This is the second part of a series on abortion care in Ontario. Read the first story here.
Ontario’s abortion care system has been in a state of disrepair for years, and last December, Queen’s Park decided to do something about it, committing to overhaul the way it funds its clinics.
The news came as a relief to people working at some of the province’s imperiled abortion centres. It also came as a surprise.
Until a reporter asked them about it, none of the six clinics Global News spoke with knew about the plans.
The government has also vowed to consider how the changes could impact providers, yet not one employee said they’d heard from the ministry of health.
“I try to be optimistic,” says one worker. “Maybe they’re busy.”
“The government doesn’t work that fast,” another says. “But we’ll see.”
Reproductive-rights advocates Global News interviewed say Ontario has neglected to include them in the planning as well.
As the province’s funding model currently stands, it pays for the overhead of four of its eight freestanding surgical abortion clinics. The other four work on a fee-for-service basis, as abortions are covered under Ontario’s health insurance plan. In other words, the province reimburses clinicians for each insured procedure, but this barely covers their expenses. These places operate as businesses and are vulnerable to things like rising equipment costs or fluctuating patient numbers due to COVID-19 restrictions.
Set up to extend the service beyond hospitals, some of the centres without government funding are struggling to stay afloat. A few of them are literally asking patients for money. One facility says it can only afford to deliver surgical abortions three days a week.
Access to abortion care is increasingly limited, even in Canada’s most populous province. While Health Canada views it as a necessary service, it’s becoming more difficult for people to get a timely appointment. Clinics say even though their openings usually book up every day, they never turn away anyone who needs urgent care. This creates a backlog – patients can be sitting in waiting rooms for hours before they’re seen.
Many abortion-rights advocates say they have long pushed for changes to the funding model, but Ontario had never reacted.
That is until around four years ago, when the province discovered that an abortion centre was illegally charging patients for the insured service. This worried Health Canada, which learned of the gouging and raised concerns about why the clinic charged the fees.
Ontario is ultimately accountable for mending this situation, so in response, its ministry of health made a promise to Ottawa: that it would be changing the way it funds surgical abortion services by early 2023. This is according to a report the province submitted to Health Canada.
But Premier Doug Ford’s government has likely blown past its own deadlines. The province said it would finish its “information gathering” phase by this fall, but none of the experts and providers Global News spoke with say they have been contacted by the government.
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When asked about meeting its markers, the ministry of health did not directly answer questions about Ontario’s timeline.
“The ministry is analysing considerations to support this initiative,” a spokesperson said in a statement sent by email.
When Global News asked why Ontario has not involved the clinics, a government media relations coordinator said in a separate statement that the situation is under active review and the ministry can’t release any more details.
If the province isn’t looking for guidance from workers, “that calls into question the validity of the plan they’re developing to provide accessible abortion care to the people of Ontario,” said Jill Doctoroff, executive director of the National Abortion Federation Canada.
As it stands, many clinic staffers say they feel like the system is in danger of failure. Their working conditions are no less fraught.
Abortion care is highly stigmatized, and there is a history in Canada of violent attacks against providers. The former Toronto Morgentaler Clinic was destroyed by arson in 1992, and during the same decade, Vancouver gynecologist Dr. Garson Romalis was shot through the window of his home. He was also stabbed in 2000.
For safety reasons, Global News has agreed to shield at least part of the identities of workers interviewed and to keep their clinic names hidden from readers.
“Maintaining what we have right now is not enough,” said Omar, who manages an unfunded abortion centre in Ontario.
The $14,000 discovery
On occasion, Ontario will target health providers it suspects may be charging patients extra costs for insured services. These fees are prohibited under the Canada Health Act. The province should get the bill, not the patients.
In June 2018, the ministry started looking into the billing practices of one Greater Toronto Area clinic. It later confirmed that the centre was charging patients up to $50 for the use of an aspirator, a piece of equipment used to remove a pregnancy through the cervix. Eventually, the province ordered the clinic to stop. In total, about 300 of the facility’s patients had paid fees out of their own pockets, adding up to almost $14,000.
An Ontario ministry of health spokesperson told Global News that under the Freedom of Information and Protection of Privacy Act (FIPPA), it can’t name the centre, but the government says this business is no longer providing surgical abortion services. Tellingly, however, the centre in question did not receive provincial funding.
“These clinics have asked to be funded for years, and this has fallen on deaf ears, so for the ministry to come after them is ridiculous,” said Joyce Arthur, the executive director of the Abortion Rights Coalition of Canada.
The $14,000 finding raised a red flag in Ottawa. When it is reported that patients are paying illegal fees, Health Canada deducts a dollar-for-dollar amount from a province or territory’s annual Canada Health Transfer (CHT) payment.
Provinces and territories can recoup their lost funds if these jurisdictions make sure that providers stop charging patients illegal fees for insured services and take steps to prevent the problem from happening again.
In reaction, Ontario sent Health Canada a promise last December. The province committed to revisiting its spending model for abortion care, “with an eye to funding all” surgical providers and facilities. This is detailed in the latest Canada Health Act Annual Report, which the federal government creates every fiscal year to show if provinces and territories have upheld the standards of the act.
Even so, patients are apparently still being charged for abortion care. A recent statement to Global News from Health Canada indicated that in addition to last year’s deductions for the province, it subtracted more than $6,000 this March. A media relations coordinator with the provincial health ministry did not answer questions about the circumstances surrounding the deduction.
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Clare Shrybman, a Toronto-based lawyer pursuing research on abortion access, says the Health Canada penalties are a “tiny slap on the wrist” for the province. This is considering Ontario’s most recent CHT payment from the Canadian government is more than $17 billion, she says.
At this point, Ontario’s promise “sounds like lip service to the feds or to the public,” said Kelly, the owner of a non-funded clinic. The name used is a pseudonym.
In both instances of illegal billing, patients who paid out of pocket were not reimbursed.
“(The fee) is not a lot of money for the province of Ontario, but it could be for an 18-year-old getting an abortion,” Shrybman says.
Carolyn Egan, spokesperson for the Ontario Coalition for Abortion Clinics, says once the province ensures funding is more equitable, facilities will no longer need to ask patients for money.
“They should not have to struggle to continue to provide such a necessary health service as an abortion,” she says.
What’s next?
Little as they’ve heard from Ontario’s Ministry of Health, the clinic employees Global News spoke with remain eager to engage.
“We would love to collaborate,” Omar said. “We’d love to come up with a better way to implement funding and provide services for women.”
“At the end of the day, that’s honestly the only thing we ever really cared about, which is being able to provide these services to women,” he continued.
Most of the abortion-rights advocates, clinic staff and doctors Global News approached want to see the province adopt a more equitable system that provides overhead funding for all the private surgical abortion centres, not just a few.
But Omar worries about the parameters that may come with government money. “My biggest fear is if we do receive public funding, would we have this kind of budgetary red tape that would make it more difficult for us to see the number of patients that we see right now?”
Read more: Abortion or carry to term? Most women say they made the right decision, poll suggests
Admission numbers don’t vary too widely, however. The weekly averages for most of the funded and unfunded clinics Global News interviewed range from 55 to 64 abortions.
When a reporter asked Health Canada how it’s making sure Ontario’s plan is on track, the federal department of health said in a statement that it meets with the province regularly to oversee this.
“I would love for us to take steps forward in making sure that these services are protected and women will always have access to them,” Omar says.