Exploring the perspectives of non-insured individuals utilizing emergency departments in Toronto: a qualitative study.

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Non-insured individuals face unique challenges when accessing emergency department (ED) care in Canada. This qualitative study explores the firsthand experiences of non-insured patients within the ED to understand how we can improve the system of care. This community-based research was conducted in collaboration with a community health center which has multiple service locations in Toronto, Ontario. 24 non-insured participants were recruited using a maximal variation sampling technique for semi-structured individual interviews. Participants must have received care as a patient in an ED in the last 3years. We analyzed the data using Braun and Clarke's thematic analysis framework. Interview participants felt unwanted and powerless, and faced health system navigation and access challenges. Subthemes include the anxiety of uncertainty regarding how to pay for ED care as well as concerns regarding insurance eligibility, healthcare access points, and language. Non-insured participants experienced stigma and discrimination; delayed care due to a lack of healthcare coverage; and difficulties with the ED registration and triage processes. The study also identified multiple instances where participants had positive experiences with clinicians and devised creative solutions to tackle challenges by engaging informal community networks and self-advocacy. Ways to improve the ED care of non-insured patients include providing ED care for all regardless of their healthcare coverage status, ameliorating clerical training, outlining clearer policies regarding payments, improving health system navigation, and fostering connections to community organizations. Many of the challenges that non-insured patients face may be applicable to other equity-deserving patient groups. By listening to and learning from the experiences of non-insured patients, a more equitable ED system can be built for this marginalized population.