The Role of Stigma in Access to Health Care for the Poor

In 2014, the Patient Protection and Affordable Care Act (ACA) offered states the option to expand Medicaid to millions of low-income, uninsured citizens, although several states had already implemented some kind of Medicaid expansion program. These “early-expansion” states served as test cases that offer lessons about how low-income populations interact with the health care system once they gain access to coverage. A recent evaluation of an early-expansion state found that insurance coverage removes some, but not all, barriers to quality care.1 Oregon was a special test case because the state used a lottery system to determine who would be allowed to apply for coverage under the state's early Medicaid expansion program. A broad mixed-methods research effort took advantage of this randomization mechanism to evaluate the causal effects of Medicaid on health care use, health outcomes, and financial well-being.2 To provide context and richness to the quantitative data collected in Oregon—which included surveys, biomarker data, and administrative data—we conducted hundreds of qualitative interviews with survey respondents. Interviews covered the attitudes, behaviors, and care experiences of a low-income population similar to those eligible for health coverage under an ACA Medicaid expansion. The interview data reveal an important story that would have been difficult to find from numbers alone: a story about what it means to be poor, what being poor means when you go to the doctor, and how difficult it can be to engage with the health care system when you believe that the system might not want much to do with you.