide CIC with some sort of plausible defence against my JR application.  The emphasized section is what I was expecting and normally this would mean it goes into the “cases needing more attention” pile.  That normally adds months onto the processing time.  But just five days later:

Reviewed file and case analysis: FOSS: PA previously refused SW application on A38, medical inadmissibility for  excessive demand. That file currently has application for leave for JR pending with Federal Court. Current medical result is Passed (M39 – EDE). No other eligibility or  admissibility concerns noted on previous file. PA residing in Canada on WP since 2009, recently applied to  extend. PA currently has TRP appln in process in Seattle. Based on evidence on file, I am satisfied the relationship is  genuine and has not been entered into primarily to gain immigration status in Canada. Eligibility passed. [redacted section on Security] Criminality: No concerns, passed. All requirements met: File RFV. File forwarded to Los Angeles for finalization.

This is what makes me think the file was being pushed.  The case notes don’t tell me who actually reviewed the file, but each officer is identified by initials and numbers.  The first entry I listed was done by ND01111.  The second one was done by SO0213.  From reviewing these files, I’ve noticed that the lower numbers generally appear to correspond to more senior individuals.  I suspect this is coincidental – that they may be sequential numbers assigned by the database, with people having been in the organization longer (or at least in the computer system longer) having lower numbers. But at any rate, the point is that SO0213 did this last review – someone more senior than ND01111.  That’s my theory, at least.

The most recent entry is from Los Angeles:

E-mail to sent to SEATTLE once visa issued, so that they may close their TRP application for subject.

This one was entered by DV00073.  If my theory is correct, this is someone very senior that added this note.  Of course, this is consistent with what the VO in Seattle had told me – she said that they’d close out the file once the COPR was issued. The actual paper file was logged into LA two days after this notation (by MY04934).

It is easy to overanalyze these notes however, and I will state right here that I’ve put forward a lot of conjecture.  Maybe some of it is right, but it’s likely I’ve mis-guessed here as well.  Nevertheless, the facts are that I appear to have been processed in record time – before more than two dozen other people I know, all of whom applied in March 2012.  Second in the group (after someone from the London Visa Office) and the first in the Ottawa/LA group.

At any rate, it doesn’t show the PPR on 26 September, even though that’s the date on this last ATIP report. Thus, i suspect it was extracted earlier in the day.

Of course, I had plenty of time to go over this both when I got it and once again on Saturday, October 13.  I also dutifully checked the CIC website. Instead of the “In Process” it had shown for the past three weeks it said “Decision Made”.  That was enough for me to jettison the paranoid fantasies – I knew the Confirmation of Permanent Residency was included in the overnight package – a relief.  I obsessively checked the FedEx website throughout the morning, so I could see the letter had made it to Memphis, then later it made it to Vancouver, then it cleared customs and finally, just before 9 am, it was loaded on a truck for delivery (by 5 pm, their service commitment).  Before heading to work my spouse asked me if I still planned on heading down to the border. Naturally I said yes – after waiting this long, I really wanted to have this matter settled once and for all.

The morning slipped away and I frittered away my time by reading the news, checking facebook and spending my time answering questions in an online immigration forum (an obsessive trait that had worsened in the previous month). I have learned quite a bit about the Canadian immigration process, and I’ve been sharing bits of that experience with others – hopefully it’s been right more often than not!

I even took the time to write my previous blog post.

I finally decided to shower and get ready to go – taking the phone with me (I wasn’t going to risk not getting that package) and quickly rushing through the process.  Still nothing…  In many ways, that morning seemed every bit as long as the months and years leading up to that point.

But it did eventually arrive.  I buzzed the driver into our building and at 1:31 pm I signed for that precious envelope.  I opened it up and found that in addition to what I expected – my passport and the COPR – they actually returned a number of the documents that I had sent along – my birth certificate, the certified copy of our marriage certificate, the photos we had sent and a couple other documents.  I must admit, I was rather surprised, since I didn’t expect to get any documents back.  But nestled in the pile was the precious COPR. Two copies, actually.  Almost identical except at the bottom where one said “CIC Copy” and the other said “Client Copy”.  Both had my picture affixed (something that confused the border officer later – he seemed to expect only his copy to have the picture on it.)

Then the frenetic activity started.  I pulled out just what I needed to land (passport, COPR copies) and realized I needed to walk the dog before I could actually go anywhere.  So I’m scrambling around, walking the dog, trying to book a zip car, text my spouse, etc.  After juggling everything we agreed that I wouldn’t book the zip car, that we’d drive to the border together after my spouse finished work.

And that’s what we did.  We picked Peace Arch (“Douglas”) because it had the lighter traffic load. Being a US Citizen, I had to get my passport stamped (a non US Citizen could have requested an “administrative refusal” which means they stamp the date on a piece of paper saying you weren’t admitted to the US.)  That’s because, as a matter of law, a US Citizen had a legal right of entry into the United States.  So we had to park the car, go inside, stand in line, all so I could get my passport stamped that I had been in the US.  I did not confirm that this is still necessary, but a friend of mine from the US had to make an extra cross-border trip to get his passport stamped several years ago in order to land, so I thought it safest.  The border guards had no problems with any of this – the primary inspection officer wrote “flag pole” on a referral slip even.

The “return to Canada” lane was barracaded, so we had to talk our way out of the secondary inspection area (since I didn’t have a slip) and then go through a pair of round-abouts (rotaries for those from New England or maybe even traffic circles for others.)  Then we were lined back up heading into Canada. I was driving (my spouse was funny – “I don’t know what to say to them at the border”) which is very unusual.

Let’s put it this way. we’ve owned this car for 13 months and this was the second and third time I’ve ever driven it!  This time we took the Nexus lane.  Practically the first thing the officer asked was “what’s your status in Canada”, to which I replied “well, until 30 minutes ago I was living with implied status on an expired work permit, but if you don’t mind I’d like to go over to the office to resolve that, because I have this COPR…” I’m pretty sure I rattled it off like that, modulo punctuation.  So he wrote “Landing” and “B” on a referral slip, called it in, handed me everything back and off we went to the Canadian immigration building.

Both the US and Canadian buildings are very new, having been completely rebuilt in the past two years.  They’re quite nice actually, so it makes the experience a pleasant one.  We pulled over, the CBSA officer in the parking area told us to go inside and we went and stood in Line B.  Two minutes later I was at the counter, giving the passport and COPR to the officer, explaining that my goods were already in Canada, and that I had no goods to follow – albeit with him prompting me for some of this information – and then he said “go sit down and I’ll call you up when I’m done.”

I posted an announcement on Facebook:

Becoming a permanent resident of Canada. Only took 3 years, 3 months and 17 days.

And just after I posted that, the officer called my name. I went up, he went over the forms, paying particular attention to the criminal charges and the undeclared dependents section.   He had me initial both places on both forms and sign along the bottom.  He kept one – he actually tried to keep the wrong one, but I corrected him.  He stamped my passport, wrote an I with the line next to it – that means “admitted as an immigrant with no departure date”, added “no goods to follow” as well, stapled my copy into my passport, folded it all up nicely and handed it back to me.

The entire process took no more than 10 minutes.

And thus, on Saturday October 13, 2012 my status in Canada changed from “foreign national” to “permanent resident”.  As I write this a week later, I still feel the euphoria.  The process was long and painful.  But it’s over now.  Time to start looking forward.

 

The Best Laid Plans…


Note:  I originally wrote this post on 11 October.

Yesterday afternoon I was excited to find that the USPS tracking website was now showing information for the prepaid Express Mail waybill for my passport – and presumably the holy “Confirmation of Permanent Residency”.

So I jumped into action – I wrote an e-mail to the folks in the US, alerting them to the incoming package and providing directions on sending it me here in Canada.  I discussed my plans for heading down to the US tomorrow in order to complete the “landing” process – this is the change in status from foreign national to permanent resident.  It’s really just a paperwork thing, but it’s the end-point of this entire process.

At  2 pm today – 5 pm ET  where my company’s offices in the US are located – I heard from them that the package never arrived.  So much for the “guaranteed delivery by 3 pm”.  But the last entry in their tracking system is:

Dispatched to Sort Facility       LOS ANGELES CA 90071                   10/10/12  6:52pm

So, basically, they haven’t seen it since yesterday evening – but USPS tracking is notoriously unreliable, though Express Mail is their best service offering.  This clearly illustrates why one can never count on anything in this process going “as expected”.  In all fairness, I would normally have used FedEx, given the choice, but there were exactly two options available to me: first class mail or Express Mail to a US address.

At any rate, I’m hoping that they find it between now and tomorrow.  Lurking in the back of my head is the “ugh, what if they LOSE it”.  It’s only my passport and that incredibly precious immigration document.  The passport can be replaced, but I have this fear that the only way to replace that immigration document will be to go through the whole process all over again.

So close to the end….