Culture, Medicine, and Psychiatry

, Volume 41, Issue 1, pp 161–180 | Cite as

“They Treat you a Different Way:” Public Insurance, Stigma, and the Challenge to Quality Health Care

  • Anna C. Martinez-Hume
  • Allison M. Baker
  • Hannah S. Bell
  • Isabel Montemayor
  • Kristan Elwell
  • Linda M. HuntEmail author
Original Paper


Under the Affordable Care Act, Medicaid Expansion programs are extending Medicaid eligibility and increasing access to care. However, stigma associated with public insurance coverage may importantly affect the nature and content of the health care beneficiaries receive. In this paper, we examine the health care stigma experiences described by a group of low-income public insurance beneficiaries. They perceive stigma as manifest in poor quality care and negative interpersonal interactions in the health care setting. Using an intersectional approach, we found that the stigma of public insurance was compounded with other sources of stigma including socioeconomic status, race, gender, and illness status. Experiences of stigma had important implications for how subjects evaluated the quality of care, their decisions impacting continuity of care, and their reported ability to access health care. We argue that stigma challenges the quality of care provided under public insurance and is thus a public health issue that should be addressed in Medicaid policy.


Stigma Insurance Poverty Healthcare Medicaid Intersectionality 



The Michigan Department of Community Health (MDCH) provided funding for this research project (Grant # 134355). The views in this paper are those of the authors, and should not be assumed to reflect those of MDCH.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in this study. All names have been changed to pseudonyms and identifying information has been removed.


  1. Ablon, Joan 1981 Stigmatized health conditions. Social Science and Medicine 15B:5-9.Google Scholar
  2. Acquaviva, Kimberly D., and Matthew Mintz 2010 Perspective: are we teaching racial profiling? The dangers of subjective determinations of race and ethnicity in case presentations. Academic Medicine 85(4):702-5.CrossRefGoogle Scholar
  3. Allen, Heidi, et al. 2014 The role of stigma in access to health care for the poor. The Milbank Quarterly 92(2):289-318.CrossRefGoogle Scholar
  4. Ayanian, John Z., Kohler, B. A., Abe, T., and Epstein, A. M. 1993 The relation between health insurance coverage and clinical outcomes among women with breast cancer. The New England Journal of Medicine 329(5):326-331.CrossRefGoogle Scholar
  5. Backus, Lisa, et al. 2001 Specialists and primary care physicians’ participation in Medicaid managed care. Journal of General Internal Medicine 16:815-821.CrossRefGoogle Scholar
  6. Baicker, Katherine, et al. 2013 The Oregon experiment–effects of Medicaid on clinical outcomes. The New England Journal of Medicine 368(18):1713-22.CrossRefGoogle Scholar
  7. Baker, Allison M., and Linda M. Hunt 2016 Counterproductive Consequences of a Conservative Ideology: Medicaid Expansion and Personal Responsibility Requirements. Am J Public Health 106(7):1181-7.CrossRefGoogle Scholar
  8. Barr, Barbara Matacera 2000 Stigma: A Paper for Discussion. Covering Kids National Program Office, Southern Institute on Children and Families.Google Scholar
  9. Becker, Gay 2004 Deadly inequality in the health care “safety net”: uninsured ethnic minorities’ struggle to live with life-threatening illnesses. Medical Anthropology Quarterly 18(2):258-275.CrossRefGoogle Scholar
  10. Becker, Gay, and Edwina Newsom 2003 Socioeconomic status and dissatisfaction with health care among chronically ill african americans. American Journal of Public Health 93(5):742-748.CrossRefGoogle Scholar
  11. Bird, Sheryl Thorburn, and Laura M. Bogart 2000 Perceived race-based and socioeconomic status (SES)-based discrimination in interactions with health care providers. Ethnicity and Disease 11(3):554-563.Google Scholar
  12. Boehm, Deborah A. 2005 The safety net of the safety net: how federally qualified health centers “subsidize” Medicaid managed care. Medical Anthropology Quarterly 19(1):47-63.CrossRefGoogle Scholar
  13. Bowleg, Lisa 2012 The problem with the phrase women and minorities: intersectionality–an important theoretical framework for public health. American Journal of Public Health 102(7):1267-1273.CrossRefGoogle Scholar
  14. Burstin, Helen R., Stuart R. Lipsitz, and Troyen A. Brennan 1992 Socioeconomic status and risk for substandard medical care. Journal of the American Health Association 268(17):2383-2387.CrossRefGoogle Scholar
  15. Crenshaw, Kimberle 1989 Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum 1989(1):139-167.Google Scholar
  16. Crenshaw, Kimberle 1991 Mapping the Margins: Intersectionality; Identity Politics, and Violence Against Women of Color. Stanford Law Review 43(6):1241–1299.CrossRefGoogle Scholar
  17. Cunningham, P. J., and L. M. Nichols 2005 The effects of medicaid reimbursement on the access to care of medicaid enrollees: a community perspective. Med Care Res Rev 62(6):676-96.CrossRefGoogle Scholar
  18. Cunningham, Peter J, and Ann S O’Malley 2009 Do Reimbursement Delays Discourage Medicaid Participation By Physicians? Health Affairs 28(1):W17-W28.CrossRefGoogle Scholar
  19. Davis, Kathy 2008 Intersectionality as buzzword: a sociology of science perspective on what makes a feminist theory successful. Feminist Theory 9(1):67-85.CrossRefGoogle Scholar
  20. DelVecchio Good, Mary-Jo, et al. 2003 The Culture of Medicine and Racial, Ethnic, and Class Disparities in Healthcare. In Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. B.D. Smedley, A.Y. Stith, and A.R. Nelson, eds. Pp. 594-625. Washington, D.C.: The National Academies Press.Google Scholar
  21. Drury, Christina Aramburu Alegria, and Margaret Louis 2002 Exploring the association between body weight, stigma of obesity, and health care avoidance. Journal of the American Academy of Nurse Practitioners 14(12):554-561.CrossRefGoogle Scholar
  22. Druss, Benjamin G., et al. 2012 Mental Comorbidity and Quality of Diabetes Care Under Medicaid: A 50-state Analysis. Medical Care 50(5):428-433.CrossRefGoogle Scholar
  23. Earnshaw, Valerie A., and Diane M. Quinn 2011 The impact of stigma in healthcare on people living with chronic illnesses. Journal of Health Psychology 17(2):157-168.CrossRefGoogle Scholar
  24. Franks, Peter, Kevin Fiscella, and Sean Meldrum 2005 Racial disparities in the content of primary care office visits. Journal of General Internal Medicine 20(7):599-603.CrossRefGoogle Scholar
  25. Gaines, Atwood D. 2005 Race: Local Biology and Culture in Mind. In Companion to Psychological Anthropology: Modernity and Psychocultural Change. C. Casey and R. Edgerton, eds. Pp. 255-278. Oxford: Blackwell.Google Scholar
  26. Goffman, Erving 1963 Stigma: notes on the management of spoiled identity. New York: Simon and Schuster.Google Scholar
  27. Goldman, L. Elizabeth, Eric Vittinghoff, and R. Adams Dudley 2007 Quality of Care in Hospitals with a High Percent of Medicaid Patients. Medical Care 45(6):579-583.CrossRefGoogle Scholar
  28. Gravlee, C. C. 2009 How race becomes biology: embodiment of social inequality. American Journal of Physical Anthropology 139(1):47-57.CrossRefGoogle Scholar
  29. Han, Xinxin, et al. 2015 Reports of insurance-based discrimination in health care and its association with access to care. American Journal of Public Health 105 Suppl 3:S517-25.CrossRefGoogle Scholar
  30. Hansen, Helena, Philippe Bourgois, and Ernest Drucker 2014 Pathologizing poverty: new forms of diagnosis, disability, and structural stigma under welfare reform. Social Science and Medicine 103:76-83.CrossRefGoogle Scholar
  31. Hatzenbuehler, Mark L., Jo C. Phelan, and Bruce G. Link 2013 Stigma as a fundamental cause of population health inequalities. American Journal of Public Health 103(5):813-821.CrossRefGoogle Scholar
  32. Henderson, Stuart, Clare L Stacey, and Daniel Dohan 2008 Social stigma and the dilemmas of providing care to substance users in a safety-net emergency department. J Health Care Poor Underserved 19(4):1336-49.CrossRefGoogle Scholar
  33. Horton, S. 2006 The double burden on safety net providers: placing health disparities in the context of the privatization of health care in the US. Soc Sci Med 63(10):2702-14.CrossRefGoogle Scholar
  34. Horton, Sarah, Abadía, C., Mulligan, J., and Thompson, J. J. 2014 Critical anthropology of global health “takes a stand” statement: a critical medical anthropological approach to the U.S.’s Affordable Care Act. Medical Anthropology Quarterly 28(1):1-22.CrossRefGoogle Scholar
  35. Horton, Sarah, et al. 2001 Transforming the safety net: responses to Medicaid managed care in rural and urban New Mexico. American Anthropologist 103(3):733-746.CrossRefGoogle Scholar
  36. Hunt, L. M., and M. J. Kreiner 2013 Pharmacogenetics in primary care: the promise of personalized medicine and the reality of racial profiling. Cult Med Psychiatry 37(1):226-35.CrossRefGoogle Scholar
  37. Hunt, Linda M., and Katherine B. de Voogd 2005 Clinical Myths of the Cultural “Other”: Implications for Latino Patient Care. Academic Medicine 80(10):918-924.CrossRefGoogle Scholar
  38. Hunt, Linda M., Nicole Truesdell, and Meta J. Kreiner 2013 Race, Genes and Culture in Primary Care: Racial Profiling in the Management of Chronic Illness. Medical Anthropology Quarterly. 27(2):253-71.CrossRefGoogle Scholar
  39. Jackson, Pamela Braboy, and David R. Williams 2006 The intersection of race, gender and SES: health paradoxes In Gender, race, class, and health: intersectional approaches. Pp. 131-162. San Francisco, CA: Jossey-Bass.Google Scholar
  40. Kaeser Family Foundation, Kaiser Commission on Medicaid and the Uninsured 2013 Medicaid: A Primer-Key Information n the Nations’ Health Coverage Program for Low-Income People, Vol. 2016. Kaeser Family Foundation.Google Scholar
  41. Kinsler, Janni J., et al. 2007 The effect of perceived stigma from a health care provider on access to care among a low-income HIV-positive population. AIDS Patient Care and STDS 21(8):584-92.CrossRefGoogle Scholar
  42. Kwok, Joseph, et al. 2010 The Impact of Health Insurance Status on the Survival of Patients with Head and Neck Cancer. Cancer 116(2):476-85.CrossRefGoogle Scholar
  43. Levinson, Arik, and Rahardja Sjamsu 2004 Medicaid Stigma. Washington D.C., Georgetown University.Google Scholar
  44. Link, Bruce G., and Jo C. Phelan 2001 Conceptualizing Stigma. Annual Review of Sociology 27:363-385.CrossRefGoogle Scholar
  45. Marrow, H. B. 2012 Deserving to a point: unauthorized immigrants in San Francisco’s universal access healthcare model. Soc Sci Med 74(6):846-54.CrossRefGoogle Scholar
  46. Mason-Whitehead, Elizabeth, and Tom Mason 2007 Stigma and Exclusion in Healthcare Settings: John Wiley and Sons.CrossRefGoogle Scholar
  47. Nadeem, Erum, Lange, J. M., Edge, D., Fongwa, M., Belin, T., and Miranda, J. 2007 Does Stigma Keep Poor Young Immigrant and U.S.-Born Black and Latina Women From Seeking Mental Health Care. Psychiatric Services 58(12):1547-1554.CrossRefGoogle Scholar
  48. Nawaz, H., and A. S. Brett 2009 Mentioning race at the beginning of clinical case presentations: a survey of US medical schools. Medical Education 43(2):146-154.CrossRefGoogle Scholar
  49. Phelan, Jo C, Bruce G Link, and Parisa Tehranifar 2010 Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav 51 Suppl:S28-40.CrossRefGoogle Scholar
  50. Piatak, Jaclyn S. 2015 Understanding the Implementation of Medicaid and Medicare Social Construction and Historical Context. Administration & Society. doi: 10.1177/0095399715581030.
  51. Piña, Darlene L. 1998 Medicaid Beneficiaries’ Experiences in HMO and Fee-for-service Health Care. Journal of Health Care for the Poor and Underserved 9(4):433-448.CrossRefGoogle Scholar
  52. Quadagno, Jill 2015 The Transformation of Medicaid from Poor Law Legacy to Middle-Class Entitlement In Medicare and Medicaid at 50: America’s Entitlement Programs in the Age of Affordable Care. A.B. Cohen, D.C. Colby, K.A. Wailoo, and J.E. Zelizer, eds: Oxford University Press.Google Scholar
  53. Reutter, Linda I., Stewart, M. J., Veenstra, G., Love, R., Raphael, D., and Makwarimba, E. 2009 “Who Do They Think We Are, Anyway?”: Perceptions of and Responses to Poverty Stigma. Qualitative Health Research 19(3):297-311.CrossRefGoogle Scholar
  54. Rovin, Kimberly, et al. 2012 Better than nothing: Participant Experiences using a county health plan. Practicing Anthropology 34(4):13-18.CrossRefGoogle Scholar
  55. Sayles, Jennifer N, et al. 2009 The Association of Stigma with Self-reported Access to Medical Care and Antiretroviral Therapy Adherence in Persons Living with HIV/AIDS. J Gen Intern Med 24(10):1101-8.CrossRefGoogle Scholar
  56. Silow-Carroll, Sharon, et al. 2001 Community-Based Health Plans for the Uninsured: Expanding Access, Enhancing Dignity. Battle Creek, MI: W.K. Kellogg Foundation.Google Scholar
  57. Skinner, Natalie, et al. 2007 Stigma and Discrimination in Health-Care Provision to Drug Users: The Role of Values, Affect, and Deservingness Judgments. Journal of Applied Social Psychology 37(1):163-186.CrossRefGoogle Scholar
  58. Sorlie, Paul D., et al. 1994 Mortality in the Uninsured Compared With That in Persons With Public and Private Health Insurance. Archives of Internal Medicine 154(14):2409-2416.CrossRefGoogle Scholar
  59. Stuber, Jennifer, and Mark Schlesinger 2006 Sources of Stigma for Means-Tested Government Programs. Social Science and Medicine 63(4):933-45.CrossRefGoogle Scholar
  60. Stuber, Jennifer, and Karl Kronebusch 2004 Stigma and Other Determinants of Participation in TANF and Medicaid. Journal of Policy Analysis and Management 23(5):509-530.CrossRefGoogle Scholar
  61. Tajeu, Gabriel S., et al. 2015 “We’ll Get to You WhenWe Get to You”: Exploring Potential Contributions of Health Care Staff Behaviors to Patient Perceptions of Discrimination and Satisfaction. American Journal of Public Health 105(10):2076-2082.CrossRefGoogle Scholar
  62. Van Der Wees, Philip J., Alan M. Zaslavsky, and John Z. Ayanian 2013 Improvements in Health Status after Massachusetts Health Care Reform. The Milbank Quarterly 91(4):663-689.CrossRefGoogle Scholar
  63. Wagenfeld-Heintz, Ellen, Victoria C. Ross, and Keon-Hyung Lee 2007 Physicians’ Perceptions of Patients in a County Sponsored Health Plan. Social Work in Public Health 23(1):45-59.CrossRefGoogle Scholar
  64. Weech-Maldonado, Robert, et al. 2012 The Relationship Between Perceived Discrimination and Patient Experiences With Health Care. Medical Care 50(9):S62-S68.CrossRefGoogle Scholar
  65. Weiss, Mitchell, and Jayashree Ramakrishna 2006 Stigma Interventions and Research for International Health. The Lancet 367:536-538.CrossRefGoogle Scholar
  66. Wen, C. K., P. L. Hudak, and S. W. Hwang 2007 Homeless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters. J Gen Intern Med 22(7):1011-7.CrossRefGoogle Scholar
  67. Willging, Cathleen E. 2005 Power, Blame and Accountability: Medicaid Managed Care for Mental Health Services in New Mexico. Medical Anthropology Quarterly 19(1):84-102.CrossRefGoogle Scholar
  68. Witzig, R. 1996 The medicalization of race: scientific legitimization of a flawed social construct. Annals of Internal Medicine 125(8):675-9.CrossRefGoogle Scholar
  69. Young, Sean D, and Eran Bendavid 2010 The relationship between HIV testing, stigma, and health service usage. AIDS Care 22(3):373-80.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.Department of AnthropologyMichigan State UniversityEast LansingUSA
  2. 2.Harvard T.H. Chan School of Public HealthHarvard UniversityBostonUSA
  3. 3.Department of Sociology and AnthropologyUniversity of Texas at ArlingtonArlingtonUSA
  4. 4.Center for Health Equity ResearchNorthern Arizona UniversityFlagstaffUSA

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