New research exposes health care inequity of “invisible” uninsured

New research on uninsured residents’ visits to ERs shows a surprising disparity: The uninsured are more likely to have more serious health issues, to leave untreated and to die.

This research tells the story of the uninsured in Ontario and, in doing so, illustrates the limitations of our system

Tommy Douglas, the father of Canada’s universal health care system, wrote, “I came to believe that health services ought not to have a price tag.”

A recent study, led by York University Professor Michaela Hynie in partnership York Professor Chris Ardern and Ms. Angela Robertson of the Queen West-Central Toronto Community Health Centre, tells the story of the uninsured in Ontario and, in doing so, illustrates the limitations of our system. This research also provides a vital look at the health status and health care of this “invisible” population.

This policy-relevant study looked at visits to Ontario’s emergency rooms (ERs) and determined that the health consequences of being uninsured, compared to the insured, are poorer care and worse health outcomes.

While less likely to be admitted to hospital, the uninsured were more likely to be triaged into the most severe categories, to be coming in for mental health problems, to leave the hospital untreated and to die in the ER.

Lack of insurance associated with migration

Most Canadian residents are insured by provincial plans. Some residents, such as government-sponsored refugees or military personnel, have federal health insurance.

Despite this, there are a number of Canadian residents who do not have health care coverage for a variety of reasons. This lack of insurance is often associated with migration, according to Hynie.

Research fills important void

Michaela Hynie

Before this work was undertaken, researchers were looking at Canadian residents with precarious migration status, and finding that those who lack insurance reported poorer health care, worse health care outcomes, and negative mental health outcomes. Qualitative studies suggested that the poorer health outcomes of those without insurance may not only be the result of more precarious living conditions; these outcomes may be attributed to comparatively limited access to health care.

This new research is unique in that it fills an important void by investigating the health outcomes of the uninsured at a population level.

CIHI data offer glimpse into ER visits of uninsured

The main challenges in this study were around the fact that some of those patients without insurance were also without legal status. So how could the researchers find these individuals to identify their health outcomes? Hynie, Ardern and Robertson hypothesized that in emergencies, those without insurance would probably access ERs at about the same rate as those with insurance. Thus, ER visits were a window into the health status and health care of this “invisible” population.

 “ER visits may offer a rough estimate of the number of individuals without insurance in a given region, and provide insight into the potential impact of being without health insurance in the Canadian context,” Hynie explains.

The research team was able to find uninsured Canadian residents visiting ERs through

The number of uninsured visits increased at a rate on par with increases in numbers of temporary foreign workers, which makes this research all the more policy-relevant.

The number of uninsured visits increased at a rate on par with increases in numbers of temporary foreign workers, which makes this research all the more policy-relevant

CIHI’s National Ambulatory Care Reporting System, which tracks all ER visits. Ontario was selected by the researchers as it is the most frequent intended province of residence for new immigrants but also the one that had the longest record of central reporting of ER visits.

Hynie, Ardern and Robertson focused on the number of acute care visits to Ontario ERs, for nine consecutive years (2002/2003 to 2010/2011). They compared the diagnoses, severity, and outcomes of visits by Ontario residents with and without insurance.

The team predicted that those without insurance would not only arrive in more serious health but they would also present with more preventable conditions, having not sought medical help earlier. “This may be a marker of whether individuals have sufficient access to health care overall,” Hynie suggests.

Key findings show children are vulnerable

The researchers were able to determine that from May 2002 to April 2011 there were over 44 million visits to Ontario’s ERs, a very small number of which involved uninsured patients (140,730, less than 1%). More than one-third of those patients coming through Ontario’s ERs without insurance were children under the age of 16.

“More than one third of those patients coming through Ontario’s ERs without insurance were children under the age of 16.”– Researchers

The key findings showed that the uninsured were:

  • Less likely to be admitted to hospital;
  • More likely to leave the hospital untreated;
  • More likely to be presenting with mental health problems, which may reflect the limited access to mental health care for those without insurance, leaving them little recourse but ER visits;
  • More likely to be diagnosed with obstetric problems;
  • More likely to be triaged into the two most severe categories (resuscitation, for example), which may reflect the more vulnerable life circumstances of those with precarious migration status or greater delays in seeking care;
  • More likely to die in transit to or on arrival in the ER.

A child on a gurney

The findings of this research suggest that children without insurance are not getting adequate preventive and chronic care

These findings also suggest that children without insurance are not getting adequate preventive and chronic care since among the uninsured, there was a higher ratio of children versus adults arriving in the ER with preventable conditions.

This discovery led Hynie, Ardern and Robertson to conclude that insurance status is associated with more serious health status on arrival at ER and more negative visit outcomes.

Importantly, over the study’s nine years, the number of uninsured visits increased at a rate on par with increases in numbers of temporary foreign workers, which makes this research all the more policy-relevant.

Don't miss this YouTube video, featuring Michaela Hynie, the second in a new series called "2 Minutes, 3 Questions," launched by the Office of the Vice-President Research & Innovation at York University.

This research was funded by Women’s College Hospital and York’s Faculty of Health.

The article, “Emergency room visits by uninsured child and adult residents in Ontario, Canada: What diagnoses, severity and visit disposition reveal about the impact of being uninsured,” was published in the Journal of Immigrant and Minority Health (2016). Read more online about Michaela Hynie’s work.

By Megan Mueller, manager, research communications, Office of the Vice-President Research & Innovation, York University, muellerm@yorku.ca