Many health care providers are unaware that military families are divided in the way they access health care—that is to say, each family is divided.
Members of the Canadian Armed Forces (CAF) receive federally funded health care directly from the military, often right on the bases they are posted to, while their spouses and children typically receive care through the provincial and territorial systems where they live, the same way most other Canadians do.
But because military families move up to four times more frequently than other families—it’s estimated that 10,000 relocate annually, and about 8,000 move provinces—they face unique and substantial barriers in their access to care. They can wait years to secure a family doctor, only to receive notice that the family is relocating. They can wait months to see a specialist in one province or territory and then have to go to the back of the line in another; they may even have to be re-diagnosed before being allowed to get in line at all.
Neither the military health care system nor the provincial/territorial ones were set up with an eye to how spouses and children of members might get caught in the gap between them. But with increasing attention being paid to this gap—both within the military and by health care providers—some potential solutions are beginning to be explored.
|What we know about military families’ access to health care|
In 2013, the military’s Ombudsman reported on the “well-being of the military family in the new millennium.” One key finding was that “accessing health care and maintaining a reasonable level of continuity during mandatory moves remains a persistent challenge for military families,” making particular note of “the reality that many [military family members] take leave and travel to their previous postings to consult their former physicians because they have not secured doctors in their current locations.”
The report recommended that the military encourage medical practitioners to take military family members on as patients, and also to explore “with provincial and professional partners the possibility of transferring the family member’s position on a wait list intra- and inter-provincially.”
In 2018, Military Family Services (MFS), a CAF organization that works to ensure the military family community is well supported, similarly reviewed the state of the military family in Canada, pointing to a 2013 Quality of Life study (conducted by the Department of National Defence) which found that 44 percent of spouses said it was “extremely difficult to re-establish medical services after relocation.”
In fact, spouses identified primary health care as the “second highest challenge overall for military families.” In the 2013 study, 24 percent of military spouses reported not having a family doctor, and 17 percent reported that their children did not have a family doctor. (This was compared with an average of 15.5 percent of civilians who did not have family doctors at the time.)
Also in 2018, Alyson Mahar, epidemiologist and assistant professor at the University of Manitoba, led a retrospective cohort study comparing 7,508 military families’ access to health care in Ontario with that of 30,032 matched civilians over a period of roughly two-and-a-half years. The study found that the military families had a significantly longer interval than civilians did to their first contact with any health care provider (including family doctor, emergency department, and specialist)—118 versus 83 days. This is in spite of the fact that military families are likely to seek out providers soon after they move. “Because this is a group that’s trying to reintegrate into the health care system, they’re more likely to be initiating contact,” says Mahar. For 18 percent of military families, the ED was their first contact with the health care system; for civilians, this number was 14.7.
Other key findings from Mahar’s study included the fact that children in military families were less likely to see a pediatrician than their civilian counterparts (17.7 percent vs. 26 percent) and were less likely to receive non-influenza vaccinations (23.2 percent vs. 32.3 percent).
|What this means for military families|
Retired Colonel Russell Mann spent five years working with MFS, travelling around Canada, and hearing about families’ experiences. Here is one of them: A young couple living in Québec, expecting a baby, received notice of posting to Alberta.
The baby was born soon after they moved and before their Alberta health insurance was available, as per the “three-month rule” in which people are covered by their previous province’s insurance for the first three months of residency in a new province. But in this case, the bilateral agreement between the provinces did not allow Québec to cover the delivery. “The rationale is, ‘You knew were pregnant, you shouldn’t have moved,’” says Mann, who now works as a senior adviser at the Vanier Institute of the Family. But this family didn’t have a choice, and they found themselves with a $22,000 bill.
This situation was one of the cases used to persuade the provinces to waive the three-month wait period for military families, which happened between 2013 and 2014. This change is “mostly built on goodwill,” says Mann. “I don’t know that there’s any legislation or amendments to health care acts.”
Mann’s own family experienced health-care barriers following a relocation. After being posted to Québec, his wife tried to find a family doctor and discovered a queue of 10,000 people ahead of her. “If we had stayed in the military, we would most likely have relocated before she ever got through that wait list,” says Mann.
The problem of access to primary care is, of course, not limited to military families. In 2016, Statistics Canada reported that nearly 16 percent of Canadians did not have a family doctor (nearly 29 percent of them had not tried to find one). Several provinces have centralized waitlists for family physicians; in Nova Scotia, that list recently topped 50,000.
At the Military Family Resource Centre in Halifax (MFRCs are not-for-profits stewarded by MFS), executive director Shelley Hopkins says this is “probably the number one frustration” for military families, who are using walk-in clinics and the ED for prescription renewal, and who travel back to the provinces where they were previously posted to see specialists for mental health conditions, diabetes, and even cancer.
Travelling back to their previous province is not a realistic option for Melissa Harrison’s family. Last fall, she posted a video on Facebook in which she explained that her son, who has autism, would have to be re-diagnosed in BC, where the family was moving, in order to go on a wait list for therapy (which he’d started in Ontario). Harrison had been told that the wait to see a pediatrician was a year, and the wait for therapy another 16 months. Despairing that her son would lose the gains he’d made, Harrison was contemplating paying privately for therapy, at $175 a session.
“The present health care system doesn’t account for families like that,” says Michelle Szkwarek, who co-founded the Canadian Armed Forces Family Advocacy Group, an online community of 500 people, including CAF members, family members, veterans and allies. “And it means those family members go under-served or face financial hardship.”
From 2012 to 2018, Szkwarek’s husband was based in the US, where her family received health care through the American military (as per an agreement between the two countries). While in the States, Szkwarek worked for MFS and heard from families with children with special needs about “how glad they were, being in the US. at the time of the diagnosis, because it was earlier access, quicker response, earlier intervention and continuity, and it set them up for success,” she says. “Whereas they felt if that process had been happening in Canada, there would not only have been delays but setbacks every time they had to move.”
|What can be done to improve military families’ access to health care?|
To open the military health care system up to families would “be a major upheaval,” says Mann. Essentially, he says, it would double the patient load for each base clinic and change the nature of patient profiles. “The feds and the provinces would have to have that discussion. I can tell you in practical terms the bases don’t have the capacity, infrastructure or physicians to do that adequately and meet the standards of care defined by provinces and the Canada Health Act.”
More modest measures have been taken at some bases. For example, the Halifax MFRC has been involved with a pilot project through which the services of Maple, a virtual health care company, are provided (through funding from MFS) for one year to 400 families that have recently relocated to that base. This has meant that people can access family doctors quickly as well as receive prescriptions and be referred for blood work and other tests. Plus, families’ records are available to them digitally, even after their year-long subscription runs out. “This was really important to families,” says Hopkins, ED at Halifax MFRC. “They want to build a health history.”
In partnership with MFS, Calian, the company currently contracted to provide medical services to the military, has launched the Military Family Doctor Network through its Primacy clinics (often housed at Loblaws grocery stores), where some physicians have opened their practices to military family members. And this points to another area of need: education of health care providers about both the access challenges and specific health care needs (for example, mental health issues related to the deployment of a family member) of military families.
In 2016, Vanier, in collaboration with the College of Family Physicians and the Canadian Institute for Military and Veteran Health Research, released “Family Physicians Working with Military Families,” a resource to help primary care doctors better understand the needs of military families. Further, in 2017, the CFP released guidelines and the Canadian Paediatric Society released a position statement specific to working with military families.
Szkwarek’s group, which formed in August 2018, has put together recommendations for the CAF’s “Seamless Initiative,” a project launched last summer which aims, largely, at easing military families’ transitions after relocation. Among the recommendations specific to health care is that the CAF work with the federal and provincial governments to eliminate wait lists for care required by “exceptional” members (such as a child with special needs) as well as for their caregivers, as “it has been well-founded that primary caregivers to the ill and injured often mortgage their own health for the sake of the sick family member.”
“Our group had a really tough time coming up with recommendations [regarding health care access], because we don’t want to see someone suffer because of us,” says Szkwerek. “But at the same time, we are suffering because of the current health care system.”
“I have never met a military family that wants to be treated different from other Canadians. They just want to be treated the same,” says Russell Mann. “Right now, they feel the military lifestyle causes them to be penalized. They don’t want to create a special circumstance where they’re getting preferential treatment, but they need to get more equitable access.”
|Dafna Izenberg, Contributor|
|Dafna is the Managing editor of special projects at Maclean’s Magazine.|
|Chika Oriuwa, Contributor|
|Chika Stacy Oriuwa is a medical student at the University of Toronto who is completing her MD/MSc with a concentration in System Leadership and Innovation. She has a keen interest in health care reform pertaining to the intersections of race and gender within medicine.|
|Joshua Tepper, Contributor|
|Joshua Tepper is a family physician and the President and Chief Executive Officer of North York General Hospital. He is also a member of the Healthy Debate editorial board.|
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