Medical Inadmissibility Study report

The economic burden of immigrants with HIV: When to say no?

2009 Medical Inadmissibility Study report, June 2009

The Canadian Immigration and Refugee Protection Act (IRPA) of 2001 outlines the conditions under which individuals may be granted or denied admission to Canada. Specifically, Section 38(1) of the IRPA stipulates that applications for residence will be rejected if an applicant’s health is expected to generate excessive demand on Canadian health or social services. The purpose of this research synthesis and knowledge dissemination paper is to derive a compelling statistical definition of excessive demand and to apply this threshold to persons with HIV who are seeking admission to Canada.

This paper represents a sixfold exercise in positive analysis. First, we review the application of Canadian immigration law and jurisprudence as it pertains to persons with HIV in the context of international restrictions on international mobility. Second, we review and assess the current threshold used to determine excessive demand on Canadian health or social services. Third, we synthesis the clinical, epidemiological and economics literatures concerning the expected economic burden placed on health or social services by persons with HIV. Fourth, we derive estimates of the economic burden associated with a new immigrant with HIV over a 5-year, 10-year, and lifetime horizon after stratifying for their underlying state of health, age and sex at the time of admission. Fifth, estimates of the economic burden are compared to the excessive demand thresholds in order to yield evidence-informed criteria for assessing medical inadmissibility. Finally, we assess the economic contributions of new immigrants in order to offer a more complete picture of the costs and benefits of immigrants.

The paper offers four substantive findings. First, the 2007 cost threshold used by Citizenship and Immigration Canada in assessing whether an applicant is likely to pose “excessive” demand (C$4,867.40/year) is too low. A statistically more appropriate threshold is three-fold greater at C$14,581.43/year. Second, there is an inverse relationship between disease progression (measured by CD4 cell counts) and health care costs, with annual costs (in 2007 C$) increasing from under C$8,000 for CD4 > 500 cells/mm3 to over C$35,000 for CD4 < 100 cells/mm3. Third, application of these cost estimates to the revised cost threshold for inadmissibility demonstrates classification depends on individual characteristics, including age, sex and health status, as well as on the time horizon over which each applicant’s projected demand is assessed. “Excessive” demand is more likely to occur for applicants with low CD4 cell counts and a shorter time horizon for assessment (i.e., 5-years versus their lifetime). Women and younger applicants are slightly more likely to be deemed inadmissible than men and older immigration applicants. Finally, estimates of the economic contributions of new immigrants to the public treasury through taxes paid on labour market earnings are substantial, and often exceed estimates of their health care costs. These economic contributions are dependent on the age, sex, and region of origin of prospective immigrants as well as on other conventional determinants. Exclusive focus on the health care costs of prospective immigrants without consideration of the economic contributions (albeit measured in tax revenue terms) yields an incomplete evaluation of immigrants. Citizenship and Immigration Canada should develop more evidence-informed policy and admit to Canada some applicants otherwise denied admission based on current policy.

Principal investigators:

Peter Coyte, PhD, University of Toronto
Michael Battista, Barrister and Solicitor, Jordan Battista LLP


Ahmed Bayoumi, MD, University of Toronto
Alan Li, MD, Regent Park Community Health Centre Dave Holmes, RN, PhD, University of Ottawa Richard Elliott, Canadian HIV/AIDS Legal Network Sandra Chu, Canadian HIV/AIDS Legal Network Francisco Rico-Martinez, FCJ Refugee Centre