Skip to main content

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

Culture, Medicine, and Psychiatry volume 41, pages 161–180 (2017)Cite this article

Abstract

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.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price includes VAT (USA)
Tax calculation will be finalised during checkout.

Notes

  1. We define “Public insurance” as Medicaid and other government funded healthcare plans, such as county funded health plans available to low-income individuals. Medicare, which is not means-tested, is not included in this definition.

  2. To protect anonymity, all proper names in this paper are pseudonyms.

References

  • Ablon, Joan 1981 Stigmatized health conditions. Social Science and Medicine 15B:5-9.

    Google Scholar 

  • 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.

    Article  Google Scholar 

  • Allen, Heidi, et al. 2014 The role of stigma in access to health care for the poor. The Milbank Quarterly 92(2):289-318.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Backus, Lisa, et al. 2001 Specialists and primary care physicians’ participation in Medicaid managed care. Journal of General Internal Medicine 16:815-821.

    Article  Google Scholar 

  • Baicker, Katherine, et al. 2013 The Oregon experiment–effects of Medicaid on clinical outcomes. The New England Journal of Medicine 368(18):1713-22.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Barr, Barbara Matacera 2000 Stigma: A Paper for Discussion. Covering Kids National Program Office, Southern Institute on Children and Families.

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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 

  • Crenshaw, Kimberle 1991 Mapping the Margins: Intersectionality; Identity Politics, and Violence Against Women of Color. Stanford Law Review 43(6):1241–1299.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Cunningham, Peter J, and Ann S O’Malley 2009 Do Reimbursement Delays Discourage Medicaid Participation By Physicians? Health Affairs 28(1):W17-W28.

    Article  Google Scholar 

  • Davis, Kathy 2008 Intersectionality as buzzword: a sociology of science perspective on what makes a feminist theory successful. Feminist Theory 9(1):67-85.

    Article  Google Scholar 

  • 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 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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 

  • Goffman, Erving 1963 Stigma: notes on the management of spoiled identity. New York: Simon and Schuster.

    Google Scholar 

  • 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.

    Article  Google Scholar 

  • Gravlee, C. C. 2009 How race becomes biology: embodiment of social inequality. American Journal of Physical Anthropology 139(1):47-57.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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 

  • 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.

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Levinson, Arik, and Rahardja Sjamsu 2004 Medicaid Stigma. Washington D.C., Georgetown University.

    Google Scholar 

  • Link, Bruce G., and Jo C. Phelan 2001 Conceptualizing Stigma. Annual Review of Sociology 27:363-385.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Mason-Whitehead, Elizabeth, and Tom Mason 2007 Stigma and Exclusion in Healthcare Settings: John Wiley and Sons.

    Book  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Piatak, Jaclyn S. 2015 Understanding the Implementation of Medicaid and Medicare Social Construction and Historical Context. Administration & Society. doi:10.1177/0095399715581030.

  • 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.

    Article  Google Scholar 

  • 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 

  • 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.

    Article  Google Scholar 

  • Rovin, Kimberly, et al. 2012 Better than nothing: Participant Experiences using a county health plan. Practicing Anthropology 34(4):13-18.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Stuber, Jennifer, and Mark Schlesinger 2006 Sources of Stigma for Means-Tested Government Programs. Social Science and Medicine 63(4):933-45.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Weech-Maldonado, Robert, et al. 2012 The Relationship Between Perceived Discrimination and Patient Experiences With Health Care. Medical Care 50(9):S62-S68.

    Article  Google Scholar 

  • Weiss, Mitchell, and Jayashree Ramakrishna 2006 Stigma Interventions and Research for International Health. The Lancet 367:536-538.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Witzig, R. 1996 The medicalization of race: scientific legitimization of a flawed social construct. Annals of Internal Medicine 125(8):675-9.

    Article  Google Scholar 

  • Young, Sean D, and Eran Bendavid 2010 The relationship between HIV testing, stigma, and health service usage. AIDS Care 22(3):373-80.

    Article  Google Scholar 

Download references

Funding

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.

Author information

Authors and Affiliations

  1. Department of Anthropology, Michigan State University, 355 Baker Hall, 655 Auditorium Drive, East Lansing, MI, 48824, USA

    Anna C. Martinez-Hume, Hannah S. Bell & Linda M. Hunt

  2. Harvard T.H. Chan School of Public Health, Harvard University, 677 Huntington Avenue, Boston, MA, 02115, USA

    Allison M. Baker

  3. Department of Sociology and Anthropology, University of Texas at Arlington, 430 University Hall, 601 S. Nedderman Drive, Arlington, TX, 76019, USA

    Isabel Montemayor

  4. Center for Health Equity Research, Northern Arizona University, 1100 S. Beaver St., Flagstaff, AZ, 86011, USA

    Kristan Elwell

Authors
  1. Anna C. Martinez-Hume
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Allison M. Baker
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hannah S. Bell
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Isabel Montemayor
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kristan Elwell
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Linda M. Hunt
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Linda M. Hunt.

Ethics declarations

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.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Martinez-Hume, A.C., Baker, A.M., Bell, H.S. et al. “They Treat you a Different Way:” Public Insurance, Stigma, and the Challenge to Quality Health Care. Cult Med Psychiatry 41, 161–180 (2017). https://doi.org/10.1007/s11013-016-9513-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11013-016-9513-8

Keywords

  • Stigma
  • Insurance
  • Poverty
  • Healthcare
  • Medicaid
  • Intersectionality