Negative treatment of Medicaid recipients is barrier to enrollment, according to new study

A new study on public benefits — and the stigma that sometimes accompanies them —reveals that traditionally held notions of welfare stigma are not a barrier to Medicaid enrollment. The problem, the study says, is the way beneficiaries are treated when they participate.

The study by the Center for Health Services Research and Policy at George Washington University in Washington, DC, involved in-person interviews with 1,400 low-income families who receive health care at community health centers. The researchers say their study design and findings are unique in that they:

1. measured distinct dimensions of stigma associated with use of public benefits;

2. were able to identify the ways in which stigma, as well as other problems, actually affect families’ decisions about enrolling in cash assistance and Medicaid programs.

"While people may complain about the stigma of being on a government program, it doesn’t influence their decision whether to enroll," lead researcher Jennifer Stuber tells State Health Watch.

Removing the stigma

She says state officials have been so concerned about possible traditional stigma (people feeling negatively about themselves when they participate in Medicaid), that they have insisted upon separate state Children’s Health Insurance programs (SCHIP) rather than combining them with Medicaid or following a screen-and-enroll procedure.

The study findings are important: For this health center patient study sample, it was estimated that 27% of uninsured adult patients and 70% of uninsured child patients were eligible but not enrolled, suggesting that at least 1.4 million health center patients were eligible for Medicaid but not enrolled in 1998.

The researchers also say their findings distinguish between perceived problems and problems that actually affect decisions about enrolling in Medicaid. Such a difference is important, they explain, because the problems reported by respondents with the greatest frequency were not necessarily the actual barriers, and policies designed to improve enrollment in Medicaid must address actual barriers to enrollment and not perceptions of problems.

The problems significantly likely to affect decisions about enrolling in Medicaid included:

• being made to answer unfair personal questions;

• a long and complicated application form;

• confusion about eligibility;

• the misperception that one must be a welfare recipient to receive Medicaid services;

• unequal treatment of Medicaid patients by many physicians.

Hispanic respondents were more than three times as likely to be eligible but not enrolled compared to white respondents, and were significantly more likely to report enrollment barriers concerning immigration fears, lack of translators, and not knowing how to apply.

Respondents were significantly more likely to report treatment stigma when applying for benefits at the welfare office than at alternate sites, according to the study.

"These findings strongly support an increased emphasis on outstationed and alternative enrollment sites. Moreover, the Medicaid take-up rate for this health center patient study sample appeared to be much higher than comparable take-up rates for the general population. This suggests that states should consider the active involvement of safety net providers in their efforts to remove barriers to Medicaid enrollment," the study states.

The study authors say their findings "provide compelling evidence that the traditionally held notion of welfare stigma’ plays no significant role in explaining why individuals are Medicaid eligible but not enrolled because they have decided not to participate. The types of stigma that do have a significant, measurable impact on the likelihood of Medicaid enrollment are related to how people are or expect they will be treated during the application process and how they believe they will be treated by providers once they are enrolled."

No generalizations, please

While the study results cannot be generalized to patients who do not access services through health centers, the authors say it is unlikely that the barriers identified in the findings would be less important to potential enrollees who are not health center patients. They make a number of recommendations that, they say, all fall within the discretion given states by the law:

• Place increased emphasis on outstationed enrollment at health centers, community clinics, hospitals, and other alternate locations such as schools and child-care centers.

• To the maximum extent possible, minimize welfare office encounters as part of the Medicaid application process.

• Eliminate all unnecessary questions such as how enrollees handle money, alcohol and drug use, their sex lives, and the father of their children (for applicants who are women).

• Shorten the application form.

• Add hours and locations for enrollment.

• Take additional steps to reduce Medicaid confusion.

• Pay special attention to minority families, particularly Hispanics.

"It’s important to change the face of the enrollment process," Ms. Stuber says. "We should be trying to create a perception of Medicaid as a middle-class program."

Meanwhile, a Princeton, NJ-based Robert Wood Johnson Foundation public opinion survey of families with children who qualify for SCHIP and Medicaid programs found that 59% of parents with uninsured children who qualify for SCHIP or Medicaid don’t believe that the programs apply to them. That misunderstanding is more prevalent among eligible households in which both parents are working (71% do not believe they would be eligible) and among those making $25,000 a year or more (69% do not believe they are eligible).

The researchers say there is a significant need to raise awareness of Medicaid and SCHIP eligibility criteria among low-income, working families. The survey revealed a significant opportunity to get millions of unenrolled children health care coverage because 82% of parents whose children are eligible but unenrolled said they would be either extremely likely or very likely to sign up their children, while 78% of parents whose children are eligible for SCHIP say they also would enroll.

Contact Ms. Stuber at (202) 416-0055.