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The refugee health care system has become so confusing that doctors are turning patients away even if they’re covered, evidence shows.

Studies in Ontario and Quebec have shown a huge drop in the number of clinics willing to give care, even to people who qualify under the modified Interim Federal Health Program, or under programs each province has put in place to make up for federal health cuts.

In the three years since Ottawa first slashed care for refugee claimants in limbo, the web of health programs has become so complex many health care practitioners won’t provide care to any refugees, period.

Some refugees are still covered by the federal health program, whose restrictions were slightly expanded following a court ruling the federal government is still appealing. And if they aren’t covered federally, they’re probably covered by either the Quebec program, administered by the provincial government, or the Ontario program, which is administered by the same third party that takes care of Ottawa’s health program.

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Confused yet? Plenty of health-care practitioners are.

And Ottawa isn’t making it easier: The federal government has refused to transfer information on rejected claims to the company administering Ontario’s health program, even though they’re housed in the same office.

Instead, rejected refugee health claims get sent back to the physician who provided the care. The doctor must then fill out more paperwork and send the information all over again to the Ontario program.

“For most people in private practise, they just don’t have the time and resources,” said Meb Rashid, a physician and medical director of at Crossroads refugee clinic in Toronto.

“There’s many physicians who I think are really well-intentioned, who are trying to understand it, and at the end of the day just say, ‘Forget it.'” Tweet This

The complex refugee claimant categories and levels of coverage have resulted in some clinics simply refusing care for refugees altogether, says McGill University researcher Janet Cleveland.

“Only 30 per cent of medical clinics provide services free, as they should, to patients with [Interim Federal Health Program] coverage,” she said.

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“Things are supposed to be covered, except that it’s so complex and so confusing and so completely ridiculous, as a system, that it really doesn’t work very well.” Tweet This

READ MORE: What does the refugee health ruling mean?

It means sick people avoid seeking care for fear they’ll be turned away or saddled with an unaffordable bill. So they ration their meds because they can’t afford to pay for refills, or put off going to hospital until they’re so unwell they end up in the Emergency Room.

That’s bad for public health when it comes to infectious diseases gone untreated; bad for the other people waiting for ER beds taken up by acutely ill refugee claimants who could have been treated earlier; and bad for vulnerable individuals who find themselves denied badly needed medical care even when they’re covered.

“Many people will delay seeking care when they can because they’re not sure if they’ll be able to access care and they fear they’ll be asked to pay,” Cleveland said. Tweet This

“For somebody who is a refugee claimant, $60, $100, is actually the difference between paying the rent or not, being able to eat or not. So those are human costs.”

Delaying “can mean in some cases more long-term, serious consequences or more expensive treatment,” Cleveland said.

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“Refugee claimants are often not getting services that they’re entitled to, that are, in principle, covered.” Tweet This

A pedestrian walks past the Christie Street Refugee Centre in Toronto. The centre sees many more inland refugees, who don’t make their claim until they’re already in Canada. Anna Mehler Paperny/Global News

Carol Makutsa deals with desperate people daily: Diabetics risk missing insulin, pregnant women forgo ultrasounds, parents weigh just how badly their children need to see a doctor. All for fear of being handed a hospital bill they can’t pay.

“People are made to think, ‘What’s an emergency, and what’s not?'” says Makutsa, administrator of the Christie Street Refugee Centre‘s health clinic. Tweet This

“I’m so, so glad we have the clinic here. With all the baggage they’re coming with, it’s nice to see the relief that at least they can see a doctor here, and not worry about paying.”

One young woman, who came from Nigeria on her own with two young daughters and a heavily pregnant belly found herself on the hook for one child’s emergency appendectomy, then her own C-section and hospital stay. (Her Canadian-born son qualifies for health care; three years later she and her daughters are still fighting for refugee status.)

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And Makutsa sees more and more people stuck in limbo as they prepare their inland refugee claims — claims made once someone’s already in Canada, as opposed to applications made at points of entry.

“They’re afraid to be turned away.” Tweet This

READ MORE: Government restores health coverage to refugee dying of cancer

Makutsa isn’t surprised doctors are confused by the chaotic levels of health coverage. She can barely keep it straight herself.

“I have no idea [what doctors know],” she said. “Doctors, sometimes, they’re busy, right? … It’s like, ‘I don’t have time for this.'”

Even Cleveland, who’s been studying this labyrinthine system for years, often finds herself stumped.

“Your eyes just start to glaze over. … Somebody will ask me, ‘Is such-and-such a person covered?’ and I’ll have to go back and check. Because there’s so many exceptions. “The way it is set up inevitably doesn’t work very well. It’s very frustrating.” Tweet This

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Immediately after the cuts took effect in the summer of 2012, “there was a sharp drop in use of hospital services by refugee claimants, and an increase in the severity of refugee claimants presenting at the ER.”

“Some doctors are not willing to provide care — specialists, particularly,” Cleveland said. “When they turn down a patient because they think it would be complicated to bill … is it ethical?” Tweet This

Ontario has spent close to $1.6 million on its own Ontario Temporary Health Program, designed to fill in the gaps left by cuts to the federal health program. And it’s sending the bill to the feds, a provincial health ministry spokesperson said.

“Lack of access to health services for refugee claimants can potentially reduce health outcomes and lead to over-use of emergency rooms, placing a greater burden on the Ontario health system,” David Jensen said in an email.

“Ontario will continue to press the federal government for the reinstatement of the full IFHP program. Ontario will also advise the federal government regularly about the costs incurred by the province as a result of the downloading of this federal responsibility to the province and will send them the bill to pay for the [Ontario Temporary Health Program].”

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That bill would be higher, says Toronto doctor Meb Rashid, if it weren’t for the onerous paperwork deterring physicians from accepting refugees.

Ottawa has been refusing to share “personal client information” with the Ontario program — even though they’re both administered by the same company, Medavie Blue Cross.

“The Government of Canada is committed to protecting the health and safety of Canadian society, including the country’s publicly funded health and social services systems,” a Citizenship and Immigration spokesperson wrote in an email.

“Canada’s immigration law strives to find the appropriate balance between those wanting to immigrate to Canada, and the limited medical resources that are paid for by Canadian taxpayers.”

Tell us your story: Have you struggled to access care or services through Canada’s refugee and immigration system? We want to hear from you.