Study Looks at Barriers to Medicaid Enrollment and Issue of Stigma

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The traditional notion of "welfare stigma" (i.e., feeling bad about participating in public assistance programs) is not a barrier to Medicaid enrollment, according to a study by the Center for Health Services Research and Policy at George Washington University. The study's authors acknowledge, however, that "to the extent that stigma is a barrier to Medicaid enrollment, it is a function of how people are treated during the application process and by health care providers." The nationwide study used in-person interviews with 1,400 low-income families who receive health care at community health centers.

The authors sought to distinguish between problems reported and problems that were actual barriers to Medicaid enrollment. The report identifies the following six barriers, of which only the first two are stigma related: 1) Medicaid officials asking applicants unfair personal questions, 2) physicians' unequal treatment of Medicaid recipients, 3) confusion about who is eligible for Medicaid, 4) the misperception that one must be on welfare to enroll in Medicaid, 5) the perception that the Medicaid application is long and complicated, and 6) inconvenient application hours.

Other findings include the following:

• About 50% of respondents reported at least one stigma-related problem. The incidence of stigma-related problems reported ranged from 11% (feel bad about themselves) to 35% (application process is humiliating);
• More than 80% of respondents reported at least one other type of problem (e.g., don't know how to apply [56%], application is long and complicated [42%], need a translator [35%], lack of transportation [42%]); and
• Hispanic respondents were more than three times as likely as white respondents to be eligible for but not enrolled in Medicaid.

The authors also discuss stigma-related concerns associated with the State Children’s Health Insurance Program's (SCHIP) "screen and enroll" provision, which requires that states ensure that children are ineligible for Medicaid before being enrolled in SCHIP. Some believe that families forego SCHIP coverage for their children because of stigma. The authors find, however, that stigma-related concerns about the process are "unfounded and should not be the basis for reconsidering this requirement."

To address Medicaid enrollment barriers, the study recommends 1) reducing the number of welfare-office encounters required for Medicaid application; 2) emphasizing outstationed enrollment at health centers, community centers, and other locations; 3) shortening the application form by eliminating unnecessary questions; 4) adding hours and locations for enrollment; 5) reducing confusion about the application process; and 6) paying special attention to minority families, particularly those of Hispanic heritage.

Stuber JP, et al. July 2000. Beyond stigma: What barriers actually affect the decisions of low-income families to enroll in Medicaid. George Washington University; Center for Health Services Research and Policy. The publication can be downloaded at http://www.hfni.gsehd.gwu.edu/~chsrp by clicking on "What's new."

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MCH Alert. 2001. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.ncemch.org/alert.