title: The role of stigma in access to health care for the poor.
abstract: BACKGROUND
  The Affordable Care Act provides new Medicaid coverage to an estimated 12 million low-income adults. Barriers to access or quality could hamper the program's success. One of these barriers might be the stigma associated with Medicaid or poverty.
  
  
  METHODS
  Our mixed-methods study involved 574 low-income adults and included data from an in-person survey and follow-up interviews. Our analysis of the interviews showed that many participants who were on Medicaid or uninsured described a perception or fear of being treated poorly in the health care setting. We defined this experience as stigma and merged our qualitative interviews coded for stigma with our quantitative survey data to see whether stigma was related to other sociodemographic characteristics. We also examined whether stigma was associated with access to care, quality of care, and self-reported health.
  
  
  RESULTS
  We were unable to identify other sociodemographic characteristics associated with stigma in this low-income sample. The qualitative interviews suggested that stigma was most often the result of a provider-patient interaction that felt demeaning, rather than an internalized sense of shame related to receiving public insurance or charity care. An experience of stigma was associated with unmet health needs, poorer perceptions of quality of care, and worse health across several self-reported measures.
  
  
  CONCLUSIONS
  Because a stigmatizing experience in the health system might interfere with the delivery of high-quality care to new Medicaid enrollees, further research and policy interventions that target stigma are warranted.
authors.affiliation: Columbia University School of Social Work.
authors.forename: Heidi
authors.initials: H
authors.lastname: Allen
authors.forename: Bill J
authors.initials: BJ
authors.lastname: Wright
authors.forename: Kristin
authors.initials: K
authors.lastname: Harding
authors.forename: Lauren
authors.initials: L
authors.lastname: Broffman
mesh_terms: D000328:Adult; D001294:Attitude to Health; D003625:Data Collection; D003695:Delivery of Health Care / Q000706:statistics & numerical data; D005260:Female; D017144:Focus Groups; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D009922:Oregon; D011203:Poverty / Q000523:psychology*; D013240:Stereotyping; D014481:United States
keywords: health care; health insurance; poverty; stigma; user's experiences