21 Health professionals’ experiences with uninsured children in Québec: A qualitative study in paediatric settings

Background The 2021 Bill 83 (PL83) aimed to provide provincial public health insurance (RAMQ) to previously uninsured migrant children in Quebec. However, many children remain uninsured, posing ethical challenges for healthcare professionals that have yet to be thoroughly examined. Objectives This study sought to explore healthcare professionals' experiences with uninsured children, focusing on practical and ethical issues arising from lack of insurance. Design/Methods This qualitative study, adopting a comprehensive paradigm focused on participants' subjectivity, included semi-structured interviews with healthcare professionals. These participants were recruited through purposive and snowball sampling at Quebec's two largest paediatric hospitals, one of which had a clinic for recently migrated children. Interview topics included clinical experiences with uninsured children, the impact of lack of insurance, and strategies for overcoming barriers. Interviews were fully transcribed, and thematic analysis using inductive coding (NVivo) revealed key themes. Results Between January and October 2024, 25 participants (52% physicians, 20% nurses, 20% social workers) were recruited. Analysis identified four main themes:Organizational and systemic factors contribute to a lack of RAMQ coverage, especially for eligible newborns whose parents do not have RAMQ coverage (uninsured migrants or asylum)Quebec’s healthcare system relies on the possession of RAMQ; its absence leads to significant challenges, including hospital bills, difficulties accessing primary healthcare services or physicians refusing consultations. It affects children insured by the Interim Federal Health Program (IFHP) who do not have RAMQ.Emergency departments (EDs) become the only option for parents seeking medical care for their children. EDs are not designed to respond to the healthcare and psychosocial needs of these marginalized populations. When EDs have access to teams dedicated to caring for migrants, these teams are also limited in their capacity to respond due to high demand and lack of resources.Participants expressed frustration and a sense of injustice toward barriers children without RAMQ face. Ethical challenges prompt professionals to find solutions to provide equitable care, such as unpaid work, longer consultations time to guide parents in navigating the system, and adapting treatments to financial limitations and life circumstances. Participants expressed helplessness, as some solutions exist but remain limited compared to the complex needs of these marginalized populations. Conclusion Insights from healthcare professionals highlight strategies used to mitigate the impact of lack of RAMQ on children’s healthcare. Potential systemic solutions include presumed eligibility based on residency proof, educating the healthcare workforce, and improving access to primary care.