Medicaid stigma

For nine years I was the office manager for a local obstetrician and gynecologist, and during those years, I saw a progression of change in our office policies toward Medicaid patients. Initially, our office accepted all new patients, but as our clientele grew, the physician no longer wanted to accept the state medical card, which has a low-rate of reimbursement for medical services, even though we continued to accept Medicare patients. The only circumstance in which we were allowed to schedule a Medicaid patient was if another physician referred that person to our office. It was and is my observation that people in our community do not have equal access to medical care, and when welfare patients are referred to an office that routinely does not accept the state medical card, those patients are treated differently by staff which often produces shame and embarrassment for the individual on public assistance.

While the quality of care was the same for all patients in our office, there was a clear pattern of treatment by our staff to determine who was "worthy" of quality care and who was "unworthy." For example, all office scheduling and billing interactions took place at the front desk, which was within hearing distance of the waiting room. Medicaid patients, who came into the office to schedule an appointment, were told that our office did not accept welfare patients but they could contact a general physician for their care. What I typically observed were young, pregnant women in need of prenatal care who had been blatantly refused and had to exit the office through the waiting room that was filled with "worthy" patients that were now aware of this individual's lack of means to pay for her medical care. Our office staff was also required to collect all billing information from patients as they entered the clinic. Many of the Medicaid patients, who were referred, had not received their state-issued medical card, so we would have to call the local state office and verify their eligibility. Now that everyone in the office was aware that this individual was on welfare, she was told to have a seat in the waiting room. It was not surprising that most of the Medicaid patients chose to wait outside or in the entrance area of the clinic away from the other patients. To further stigmatize a Medicaid patient, she was not allowed to leave the office until the state had authorized payment for the medical services she had just received which often took between thirty to forty-five minutes. However, this practice was not extended to individuals with private health insurance or Medicare patients who were allowed to immediately leave following their appointment.

As a result of these office practices, it is understandable that Medicaid patients do not want others to know their means of paying for medical care. Women on welfare are well aware of the negative attitudes and image that others have of them and are often ashamed and embarrassed by office policies which require different treatment of them and further marginalize them from the rest of society.