Mifegymiso Access for Federal Patients

While most people’s health care is delivered through provincial and territorial programs, the federal government is directly responsible for the health care of several groups of people.

When we advocate for better access to sexual and reproductive health services (including abortion services) for all people, it is important to make sure the federal government provides high quality and equal access to those services to those who access health care through the Non-Insured Health Benefit Program (for First Nations and Inuit people), the Interim Federal Health Program (for refugees arriving in Canada), Programs from Correctional Services of Canada (for federal inmates), National Defense Health Services (for Canadian military personnel), Public Safety and the Royal Canadian Mounted Police (for RCMP members) and the Veterans Affairs (for veterans).

Here's what’s covered to date:

NON-INSURED HEALTH BENEFIT PROGRAM (FOR FIRST NATIONS AND INUIT PEOPLE)

In May 2017, it was announced that the Non-Insured Health Benefit Program was going to cover the costs for Mifegymiso for eligible First Nations and Inuit individuals.

In every province and territory, regardless of whether universal cost coverage plans have been implemented by the government, those with coverage under NIHB are eligible to receive Mifegymiso free of cost. The only exception is British Columbia, where those who were previously covered by NIHB are now covered by BC PharmaCare and so, get the medication free of cost under that program instead.

Barriers to Access

While Action Canada views the NIHB’s cost coverage of Mifegymiso as a step in the right direction, it is crucial that beyond covering the costs of medical abortion, the federal government takes all the steps necessary to address what fundamentally impacts the health of Indigenous peoples and all barriers that compromise access to high quality and comprehensive health care.

We encourage the government to:

While Action Canada views the NIHB’s cost coverage of Mifegymiso as a step in the right direction, it is crucial that beyond covering the costs of medical abortion, the federal government takes all the steps necessary to address what fundamentally impacts the health of Indigenous peoples and all barriers that compromise access to high quality and comprehensive health care.

1. Ensure the equitable, easy and timely access to comprehensive package of reproductive and sexual health services, including abortion services, for all Indigenous people, many of them residing in rural and remote communities and therefore, requiring different strategies and financial investment to access the same high quality of care.
2. Implement the Truth and Reconciliation recommendations.
3. Mandate cultural safety training for all people associated with the delivery of health care services.
4. Ensure the appropriate and timely funding of health care services delivered via the FNIHB so people can access all services available to people covered by provincial and territorial health insurance.
5. Support the creation of Indigenous directed, and Indigenous-led health and health related services.
6. Support the efforts to increase the number of Indigenous health care providers.
7. Support the employment of specialized roles such as Indigenous patient navigators to serve as a bridge between Indigenous patients and the health care system serving them.

PROGRAMS FROM CORRECTIONAL SERVICES OF CANADA (CSC)

Correctional Services of Canada will be listing Mifegymiso on the CSC National Formulary as of April 1, 2018 following a listing recommendation by the Canadian Agency for Drugs and Technologies in Health (CADTH) and the CSC National Pharmacy and Therapeutics (NP&T) Committee.

Barriers to Access

Due to the time-sensitive nature of the medication, any request for Mifegymiso is to be addressed quickly and efficiently for people who are incarcerated in federal facilities. That said, while it is an important development in ensuring access to a complete package of sexual and reproductive health services, it is crucial that better access to Mifegymiso does not preclude people who are incarcerated from accessing surgical abortion care. Having access to Mifegymiso inside correctional facilities does not necessarily mean that people would want to terminate their pregnancy using Mifegymiso especially if they would have to experience the termination process inside the institution.

People who are incarcerated have a right to health, as recognized in sections 85-86 of the Corrections and Conditional Release Act. Yet, they are often forgotten, undervalued, unconsidered, despised and deemed undeserving of quality and responsive health care. In fact, delivery and access to health care services within the federal correctional system is the number one complaint made to the Office of the Correctional Investigator, which highlights the dire situation of health care received within the federal correctional system. It is often assumed that prisoners don’t care about their health or are out to "trick us" (especially if they are people who use drugs or need pain management). It is also often assumed that the deprivation of health care services is a part of the punishment of incarceration when in fact, prisoners are entitled to receive equivalent or comparable health care to what people receive in the outside community.

Mifegymiso being added to the formulary is a step in the right direction in terms of ensuring people who are incarcerated have options when it comes to their reproductive health care but, in addition to stigmatic assumptions, overarching systemic barriers to health care remain. They include but are not limited to: bed space and capacity, limited access to regional treatment centres and psychiatric hospitals, and the arbitrary nature of decisions being made by individual service providers in each facility. It is also important to highlight how people who are incarcerated are often not afforded timely and responsive access to health care facilities and staff, continuity and consistency of care, including as it regard access to their medication.

While Mifegymiso is now on the formulary, it is very important to look at what can facilitate or hinder access to a comprehensive package of sexual and reproductive health services for people who are incarcerated.

We encourage the government to:

1. Actively address what contributes to the disproportionately high rate of incarceration among low income, racialized and Indigenous populations, including Mandatory Minimum sentencing laws.
2. Ensure the equitable, easy and timely access to comprehensive a package of reproductive and sexual health services for all people in federal facilities, including cost coverage of Mifegymiso. To this end, while Mifegymiso is now the Correctional Services of Canada formulary, it must not preclude people from accessing surgical abortion care if they prefer that option. If people choose to terminate a pregnancy using Mifegymiso, accommodations must be made to ensure privacy and comfort as well as access to pain management.
3. Institute needle exchange and safe tattooing prison programs to address HIV and HCV prevention needs.
4. Ensure easy access to nasal spray naloxone kits in response to the fentanyl crisis.
5. Ensure the better access to community-based organizations that support the physical, emotional, spiritual and psychological well-being of incarcerated people during and after incarceration. Building on the progress made on the timely access to HIV and HCV treatment for people in federal facilities, we encourage the federal government to assure continuity of care and a holistic approach to health care by facilitating the building of strong relationships with community-based organizations addressing health.
6. Support peer health ambassador programs to assist incarcerated people in addressing their overall health needs.
7. Implement the recommendations included in the Mother Baby Guidelines to ensure we uphold the rights of incarcerated parents to nurse and bond with their babies.
8. Give all trans prisoners the right to choose their gendered housing and ensure policies around searching and access to medical care upholds the right of trans people, including initiating or continuing hormone therapy.

INTERIM FEDERAL HEALTH PROGRAM (IFHP)

Immigration, Refugees and Citizenship Canada has added Mifegymiso to their Prescription drug coverage.

Immigration, Refugees and Citizenship Canada (IRCC) administers the Interim Federal Health Program (IFHP). The program provides limited, temporary health coverage for protected persons, including resettled refugees, refugee claimants, and certain other groups who are not eligible for provincial or territorial health insurance. This includes coverage for most prescription medications and other products listed on provincial or territorial public drug plan formularies and is provided through Medavie Blue Cross.

However, while they added Mifegymiso to their list, this coverage remains limited to only those provinces/territories that have added it to their formulary, as coverage via IFHP depends on provincial and territorial formularies.

Provinces with Mifegymiso on their formularies: BC, AB, SK, MN, QC, NB, NS

Provinces and territories that do NOT have Mifegymiso on their formularies: ON, NL, PEI, YK, NWT, Nu

This gap has come to our attention as, while it is most often the case that a province / territory will add a medication to a formulary as a necessary step to implementing full cost coverage, an issue is arising in provinces like Ontario which have implemented universal cost coverage for Mifegymiso but have not added it to the formulary (a prerequisite to access the medication through the prescription drug coverage of IFHP). In some instances, prescribers may be able to bill IFHP directly if they dispense the medication as oppose to send the client to the pharmacy to pick up their prescription.

Barriers to Access

Many factors impact the health of newcomers to Canada as well as their access to health care. These include but are not limited to: precarious immigration status that prevents people from accessing public healthcare (including coverage by the IFHP in the first place), economic barriers, language barriers, racism and harmful assumptions as well as mental health issues exacerbated by migration and discrimination.

In addition to those systemic barriers to health care, in June 2012, major cuts were made to the IFHP by the then federal government which was later ruled a charter rights violation. Although access to healthcare through the IFHP has since been reinstated for most refugees and refugee claimants, there remains confusion about who is eligible and difficulties in processing claims under the IFHP have resulted in some healthcare providers turning away eligible patients and denying them care.

We encourage the government to:

1. Ensure the equitable, easy and timely access to a comprehensive package of reproductive and sexual health services (including medical abortion) for all people covered by the IFHP (regardless of whether they are residing in a province or territory that has implemented Mifegymiso cost coverage) by listing medical abortion as part of the basic coverage package instead of listing Mifegymiso on the prescription drug coverage.
2. Actively address barriers to newcomers accessing health care in Canada, including measures and programs causing delays in coverage of health care services and goods.
3. Implement measures to encourage and support health care providers’ participation in the program.
4. Develop education pieces for health care providers on best practices for treating people covered by the IFHP.
5. Work with Medavie/Blue Cross to create a more streamlined way to make claims or educate health practitioners on this as well as ensure transparency and collaboration with practitioners and Medavie/Blue Cross.
6. Ensure pharmacies have the resources and training needed to provide, process and bill for prescribed medication covered by IFHP.
7. Fund Interpretation services and system navigation assistance programs, including peer navigator programs.

CANADIAN FORCES HEALTH SERVICES

As of March 2018, the National Defense and Canadian Armed Forces have added Mifegymiso to their Drug Benefits list for people covered by Canadian Forces Health Services.

The Canadian Forces Health Services (CFHS) is the designated health care provider for Canada's military personnel, delivering medical and dental services at military installations across Canada and overseas. CFHS provides prescription and non-prescription drug benefits to its members as defined in the Canadian Armed Forces (CAF) Drug Benefit List.

Barriers to Access

A study completed in the United States in 2008uncovered that the military have higher unplanned pregnancy rates than the general population. Another 2013 study showed that one-third of deployed servicewomen were unable to access the birth control they wanted for deployment. 59% did not speak to a military provider about birth control before deployment, and 41% of servicewomen who needed medication refills thought they were difficult to obtain. 

What makes it more difficult for people to seek out the sexual and reproductive health care they need is often what fuels the high rates of sexual assault and harassment in the military. A 2015 external review of sexual misconduct and sexual harassment in the Armed Force by former Supreme Court of Canada Justice Marie Deschamps found a “sexualized environment” within the Forces “conducive to serious incidents of sexual harassment and assault.” Among Canadian Forces members, females were overwhelmingly more likely to experience sexual assault or harassment, with one in four female members saying they’d been targeted at least once during their careers. Among female survivors, their seniors were most often pegged as the alleged perpetrators. Male survivors, however, most often pointed to one or more peers.

Addressing gender based violence and how it impacts people serving in the Canadian Forces is crucial to improving access to health care, including sexual and reproductive health care.

We encourage the government to:

1. Ensure equitable, timely and easy access to a comprehensive package of sexual and reproductive health services and goods, including Mifegymiso.
2. Implement measures to more accurately assess the rates of reported and unreported cases of sexual harassment and assaults, review educational programs and policies addressing gender-based violence in the military and spur broad-scale cultural reform regarding the treatment of women, trans and LGBQ members.
3. Improve the integration of individuals from marginalized populations, including women, trans and LGBQ individuals, in the CAF leadership structures.
4. Establish an independent agency to receive reports of inappropriate sexual conduct and to provide support to survivors as one part of improving processes to address sexual harassment and assault.

Here's what’s not covered:

VETERANS AFFAIRS CANADA

Veterans Affairs Canada has not yet announced cost coverage and access to Mifegymiso for people covered by their program if the province or territory where a member resides does not have a coverage program in place.

Veterans Affairs Canada provides supplemental coverage to veterans who require health services or medications as a result of injuries sustained in the line of duty. For all other coverage, veterans are covered by their provincial and territorial health insurance plans. As such, access to Mifegymiso for veterans depends on whether they reside in a province or territory that has implemented full cost coverage for this medication. That said, as federal patients, veterans deserve supplementary coverage on top of what is offered through provincial and territorial plans, and as such, should have access to free Mifegymiso regardless of whether they are eligible for Veterans Affairs Canada’s benefits and pensions.

Barriers to Access

Access to comprehensive and timely medical care can be difficult for many veterans. The department’s own statistics suggest many veterans must wait far longer than the department’s service standards dictate. Just 52% of applications for disability benefits are processed within the departmental target of 16 weeks. Just 65% of veterans in need of long-term care received it within the target of 10 weeks. And just 53% had access to the career-transition program within the target of four weeks.

It is also important to note that women make up a significant percentage of the veteran population and the number of female veterans living homeless/in-crisis appears to be on the rise. In 2015, VETS Canada identified that 6% of the in-crisis veterans supported by the organization were female. Last year, that number jumped to 16%. Many of these female veterans that were assisted by VETS Canada were single mothers.

We encourage the government to:

1. Ensure equitable, timely and easy access to a comprehensive package of sexual and reproductive health services and goods, including cost coverage for Mifegymiso in provinces or territories where no universal cost coverage program is in place.
2. Address the lack of support, capacity and funding delaying access to appropriate and timely health care, including mental health care for veterans.3. Improve the integration of individuals from marginalized populations, including women, trans and LGBQ individuals, in the Veterans Affairs leadership structures.
3. Establish an independent agency to receive reports of inappropriate sexual conduct and to provide support to survivors as one part of improving processes to address sexual harassment and assault.
4. Assess and respond to the specific health needs of women and LGBTQ veterans.

THE ROYAL MOUNTAIN POLICE

The Royal Canadian Mounted Police has not yet announced cost coverage and access to Mifegymiso for people covered by their program if the province or territory where a member resides does not have a coverage program in place.

Since April 1, 2013, all serving RCMP members are considered to be “insured persons” under the Canada Health Act and receive their basic health care through the health care system in the province or territory they reside. The province or territory provides the same basic health services to serving RCMP members as it does to its other residents. The RCMP will cover the additional cost of providing basic health care in exceptional circumstances. These include when an on duty RCMP member incurs basic health care medical expenses outside his or her province/territory; when there are fee differences during a waiting period after transfer to another province; and other similar situations. Action Canada believes that lack of access to Mifegymiso in provinces and territories where the medication is not universally covered or on the formulary should qualify members for coverage through the RCMP Health care package.

Barriers to access

Several class action lawsuits and the public sharing of personal stories has demonstrated how the RCMP can be a hostile workplace for their members who are not cisgender men. This past year, as many as 1,100 women have begun the process of opening sexual harassment or discrimination claims against the RCMP. The claims stem from two class-action law suits filed against the RCMP – one from 2012 and another from 2015. The suits alleged a long history of sexual harassment, intimidation and gender-based discrimination perpetrated by male members of the RCMP against their female colleagues. As part of the settlement that was reached, the RCMP has agreed to a number of initiatives, including improved training of current members and new recruits, as well as striving to increase the number of women in its ranks.

Working towards becoming a workplace that is more welcoming of gender diversity, that is safer for all people, means addressing gender-based violence, degradation and discrimination. It means taking important health care needs seriously, including sexual and reproductive health care needs.

We encourage our government to: 

1. Ensure equitable, timely and easy access to a comprehensive package of sexual and reproductive health services and goods, including cost coverage for Mifegymiso in the provinces and territories where no universal cost coverage program is in place.
2. Implement measures to more accurately assess the rates of reported and unreported cases of sexual harassment and assaults, review educational programs and policies addressing gender-based violence in the RCMP and spur broad-scale cultural reform in regard to the treatment of women, trans and LGBQ members.
3. Improve the integration of individuals from marginalized populations, including women, trans and LGBQ individuals, in the RCMP leadership structures.
4. Establish an independent agency to receive reports of inappropriate sexual conduct and to provide support to survivors as one part of improving processes to address sexual harassment and assault.