medicaid vs nursing home care

ORIGINAL PAPER

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

Anna C. Martinez-Hume1 • Allison M. Baker2 •

Hannah S. Bell 1

• Isabel Montemayor 3

•

Kristan Elwell4 • Linda M. Hunt1

Published online: 26 December 2016

� Springer Science+Business Media New York 2016

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.

Keywords Stigma � Insurance � Poverty � Healthcare � Medicaid � Intersectionality

& Linda M. Hunt [email protected]

1 Department of Anthropology, Michigan State University, 355 Baker Hall, 655 Auditorium

Drive, East Lansing, MI 48824, USA

2 Harvard T.H. Chan School of Public Health, Harvard University, 677 Huntington Avenue,

Boston, MA 02115, USA

3 Department of Sociology and Anthropology, University of Texas at Arlington, 430 University

Hall, 601 S. Nedderman Drive, Arlington, TX 76019, USA

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

AZ 86011, USA

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Cult Med Psychiatry (2017) 41:161–180

DOI 10.1007/s11013-016-9513-8

Introduction

A key feature of the Affordable Care Act is Medicaid Expansion, which extends

Medicaid eligibility to many low-income adults with the goal of improving health

equity through increased access to care. While addressing an urgent public health

need, issues within the social context of public insurance may diminish the success

of such programs in effectively addressing health disparities. One such concern is

stigma associated with public insurance coverage, including Medicaid and other

state-sponsored programs for the low-income, which may meaningfully affect the

nature and content of health care.

Stigma—the negative experience of stereotyping, labeling, exclusion and

discrimination due to some personal attribute—is commonly reported by individuals

using Medicaid and other state-sponsored health plans (Allen et al. 2014; Horton

et al. 2014; Stuber and Kronebusch 2004; Wagenfeld-Heintz, Ross, and Lee 2007).

Being stigmatized in the health care setting, specifically, due to public insurance

status may have important impacts extending beyond just bad feelings; it may result

in increased disparities in health care. In this paper, we examine the experiences of

stigma in health care described by a group of low-income individuals eligible for

Medicaid in Michigan. We discuss the types of stigma experienced by these

individuals when using public insurance, 1 and the influence of such stigma on their

health-seeking behaviors. Based on these case examples, we consider how stigma

associated with public insurance may combine with other types of stigma to impact

the quality and continuity of care for those using Medicaid and other public

insurance programs. Finally, we argue that to promote the health equity goals of the

Affordable Care Act, health policy should be developed to address the multiple

interactive factors that induce stigma and its impacts on health care.

Public Health Insurance in Michigan

Medicaid has been the main form of health insurance for low-income Americans

since its inception in 1965; providing coverage to pregnant women, children, the

blind and disabled, and the elderly, depending on income. Federal laws have long

excluded most adults without dependent children from Medicaid coverage, leaving

large numbers of adults uninsured. (Kaeser Family Foundation 2013).

Beginning in the late 1990s, Michigan, like many other states, instituted

community health plans managed by county governments, to help provide access to

health care for those not eligible for Medicaid. The Ingham Health Plan (IHP)

provides an example of one such plan. Michigan regulations require health

insurance plans to provide a minimum set of benefits. In order to maximize the

number of people to be covered, the IHP was expressly designed not as a health

insurance plan, but rather as a program with a limited set of ‘‘medical benefits,’’

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.

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providing access to primary care services and some medications. (Rovin et al. 2012;

Silow-Carroll et al. 2001).

Despite the large numbers of Michigan residents being left uninsured and

underinsured by these programs, the state legislature, dominated by conservative

politicians, was reluctant to pursue Medicaid expansion as called for by the ACA.

After much contentious debate, the Michigan legislature passed a bill expanding

Medicaid under a Section 1115 Waiver, amending the usual Medicaid regulations to

add personal responsibility requirements in the form of cost-sharing and financial

incentives for healthy behaviors. These added features of the Healthy Michigan Plan

(HMP) are designed to assure that recipients have ‘‘skin-in-the-game,’’ and take

responsibility for their lifestyle choices (Baker and Hunt 2016).

While at its inception, it had been anticipated that about 400,000 people would be

covered under HMP (Ayanian et al. 1993), more than 600,000 people had enrolled

in the plan in the first year (MDHHS 2016). The study we report here draws on data

collected just as HMP was beginning to enroll beneficiaries. The experiences of

stigma they report in using public insurance, therefore, refer to standard Medicaid,

IHP, and similar plans that pre-dated Michigan’s Medicaid expansion under the

ACA.

Stigma and Its Implications for Health Disparities

How experiences of stigma may impact those subject to its influence has long been

of concern to social scientists and health researchers. Stigma is manifest through

processes of exclusion, rejection, or blame. Goffman (1963) notes that stigma is a

product of power differentials in an interpersonal relationship that is ‘‘deeply

discrediting’’ to an individual’s social identity. In the health care setting,

interpersonal stigma originates from the in-group (i.e., health care providers),

who have the power to stigmatize and exclude others (i.e., patients) (Mason-

Whitehead and Mason 2007) and can stem from the provider’s assumptions about

the patient’s personal attributes (Weiss and Ramakrishna 2006).

It has been widely demonstrated that sources of stigma affecting health care

experiences may include race, class, gender, and illness-status (Bird and Bogart

2000; Drury, Aramburu, and Louis 2002; Earnshaw and Quinn 2011; Franks,

Fiscella, and Meldrum 2005; Henderson, Stacey, and Dohan 2008; Kinsler et al.

2007; Reutter et al. 2009; Stuber and Schlesinger 2006). Stigma associated with

such personal attributes has been shown to have real and serious consequences for

health status. For example, studies show that health care stigma is associated with

underutilized care, infrequent routine check-ups, delaying care, forgoing needed

tests, illness progression, and lower quality of life (Becker and Newsom 2003;

Drury, Aramburu, and Louis 2002; Earnshaw and Quinn 2011; Nadeem et al. 2007;

Sayles et al. 2009; Young and Bendavid 2010).

Additionally, studies have documented that stigmatization may be based on

having public insurance or being uninsured. Patients with public insurance report

feeling ignored, disrespected, or rushed, have difficulty scheduling appointments,

and often face long wait times; which may lead them to have low satisfaction with

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healthcare providers and staff, and to perceive public insurance as providing

substandard care. As a result of these experiences some patients with public

insurance miss follow up appointments, change health care providers, and become

reluctant to access essential services (Allen et al. 2014; Becker 2004; Becker and

Newsom 2003; Piña 1998; Wagenfeld-Heintz, Ross, and Lee 2007).

Because racial and ethnic minorities are often over-represented among the poor,

these groups are also over-represented among public insurance beneficiaries (Kaeser

Family Foundation 2013). Ablon (1981) notes, groups who experience stigma in

health care are likely to be individuals who enter into the health care system as

already stigmatized patients. Becker and Newsom (2003) reported that a majority of

the low-income African American participants in their study felt racism impacted

the care they received, and Sayles et al. (2009) found that stigma associated with an

HIV diagnosis negatively impacted patients’ treatment experiences. In a large

survey, Weech-Maldonado et al. (2012) found that Medicaid beneficiaries reported

experiencing racial and ethnic discrimination when receiving care.

Stigma in healthcare for Medicaid and other public insurance beneficiaries may

occur for a variety of reasons. DelVecchio Good et al. (2003) write that the

‘‘medical gaze,’’ or the culture of medicine, may lead providers to unknowingly

treat some patients differently than others. Medical providers generally follow

regimented consultation protocols, often including structured patient interviews

under strict time constraints. Low-income patients with complex social problems

may disrupt the context of the provider’s expected clinical encounters, and may be

interpreted as troublesome or non-compliant patients, (see also Horton 2006).

Furthermore, providers are encouraged to treat minority patients differently by

contemporary epidemiological and medical research which often presumes racial

and ethnic groups share genetic, socio-economic and cultural characteristics

(Acquaviva and Mintz 2010; Gaines 2005; Gravlee 2009; Nawaz and Brett 2009;

Witzig 1996). Through their medical training, published articles, and clinical

guidelines, clinicians are regularly instructed that race and ethnicity are clinically

relevant, and they routinely embrace and act upon these notions (Hunt and Kreiner

2013; Hunt and de Voogd 2005; Hunt, Truesdell, and Kreiner 2013). Thus,

differential treatment in healthcare is clearly the result of multidimensional

processes, many of which are structural in nature.

Stigma in health care is associated with a variety of factors, and it is well-known

to importantly affect the quality and content of care patients receive. However, it is

essential to further recognize that, in the course of health seeking, patients may be

impacted by not just one type of stigma, but by the combined effect of the various

sources of stigma they face. This understanding of stigma is grounded in

intersectionality theory, which recognizes that each individual’s unique experience

of stigma and discrimination is the result of their social positioning within a range of

attributes which may be sources of power and oppression (Crenshaw 1989;

Crenshaw 1991; Davis 2008). In public health discourse, it is increasingly

recognized that in order to understand health disparities, we must consider how

various social conditions may interact to affect health care access (Bowleg 2012;

Jackson and Williams 2006; Phelan, Link, and Tehranifar 2010).

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Clearly, stigma may have important implications for the health of public

insurance beneficiaries, affecting their ability and likelihood to access high-quality

health care. Hatzenbuehler, Phelan, and Link (2013) argue that stigma is a critical

influence on population health because of its persistent association with health

inequities. Thus the issue of stigma merits closer scrutiny in light of Medicaid

expansion. States that expanded Medicaid prior to the Affordable Care Act saw an

increase in utilization of health care services and a general improvement in

beneficiaries’ self-reported health status and access to health care (Baicker et al.

2013; Van Der Wees, Zaslavsky, and Ayanian 2013). Understanding how stigma

may contribute to historical patterns of late diagnoses, higher mortality, and poorer

health outcomes for public insurance recipients, (Ayanian et al. 1993; Burstin et al.

1992; Kwok et al. 2010; Sorlie et al. 1994) may point to strategies to address those

issues, and thereby maximize the positive effects of Medicaid expansion. In this

paper we examine specific ways insurance status may impact health care

experiences, how other stigmatized patient characteristics may amplify those

experiences, and how the combined effects of these sources of stigma may impact

the quality of health care. We present a series of case examples illustrating how

stigma has impacted health-seeking experiences and perceived quality of care

among a group of Medicaid-eligible adults.

The Study

As part of a study examining the experiences and concerns of people targeted by

Michigan’s Medicaid expansion program, the HMP, we conducted interviews with a

group of low-income individuals in Mid-Michigan. We recruited participants

through community organizations and gathering places, such as farmers markets,

health fairs and food banks, and through snowball sampling. Individuals were

eligible to participate if they met the main criteria for HMP: being between 19 and

64 years of age with income less than or equal to 138% of the federal poverty level,

and not covered by private health insurance or Medicare. If individuals expressed

interest we assessed their eligibility, obtained informed consent and scheduled

interviews at participants’ homes or in public spaces. In-depth, semi-structured

interviews lasted approximately 1 hour, were conducted in English, and were audio

recorded and transcribed. Participants each received a $25 gift card to a local

grocery store in appreciation for their time.

The study protocol was approved by the Institutional Review Board of Michigan

State University. Interview questions explored participants’ general health concerns,

previous health care experiences, experiences with health insurance and being

uninsured, and understandings and expectations about Medicaid expansion. It

should be noted that our recruitment strategy allowed us to sample a cross-section of

Medicaid-qualified individuals who had received care from a wide variety of health

care providers and institutions, about which we did not collect any specific

information.

Interview transcripts were checked for accuracy and then coded using NVivo 10,

a qualitative data analysis program. Using a general inductive approach, codes were

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designed to capture overarching thematic responses including health-seeking

experiences, behavioral strategies, and emotional responses, such as frustration or

dissatisfaction. The research team met regularly to compare and review coding

themes before finalizing a code book. Although not a central focus of the project,

stigma emerged as a common theme in participant responses. Comments coded for

‘‘stigma’’ included all references to perceptions of and experiences with stigma or

discrimination when accessing or receiving any health service, treatment, or health

coverage. At later stages of analysis, we refined the stigma code to include

descriptive subcodes, such as ‘‘experiential stigma’’ and ‘‘outcomes of experiential

stigma.’’ We conducted NVivo queries examining various factors associated with

the stigma code.

Of 31 total participants, 21 were women and 10 were men. About half were self-

identified white, a third African American, and the remainder Hispanic. Their ages

ranged from 20 to 63 years, with most (65%) being under 40 years old. Most had

incomes that fell well below the federal poverty level, and almost half (48%)

reported no income at all. Nearly all (81%) had health insurance through some form

of Medicaid, and only a handful (13%) were uninsured at the time of the interview.

Detailed demographic information for our sample is presented in Table 1.

Those enrolled in Medicaid had the standard state plan which pre-dated the ACA,

which used private insurers contracted by the state to provide Medicaid coverage.

Our participants were enrolled in a variety of different plans managed by these

private companies. At the time of the interviews, Michigan had just begun enrolling

individuals into HMP: while 11 of our participants reported having enrolled in HMP

none had yet begun using the plan.

Experiences of Stigma with Public Insurance

Participants reported encountering a range of experiences with stigma as they

navigated the health care system, much of it related to insurance status. When asked

if they felt public insurance status affects how health care providers treat people,

three quarters (77%) said they thought it did, and more than half (65%) said they

had either personally experienced such treatment or observed others being treated

differently. As Lauren, 2 a 24-year-old white part-time nurse covered by Medicaid,

expressed:

I see it every day. I see different physicians treating Medicaid people different

than if you came in with…something that’s actually paid for out of your pocket…Yeah, I feel strongly that Medicaid holders are treated way differently than if you came in with a paid insurance.

Participants’ stories about being treated differently focused on two central stigma

themes: receiving poor quality care and experiencing negative interpersonal

interactions.

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

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Perceptions of Poor Quality Care

Participants described a variety of ways in which they felt they had received lower

quality of care when using public insurance, as compared to private insurance

holders. They told of being offered different prescriptions and treatment options,

and of providers being rushed or reluctant to provide them treatment at all. Jennifer,

a 50-year-old white woman who had been unemployed since losing her job at a dry-

cleaners, shared this story about seeing a specialist at a university based private

hospital for a back condition while she was unemployed and covered by Medicaid:

I was sent to see if I was a candidate for back surgery…It was a long drive, and I get there and I’m expecting to see this specialist come in, and he takes—

I don’t even know what kind of instrument it was—but he ran it down the side

of my thigh and down my leg and turned around and walked out of the room.

He didn’t say anything to me. And I’m sitting there like, ‘‘What the hell?’’ I

really felt that if I had walked in there with Blue Cross Blue Shield, I would

have had surgery.

Table 1 Interview participant demographics

N %

Participants 31

Sex

Female 21 68

Male 10 32

Age

18–29 12 39

30–39 8 26

40–49 3 10

50–59 6 19

60–64 2 6

Race/ethnicity

White 16 52

African American 10 32

Hispanic 5 16

Household income as % FPL

0 15 48

1–49 4 13

5–99 7 23

100–138 5 16

Current health coverage

Uninsured 4 13

County plan 2 6

Medicaid 25 81

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While Jennifer’s encounter occurred in a private hospital, a setting that may see

relatively fewer patients with public insurance, others reported similar experiences

in health care settings like emergency rooms or health centers, where public

insurance is common. Carrie, a 38-year-old white, unemployed paralegal, described

the receptionists at a public hospital clinic she normally visits for gynecological

appointments as quick and ‘‘rude.’’ She said, ‘‘I hate going to the obstetrician there

or gynecologist…It’s like an assembly line…. there’s like 100 pregnant ladies. I think oh, because we have Medicaid…’’’ Similarly, Destiny, a 25-year-old white woman, recounted her experience taking her young son to a clinic she called ‘‘the

welfare clinic.’’ Destiny attributed the rushed and poor quality care her children

received to their having public insurance. She explained:

The wait was an hour long…and then they were very quick with us, they didn’t take their time to ask questions…It’s like they weren’t patients, they were just another number, you know, to get them out the door, and the next

one in… [The doctor] just sent us on our way without even fully understanding what the problem was… [My son] had a really bad cold or bronchitis and I told the doctor before he’s allergic to amoxicillin, penicillin,

and he actually wrote him an amoxicillin script. It was in his file. He didn’t

even read through his file.

Like Destiny, other participants felt that public insurance beneficiaries are often

given little attention by health care personnel and not allotted long enough

appointment times. Many participants also said they had experienced very long wait

times in both public and private health care settings, which they attributed to having

public insurance. Oftentimes the situation was made doubly frustrating because the

long wait was followed by a rushed appointment. Ella, an unemployed 48-year-old

African American woman who had just recently enrolled in Medicaid after being

uninsured for three years, discussed her experience:

It was like, you may have an appointment, you could be the first one to sign

up…but if somebody’s insurance might be better than yours, they get better service…Since they know that’s the type of insurance you get, your background like, you’re working [or] not, it has an effect on how people act

towards you…It’s like, gosh, I’ll be the first one here, be the last one coming on out of here.

For Ella, public insurance represented more than just insurance coverage. It

denoted other presumed social attributes, including her ‘‘background’’ and

employment status, which influenced the way health care personnel treated her.

Teresa, a 57-year-old African American mother of five, was an unemployed

computer repair specialist and uninsured at the time of the interview. She recounted

having similar experiences when she was covered by public insurance in the past:

[Health care providers] just think people that are on assistance have all the

time in the world…I can remember having to wait for hours at the doctor’s office, where someone that came in and pulled out their Blue Cross Blue

Shield card they got right in. I would have an appointment also…and then they

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would tell me, ‘Well she had to get back to work,’ and it was like, ‘What

difference does it make? I was on time.’

Like Ella, Teresa felt her public insurance status is taken to be a reflection of her

employment status—that she has time to wait and no job to get back to. In their

experience, their public insurance status was conflated with other socially

disempowering characteristics, intensifying the stigma they encountered.

Thus far we have seen a variety of ways in which public insurance beneficiaries

felt their insurance status caused them to receive poor quality care. Participants

described long wait times, rude behavior, or rushed and inattentive care in the health

care setting, which they attributed to their insurance status. Some also felt that this

intensified the impact of other perceived and stigmatized social attributes such as

being unemployed. In what follows, participants describe a related concern: their

experiences with negative interpersonal interactions in the health care setting.

Negative Interpersonal Interactions

Participants described a variety of negative interpersonal interactions with health

care personnel or staff many of which they attributed to their public insurance

status. These included shaming, mistreatment, being disrespected or ignored, not

being believed, and being treated like they were unintelligent. Kimberly, a 39-year-

old white woman who works in retail, remembered having such encounters when

being treated for pain at an out-of-state hospital while covered by Medicaid:

I couldn’t even move, and first of all they didn’t even want to treat me. I was

in pain, crying, bent over, couldn’t move. He [the health care provider] was

like, ‘just get up’ and just treated me like dirt…They didn’t run no tests or nothing, they just gave me some meds.

Kimberly’s treatment at the hospital exemplifies how patients may interpret

negative interpersonal interactions with providers as inadequate care. Similarly,

Shannon, a 31-year-old unemployed white woman covered by Medicaid, described

negative interpersonal interactions she had experienced, comparing her experiences

when using private insurance versus Medicaid:

When we had Blue Cross and Blue Shield, we were treated much differently

even by the receptionist. People treat you differently. They look at you

differently…It’s a stigma almost. I sometimes don’t want to pull out my green [Medicaid] card when I’m in the line at the pharmacy…the lady in front of me has a Blue Cross Blue Shield card and the way they talked to her or interact

with her…is much different than when I roll up with my green card and my cardboard [Medicaid health plan] card. It’s ‘here, sign this, birth date, co-pay,

have a great day.’

Shannon also told us that health care staff engaged in less conversation with her

and treated her more curtly when she used Medicaid compared to Blue Cross Blue

Shield, further reinforcing her sense of stigmatization when using public insurance.

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Other negative interpersonal interactions commonly described by our participants

include being ignored, not being believed by health care personnel, and being

treated like they were ‘‘dumb’’ or ‘‘stupid.’’ Melina, a 28-year-old Hispanic

unemployed waitress, told us that she was ignored after going to the hospital for an

emergency while covered by Medicaid. She said, ‘‘They don’t pay attention to you

because they know you got this card, you know, sometimes…they discriminate— They treat you different than other persons that pay at the hospital.’’ Jacquie, a

28-year-old African American who works as a home health aide, expressed a similar

sentiment. Jacquie felt that due to her Medicaid coverage, health care providers

treated her as if she were unintelligent:

Sometimes, maybe nurses or whatever will go out of their way to explain

something that, to me, might be common sense. They’ll go through your charts

and say, ‘Okay, this. Oh okay, Medicaid,’ and they’ll start talking to you about

something stupid…I assume that they assume…if you have regular insurance or whatever, that you must have a job or something like that and then they

don’t talk to you like you’re all dumb.

In these examples, we have seen that patients may feel medical staff make

negative assumptions about them based on their public insurance, and treat them

differently than they would be if they had private insurance.

Some study participants expressly noted feeling victim to multiple sources of

stigma. They described providers’ negative assumptions associated with insurance

status being amplified by other personal characteristics like physical appearance,

race, class, and illness status. Crystal, for example, a 35-year-old unemployed social

worker covered by IHP (the county health benefits plan), described feeling

mistreated at a private, suburban clinic due to being a low-income ‘‘young black

woman.’’ She said, ‘‘Most of the clientele there, they appeared to be well-to-do.

They were white. And I noticed that the way the receptionist would talk to me, you

know, she was kind of standoffish, didn’t even give me eye contact.’’ This

participant, who has a master’s degree in sociology, described the negative

assumptions the specialist seemed to make about her:

The way the doctor would ask questions to me—kind of like I was dumb. You

know, the way he would talk to me? But when he heard the way I talk and my

lingo, I shut that down. But the point was, his initial impression of me

was…that maybe I wasn’t as intelligent or probably wasn’t responsible. And so, his conversation with me reflected that. But I noticed that interactions with

other clients that came in were quite different.

Crystal compared this with her experiences at low-income health care facilities,

saying she did not notice the same treatment in those settings. She attributed this

particular discriminatory experience largely to her race and low-income status,

highlighting that stigma can be compounded and exacerbated by other sources of

disempowerment, discrimination and prejudice.

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Health Implications of Stigma

As participants described their experiences with stigma, several also discussed how

those experiences impacted their health-seeking behaviors, causing them to

interrupt care, forgo treatment and doctor visits, or change primary care providers.

Kelly’s story illustrates how experiencing stigma can interfere with continuity of

care. Kelly is a 32-year-old white bartender who suffers from Graves’ disease, a

chronic autoimmune condition of the thyroid. She was uninsured for two years

before enrolling in Medicaid and was unemployed at the time of the interview.

When asked if she thought people with public insurance were treated differently

than others, Kelly told us ‘‘[it] depends on where you go’’, noting that she never felt

mistreated at university based facilities. However, Kelly strongly felt she was

treated poorly by health care providers at a public hospital clinic because of her

Medicaid insurance, saying, ‘‘They didn’t listen! They just didn’t listen, didn’t

care.’’ She felt that because providers wouldn’t listen to her, she was given an

incorrect prescription, one that she already knew would negatively affect her thyroid

condition. After receiving that prescription, she requested to be seen by a different

doctor at the clinic. Instead, she was only permitted to see a nurse practitioner. Kelly

said she got angry at being treated this way, and told us ‘‘I don’t want to come back,

I don’t. I don’t ever want to come back again.’’

Similarly, Kimberly, the 39-year-old white retail worker we met earlier,

experienced poor treatment which she felt was due to her being covered by

Medicaid, resulting in her leaving her provider. She told us that when she had a

miscarriage, her doctor declined to perform a dilation and curettage procedure when

she requested it. She had to wait a long time before he finally performed the

procedure, a period she described as ‘‘awful.’’ Kimberly strongly felt the delay was

due to her Medicaid coverage status. After this experience, she decided to no longer

use that doctor’s health system. Experiences like Kelly and Kimberly’s were

commonly described by those we interviewed, and often resulted in patients opting

to discontinue seeing their providers, disrupting their continuity of care.

Perhaps the most disquieting account of disruption to care due to stigma came

from Carrie, the 38-year-old unemployed paralegal. Carrie’s HIV-positive status

and Medicaid coverage combine as sources for stigmatization in her health care

encounters, negatively affecting her care. When asked if she thought Medicaid

affects how she gets treated, she said that she has been treated very rudely by

receptionists and clinical staff alike. She told us that she used to have private, ‘‘good

insurance’’ and visited a specialist hospital clinic, noting that ‘‘it’s just a different

experience’’ compared to using Medicaid. When using her current Medicaid

insurance, Carrie stated, ‘‘They just treat you differently, and especially when you

have HIV, you get treated a whole bit differently.’’

Carrie described how one of her doctors put on two pairs of gloves before

examining her, and she told us her medical records folder was ‘‘flagged’’ at the

dentist. Although such actions may be appropriate medical precautions given her

health status, Carrie experienced this behavior as demeaning. She further reiterated,

‘‘You get a lot of stigma in health care, especially if you have [HIV],’’ adding that

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this stigma makes her reluctant to go to the gynecologist. In addition to feeling

mistreated by her doctors, Carrie also talked about enduring long wait times due to

her insurance status. When asked if these experiences affected her desire to go to the

doctor, she said, ‘‘Absolutely. I’m out of care—I’ve missed three appointments for

my HIV doctor because I cannot stand sitting two hours in the lobby…I have to go to work.’’ Carrie’s care was further interrupted when a particularly disturbing

incident prompted her to change her doctor:

My doctor asked me to swab myself one time when I was being tested for

STDs… How the hell can you work in infectious disease and you don’t want to swab me? Like okay, I can do that. But how humiliating is that? I’m

switching doctors…I just don’t want to go. I want to be able to sit down and talk to somebody about what’s going on with me because I’ve been missing

medicine, and that’s serious. It’s a serious thing, and they’re so callous to it.

As Carrie’s story so clearly illustrates, stigmatization can have significant health

consequences for public insurance beneficiaries, particularly those for whom other

personal attributes, such as illness-status or race, compound the stigma experience.

An intersectionality approach suggests that health care stigma experienced by

participants like Carrie emerges from multiple, interacting and discredited social

positions beyond just a stigmatized insurance status.

For our participants, health care stigma towards their public insurance status

combined with other sources of stigma to impact the quality of health care they

received and their interpersonal interactions with providers, which in turn had

significant implications for their health seeking. For some, such experiences led

them to forgo much needed care or discontinue seeing their health care providers,

which may have serious consequences for their health.

Discussion

In this paper we have examined the stigma experiences described by a group of

public insurance beneficiaries in their efforts to access health care. Participants quite

commonly felt stigmatized in being ignored, disrespected, and not believed, being

given rushed and insufficient care, and being forced to wait well past their

appointment times. We have also seen that the stigma associated with public

insurance was compounded for many by stigma due to other personal characteristics

such as class and race, resulting in intersectional stigma. This sometimes had

important consequences for the health and health care of these public insurance

beneficiaries.

Past research has found that stigma due to various personal attributes, including

race/ethnicity, illness-status, socioeconomic status, and gender, is a common

experience in the health care setting (Bird and Bogart 2000; Drury, Aramburu, and

Louis 2002; Earnshaw and Quinn 2011; Kinsler et al. 2007; Reutter et al. 2009;

Sayles et al. 2009; Stuber and Schlesinger 2006). Our findings illustrate some

specific examples of how stigma based on public insurance status may manifest in

clinical encounters and combine with other stigmatized attributes, having an

172 Cult Med Psychiatry (2017) 41:161–180

123

important impact on health care. For example, Crystal’s description of being spoken

to condescendingly as a woman who is low income, young, and African American

reflects her experience of multiple sources of stigma including her gender,

socioeconomic status, age, and race. Similarly, Carrie’s story illustrates dual

stigmatization related to both her Medicaid coverage and her HIV-positive status.

Others, like Ella and Teresa, felt their public insurance status prompted negative

assumptions about their employment status, which presented additional sources of

stigma.

Our findings build on previous studies that have found stigma can have

significant implications for access to care, disease management and progression, and

quality of life (Drury, Aramburu, and Louis 2002; Earnshaw and Quinn 2011;

Sayles et al. 2009; Young and Bendavid 2010). We found that in addition to

perceptions of suboptimal care, stigma resulted in some of our participants changing

providers, forgoing care, or becoming reluctant to continue seeking care. For

individuals who require ongoing medical care for serious illnesses, this can be both

distressing and dangerous.

Some participants, like Carrie, Kelly, and Crystal, reported they had noticed a

difference in how they were treated at certain healthcare facilities over others.

While some mentioned that their treatment might be worse in places who served

few people with public insurance, it was not always clear from their stories whether

they felt the type of healthcare environment (i.e. private versus public) determined

whether or not stigma might occur. While we did not ask our participants to indicate

where their care experiences had occurred, we were able to garner from their

accounts, that they had experienced stigma in both public and private facilities. This

included federally qualified health centers and other clinics targeting the

underserved, which is somewhat surprising since they may be less impacted by

low reimbursement rates than are other kinds of clinics. Previous research has

shown, however, that healthcare facilities treating a high percentage of Medicaid

patients may not provide high quality care, as indicated by their failure to meet

quality measurements (Goldman, Vittinghoff, and Dudley 2007). Thus, while such

clinics may be designed for serving patients with public insurance, the quality of

care they receive may still be compromised. We also found that our participants

experienced stigma not just from doctors and other clinicians, but from support staff

as well, including receptionists and clerks. For example, many participants

described long wait times which they felt were attributable to support staff acting

as discriminatory gate-keepers. Others, like Crystal and Carrie, experienced

‘‘standoffish’’ and ‘‘rude’’ behaviors from receptionists. Our findings are consistent

with other studies that have found discrimination in healthcare does not just

originate within the doctor-patient relationship, but also between patients and

clinical support staff (Tajeu et al. 2015; Wen, Hudak, and Hwang 2007). Thus,

discrimination and stigmatization may be experienced at many levels of the

healthcare encounter, including outside of the consultation room.

While, as our data shows, stigmatizing attitudes may be held by various actors in

the clinical encounter including the doctors, nurses, receptionists and other medical

staff, it is in its essence embedded in interpersonal power differentials (cf: Goffman

1963). Power differentials in interpersonal relationships, while experienced on an

Cult Med Psychiatry (2017) 41:161–180 173

123

individual level, are rooted in structural inequalities. These inequalities constitute

the upstream causes of stigma in the health care setting. Link and Phelan (2001)

write that ‘‘by itself the standard model that asks ‘what-makes-person-A-discrim-

inate-against-person-B’ is inadequate for explaining the full consequences of stigma

processes’’ because it obscures the hand of power that structurally discriminates and

stigmatizes groups of people (Link and Phelan 2001:372). While discussion of the

full range of structural causes of health care stigma is beyond the scope of this

paper, we wish to focus on one important concern: that public insurance status itself

may amplify interpersonal stigma in the health care setting.

Medicaid has long carried a burden of stigma in the United States as a ‘‘symbol

of the waste and excess of the welfare state,’’ (Horton et al. 2014:7) carrying with it

sets of assumptions about the people who utilize these resources. Medicaid

recipients are often socially characterized as lazy, willingly unemployed, and less

educated (Barr 2000; Han et al. 2015; Hansen, Bourgois, and Drucker 2014;

Levinson and Sjamsu 2004). The social construction that low-income individuals

who enroll in Medicaid are ‘‘undeserving,’’ needy, and dependent, in contrast to

‘‘deserving’’ Medicare beneficiaries, emerged during the inception of the two

programs (Piatak 2015), and continues to be a dominant political perspective today

(Baker and Hunt 2016). Indeed, the personal responsibility requirements built-into

Medicaid expansion Waivers, like Michigan’s, reflect this notion.

Health care providers have been shown to draw on a variety of domains in

constructing their judgements about who is deserving and who is not, for example,

some groups may be perceived as more of a financial burden than others, or as

failing to meet entitlement norms (Marrow 2012; Skinner et al. 2007). Furthermore,

public insurance stigma has been shown to be exacerbated by low reimbursement

rates, treatment constraints, and high administrative costs (Boehm 2005; Horton

et al. 2001; Willging 2005). In states with higher reimbursements rates for

Medicaid, quality and access of care has been found to be better than those with

lower rates (Cunningham and Nichols 2005; Cunningham and O’Malley 2009;

Druss et al. 2012). Providers struggling to navigate such financial constraints may

be more inclined—whether consciously or not—to hold stigmatizing opinions of

public insurance and its beneficiaries and not accept them as patients, which may

amplify the institutional limitations patients encounter when receiving care in

poorly funded clinics where long wait times and rushed appointments are endemic.

For example, Backus et al. (2001) found that primary care physicians and specialists

described Medicaid patients as posing many challenges, such as being noncompli-

ant, needing extra time for medical explanations during consultations, and having

complex clinical and psychosocial problems.

It should be noted that this study draws on a small convenience sample of

respondents who are qualified for public insurance, and as such was not designed to

produce generalizable findings nor draw comparisons to people with private

insurance. Still, our findings provide useful insight into the complex and concerning

ways Medicaid recipients may experience stigma in their health seeking while using

public insurance. Because we interviewed only Medicaid qualified individuals, we

had no access to how their clinicians actually viewed them, or knowledge of the

characteristics of the specific clinics they described. We can merely surmise how

174 Cult Med Psychiatry (2017) 41:161–180

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clinicians’ attitudes and institutional factors might impact patient’s experiences of

stigma. Future research may add important insights to the understanding of how

stigma impacts such patients, exploring, for example, whether clinicians’ knowl-

edge of public insurance status affects their views of patients, or how specific

institutional factors may act to promote or discourage stigma. Future research might

also explore how funding limitations affect quality of care at public and private

healthcare facilities, and how the experience of stigma may be related to the actual

quality of care.

Conclusion

Stigma merits careful consideration in public insurance policy planning because, as

we have demonstrated, it ultimately challenges health care equity for certain groups.

Stigma can importantly affect the accessibility, continuity, and quality of health care

received by low-income individuals. The Affordable Care Act’s expansion of the

Medicaid program is an important step toward ensuring health equity among low-

income Americans. New state Medicaid expansion plans challenge typical

assumptions about who Medicaid beneficiaries are by extending eligibility and

entitlement to middle class and working individuals (Quadagno 2015), however, it

remains to be seen whether those of middle class status experience similar levels of

stigma when using public insurance.

The experiences of stigma described by the participants in this study are inherent

to the ways public insurance is viewed not just in health care, but in our society in

general. Simply expanding coverage will not in itself necessarily dispel the

historical legacy of stigma associated with the Medicaid program. The positive

impact of Medicaid expansion may be enhanced through interventions focused on

reducing the stigma encountered by those using public health coverage. To that end,

we join others (Allen et al. 2014; Barr 2000; Mason-Whitehead and Mason 2007;

Reutter et al. 2009) in arguing that policy should attend unambiguously to the issue

of stigma and its institutionalization within government programs.

In the context of the recent presidential election, the future of expanded Medicaid

programs may be in question. Still, Medicaid expansion remains the only way many

uninsured Americans can obtain health insurance and access the care they need. It is

our hope that states continue to expand Medicaid programs, and that they will

simultaneously endeavor to identify, revise and remove symbols of Medicaid as a

stigmatized status. For example, removing the ‘‘Medicaid’’ label as the main

signifier of beneficiaries’ health plan coverage and replacing it with a neutral state-

specific plan name, such as Michigan’s ‘‘Healthy Michigan Plan,’’ may be a starting

point in mitigating Medicaid’s stigmatized status. Policy-makers might also

consider improving provider reimbursement rates for Medicaid and further

incentivizing providers to accept more Medicaid patients, in the form of financial

bonuses, perhaps. Including assessment of beneficiaries’ experiences of health care

stigma and discrimination in patient satisfaction surveys might help identify

particularly problematic locations or providers.

Cult Med Psychiatry (2017) 41:161–180 175

123

Such attention to the realities of beneficiaries’ lives and experiences may help

alleviate the problem of intersectional stigma in health care and illuminate the ways

in which social attributes such as class, race, and gender may combine with public

insurance stigma to impact health. Training programs might raise awareness among

health care personnel of the importance of insurance status as a source of stigma, the

compounding effect of intersectional stigma, and the impact of these on the health

care they provide.

Inequitable health care received under the stigma of public insurance is a public

health issue as it disadvantages and compromises the health of low-income health

seekers. Toward maximizing our ability to reach the goal of health equity, stigma

should be addressed directly in Medicaid policy planning and development.

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.

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.

References

Ablon, Joan

1981 Stigmatized Health Conditions. Social Science and Medicine 15B: 5–9.

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): 702–705.

Allen, Heidi, B. J. Wright, K. Harding, and L. Broffman

2014 The Role of Stigma in Access to Health Care for the Poor. The Milbank Quarterly 92(2): 289–

318.

Ayanian, John Z., B. A. Kohler, T. Abe, and A. M. Epstein

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.

Backus, Lisa, D. Osmond, K. Grumbach, K. Vranizan, L. Phuong, and A. B. Bindman

2001 Specialists and Primary Care Physicians’ Participation in Medicaid Managed Care. Journal of

General Internal Medicine 16: 815–821.

Baicker, Katherine, S. L. Taubman, H. L. Allen, M. Bernstein, J. H. Gruber, J. P. Newhouse, E. C.

Schneider, B. J. Wright, A. M. Zaslavsky, and A. N. Finkelstein

2013 The Oregon Experiment–Effects of Medicaid on Clinical Outcomes. The New England Journal

of Medicine 368(18): 1713–1722.

Baker, Allison M., and Linda M. Hunt

2016 Counterproductive Consequences of a Conservative Ideology: Medicaid Expansion and Personal

Responsibility Requirements. American Journal of Public Health 106(7): 1181–1187.

176 Cult Med Psychiatry (2017) 41:161–180

123

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.

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.

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.

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.

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.

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.

Crenshaw, Kimberle

1989 Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrim-

ination Doctrine, Feminist Theory and Antiracist Politics. University of Chicago Legal Forum

1989(1): 139–167.

1991 Mapping the Margins: Intersectionality; Identity Politics, and Violence Against Women of

Color. Stanford Law Review 43(6): 1241–1299.

Cunningham, P. J., and L. M. Nichols

2005 The Effects of Medicaid Reimbursement on the Access to Care of Medicaid Enrollees: A

Community Perspective. Medical Care Research and Review 62(6): 676–696.

Cunningham, Peter J., and Ann S. O’Malley

2009 Do Reimbursement Delays Discourage Medicaid Participation By Physicians?. Health Affairs

28(1): W17–W28.

Davis, Kathy

2008 Intersectionality as Buzzword: A Sociology of Science Perspective on What Makes a Feminist

Theory Successful. Feminist Theory 9(1): 67–85.

DelVecchio Good, Mary-Jo, C. James, B. J. Good, and A. E. Becker

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.

Drury, Alegri, Christina Aramburu, 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.

Druss, Benjamin G., L. Zhao, J. R. Cummings, R. S. Shim, G. S. Rust, and S. C. Marcus

2012 Mental Comorbidity and Quality of Diabetes Care Under Medicaid: A 50-State Analysis.

Medical Care 50(5): 428–433.

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.

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.

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.

Cult Med Psychiatry (2017) 41:161–180 177

123

Goffman, Erving

1963 Stigma: Notes on the Management of Spoiled Identity. New York: Simon and Schuster.

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.

Gravlee, C. C.

2009 How Race Becomes Biology: Embodiment of Social Inequality. American Journal of Physical

Anthropology 139(1): 47–57.

Han, Xinxin, K. T. Call, J. K. Pintor, G. Alarcon-Espinoza, and A. B. Simon

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–S525.

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.

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.

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. Journal of Health Care for the Poor and Underserved 19(4): 1336–1349.

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. Social Science and Medicine 63(10): 2702–2714.

Horton, Sarah, C. Abadı́a, J. Mulligan, and J. J. Thompson

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.

Horton, Sarah, J. McCloskey, C. Todd, and M. Henriksen

2001 Transforming the Safety Net: Responses to Medicaid Managed Care in Rural and Urban New

Mexico. American Anthropologist 103(3): 733–746.

Hunt, L. M., and M. J. Kreiner

2013 Pharmacogenetics in Primary Care: The Promise of Personalized Medicine and the Reality of

Racial Profiling. Culture, Medicine and Psychiatry 37(1): 226–235.

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.

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): 253–271.

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. A. Shulz and L. Mullings, eds., pp. 131–162. San Francisco,

CA: Jossey-Bass.

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., M. D. Wong, J. N. Sayles, C. Davis, and W. E. Cunningham

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): 584–592.

Kwok, Joseph, S. M. Langevin, A. Argiris, J. R. Grandis, W. E. Gooding, and E. Taioli

2010 The Impact of Health Insurance Status on the Survival of Patients with Head and Neck Cancer.

Cancer 116(2): 476–485.

Levinson, Arik, and Rahardja Sjamsu

2004 Medicaid Stigma. Washington D.C.: Georgetown University.

Link, Bruce G., and Jo C. Phelan

2001 Conceptualizing Stigma. Annual Review of Sociology 27: 363–385.

178 Cult Med Psychiatry (2017) 41:161–180

123

Marrow, H. B.

2012 Deserving to a Point: Unauthorized Immigrants in San Francisco’s Universal Access Healthcare

Model. Social Science and Medice 74(6): 846–854.

Mason-Whitehead, Elizabeth, and Tom Mason

2007 Stigma and Exclusion in Healthcare Settings. Chichester: Wiley.

Nadeem, Erum, J. M. Lange, D. Edge, M. Fongwa, T. Belin, and J. Miranda

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.

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.

Phelan, Jo C., Bruce G. Link, and Parisa Tehranifar

2010 Social Conditions as Fundamental Causes of Health Inequalities: Theory, Evidence, and Policy

Implications. Journal of Health and Social Behavior 51(Suppl): S28–S40.

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.

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: Oxford.

Reutter, Linda I., M. J. Stewart, G. Veenstra, R. Love, D. Raphael, and E. Makwarimba

2009 ‘‘Who Do They Think We Are, Anyway?’’: Perceptions of and Responses to Poverty Stigma.

Qualitative Health Research 19(3): 297–311.

Rovin, Kimberly, R. Stone, L. Gordon, E. Boffi, and L. Hunt

2012 Better than Nothing: Participant Experiences Using a County Health Plan. Practicing

Anthropology 34(4): 13–18.

Sayles, Jennifer N., M. D. Wong, J. J. Kinsler, D. Martins, and W. E. Cunningham

2009 The Association of Stigma with Self-reported Access to Medical Care and Antiretroviral

Therapy Adherence in Persons Living with HIV/AIDS. Journal of General Internal Medicine

24(10): 1101–1108.

Silow-Carroll, Sharon, S. E. Anthony, P. A. Seltman, and J. A. Meyer

2001 Community-Based Health Plans for the Uninsured: Expanding Access, Enhancing Dignity.

Battle Creek, MI: W.K. Kellogg Foundation.

Skinner, Natalie, N. T. Feather, T. Freeman, and A. Roche

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.

Sorlie, Paul D., N. J. Johnson, E. Backlund, and D. D. Bradham

1994 Mortality in the Uninsured Compared With That in Persons With Public and Private Health

Insurance. Archives of Internal Medicine 154(14): 2409–2416.

Stuber, Jennifer, and Mark Schlesinger

2006 Sources of Stigma for Means-Tested Government Programs. Social Science and Medicine 63(4):

933–945.

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.

Tajeu, Gabriel S., A. L. Cherrington, L. Andreae, C. Prince, C. L. Holt, and J. H. Halanych

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.

Van Der Wees, PJ, Alan M. Zaslavsky, and John Z. Ayanian

2013 Improvements in Health Status after Massachusetts Health Care Reform. The Milbank Quarterly

91(4): 663–689.

Cult Med Psychiatry (2017) 41:161–180 179

123

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.

Weech-Maldonado, Robert, A. Hall, T. Bryant, K. A. Jenkins, and M. N. Elliott

2012 The Relationship Between Perceived Discrimination and Patient Experiences With Health Care.

Medical Care 50(9): S62–S68.

Weiss, Mitchell, and Jayashree Ramakrishna

2006 Stigma Interventions and Research for International Health. The Lancet 367: 536–538.

Wen, C. K., P. L. Hudak, and S. W. Hwang

2007 Homeless People’s Perceptions of Welcomeness and Unwelcomeness in Healthcare Encounters.

Journal of General Internal Medicine 22(7): 1011–1017.

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.

Witzig, R.

1996 The Medicalization of Race: Scientific Legitimization of a Flawed Social Construct. Annals of

Internal Medicine 125(8): 675–679.

Young, Sean D., and Eran Bendavid

2010 The Relationship Between HIV Testing, Stigma, and Health Service Usage. AIDS Care 22(3):

373–380.

180 Cult Med Psychiatry (2017) 41:161–180

123

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