‘Through the cracks’: Minding the gaps in UBC's fractured healthcare system

The financial and logistical constraints of insuring and getting students the care they need have impacts on more than physical health.

First-year science student Michelle Huang self-identifies as a “unique profile” — one of the “difficult students” who attend UBC.

But she doesn’t mean difficult in terms of behaviour.

Huang, who is a mature student at UBC, suffers from a reading disorder, central auditory processing disorder and mental health concerns — including PTSD — which have severely impacted her studies. Throughout her time at UBC, she has accessed services through UBC Student Health Services (SHS), UBC Counselling and Access & Diversity — none of which she feels are equipped to handle cases as “complex” as her own.

“I was told they weren’t able to help me because my case was more complicated, because I have both a learning disability and mental health concerns,” said Huang, who has taken multiple semesters off, reduced her course load significantly and even switched out of required courses to maintain her health.

“I’m one of those people who falls through the cracks all my life, so I’m kind of used to it.”

For Huang and the many other students with complicated or chronic health concerns, the gaps in UBC’s ability to support and care for its students' well-being are cast in sharp relief. In the context of a fractured national and provincial healthcare system, the financial and logistical constraints of insuring and getting students the care they need have impacts on more than physical health.

‘Uniquely incomplete’

Even in a country as lauded for its healthcare as Canada, structural barriers to covering and accessing care continue to catch students and other vulnerable populations in the mud.

According to Dr. Steve Morgan, a professor of health services and policy at the UBC School of Population and Public Health, Canadian medicare is “uniquely incomplete.”

“Medicare is a cherished institution, this idea of universal public insurance for medically-necessary services is laudable in many ways,” said Morgan.

“But every other comparable country with high income in a westernized, democratic society achieved universal health insurance in the post-war era, or a couple of them in the pre-war era. And every similar program is much more comprehensive than Canada’s is.”

Among the areas in which Canadian healthcare lacks consistency in coverage are dental care, vision care, pharmaceuticals and long term or home care services, although many provinces have committed to expanding coverage in a variety of areas. Ontario recently implemented free pharmacare for all youth under 25, while in Quebec, a commitment to providing universal primary mental health care coverage has been made.

“I’m one of those people who falls through the cracks all my life, so I’m kind of used to it.”

— Michelle Huang, first-year student

A similar pharmacare plan is unlikely to come to BC anytime soon, but the BC NDP and Greens included a commitment to “develop a proposal to implement an essential drugs program, designed to reduce the costs of prescription drugs,” in the confidence and supply agreement signed between the two parties in order to form government.

While the budget and progress towards this goal will not be announced until BC’s budget is released on February 20, Morgan sees pharmaceuticals in particular as a point of pain in the care and coverage of students.

“You would have thought that in the ’70s and ’80s, we would’ve expanded to have pharmaceutical coverage, expanded to have dental coverage. And those gaps in coverage matter a lot, particularly to groups that can’t avail themselves of work related private health insurance that covers those gaps,” said Morgan.

“We have this fragmented system of insurance that makes the cost of the services expensive, but also creates a safety net that is fragmented and through which people can quite realistically fall through the cracks.”

‘The only affordable option’

Students unions, just like federal and provincial governments, face financial and logistical challenges as they work to bridge the gap between public insurance provisions and the healthcare needs of students. For students who don’t have extended coverage through their parents’ workplaces or who don’t qualify due to part-time student status or having aged out — like Huang — insurance provided by the AMS is the only affordable option.

“[Student populations] don’t have that work-related health benefits and as a consequence, student unions are in the position of trying to negotiate those benefits on behalf of their student bodies,” elaborated Morgan. “Depending on the student union [and] on the student group, they may or may not have full coverage for dental services ... and they certainly may or may not have full coverage for pharmaceuticals.

“That can result in burdens for people who have needs for those uninsured services.”

Alim Lakhiyalov, the current AMS Vice-President Finance, decides where and for whom those burdens are too much. As the lead executive for the AMS/GSS insurance plan provided through StudentCare — which currently costs students $232.49 per year — Lakhiyalov works to monitor and evaluate usage of the plan in order to balance utility and affordability for its over 40,000 subscribers.

“We don’t want to cross boundaries where the health plan becomes less affordable for students and it’s very hard to actually get access to it. So it’s like we’re playing in a balanced medium.”

— Alim Lakhiyalov, AMS VP Finance

But if the AMS is to fill the most important gaps, it has to navigate the troubles of insuring a massive population, maximizing student money and avoiding an insurance gaffe that could endanger students’ lives. Recently, the University of Victoria Student Society changed their own plan, which resulted in a drastic reduction in the number of prescription drugs covered under the plan and excluded a $250,000 per year medication that one student takes to manage her cystic fibrosis.

“I’d like to see it expand in terms of yes, the number of services and the number of in-network practitioners, that would be awesome, but at the same time I do want to keep it as affordable as possible for students because I think that’s really the key here,” said Lakhiyalov.

Included in the plan as it stands is coverage for prescription drugs (up to 80 per cent of cost), psychology services ($300 per policy year) and substantial vision and dental care coverage, among other partially-covered services such as physiotherapy and chiropractor work. According to Lakhiyalov, the plan sees strong utility from students, but the AMS is certainly looking to improve it in areas where supply for coverage doesn’t meet demand.

“We don’t want to cross boundaries where the health plan becomes less affordable for students and it’s very hard to actually get access to it. So it’s like we’re playing in a balanced medium.”

Making do

In recent utility reports, Lakhiyalov noted that the coverage for psychology and counselling services is often maxed out.

“One of the real focuses that I want the plan to shift towards is that mental health support network,” said Lakhiyalov. “We need to start — while maintaining the benefits it already has — gearing it more towards the mental health stream.”

He noted that this goal could be achieved through new services offered such as the 24/7 counselling hotline Empower Me, or by increasing the $300 limit on psychology claims. With the average market rate for psychology running around $120 per hour, the benefit currently covers just over two sessions of private counselling.

According to Dr. Marna Nelson — director of UBC SHS — the wait for a non-emergency appointment with a SHS psychiatrist or psychologist is now “down to one to two months.”

“We have contracted to have services from two additional psychiatrists, one who was full time in the last six months, and we have another who was on leave who is now back. So we have substantially more psychiatry appointments than a year ago,” said Nelson.

Still, UBC students continue to raise concerns about the length of the wait for psychology and counselling appointments. According to the 2017 Academic Experience Survey (AES) conducted by the AMS, only 27 per cent of undergraduate students have accessed help from SHS, with only 10 per cent claiming that it “helped significantly.” Of the 13 per cent of undergraduates who have used UBC Counselling Services, only 4 per cent claimed that it had a significant impact on their mental health.

Huang — who was assigned a psychiatrist through UBC SHS and then had her request to change psychiatrists denied after she felt they did not “click” — feels that the lack of consistent and immediate care available for mental health support shows a gap in the mindset of SHS in general.

“[SHS are] more equipped to deal with topical issues, like anxiety or depression, so it’s very basic mental health support. I don’t feel like they were able to help me with more complicated issues,” said Huang, who has now paid for her mental health support out of pocket into the “tens of thousands of dollars” since beginning at UBC in 2014.

“They’re definitely not there for long term support, they made that clear.”

Morgan echoed Lahkiyalov’s concern for the “shameful omission” of public mental health coverage, noting that it is one of the areas that is difficult to approach from a policy perspective because there is no regulatory body for all types of mental health care providers in BC or Canada.

“People make do. People who have some sort of mental health coverage maybe through the AMS or maybe through their parents’ workplace, might find they can get a limited amount of counselling sessions, but that’s another area of our healthcare system where there’s definitely room to improve,” said Morgan.

Learning to cope

As SHS continues to offer a broad range of youth-specific health services — from dermatology to contraceptive services to sports medicine — students’ varied health concerns persist, especially for those with chronic health issues.

Gabi Rosu is a second-year combined science major who lives with Crohn’s disease, which causes her extreme abdominal pain, bleeding and excessive washroom use. While she has had positive experiences with SHS and Access & Diversity, Rosu is concerned that physical illness and chronic conditions in general aren’t discussed enough.

“People just push off physical illness to the side like it’s nothing … and it’s hard to be a university student with such a severe level of Crohn’s,” said Rosu in a previous interview with The Ubyssey.

Nelson, who finds it “very rewarding” to help students with chronic health conditions thrive at UBC, reiterated that SHS is focused on keeping students healthy so they are able to do well in their studies.

“Ideally, if you are in good physical and mental health, that increases your chance of doing well.”

Concerns from “unique” students like Rosu and Huang, however, also illustrate a common misconception surrounding healthcare concerns — that university students are healthy to begin with.

“We tend to think, ‘well, lack of coverage for services for young adults is not that big of a deal because they don’t need it on average,’” said Morgan.

“As a consequence … you can kind of brush aside the whole demographic because of their average health but in fact what’s happening is you’re ignoring the particular needs of small populations.”

“we do recognize that student well-being is multifaceted.”

— Patty Hambler, director of the UBC Student Wellbeing Promotion Unit

With these concerns and the Okanagan Charter for Health Promoting Universities and Colleges in mind, UBC has moved forward on its Student Wellbeing Strategy with the launch of the Student Wellbeing Promotion Unit (SWPU), which will focus on making students aware of resources available to them on campus and training faculty and staff to incorporate wellbeing practices into their own work.

“This new unit is an expanded effort that the university has undertaken toward health promotion and education,” said Patty Hambler, director of the SWPU. “We work both on proactive approaches [and] we also work responsively with faculties in the sense that they require consultation or coordinated support for students.”

In the broader discussion of health in a university’s student population, Hambler emphasized that her goal is to support students in learning the skills to take care of themselves, too.

“We can consider university as a rehearsal space for life — there are daily stressors that you experience as a student and part of being a university student is learning how to cope with those daily stressors,” said Hambler.

“[And] we do recognize that student well-being is multifaceted.”

However, both Nelson and Hambler largely discussed maintaining student health only to the point that these students are able to graduate.

“Our family physician team and our psychiatry team as well have been encouraged by the number of students we have been able to help cope and graduate in a timely manner,” said Nelson.

Speaking the language

Even for “typical” student health problems, UBC and the AMS face structural, political and financial barriers that make it difficult to fill the gaps between what government and insurers provide, what UBC feels it can do and what individual students need.

“[Canada has] this long history of private and fragmented public programs for everything outside of the hospital [so] we don’t speak the language of ‘this is just a fundamental human right,’” said Morgan.

Ultimately, it remains difficult to repair the cracks in a fragmented system when the financial and political wills simply aren’t there at all levels.

“I think that it can be said that even if this weren’t economically sound, it’s still the right thing to do.”