Class and insurance stigma are barriers to good health care

Some low-income, uninsured and Medicaid patients report feeling stigma when interacting with health care providers, finds a new report in The Milbank Quarterly.

"These findings were most often related to poverty or insurance status, such as the doctor who told a patient she was wasting tax-payer dollars and the only reason she had insurance was because people like him were paying for it," said Heidi L. Allen, Ph.D. the study's lead author and assistant professor at Columbia University School of Social Work. "Feeling judged by providers was associated with higher reports of unmet physical and mental health needs, and declining health."

For the study, researchers reviewed survey data from 574 low-income adults enrolled in the Oregon Health Plan. The survey included questions about access to care, overall health and personal finances. Follow-up interviews in English and Spanish were conducted over 30 months in clinics or in patients' homes.

14 percent of patients reported a stigmatizing experience with the health care system. 80 percent of patients reporting stigma felt it from a personal interaction with a provider or the health care system. People reporting stigma were also more likely to perceive their health as fair or poor, rather than good, very good or excellent.

Allen noted that stigma can decrease the effectiveness of our investment in Medicaid. "Stigma can be thought of as an access barrier to quality health care, dampening the effect of the resources invested in getting people insured through the Affordable Care Act," she said.

"We sometimes separate how we treat people from how we want them to respond as patients," she said. "Can a health care environment be disrespectful and patient-centered at the same time? Can a patient engage or make shared decisions while feeling stripped of dignity?"

Matt Salo, executive director of the National Association of Medicaid Directors in Washington D.C., said there does appear to be some stigma associated with being poor and/or uninsured and/or on Medicaid. "To the extent that physicians or other health care providers treat lower income patients differently, we should examine whether this is an inherent bias or financially motivated. In the broader sense, if lower income patients have poor self-worth, that's also problematic. How can we improve that?"

Salo added, "At the end of the day, for the health care system to work at peak functionality, you need all parties—patients, providers, plans and payers to be highly motivated in improving health," said Salo. "If the patient has low expectations or if the provider is dismissive of a huge swath of the population, we're never going to get optimal results."