Stigma and Medicaid: A Struggle for Health Equity

Before the expansion of Medicaid, the inability to afford health insurance proved to be one of the largest barriers to healthcare for low-income uninsured individuals. It can be easy to think that Medicaid enrollees who now have health insurance would finally have all the means necessary to easily access healthcare. However, this isn’t always the case. Many non-financial social barriers persist, making healthcare inaccessible to low-income patients. One barrier is the negative stigma surrounding poverty and the Medicaid system.

Medicaid has a history of being an unpopular program and generally has a negative reputation of being welfare for the poor. This is especially evident in the twelve states that have currently refused to expand Medicaid. This stigma can cause patients to feel shame, inadequacy, and low self-worth when reliant on Medicaid as their sole form of health insurance. Patients might feel embarrassed that they can’t afford health insurance on their own [2]. Internalized stigma that Medicaid patients may feel is an added stress that hinders access to healthcare as it discourages patients from seeking out help.

Apart from internalized stigma, Medicaid patients have also experienced stigma by receiving suboptimal care. Insurance-based discrimination is when healthcare providers unfairly treat patients based on their insurance type, and about 21% of patients with Medicaid reported expereincing insurance-based discrimination, as compared to 3% of patients with private insurance [4].

This difference in how Medicaid patients are treated versus their private insurance counterparts could be partially due to dissatisfactory physician opinions towards Medicaid and its low reimbursement rates. Physicians get paid the highest fees when treating patients with private insurance, but they get paid the smallest fees when treating patients with Medicaid. This is because private health insurance companies offer physicians higher reimbursement rates for the services that patients incur, whereas Medicaid, on the other hand, offers physicians low reimbursement rates. Thus, physicians have financial incentive to prioritize private insurance patients over Medicaid patients. In fact, in 2011 nearly one-third of physicians were unwilling to accept new Medicaid patients [3]. Medicaid beneficiaries are consequently subject to more difficulty when trying to find a provider.

Stigma around Medicaid also has adverse effects on patient health. It can manifest into delayed care, unmet needs, and forgone care. One study found that those who reported frequent insurance-based discrimination were also more likely to experience delays in seeking medical care [1]. Because Medicaid patients have a smaller network of providers, the process of finding an adequate provider could delay the necessary care that they would have gotten if they were privately-insured. Additionally, of the Medicaid patients who reported frequent discrimination, 31% also reported receiving no preventative care within the last year [1]. This further illustrates the extent of unmet needs and forgone care. The stigma coupled with a lack of primary care could lead to higher chances of developing health conditions that could be more intensive and expensive to treat down the line.

As of May 2021, the total number of Medicaid enrollees is 75.9 million [5], accounting for approximately 23% of the US population, and this number has been increasing for the past twenty years. Stigma surrounding Medicaid and the effects it has on patient health is even more pronounced considering its large scale. Medicaid patients face unequal barriers to healthcare as seen with insurance-based discrimination and the adverse health outcomes that result from it, which ironically contradicts the ACA’s fundamental goal of improving health quality and access. In order to work towards achieving health equity, healthcare providers and policy makers must understand the negative health effects surrounding the stigma around Medicaid and the added health barriers Medicaid patients face.

References:

1. Allen, E. M., Call, K. T., Beebe, T. J., McAlpine, D. D., & Johnson, P. J. (2017). Barriers to Care and Health Care Utilization Among the Publicly Insured. Medical care, 55(3), 207–214. https://doi.org/10.1097/MLR.0000000000000644

2. Allen, H., Wright, B. J., Harding, K., & Broffman, L. (2014). The role of stigma in access to health care for the poor. The Milbank quarterly, 92(2), 289–318. https://doi.org/10.1111/1468-0009.12059

3. Decker S. L. (2012). In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help. Health affairs (Project Hope), 31(8), 1673–1679. https://doi.org/10.1377/hlthaff.2012.0294

4. Han, X., Call, K. T., Pintor, J. K., Alarcon-Espinoza, G., & Simon, A. B. (2015). Reports of insurance-based discrimination in health care and its association with access to care. American journal of public health, 105 Suppl 3(Suppl 3), S517–S525. https://doi.org/10.2105/AJPH.2015.302668

5. Medicaid.gov. May 2021 Medicaid & Chip Enrollment Data Highlights. (2021). Retrieved from https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html.