Exploring the perspectives of healthcare providers that care for non-insured individuals utilizing emergency departments in Toronto.

Background: Non-insured individuals have different healthcare needs from the general Canadian population and face unique barriers when accessing emergency department (ED) care. This qualitative study aims to better understand the system of emergency care for non-insured individuals from the perspective of healthcare providers.

Methods: The study uses a critical realist framework to explore structural factors that facilitate or impede access to care for non-insured individuals. Semi-structured interviews were conducted with 13 interdisciplinary healthcare professionals with experience working with non-insured populations in the ED and in community health centres. Data were analyzed with the use of Braun and Clark's thematic analysis framework and organized into themes through an iterative process until thematic saturation was reached.

Results: Healthcare providers face distinct challenges when providing care for non-insured patients including patients presenting with increased illness complexity and providers having to navigate systemic barriers. Interview participants noted stigma and bias, lack of privacy, unclear care pathways, and access to post-ED care as challenges facing non-insured patients. Suggestions to improve the ED experience for non-insured patients include improved staff training, clearer policies, and consistency between hospitals. Most of all, healthcare providers believed that the most effective way to improve the care of non-insured patients would be to make permanent the temporary extension of health coverage to non-insured patients enacted during the COVID-19 pandemic.

Conclusion: Interviews with healthcare professionals have highlighted that marginalized populations, including non-insured individuals, face multiple barriers when accessing the ED, especially during the COVID-19 pandemic. At the same time, the temporary extension of health coverage to non-insured patients enacted during the COVID-19 pandemic has likely improved patients' healthcare experience, which we will explore directly with non-insured patients in a future study. In this post-COVID world, we now have an opportunity to learn from our experiences and build a more equitable ED system together.