TORONTO -- The call came 35 weeks into her pregnancy, right around the time her abdominal cramps began. It was the receptionist from her gynecologist's office saying the government's changes to the Interim Federal Health Program meant her prenatal care was no longer covered.
That's when Tiffany started to panic.
"I asked, `What am I supposed to do?'... I got scared," recalled the 27-year-old originally from the Caribbean.
"She told me that if I come and see the doctor I would have to pay the doctor a fee."
The Toronto resident -- who wouldn't give her full name for fear it would affect her application to live in Canada -- has valid IFH papers and had been going for regular prenatal check-ups until that call.
Some doctors say her story is an example of the confusion and compromised care resulting from changes to the program which provides temporary health coverage for protected persons, refugee claimants and other groups not eligible for provincial health insurance.
Under those changes announced this spring, some refugee claimants saw cuts to their drug, dental and vision coverage. Additionally, those whose refugee claims are rejected and those from a yet-to-be defined list of "safe" countries will only receive medical care if their condition is deemed a risk to public health or safety.
The government hopes the changes will deter bogus refugee claims and ensure failed asylum seekers can't take advantage of Canada's free health care. The Conservatives also insist that care for "bona fide" refugees -- including prenatal care -- isn't affected.
While politicians and refugee activists engage in a fierce debate over the issue, a number of health-care professions have set up free clinics to help people without health insurance like Tiffany.
It was at one such clinic that she first met Dr. Paul Caulford.
"She was so scared when she came to us," said Caulford, medical director of the Volunteer Clinic for Medically Uninsured Immigrants and Refugees.
"It was just a very painful thing to see that kind of fear, that kind of desperation be on her face."
The walk-in clinic in east-end Toronto is run by volunteer doctors and nurses twice a week. Caulford said he has seen the number of patients triple ever since the IFH changes took effect July 1.
In addition to Tiffany's case, Caulford also tells the story of a woman considering an abortion nine weeks into her pregnancy because her financially taxed family simply could not afford to pay for the prenatal care. There are other stories of patients with asthma or diabetes whose medications are no longer covered.
"This is an extraordinarily unprecedented crisis in Canada," Caulford said, adding he finds it "appalling" that the government would willingly target the most vulnerable.
A group of doctors, the Canadian Doctors for Refugee Care, are calling on the government to reconsider the changes and study their impact.
The multiple categories of the IFH program now leave health-care providers and their patients extremely confused over who is eligible for what, Caulford said.
Tiffany's case provides an example of that lack of clarity, he said.
After her son was born last month, the young mother received a hefty bill from the anesthesiologist who provided her epidural. She was in the process of paying it when she received a call just over a week ago.
"He called me back to apologize and say that he was being paid," she said. "The government wasn't supposed to pay him but they paid him."
According to Immigration Canada, health-care services related to pregnancy are considered essential.
Under the reformed IFH program, there are only three exceptions to coverage for such care: rejected refugee claimants who have exhausted all their appeal rights, refugee claimants whose claim is suspended and refugee claimants from "Designated Countries of Origin" or DCOs, which are countries the government generally considers safe.
Refugee claimants from DCOs will have their claims processed faster to ensure those in need get protection quickly, while those with unfounded claims are sent back quickly.
The DCO policy is still being developed, said spokeswoman Nancy Caron, and when it eventually takes effect, refugee claimants from those countries who made their asylum claim before the policy takes effect will still be eligible for prenatal coverage.
For others who fall into the three categories, only health-care services necessary to prevent and treat disease which pose a risk to public health and safety will be covered.
"The reformed IFHP offers different coverage depending on the immigration status of the beneficiary," said Caron. "As that status changes, the beneficiary's coverage can also change without notice."
Some experts on refugee policies say the changes to the IFH program, particularly for claimants who will be coming from countries the government considers safe, are highly troubling.
"It's appalling and it's just very clear to me that we're putting the rights of children and families at serious risk," said Sharry Aiken, a law professor at Queen's University.
"I'm not going to say that there aren't people coming to Canada without a genuine claim, sure there are, but does that mean in the process of adjudicating their claim we should introduce measures that could potentially kill them? Or if not kill them, seriously compromise their health status?"
According to Aiken, the government is likely to face legal challenges in the future if it doesn't roll back some of its changes.
She also foresees an increased burden on the country's hospitals as those with limited coverage eventually turn to hospital emergency rooms for urgent care.
"It's very short-sighted," she said. "All we're doing is reshuffling the cost."
Aiken, and other advocates for refugee care, don't dispute the need to crack down on illegitimate asylum claims, but they believe cutting essential health care for some in the process goes against the country's values.
"During the time that they're here, everybody should be treated to the basic standards of health care," Aiken said. "It's a fundamental tenet of Canada."
