Soon after psychologist Leigh Sheldon opened a mental health clinic in Edmonton in 2021, the desperate calls for help started pouring in.
Each call carried an Indigenous voice in crisis. And with each call, Sheldon came to the same depressing realization: the coverage provided by the federal health benefits program for Indigenous people was failing them.
Canada’s Non-Insured Health Benefits (NIHB) program covers the cost of counselling and therapy for First Nations and Inuit people for whom mental health coverage is not provided by the provinces. It’s supposed to be a lifeline for a community with some of the world’s highest rates of suicidality and mental health challenges.
But the NIHB is mired in red tape, Sheldon and others said. The system’s unreliable reimbursement means many health professionals choose not to enrol with the NIHB, meaning fewer people to help those in need and crushingly long wait times.
Meanwhile, many therapists who are enrolled do not have the cultural sensitivity training that current and former clients say is essential to navigate the unique challenges Indigenous people face.
The federal system meant to help vulnerable Indigenous people is too often failing them, according to the more than 60 clients, therapists, physicians and Indigenous mental health advocates interviewed for this story.
“It’s so hard to see people suffer, and I can’t do anything because of a system,” said Sheldon, who runs Indigenous Psychological Services.
Instead of turning away patients who can’t get coverage and can’t afford to pay out of pocket, Sheldon has donated more than 2,300 free counselling sessions to First Nations clients whom she said should be covered by NIHB. That amounts to more than $160,000 in free counselling that deeply strains her practice, she said.
“How many people are going to be lost by suicide and addictions for the government to actually listen that this is a need.”
Finding a therapist becomes a depressing game of hide-and-seek
First Nations and Inuit people have the option to pay out of pocket for therapy from provincially regulated therapists and submit receipts to NIHB for reimbursement, as with any other private health insurance.
But the many who can’t afford that option are often stuck with the frustrating process of seeking care from an NIHB-enrolled therapist or counsellor who can bill the federal government directly.
The first challenge is figuring out which therapists in their area are NIHB-approved. Unlike many private insurers, which provide users with a searchable list of covered providers who are based nearby, the federal government keeps its master list of roughly 5,000 approved providers from public view. Potential clients must call the program and request a list of approved providers in their area, according to instructions buried in the government website.
Clients and mental health care advocates say they are often left playing a demoralizing game of hide-and-seek to find an NIHB-approved therapist.
“The only thing that I’ve concluded is that (the government) is concerned that people like myself connecting people to the list, it would be used much more often than it is,” said Leslie Saunders, a manager at Anishnawbe Health Toronto who said several requests she’s made to ISC for a copy of the list have been denied.
Reporters obtained a recent version of the list via a request under access to information legislation.
In response to criticism about the lack of access to the list, ISC said that “due to the dynamic nature of the information and guidelines for (federal) web content, it is not possible to web post the enrolled provider lists in their current format.” The program is exploring how to make lists of providers more accessible to the public, ISC added.
The IJB/Star contacted 100 randomly selected mental health clinics in Ontario and found just 15 of them reported having one or more counsellors who accepted NIHB. In those 100 clinics, 98 per cent of the roughly 1,300 psychologists, psychotherapists, and social workers said they did not accept NIHB.
A reason for low uptake among health care providers is a Byzantine system that sees the providers wasting too much time trying to bill for their services, then having to wait far too long to receive payment.
“The health care providers I spoke to basically said that it wasn’t worth the hassle, that they did not want to provide services only to be paid six months later,” said Janine Manning, a 44-year old who called two dozen Ontario clinics before finding a mental health provider who accepted the program.
“ I think the NIHB program is set up to deter people from accessing services.”
Most ‘inefficient and restrictive’ health insurance program in Canada
Dr. Chetan Mehta, an addictions specialist at Anishnawbe Health in Toronto, said overextended health care providers work extra hours troubleshooting the NIHB system.
“When you start adding in all the overhead of running a practice and so on and so forth, (challenges with NIHB) start to become a deterrent really quickly,” he said.
ISC said in its written statement that it aims to offer reimbursements in a timely manner.
“We are ready to work with any provider that has concerns regarding billing and have set up specific lines for different health providers to help address any concerns enrolled providers may have.”
The federal agency said that therapists and counsellors make their own decisions about enrolling in the NIHB as they would with any other health insurance plan and that it “remains open to receiving feedback from clients and providers and strives to continually improve the program.”
Cree family physician James Makokis compares NIHB to other major health benefits programs, this way: “It is the most cumbersome, inefficient, restrictive program that exists … in this country.”
For NIHB patients, he has come to expect prescriptions won’t be covered. “And the patient who needs their medication or supply will be without that causing their illness to prolong and become more severe.”
At Greendale Drugs in downtown Toronto, pharmacist and owner Kamal Yousf, has clients in the NIHB program being treated for addiction and other chronic conditions.
For one patient, the pharmacy forgave payments of about $7,000 a year in costs not covered by the NIHB program, he said.
“I feel myself obligated,” said Yousf. “I have lots of clientele from NIHB and I think it is very crucial for serving the people. I would rather go the extra mile than cut relations with them.”
“It’s so hard to see people suffer, and I can’t do anything because of a system”
Sometimes, no matter what health care providers are willing to do to ensure patients don’t fall through the cracks, it isn’t enough.
Sheldon said one of her former clients who was living on the streets couldn’t get counselling because he was unable to prove he lost his previous coverage when he lost his job. In order to receive benefits, he had to call the government and provide documents to prove he no longer had private insurance. But he didn’t have a phone or the resources to collect what was required.
Sheldon and her team tried to help him. But he eventually gave up trying to get care, she said.
“We never saw him again … That’s the impact.”
Many NIHB therapists don’t report having previously worked with Indigenous clients
An Star/IJB analysis shows only about a quarter of the more than 5,000 NIHB-approved therapists across Canada submitted information detailing cultural competency or previous experience working with First Nations or Inuit clients, who can have unique generational trauma caused by residential schools and colonialism.
Two clients interviewed by the Star/IJB said they were not believed by their therapists, further undermining their trust in mental health services. Indigenous therapists said some of their clients have shared similar complaints about care they previously received under NIHB.
Corenda Lee, a member of the Saddle Lake Cree Nation in northeastern Alberta, remembers sitting in a therapist’s office recounting how painful trauma passed down through generations. The NIHB-enrolled therapist appeared distracted as she bit her nails and watched the clock. Then Lee realized her therapist was completely unaware of the history of residential schools.
She walked out midsession and never returned.
“I just figured if (the therapist) is funded by NIHB, then most likely they have some cultural training, some understanding of intergenerational trauma … There was nothing,” said the 37-year-old, now a mother of six in Edmonton. “I just remember feeling so let down. How am I ever going to heal if I can’t find somebody to help?”
The therapist told the Star/IJB that she cannot confirm whether she has worked with Lee, but said she asks her clients questions to gain cultural understanding.
“I had lots of people teach me and want to inform me and that’s been wonderful,” she said. “Would that be a sign that I’m not culturally aware? I don’t know, but I also don’t know another way of doing it in the moment.”
Long wait times for people ‘in crisis’
Long wait times for care is another common complaint among patients and mental health practitioners.
The median wait time for Canadians seeking community mental health counselling is about a month, according to data from the Canadian Institute for Health Information.
NIHB patients and counsellors say delays for service under the program typically range from three months to well beyond six months. Fewer available therapists, and ever fewer Indigenous providers, who are hampered by slow bureaucracy, are the culprits, they say.
The longer the wait for long-term support, they say, the greater the likelihood that vulnerable people will fall into substance abuse and self harm.
ISC said clients experiencing difficulties can contact their regional office to “facilitate access to service from other eligible providers.” ISC does not collect data on wait times among these therapists, it said in a statement, but the program offers a helpline for crisis assistance.
“I have sadly heard more than a handful of stories where the (NIHB) system has failed people and those kids have successfully taken their lives,” said Kelly Hawreliak, an Indigenous trauma therapist in Alberta. “When people call for help, it’s … because they’re in crisis, because their past trauma is exploding inside of them. And so they can’t wait one week, one month, one year.”
The rate of suicide for Indigenous people in Canada was three times higher than the suicide rate among non-Indigenous people, according to a Statistics Canada analysis in 2019. And the gap jumps to six times higher for Indigenous youths aged 15 to 24.
“The insufficient use of mental health services is associated with suicide among Indigenous people,” the Statistics Canada analysis reads. “This level of use may be related to the lack of culturally competent services and inadequate access.”
In its written statement, ISC did not respond directly to wait time concerns but acknowledged a growing demand for mental health care services under NIHB.
A model to emulate
NIHB critics say the program’s core mission is now more relevant than ever. But a dramatic overhaul is necessary to make it more accessible, culturally sensitive and responsive to the unique needs of clients.
There’s already a model to follow here in Canada, advocates say.
In 2013, the First Nations Health Authority (FNHA) broke away from NIHB to become the primary institution providing health coverage to First Nations people and Inuit in British Columbia. The move followed consultations with First Nations that identified “critical issues” with the federal program. The objective, in part, was to “bring decision-making closer to home” and to facilitate “the integration of culturally relevant practices and traditional knowledge into health benefits.”
Unlike the NIHB, the FNHA publishes an up-to-date list of mental health care providers on their website and requires mental health providers to take an eight-week cultural competency course.
The health authority also allows psychotherapists and counsellors not covered by a provincial regulatory college to provide care. In fact, they make up the majority of the system’s psychotherapists and counsellors, the FNHA said in a statement. “Removing them would have a significant client impact.”
Tristen Schneider, a 28-year old from Shawanaga First Nation in Ontario has had experience with both systems.
In B.C., Schneider had a much easier time finding registered providers as well as navigating and accessing services through the website.
“They have more of a system in place in terms of how to really offer those supports,” she said.
“Here in Ontario, it’s more like you’re on your own,” she said, describing her experience with the NIHB as “walking through a tunnel in the dark with no flashing.”
Many Indigenous mental health providers and their clients say the government should do away with the NIHB list altogether. Those seeking care should have the freedom to choose the therapist or counsellor they want while being assured they will receive timely and accessible care.
“If the government is willing to pay for (our) healing journey through counselling, then they should trust that (we) know what’s best for (us),” said Hawreliak. “They think they know what’s good for us and they don’t.”
With files from Owen Thompson, Max Loslo and Norma Hilton from the Investigative Journalism Bureau
This story was also published in the Toronto Star.
Read more from this series:
A murder conviction. Sex with an ex-client. Defending residential schools. Critics are alarmed at background of therapists approved for Indigenous mental health program
A program meant to fund care for Indigenous patients is instead failing them by endorsing therapists with spotted histories, critics charge.
‘Deeply troubling’: Ontario chiefs call for reforms to federal health program after Star/IJB investigation
The Chiefs of Ontario is demanding the federal government immediately review the professional backgrounds of therapists approved to treat First Nations and Inuit patients and remove those with questionable histories.
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