Impact of government cuts to uninsured funding on clients in midwifery care

An open letter to obstetrical colleagues written by Midwives Manavi Handa and Shezeen Suleman

As you are likely aware, the provincial government announced on Friday they are cutting the funding program that has allowed a pathway for uninsured residents of our province to seek essential medical care and has allowed doctors a mechanism to bill for this care. The program is set to end on March 31, 2023, and this comes as very distressing news. As midwives who have worked for many years with uninsured clients, we are sharing some thoughts with you about the devastating impacts of these cuts to perinatal clients we serve. We are reaching out to you, our obstetrician colleagues, to highlight some of these impacts as we know you too serve these communities – the care you deliver will undoubtedly be impacted as well.  

To start, cutting this program is a health equity issue. It is well recognized that many people living in Ontario without OHIP cards are impacted by homelessness, mental health or disability. Some people may be leaving violent homes with no belongings, other may be struggling with addition. Many of the uninsured clients we see are on temporary work or study permits or without authorized immigration status, living and working in Ontario but with no access to provincial health insurance. Each of these scenarios we’ve just outlined to describe the uninsured disproportionately impacts Black, Indigenous and racialized communities and those living at intersections with poverty. Not having access to OHIP is an equity issue. Cutting a program that finally created access is, as such, egregious.

It’s important to highlight that people impacted are our neighbours and the families our kids go to school with. They are the people who clean our homes, deliver our packages and build our hospitals. With a federal government insistent on increasingly temporary immigration pathways, the number of people who are uninsured is likely to grow. It is unreasonable that we do not have an accessible health care net for these people.  As we know from our practices, these same people are pregnant and rightly seeking care.

Over the past three years, with this funding program in place, pregnant clients have been able to seek essential services in hospitals. The proposed cuts will NOT decrease the number of people who need your care as obstetricians, it will simply decrease your ability to be remunerated for the care you provide, unless they are tied to midwifery or Community Health Centers (which of course, is not the case for many).

These are just some of the ways we foresee obstetricians being directly impacted by these cuts:

• These cuts mean less access to prenatal care overall and less access to prenatal care results in higher risk pregnancies.
• Afraid of the financial implications, clients will be less likely to report to triage for assessments when they are indicated. In labour, they will be less likely to pay their bills to hospital (facility fee).
• It’s possible that some obstetricians will opt not to take uninsured patients into care. This will result in more people with inadequate prenatal care coming to the emergency department (ED) to access care only when they absolutely need to. These patients will be deferred to labor and delivery units for care at that point, with no records, often sicker than they would have otherwise been, needing a higher level of care much more urgently. This will add stress to an already strained clinician pool.  
• Without hospital facility fee coverage, it will mean pressure to discharge people from hospital sooner than clinically or socially indicated (a pressure that is already at its boiling point).
• For hospitals that covered Early Pregnancy Complication Clinic care under the ministry-funded program, it will mean no clear pathway for ED physicians to refer patients for follow up. More ED docs will likely manage cases they wouldn’t otherwise. More patients will be left to manage early loss and the various complications without adequate clinical follow-up. And people presenting with a ruptured ectopic requiring surgical intervention will still require obstetric services, but again without remuneration.
• Most importantly, this cut will mean less adequate prenatal care and, as a result, more preterm birth and more low birth weight babies – both of which put a massive strain on our health-care system in terms of cost, human resources and the need for specialized care.

We have seen what a difference access to care meant to uninsured people over the past three years. A report released just last week by the Health Network for Uninsured Clients detailed the many positive impacts of this program, with a focus on pregnant people. Pregnant people sought care at the right place and at the right time. They were much less likely to delay seeking care. Clinicians reported feeling relieved of the moral burden involved in caring for people who, before this time, had to pay for each aspect of care – including labs, diagnostics, referrals and urgent in-hospital care. Follow-up for patients back to community post discharge was also vastly improved.  

All of these gains will be undone with the cuts proposed on Friday. The program is set to end on March 31. It is time for obstetricians to be vocal about this issue. We have three days to potentially stop these cuts from happening. The time to act is now.

Please share this message widely with your colleagues. We know this important issue is striking a nerve with many. A petition released just on Tuesday this week has already received over 2000 signatories in just over 24 hours, many of the signatories being health-care providers. Please sign the petition. Consider calls and letters to your hospital, MPPs and Professional Associations. Many organizations have already sounded the alarm on these cuts, including the Ontario Medical Association; perhaps it is time for the Society of Obstetricians and Gynecologists of Canada to join these other associations and specialists.

If you have any further questions, please do not hesitate to reach out to one of us.

Shezeen Suleman, RM (she/her)
Midwife Team Lead
MATCH - Midwifery and Toronto Community Health, South Riverdale Community Health Centre
Health Network for Uninsured Clients (HNUC) Co-Chair

Manavi Handa, RM, MHSc (hear-my-name-pronounced) (she/her)
Associate Professor, Midwifery Education Program, Toronto Metropolitan University
Midwifery Clinical Director, Non-Insured Walk-In Clinic, AAMHCC
West End Midwives, founding partner