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The Law, Policy, and Ethics of Migrants' Health Care Entitlement

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The Law, Policy, and Ethics of Migrants' Health Care Entitlement The Law, Policy, and Ethics of Migrants’ Health Care Entitlement by Yin-Yuan Brandon Chen A thesis submitted in conformity with the requirements for the degree of Doctor of Juridical Science Faculty of Law University of Toronto © Copyright by Yin-Yuan Brandon Chen 2020 The Law, Policy, and Ethics of Migrants’ Health Care Entitlement Yin-Yuan Brandon Chen Doctor of Juridical Science Faculty of Law University of Toronto 2020 Abstract This dissertation examines laws and policies in Western receiving countries concerning migrants’ health care entitlement and queries their defensibility. Using Canada as a case study and drawing international comparisons where appropriate, it is shown that Western receiving countries often provide migrants with a level of health care coverage inferior to what is bestowed on their respective citizens. Proponents of such unequal health care entitlement between migrants and receiving-country citizens have commonly rationalized it as a measure to reduce public spending and to deter immigration-related fraud. Available evidence, however, challenges the validity of these claims. Instead, migrants’ lesser health care entitlement is more appropriately understood as a product of their social exclusion in receiving societies. To characterize all migrants as “others” fails to appreciate the reality that certain migrants constitute rightful members of receiving communities according to the theory of social membership. Like their citizen counterparts, migrants who are ordinarily resident and those whose establishment of ordinary residence can be confidently foretold are closely linked to Western receiving countries given their communal affiliations, involvement in social cooperation, self-identification, and subjection to the relevant state’s coercive authority. As their members, Western countries ought to afford these migrants the same extent of health care entitlement as they do their citizens in order to satisfy the dictates of equality and reciprocity. ii In contrast, differential health care entitlement between citizens of Western receiving countries and migrants whose residence therein is not ordinary in nature is morally permissible. In a world that largely depends on broad-based, ongoing resource redistribution within each nation to realize individuals’ right to health care, membership in these political communities is key to generating the solidarity needed to sustain such communal resource sharing. The inclusion of migrants who are not members of receiving societies in these redistributive processes raises concerns about illegitimacy. Nevertheless, given their territorial presence, pursuant to the principles of causation and remedial capacity, even non-member migrants should be entitled to a basic set of health care rights in Western receiving countries, including, at minimum, coverage for primary care and provision of medical treatment that cannot be deferred. iii Acknowledgments This project is a long time in the making, too long in fact by all measures. Fortunately, I am surrounded by people who have shown me a great deal of patience along the way, to whom I now owe a debt of gratitude. In particular, I must thank my supervisor, Colleen M. Flood, and the members of my doctoral committee, Audrey Macklin and Mariana Mota Prado, for their incredible generosity with their time and expertise. Their willingness to indulge my half-baked ideas created a safe space for my arguments to mature, and their confidence in my ability to do better gave me the motivation I needed to bring my vision for this dissertation to life. Similarly, I must thank my thesis examiners, Constance MacIntosh and Trudo Lemmens, whose invaluable comments and suggestions have greatly improved my work. I am also indebted to my family. Not only is my family the source of my emotional support, especially in the lonely days of dissertation writing, but also in many ways, my family’s immigration story was what sowed the seeds of this research. I would not have been the person I am today without all the sacrifices my parents have made as immigrants. This dissertation, therefore, is dedicated to them. Another person that I absolutely must thank is my better half, Marc. Perhaps more than anyone, he bore the brunt of my mood swings throughout my doctoral study. Yet he has stood by me every step of the way. His companionship and unconditional love fill my heart with joy, and they are what propel me forward on occasions where I find myself overcome with self-doubt. I could not have asked for a better partner in life. Finally, I wish to acknowledge the Vanier Canada Graduate Scholarships Program, the Canadian Institutes of Health Research, the University of Toronto, and the Lupina Foundation for their generous funding support. And to everyone else who has ever contributed to my personal and professional development: thank you from the bottom of my heart! iv Table of Contents Acknowledgments.......................................................................................................................... iv Table of Contents .............................................................................................................................v List of Tables ................................................................................................................................. ix List of Figures ..................................................................................................................................x Chapter 1 Introduction: The Nuts and Bolts of a Study on Migrants’ Health Care Entitlement ................................................................................................................................1 1.1 Impetus for Research ...........................................................................................................1 1.2 Design of the Project ............................................................................................................5 1.2.1 Methods....................................................................................................................5 1.2.2 Scope ........................................................................................................................7 1.2.3 Normative Assumptions.........................................................................................11 1.3 Outline of Chapters ............................................................................................................19 Chapter 2 Mapping Inequality: Health Care Entitlement of Migrants and Citizens ...........22 2.1 Introduction .......................................................................................................................22 2.2 Overview of the Canadian Health Care System ...............................................................24 2.3 Summary of International Migrants’ Current Health Care Entitlement ...........................27 2.3.1 Health-Related Immigration Controls....................................................................29 2.3.1.1 Medical Inadmissibility ...........................................................................29 2.3.1.2 Lawful Presence Requirements ...............................................................32 2.3.2 Gaps in Provincial Health Care Coverage .............................................................37 2.3.2.1 Permanent Residents ...............................................................................39 2.3.2.2 Temporary Foreign Workers ...................................................................41 2.3.2.3 International Students ..............................................................................46 2.3.2.4 Asylum Seekers and Other Humanitarian Migrants without Permanent Resident Status ......................................................................49 2.4 Retrenchment of Migrant Health Care Entitlement in Recent Decades ...........................58 v 2.4.1 Ontario’s Medicare Reform ...................................................................................60 2.4.2 Asylum Seekers’ Exclusion from Medicare ..........................................................65 2.4.3 Similar Policy Developments in Other Western Democracies ..............................69 2.5 Conclusion ........................................................................................................................75 Chapter 3 Contextualizing Inequality: Neoliberal Underpinning of Contemporary Migrant Health Care Policies .................................................................................................77 3.1 Introduction .......................................................................................................................77 3.2 Making of a Global Neoliberal Hegemony .......................................................................79 3.2.1 Postwar Keynesian Welfare State ..........................................................................79 3.2.2 Neoliberalism’s Rise to Dominance ......................................................................82 3.2.2.1 Neoliberalism in a Nutshell .....................................................................82 3.2.2.2 Constructing a Global Neoliberal Order ..................................................84 3.3 Neoliberalization of Health Care ......................................................................................90 3.3.1 Private Sector Participation in Health Care ...........................................................90
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