Abortion access in New Brunswick: the sale of Clinic 554
This is a primer on the funding restrictions Clinic 554 faces on surgical abortion, what they mean, and why government should care. This post doesn’t deal with other challenges that Clinic 554 has stated it’s facing (including underfunding for non-surgical abortion and trans health care).
What is Clinic 554?
Clinic 554 is a family practice in Fredericton that also has expertise in serving the LGBTQ2S+ community and is the only non-hospital provider of surgical abortions in New Brunswick. In his statement on Clinic 554 being placed for sale due to financial instability, the clinic’s medical director Dr. Adrian Edgar says that 3 000 patients use or have used their services. Clinic 554 is located in a building that was a Morgentaler Clinic (a stand alone abortion provider) until 2014 when it closed after years of operating at a loss.
Clinic 554 is often framed as a dreaded “private clinic.” Because of the way our health care system works, it can be more accurate to talk about insured and uninsured services as opposed to private and public providers. Insured services are paid for by Medicare; you get them at a public health care facility like a hospital or community health care clinic or at a family practice or walk-in clinic which then bills Medicare. Clinic 554 is like other family practices in that it bills most of its services back to Medicare — but not surgical abortions.
Why can’t Clinic 554 bill surgical abortions to Medicare?
Schedule 2 of Regulation 84–20 under the Medical Services Payment Act identifies medical services that are not insured (or, to use the language of the regulation, that are not “entitled services”). This includes abortion, “unless the abortion is performed in a hospital facility approved by the jurisdiction in which the hospital facility is located.”
This means is that surgical abortions in the three designated hospitals in the province are paid for by Medicare; those at Clinic 554 are uninsured and therefore patients have to pay for them — or the Clinic waives the patient fee and absorbs the cost themselves. The former Morgentaler Clinic, which had a policy of never turning away a patient who couldn’t pay, demonstrated that this practice is not sustainable. This payment is why Clinic 554 gets framed as a private clinic.
It’s worth noting that most surgical abortions performed outside of hospitals in other Canadian jurisdictions are insured (British Columbia, Alberta, Saskatchewan, Manitoba, Quebec, and Newfoundland and Labrador insure surgical abortions in clinics; Ontario funds some of its clinics; and the territories, Nova Scotia, and PEI have no out of hospital clinics offering surgical abortions). Since 2015, Health Canada’s annual reports on the Canada Health Act have expressed concern regarding out-of-hospital abortions not being funded by New Brunswick Medicare. Earlier this year, the federal Minister of Health reiterated these concerns in letters to the provinces stating that, “Such charges for a publicly insured service are contrary to the Canada Health Act.”
The historical context of this regulation is important. The specific provisions on abortion were added by the provincial government in the late 1980s in the wake of the full decriminalization of abortion. In 1988, the Supreme Court of Canada ruled that including abortion in the Criminal Code of Canada violated the Canadian Charter of Rights and Freedoms; prior to that, abortion was only legal when approved by a hospital committee. After the ruling (and after Dr. Henry Morgentaler began efforts to establish stand alone abortion clinics throughout Canada, which he argued would offer better and more cost-effective abortion care than hospitals), the provincial government created a regulation that stated that for abortion to be insured it had to be certified as medically necessary by two physicians and performed by a specialist in an authorized hospital. In our opinion, this made abortion access look a lot like the pre-1988 days with cost replacing criminalization as a penalty.
The regulation has loosened over the years but still stands. In 2014, the requirements for a two-doctor referral and a specialist were removed; in 2015, the Moncton Hospital began offering surgical abortions. While this expanded access to three hospitals in the province, it didn’t improve regional access as the Moncton Hospital is less than three kilometres from another provider, the Dr. George Dumont Hospital.
Government’s position seems to be that the hospital sites are meeting the demand for service. In 2016, the Health minister of the day said as much to media; later the same government focused on funding non-surgical abortions to improve access. A representative for the current government provided a statement to CBC that said that their stance “remains unchanged from that of the previous government.” We would suggest that the actual demand isn’t known as Clinic 554 is addressing some of the need while not receiving Medicare payment.
Does New Brunswick really need the surgical abortion access that Clinic 554 provides?
Abortion access in New Brunswick has improved in recent years. Patients can now self-refer themselves for abortions at hospitals in Moncton and Bathurst. Mifegymiso (the drug combination used in non-surgical abortions, referred to as medical abortion) is free to individuals with a valid Medicare card. If Clinic 554 closes, those options will still be available.
So do we really need Clinic 554? Many New Brunswickers have to travel away from home for medical procedures, so why isn’t hospital access in Moncton and Bathurst enough?
People need as many options as possible when it comes to abortion access. An abortion has to be completed within a specific time frame, is often sought under difficult circumstances, and involves heightened privacy concerns for patients. Patients need options so that they can make the best and safest choice for themselves based on their particular circumstances.
Some people may prefer medical abortions. Others may prefer or only have the option of surgical abortions. Patients may seek a surgical abortion at a particular location because it is close to them and they can minimize the cost of travel. Others may decide to travel to obtain the service at a location where they feel less at risk of being recognized or where they are unlikely to seek services again. Patients may prefer a non-hospital setting as they feel it will help preserve their privacy or they find it less intimidating.
For some patients, having limited options may force them to disclose their pregnancy and intention to terminate to a partner, friend, or family member to arrange transportation, child care, elder care etc. This could not only lead to the patient facing judgement and stigma, but could also present a threat to their safety. According to one study with the BMC Pregnancy & Childbirth journal, women who have already experienced violence are more likely to experience an unplanned pregnancy. Additionally, a paper from Journal of Obstetrics and Gynaecology Canada reports that “Women who seek termination of pregnancy seem to be particularly at risk of physical abuse.”
By offering surgical abortion services, Clinic 554 is expanding access regionally and providing patients with the option of a community-based setting. Clinic 554 also offers surgical abortions up to 16 gestational weeks while the hospitals only go to 13 weeks and six days (individuals who are further along in their pregnancy must go out of province for surgical abortion care).
Why should government care?
The obvious answer is: because this is a health care and a human rights issue. Additionally, women and individuals belonging to gender minorities in New Brunswick have told the Women’s Council, through our Resonate initiative, that health care is a top issue affecting their lives and that needs to be addressed. Many women spoke specifically about challenges with accessing reproductive health and getting their basic health care needs met.
But why should this particular government care? There are a few reasons:
Here are the platform commitments from the current government that were explicitly linked to women:
· the creation of a Provincial Advisory Council on Women’s Health;
· establishing a New Brunswick Women’s Health Research Trust;
· reducing wait times for gynecological surgeries; and
· ensuring information on breast density is shared with patients.
Each of these commitments are related to health care. We hope that means that government understands that women have unique health care needs that are not being met and that they’re interested in addressing this issue. Equitable access to reproductive health care must be part of the conversation.
Government’s focus on health care extends into their stated priorities as well. Under the priority of “Dependable health care,” government says that it is “redesigning New Brunswick’s health-care system so that it is more sufficient and offers high-quality services for all New Brunswickers.” Insuring out of hospital surgical abortions would not only improve abortion access but in the case of Clinic 554 it could prevent the closure of a family practice, which will in turn reduce stress on hospitals. All of this aligns with offering dependable, sufficient, high quality health care.
Another government priority is affordable and responsive government. One aspect of this is “insisting our public services and programs are sustainable and provide good value for money.” Clinic 554 has stated that it can provide surgical abortions at a lower cost than hospitals can (and there is research that bears this out) and keep some patients who are further along in their pregnancies from having to travel out of province for surgical abortions. This, along with avoiding the closure of a family practice, lines up with saving public dollars on health care spending.
What’s the council’s position?
We’ve advised government that surgical abortions performed outside of hospitals should be publicly funded. The necessary stakeholders need to work together to change Regulation 84–20 Schedule 2 and establish a reasonable fee for service and claim code so that providers outside of hospitals can bill Medicare for surgical abortions.
Note: you may have noticed we’ve consistently talked about individuals and patients in this post. This is because it’s not just women who get abortions. Individuals who belong to gender minorities who aren’t women may also get pregnant and require abortion care. We chose to use language that includes these folks in our work on reproductive justice.
