Mifegymiso is fully covered for Ontario residents with a valid health card.
Billing code
Billing codes are used by physicians to bill provincial/territorial health insurance plans for the different services that they provide. When there isn’t a billing code for medical abortion, physicians can be de-incentivized from providing it.
Telemedicine abortion has been found to be as safe and effective as medical abortions provided at clinics. Because telemedicine abortion allows patients to access care in their homes and often requires just one trip to a pharmacy or clinic, expanding its availability is critical to improving abortion access for people who live in rural communities, who can’t take time off work to go to appointments, or who are at risk of stigma or discrimination.
Telemedicine abortion is considered a Comprehensive Virtual Care Service under Ontario’s Schedule of Benefits. Video visits are billed at the same rate as in-person fees, and telephone visits are billed at 85% of in-person fees.
As part of the 2021-2024 Physician Services Agreement, the Ministry of Health (MOH) and the Ontario Medical Association (OMA) agreed to a new virtual care funding framework that adds certain services provided by video and telephone as insured services under OHIP.
Comprehensive Virtual Care Service refers to services rendered where an Existing/Ongoing Patient-Physician Relationship exists, and in the physicians’ professional opinion, the person's care and support requirements can be effectively and appropriately delivered by video or telephone. When a physician provides medical management of early pregnancy and the initial service was by video or telephone, this establishes an Existing/Ongoing Patient-Physician Relationship for claiming purposes.
The Health Care Consent Acthas no established age restriction when it comes to a person’s ability to give informed consent to medical treatments. The determining factor is whether the person is capable, meaning if “the person is able to understand the information that is relevant to making a decision about the treatment, admission or personal assistance service, as the case may be, and able to appreciate the reasonably foreseeable consequences of a decision or lack of decision.” Further, the Substitute Decisions Act presumes that a person 16 years of age or older is capable of giving or refusing consent in regards to their own care, unless there are reasonable grounds to believe otherwise.1
Bubble zone legislation
Bubble zone legislation aims to prevent anti-abortion protestors from harassing people within the vicinity of a facility that provides abortion care. Even though criminalizing individual people will not effectively curb the larger anti-abortion movement, these laws can be effective in deterring anti-choice protestors from harassing providers and patients entering and exiting abortion clinics.
The Safe Access to Abortion Services Act was passed on October 25, 2017 and established safe access zones around abortion clinics as well as the homes and offices of abortion providers, which includes all clinic staff. The Act allows other facilities that provide abortion care (e.g., hospitals) and other regulated health professionals who may be involved in abortion provision (e.g., pharmacists) to apply for safe access zones. Harassment of abortion providers outside of the safe access zone is also prohibited under the Act.
It is based largely on British Columbia’s bubble zone law (the first in Canada) and is very similar to it, but with some additional features:
Eight private abortion clinics in Ontario have automatic safe access zones of 50 metres, which can be decreased or increased up to 150 metres by regulation.
Other facilities (hospitals, medical clinics, etc.) that offer abortion services can apply for safe access zones of up to 150 metres.
Abortion providers and clinic staff have automatic safe access zones of 150 metres around their homes.
Physicians who provide abortions have automatic safe access zones of 150 metres around their offices, regardless of whether they provide abortions at that location.
Regulated health professionals who provide abortion services outside of clinics, including pharmacists, nurse-practitioners (and other health professionals who may be involved in abortion provision), will be able to apply for safe access zones of up to 150 metres around their pharmacies or offices.
The Morgentaler Clinic in Toronto also has a private injunction that specifies a 500-foot zone (150m) around the clinic. The injunction is not location-bound and can move with the clinic. It is enforced by the sheriff rather than the local police. The injunction remains valid and in force, even after the passage of Ontario’s Safe Access to Abortion Services Act in October 2017.
Belief-based care denial
Although abortion is an essential medical service, physicians and nurse practitioners can refuse to provide abortion care due to their personal beliefs under current legislation and policies set by regulatory bodies. This practice is often referred to as “conscientious objection,” although a more accurate term may be “belief-based care denial.”
Physicians
The College of Physicians and Surgeons of Ontario’s Professional Obligations and Human Rights policy requires physicians to provide a timely “effective referral” to another physician, health-care professional, or agency in cases of belief-based care denial. It also obligates physicians to provide care in an emergency, even if it contradicts their personal or religious beliefs.
The policy states that while physicians have “the right to limit the health services they provide for reasons of conscience or religion,” they have a responsibility to respect the patient’s dignity and to ensure the patient has access to care (by another provider).2
The policy recognizes the court’s finding in Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393 at para 187, that where a conflict of this nature is present between a patient and physician, the patient’s interests must be prioritized.
In cases of belief-based care denial, the policy states that physicians must communicate their objections directly, with sensitivity, and without judgement, and inform the patient that the objection is due to personal and not clinical reasons. Physicians cannot refuse or delay treatment if they believe the patient’s own actions have contributed to their condition, nor promote their own religious beliefs.
The policy also states that:
Physicians must provide information about all clinical options that may be available or appropriate to meet patients’ clinical needs or concerns.
Physicians must not withhold information about the existence of any procedure or treatment because it conflicts with their conscience or religious beliefs.
Where physicians are unwilling to provide certain elements of care for reasons of conscience or religion, they must provide the patient with an effective referral.
Physicians must provide the effective referral in a timely manner to allow patients to access care.
Physicians must not expose patients to adverse clinical outcomes due to a delayed effective referral.
Physicians must not impede access to care for existing patients, or those seeking to become patients.
Physicians must proactively maintain an effective referral plan for the frequently requested services they are unwilling to provide.
Nurse practitioners
The College of Nurses of Ontario has a Practice Standard on Conflicts of Interest, which states that where there may be a conflict of interest, a nurse must continue to provide essential health care services, whenever feasible, until another provider has been identified.
Freedom of Information and Protection of Privacy Act provisions
This law gives the public a right to access information from institutions (for example, hospitals), with some exceptions. One exception applies in accessing abortion-related information, and is found in section 65(13). This section exists to protect the privacy and safety of individuals receiving abortion services, and the facilities and people who provide abortion care. This section says that the public cannot obtain information about abortion services if the information identifies, or seems like it could be used to identify, an individual or facility. This section also says that the public cannot obtain information relating to abortion services if it could be seen to put the health or safety of an individual at risk, or put the security of a facility or other building at risk. Section 65(15) specifies that this exception applies to statistical or other information related to abortion services.
Independent Health Facilities Act, 1990, and Integrated Community Health Services Act, 2023
The Independent Health Facilities Act, 1990provided additional funding to cover overhead costs, or “facility fees,” of four private abortion clinics in Ontario. Four other abortion clinics that opened after 1990 were not covered under the Act and were found to charge patients fees for uninsured services related to insured procedural abortion services, a violation of the Canada Health Act. Ontario was penalized for this with a deduction to their Canada Health Transfer payment.3 This Independent Health Facilities Act was recently replaced by the Integrated Community Health Services Act, 2023, which now governs funding for private healthcare clinics in Ontario, including abortion clinics. Clinics that were already licensed to receive funding under the Independent Health Facilities Act will continue to have that license under the new regime.4 New licences that cover clinics’ facility fees under the new Act are expected to be issued through a call for application process.5
An application form must be submitted by the patient’s physician and receive approval from the Ministry of Health and Long-Term Care in order for the patient to receive coverage. When an application meets the regulatory criteria, the ministry will negotiate applicable costs with the out-of-country facility and surgeon directly. The approved amount represents costs payable by the ministry for all hospital, professional, and ancillary services. If the prior approval isn’t granted ahead of a medical treatment, the patient is not eligible for coverage. Travel, accommodation and meals (except where included as part of insured hospital services) are not eligible for coverage. Coverage for take home prescription medication is also not included.
Travel support
Travel, accommodation and meals (except where included as part of insured hospital services) are not eligible for coverage under Ontario’s Out of Country Services program.
Northern Ontario residents in the districts of Algoma, Cochrane, Kenora, Manitoulin, Nipissing, Parry Sound, Rainy River, Sudbury, Thunder Bay, or Timiskamingmay be eligible for the Northern Health Travel Grant, which provides some financial travel and accommodation assistance for Northern Ontario residents who must travel within Ontario or to Manitoba to access medical specialist services. In order to be eligible, a patient must have a referral from a Northern Ontario referring health care provider and fill out the application form before travel takes place. Patients without a referring physician may still qualify for the program and can call the Ministry of Health, Claims Services Branch, at 1-800- 262-6524 for more information.
The travel grant pays 41 cents per kilometre for patients who must travel at least 100 km one-way, and has a 100 km deductible. Patients can also apply for an accommodation allowance if they have to travel at least 200 km. The patient’s medical specialist is responsible for requesting stays for more than one night. For eligible patients, the accommodation allowance per treatment trip is:
$100 per lodging night up to 2 lodging nights
$250 for 3 lodging nights
$500 for 4-7 lodging nights
$550 for 8 or more lodging nights
Financial barriers to accessing abortion services exist on reservations, including limited access to banks, difficulties depositing cheques, and lack of access to direct deposit. Additionally, there are challenges with processing reimbursements for those who are accessing services through the financial assistance of the Northern Health Travel Grant Program.
The government of Ontario sought a court order to limit anti-abortion protests occurring around several abortion-related locations. The Ontario Supreme Court balanced the desire of some individuals to protest, oppose, or express dissent with the rights of others to exercise individual autonomy. In its decision, the Ontario court granted the province an injunction providing limits on protest activity and a buffer zone where anti-abortion protestors are not permitted.
Carleton University (CU) refused Carleton Lifeline’s request to display anti-abortion demonstrations on campus. The Ontario Court of Appeal held that booking space for “non-academic extra-curricular” use is not deemed a “specific government policy or program”. As such, the University’s decision is not subject to Charter scrutiny.
This case held that s.243 of the Criminal Code, which prohibits disposal of a child’s body with intent to conceal its delivery, does not apply to miscarriages or abortions.
In 2015, the City of Peterborough had refused to post advertisements from the Canadian Centre for BioEthical Reform (CCBR) that contained images and messages advocating against abortion. Their refusal was not based on any policy or bylaw. They expressed that “advertisements which promote an issue which is divisive or controversial, and which could be perceived to be sanctioned by the City, by allowing an advertisement to appear on or in City-owned property, are not permitted.”
The CCBR sought a declaration that the limit on its freedom of expression caused by the City’s decision was unconstitutional, which was declined by the court, since there were no evidentiary record or submissions from the City.
Christian Medical and Dental Society of Canada v. CPSO (ON, 2019)
In Ontario, The College of Physicians and Surgeons of Ontario (“CPSO”) implements two policies requiring physicians who object to specific treatments, such as abortion services, on a moral or religious basis to provide effective referrals to another health care professional. The Christian Medical and Dental Society of Canada and several other applicants legally challenged the constitutional validity of these policies. The Ontario Court of Appeal held that the policies violated religious freedoms under s.2(a) of the Charter but justified the infringement under s.1. Further, the Ontario court found no violation of the applicant's claim that the policies infringed on their equality rights under s.15.
Association for Reformed Political Action Canada v. Hamilton (ON, 2023)
The City of Hamilton refused to run an ad on city buses that had been submitted by the anti-choice group Association for Reformed Political Action (ARPA) Canada. The ad depicted a fetus as a person, which was deemed by Ad Canada to be a likely violation of the Canadian Code of Advertising Standards, because a fetus is not a person under Canadian law.
ARPA sued to have the ad posted, citing a violation of their freedom of expression. Prior to the hearing, the City of Hamilton conceded that it did not provide adequate reasons for their refusal. The Court therefore granted ARPA’s application for judicial review and remitted the matter back for consideration by the City. The Court pointed to the fact that cities cannot rely on the Code of Advertising Standards alone but must also do a Charter balancing exercise related to freedom of expression.
References
1 Canadian Paediatric Society. (2018, April 12). Medical decision-making in paediatrics: Infancy to adolescence | Canadian Paediatric Society. https://cps.ca/en/documents/position/medical-decision-making-in-paediatrics-infancy-to-adolescence
2 College of Physicians and Surgeons of Ontario, supra note 2 at s 9.
50%urban points of service |50%rural points of service*
87% urban population |13% rural population*
56 points of service per 3,201,165 women of reproductive age*
72unregulated pregnancy centre(s)*
56publicly listed point of service offering both medication and procedural abortion*publicly listed points of service*
46point(s) of service for medication abortion
25point(s) of service for procedural abortion
Functional gestational limit of24 weeks and 6 daysFunctional gestational limit of24 weeks and 6 days*
No centralized system to assist the public in connecting with abortion services
Information about abortion is available on aprovincial/territorial website
Information about abortion is not available on the provincial/territorial website
