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

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

Emergency department image with graphic of doctors

What is this research about?

This study investigates how people who do not have health‑insurance coverage experience care in Toronto’s emergency departments (EDs). Researchers wanted to understand, from the patients’ own point of view, what it is like to seek emergency care without insurance and how the system could be improved. Their central questions were:

1. What are the firsthand experiences of non‑insured patients when they attend an ED?
2. What barriers and facilitators shape those experiences?
3. What changes could make ED care more equitable for this group and improve their ED experience?

The study offers an insightful, patient‑driven picture of the barriers non‑insured individuals face in Toronto’s emergency departments. Researchers propose actionable steps for clinicians, administrators, community groups, and policymakers to move toward a more equitable emergency‑care system.

By listening to and learning from the experiences of non-insured patients, a more equitable ED system can be built for this marginalized population. This can result in improving care for other equity-deserving populations as well.

Why is this research needed?

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 in the ED to understand how we can improve the care system.

In Canada, an estimated 20,000 to 500,000 people lack provincial health coverage. Almost half of those people live in Toronto, Ontario. In this study, non-insured patients are defined as patients who do not have healthcare access coverage under the Ontario Health Insurance Program, Interim Federal Health (IFH) Program, or Ontario Temporary Health Program. This includes temporary foreign workers, undocumented residents, and refugee claimants whose claims have been denied. Temporary foreign workers and undocumented residents cannot access public healthcare coverage in Canada. Refugee claimants can access the IFH program but subsequently lose access if their claims are denied.

Because they are a hidden and hard‑to‑reach population, little is known about how they experience emergency care. Previous work had mainly d on provider perspectives or on quantitative utilization data. By directly listening to patients, this study fills a gap. It shows how systemic, administrative, and interpersonal factors combine to create feelings of exclusion, stigma, and delayed treatment. The findings, therefore, advance understanding of health equity gaps in a publicly funded system and point to concrete, patient‑centred improvements.

The study uses a community‑based, appreciative‑inquiry design partnered with Access Alliance, a trusted multicultural health centre. Researchers captured diverse voices (different genders, ethnicities, languages, immigration statuses) and conducted semi‑structured, one‑on‑one interviews that were transcribed with an approach designed to preserve participants’ intended meaning.

What did the researchers find?

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.

Three main themes emerged from the 24 interviews:

Feeling unwanted and powerless – Participants described intense anxiety about not knowing whether they could pay for care. One quoted participant said, “There’s this huge sense of insecurity because you’re so scared to what the answer will be next and what other associated costs would come with that.” They also described the challenges of navigating the health system. Newcomers struggled with insurance eligibility, language barriers, and locating appropriate services. A participant recounted, “I didn’t know English, they asked me about OHIP, I felt bad because I thought, why didn’t I get it right away?” Repeated questioning about insurance status and accent‑related bias made many feel unwelcome, stigmatized, and discriminated against. One said, “I felt I’m not like a Canadian. I felt I’m not welcomed and felt very tiny.”

Health‑system concerns (delayed care, registration/triage issues, privacy) – Lack of clear payment policies and intrusive registration questions caused delays and embarrassment. ED staff were inconsistently knowledgeable about the scope of healthcare coverage for non-insured patients. There were also concerns about patient privacy at triage and registration. Non-insured individuals described finding ways around systems issues by engaging informal community networks. They also were supported by non-health system care providers.

Coping, resiliency, and advocacy – Participants found ways to get around systems issues by leveraging informal community networks and non-health system care providers such as shelter staff. Participants also engaged in self-advocacy to health institutions.

Despite these challenges, positive experiences were reported when clinicians showed compassion. Participants reported mostly positive experiences when interacting with clinicians. They reported feeling cared for and treated appropriately. They differentiated clearly between the challenges with system design and navigation, and the individual care they received from clinicians.

How can you use this research?

For clinicians and ED staff – Incorporate cultural‑safety and implicit‑bias training to reduce stigma. Learn the organization’s payment policies for non‑insured patients and communicate them clearly at the bedside, not only at registration.

For hospital administrators – Redesign registration and triage workflows to separate insurance questions from clinical assessment, protecting privacy. Provide clear signage and patient‑navigator roles to help non‑insured visitors understand where to go for care and how payments are handled. Co-design ED policies with community members.

For community organizations (e.g., Access Alliance) – Continue partnering with hospitals to supply letters or vouchers that can waive fees. Offer multilingual health‑system navigation workshops for recent arrivals.

For policymakers – Consider extending universal coverage to all residents regardless of immigration status, as the authors argue this would eliminate many of the identified barriers. Fund training programs and patient‑navigator positions in EDs serving high‑need neighbourhoods.

For researchers – Build on this work by conducting longitudinal studies that follow non‑insured patients through the entire care pathway, from ED visit to discharge and follow‑up. Explore quantitative links between the identified themes (e.g., stigma) and measurable outcomes such as length of stay or readmission rates.

What did the researchers do?

Design – Community‑based qualitative study using appreciative‑inquiry, guided by a critical‑realist framework.
Sampling – Maximal‑variation purposive sampling of 24 non‑insured adults who had visited an ED in the past three years. The sample reflected a wide range of gender identities, ethnic backgrounds, languages, and lengths of residence in Canada.
Data collection – One‑on‑one semi‑structured interviews (up to 60 minutes each) conducted at Access Alliance’s Non‑Insured Walk‑In Clinic. Interviews were recorded, transcribed with an “intelligent verbatim” method, and participants could review their transcripts for accuracy.
Analysis – Three researchers independently coded the transcripts in NVivo 12, followed by triangulation and thematic analysis using Braun and Clarke’s six‑step framework. Themes were refined through team discussion and member checking.

Related Access Alliance Activities

A qualitative study on the Virtual Emergency Department care experiences of equity-deserving populations
This is collaborative research between Access Alliance MHCS led by Dr. Akm Alamgir and Sunnybrook Health Science Centre led by Dr. Sander Hitzig. Founded on the principles of Appreciative Inquiry, whereby the strengths and experiences of all stakeholders are equally respected, this research examines the experiences of equity-deserving populations (EDPs) who received care from a Virtual Emergency Department (Virtual ED) in Toronto, Canada. The study aimed to understand how virtual care options compared to in-person care and what features promoted or hindered equitable access across diverse patient backgrounds.