Kimberly Gloade wasn't the first Indigenous person without a medicare card to fall through the cracks of the health system, but advocates for universal public health care want her to be the last.
The Mi'kmaq woman's 2016 death has prompted Médecins québécois pour le régime public, which represents about 500 doctors and medical residents, to call for system-wide changes.
"It's not a fair expectation for hospitals and other health care institutions to expect that everyone's going to have all their papers in order," said Samir Shaheen-Hussain, a pediatric emergency doctor and a spokesperson for the public health-care advocacy group.
"The deplorable state of affairs is that a lot of these people just end up being used to it, which is obviously not the way it should be."
Gloade, 43, walked out of the emergency room at the MUHC's Royal Victoria Hospital without having been treated in February 2016. She died at home a month later from cirrhosis of the liver.
Case forces soul-searching at MUHC
An internal investigation showed Gloade was seen by a triage nurse and sent to the registration desk, but she didn't have a valid Quebec medicare card.
In a letter she wrote to her mother but never posted, Gloade said she'd been told at the hospital she'd have to pay $1,400 to see a doctor.
In response to a scathing coroner's report and its own investigation, the MUHC reviewed its admission practices.
Now if a patient wants to leave because they don't have insurance, the clerk is instructed to send the patient back to the triage nurse to see if it is medically safe to do so.
"That case enlightened a lot of administrators," said Dr. Gilbert Boucher, vice-president of the Association des spécialistes en médecine d'urgence du Québec, and an ER doctor at the MUHC's Royal Victoria Hospital.
"From a doctor's standpoint, nothing changed," he said. "The hospital definitely changed."
Boucher says while a discussion of payment for the uninsured does happen at some point, it's rarely right at the start.
"Until the patient is safe, we cannot have that discussion about payment."
But Shaheen-Hussain thinks the policy needs to be more clear cut.
"What has to happen is the Ministry of Health has to institute a policy where people are not charged up front for the health care that they need, " he said.
According to Health Ministry policy, patients will be billed for services, according to a fee schedule, under several circumstances:
- If they not meet the eligibility requirements for Quebec health insurance.
- If they are not asylum seekers.
- If they come from a country with which Quebec does not have a billing reciprocity agreement and do not have proof of private insurance.
However, ministry policy also states that doctors "must provide the best possible care for a patient when a person's medical condition could lead to severe consequences if not treated," regardless of their financial situation.
Shaheen-Hussain says those conflicting policies pose a dilemma for front-line health care workers.
"It's disingenuous — if not risks being dishonest — to suggest it's up to the physician, or putting it on the shoulders of nurses," he said.
The doctor says the sticker shock of a big hospital bill is enough to chase some people away without getting needed care.
"I think this is where the distinction between being 'turned away' formally and de facto being turned away comes into play," he said.
'You'll be treated. Period,' says Barrette
Quebec Health Minister Gaétan Barrette calls Gloade's case an "extremely sad story," but he insists the ministry's main directive is clear.
"The rule in Quebec is a very simple rule. If you go to an ER, and you have an urgent health problem, you'll be treated. Period."
Barrette did not respond to questions about whether billing discussions could deter marginalized patients from seeking treatment.