My family arrived in Canada as new permanent residents towards the end of this past summer, having moved from Nebraska in the US.

We knew coming here that Ontario (and elsewhere in Canada, but I'm most familiar with Ontario & that's where we live now) is having a crisis in healthcare access and especially in primary care. We now have a little bit of our own experience navigating this system, so I thought I'd write up what I've learned.

# OHIP Coverage & Insurance

It used to be that after moving to Ontario, a new resident had a three month wait before they would qualify for the provincial healthcare program, OHIP. That waiting period was removed in March 2020 as a pandemic response measure, and hasn't been put back yet. I'm hopeful (but uninformed on how likely it is) that it will not be put back and newcomers can start accessing medical care right away!

OHIP pays for things like doctor visits, hospital stays, laboratory services, and a few other miscellaneous items. It doesn't cover prescriptions except those given in a hospital setting. It also doesn't cover mental health talk therapy for physical therapy, for the most part. Many people's jobs offer supplemental insurance coverage. The supplemental insurance works a little more like a reimbursement program or pre-loaded US FSA than how employer-sponsored insurance works; plans often define a max reimbursement amount for each covered person for each category of care, and you can get reimbursed/covered for only up to that amount. You might get $1,000/year in covered talk therapy, $1,000/year in physical therapy, $500/year in dental, etc. These plans often cover prescription drug costs that would be out of pocket, too. The plan might also pay some amount towards upgrading any hospital stays from whatever basic shared hospital room is offered to a private or semi-private room, which is available in hospitals for an extra charge.

My employer was able to offer a plan like this and it's been working well. It also comes with a telehealth service I can access for certain kinds of routine care - very minor ailments that can be consulted on without an in-person visit, and prescription renewals for existing prescriptions for well-controlled conditions.

# Pregnancy Care

First of all, the good: I was about halfway through pregnancy when we arrived. In Ontario, many people just go to their family doctors (primary care providers) for pregnancy & prenatal care. Pregnant people can also be referred to an OB, who are also the go-to for any high risk conditions that may develop in pregnancy. The third option is to get prenatal/birth care from a licensed midwife. Midwives in Ontario are primary care doctors who specialize in prenatal and birth care in healthy/normally progressing pregnancies. You don't need a referral to see a midwife, but there are often very competitive waitlists.

Midwives in Ottawa are covered by OHIP if you have it, but they also have funding to be able to see pregnant patients who don't have provincial health coverage. That's pretty neat!

When we had a date we were planning to be in Ottawa by, one of my first tasks was to add myself to the waitlists for all of the Ottawa area midwifery groups, letting them know when I planned to arrive & my estimated due date. I ended up getting contacted by two different organizations who had an opening for me. I was able to meet my new midwife briefly over a phone call before we moved, then had my first official visit with her after we arrived.

Interestingly, I was given a special form to sign by the midwifery practice since I am a US citizen. The form says that while I retain all my rights to sue the midwife/practice for any breaches of care, I have to promise to do so under Canadian jurisdiction if the need ever arises. The midwife explained that their insurance can't handle the liability levels or the cost of defending a claim in the US, so they have to issue this form. I'll sign another one later on for the Ottawa Birth Centre if I choose to have the baby there.

When it comes time to give birth, as long as I am at term, I will have the option of a midwife-assisted home birth, midwife-assisted birth in the standalone Ottawa Birth Centre, or a midwife-assisted birth at the hospital my midwife's practice is connected with.

# Prescription Refills & Renewals

My partner and I had made sure we had plenty of refills available on our prescription medications before we left Nebraska, but it turns out that Ontario pharmacies will not honor or fill prescriptions from US doctors. We were each able to use a telehealth service to get a new Canada-based prescription that we were able to fill, however.

Another thing we've found is that ADHD diagnoses made in the US will need to be re-diagnosed in Canada. Similarly to the US, you can get an official ADHD diagnosis through a traditional local psychiatrist that probably has a long wait list and a high out of pocket cost, or through a telehealth service that can get you in much more quickly while still ensuring that you will have your care managed by a licensed and qualified medical provider.

# Family Doctors & Walk-In Clinics

In Ontario, the system is set up so that each person (in theory) can be officially rostered with a family doctor who will be their go-to for any acute or chronic healthcare needs, like a primary care doctor would in the US. The family doctor can also make referrals for the person to see a specialist - and for many kinds of specialists, that referral is a hard requirement in order to get on a waitlist to be seen.

More than 6 million Canadians do not have a family doctor (1) and the situation seems to be getting worse. Family doctors who are over age 65 are currently serving 1.7 million Ontarians ((1)) - those doctors will not be doctors forever. And many family doctors who aren't at retirement age are leaving for other professions or other specialties. Many cite the high administrative burdens they face, doing lots of paperwork that they don't get directly paid for. They also cite ever-rising costs of running a practice which have far outpaced the reimbursement rates they get from OHIP.

Canadians who don't have a family doctor can go to walk-in clinics and see a doctor instead. There are some definite downsides here: walk-in clinics can't prescribe certain kinds of medications like stimulants and opioids, and you don't get the same kind of continuity of care as when the same doctor gets to know you and your health over many years or even just months of working together. The wait times are a big factor here as well: common advice for Ottawa walk-in clinics is that whenever you can, you should show up an hour or two before the doors open so you can get in line right away to wait for your turn to be seen.

There is an official centralized waitlist called Healthcare Connect one can get on to attempt to find a family doctor, but many people say they've been on the list for years with no success. Instead, it's likely that to find a family doctor, we'll need to make a lot of phone calls directly to clinics and keep an eye on Facebook groups where people share possible availabilities. Some folks also choose to roster with a doctor at the Appletree Clinics, which are mainly walk-in clinics but if you are rostered with them, you can actually make an appointment to see one of the doctors in their network, rather than needing to wait for possibly hours.

For young children with cold- and flu-like symptoms, the Ottawa children's hospital has a walk-in clinic. After a couple days of trying fruitlessly to get our kid an appointment through the online system that had zero availability, my partner set an alarm to remember to log on just before midnight, when Reddit comments suggested new appointments might become available on the site, and was able to finally book an appointment. Even with a scheduled appointment for a particular time, the visit ended up taking several hours more than expected, but the care received was good, and it was free, other than the parking.

I have to admit that even though I knew about the difficulties we'd face in accessing routine primary care here, it surprised me a bit how adrift I have felt recently when I or my kid are experiencing some minor ailment that I am concerned about and wishing for an expert opinion on how concerned to be or what to do about it. My midwife team is great, but only stuff that's clearly pregnancy-related is within their scope of practice. Unfortunately, there is a lot that can also be wrong or just weird about a body that is pregnant that is not actually considered a pregnancy issue. I would really like to have a family doctor, for all of us!