Inclusive Citizenship and Health Care

Human rights lawyer Pearl Eliadis gives an overview of the discriminatory public health insurance regime in Quebec, which systematically refuses to issue health cards to Quebec-born children whose parents do not have permanent residence. Eliadis argues that inclusive citizenship should include equal rights for all citizens, regardless of nationality or country of origin.

This piece was adapted from Pearl Eliadis’ opinion letter, All children in Quebec should have health coverage, ” published 13 October 2020 in the Montreal Gazette.

At a bare minimum, inclusive citizenship in a democratic state should include equal rights for all citizens, recognizing the independent status of each human being, regardless of nationality or origin. Quebec has given rhetorical significance to citizenship as a unifying concept, but newcomers and their children are often excluded by systemic, discriminatory practices which have a disproportionate impact on racialized minorities and vulnerable communities.

Nowhere is this more evident than in access to public health insurance. Like the rest of Canada, Canadian citizens who are resident in a province for more than 183 days have access to free health services. A notable exception is Quebec-born children whose parents do not have permanent residence in Quebec, despite the fact that these children are Canadian citizens and are settled in the province.

Quebec’s Civil Code says that a minor child under parental care who lives in Quebec is considered “domiciled” and therefore resident in Quebec. The law was changed in 1999 to ensure that such children would receive the care they need based on their own, independent status in law, and not that of their parents.

Nonetheless, the Régie de l’assurance maladie du Québec (RAMQ), the administrative body that determines eligibility for public health insurance, systematically refuses to issue identity cards to these children.

Quebec-born children denied health care

Children like little Psalm, pictured above, are victims of this bureaucratic intransigence. RAMQ has refused to recognize him as a resident because his parents are not permanently residing in Quebec, at least in RAMQ’s eyes.

Psalm is nine months old. His parents are from Ethiopia. His father is an award-winning PhD student and a former Sauvé Scholar, now in his second year at Concordia University. His mother holds a valid work permit and is currently on maternity leave. Both are lawfully residing in Quebec and would like to stay. For now, both parents pay for their own medical care and will continue to do so until their status changes.

But Psalm, like any child, needs his regular checkups. He also has specialized medical needs following a shoulder injury sustained at birth. The costs are beyond his parents’ financial means.

Every major political party in Quebec has continued this practice

But the practice of refusing health care to those in Psalm’s situation has persisted, first under the Parti Québécois, then the Quebec Liberal Party, and now under the Coalition Avenir Québec.

Quebec doctors, lawyers and people working for social justice in health care have denounced the RAMQ’s practice, to no avail.

In 2018, Quebec’s ombudsperson Marie Rinfret issued an investigative report urging RAMQ to register all children born in Quebec who are residing in the province, provided they meet the rule the rest of us must respect: physical presence in the province for 183 days of the year.

A year later, nothing had changed and a second report was issued. Nothing happened.

In April 2019, the Quebec-based Observatoire des tout-petits, prepared a comprehensive research file on the impacts of RAMQ’s practices on children, families, women, and health-care providers.

The situation has forced doctors like those at Médecins du monde to provide volunteer clinical services to children who have been denied public health services. But such organizations cannot do much to help children with chronic and severe medical conditions. Another group, the Caring for Social Justice Collective, has launched the campaign #RAMQpourTLM (“RAMQ pour tout le monde” — RAMQ for everyone).

Extending health care to Quebec-born Canadians is just the first piece of a complex puzzle to get all children who are living in the province registered, but it is a place to start.

On July 9, the Montreal law firm Trudel, Johnston & Lespérance filed a class action lawsuit on behalf of Canadian children excluded by the RAMQ’s allegedly discriminatory practice.

On July 23, the Quebec government quickly announced that it would reverse its practice and do the right thing, but as it turned out, celebrations were premature.

On August 5, Psalm’s parents received a letter from the RAMQ refusing medical insurance again. And that refusal was reiterated a month later.

Dismantling systemic discrimination in the health care system

The Coalition Avenir Québec is adamant that systemic discrimination does not exist in the province of Québec, arguing that “Quebecers are not racists”. By confounding systemic and structural practices with individual bigotry, the government has sought to reassure the majority white and Francophone population, while maintaining structures that have severe and adverse impacts mainly on linguistic and racialized minorities.

At the time of writing, there was no indication that the current government had taken any concrete steps to respect its commitments to extend healthcare to all Quebec-born Canadian citizens, in violation of Québec’s Civil Code, the Québec Charter of human rights and freedoms, and the Canadian Charter of Rights and Freedoms. To do so would confirm the province’s resolve to guarantee equal rights for all citizens, regardless of nationality or origin.

About the author

Pearl EliadisPearl Eliadis, BCL’85, LLB’85, is a Montréal lawyer working with Julius Grey, BCL’71, and Arielle Corobow, BCL/LLB’16, of the firm Grey Casgrain to provide pro bono assistance to Psalm’s family.

She also teaches Civil Liberties at McGill's Faculty of Law.

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