Qualitative Evaluation of a Mandatory Health Insurance 'wait Period' in a Publicly Funded Health System: Understanding Health Inequities for Newcomer Im/migrant Women

Objectives: To evaluate impacts of a residency-based waiting period for health insurance coverage on lived experiences of health and settlement for im/migrant women in British Columbia, Canada.

Design: The IRIS study is a mixed-methods, community-based, qualitative evaluation of recently arrived im/migrant women's access to sexual and reproductive care. In-depth, semistructured interviews were conducted by trained multilingual and multicultural interviewers with lived migration experience in the participant's preferred language.

Setting: Metro Vancouver, British Columbia, Canada from July 2018 to January 2020.

Participants: Data collected from community focus groups (four groups, n=29) of both service providers and im/migrant women was used. Following this, qualitative interviews with service providers (n=10) and im/migrant women (n=47) were conducted. Eligible participants self-identified as women; were aged 18-49 and had arrived in Canada from another country. Eligible providers were employed in the health, social or legal sectors working with im/migrant women.

Results: The wait period resulted in mistrust and internalised stigma for racialised im/migrant women, for whom the policy resulted in feeling 'undeserving' of care. Resulting administrative burden produced delays and unmet need for care, particularly related to sexual and reproductive healthcare and children's health. Unexpected costs meant difficult choices between survival and care. Negative health outcomes included the inability to family plan, difficulties during pregnancy, as well as hardships related not being able to seek help for sick children. Community-based organisations provided support in many areas but could not fill all gaps produced by this policy.

Conclusions: Findings highlight severe, yet commonly overlooked, health inequities produced by a mandatory health coverage wait period within a purportedly 'universal' healthcare system. Health system policies such as mandatory 'waiting periods' produce discriminatory and inequitable outcomes for im/migrant women. Policy reforms towards full 'healthcare for all' are urgently needed to affirm the health and human rights of all im/migrants.