Date on Master's Thesis/Doctoral Dissertation

8-2024

Document Type

Doctoral Dissertation

Degree Name

Ph. D.

Department

Health Promotion and Behavioral Sciences

Degree Program

Public Health Sciences with a specialization in Health Promotion, PhD

Committee Chair

Buchino, Buchino

Committee Co-Chair (if applicable)

Wendel, Monica

Committee Member

Wendel, Monica

Committee Member

Creel, Liza

Committee Member

Choate, Sara

Committee Member

Harris, Lesley

Author's Keywords

stigma; Kentucky; medicaid; ACA; qualitative

Abstract

Health insurance is only one of many factors involved in becoming and staying healthy, but the importance of having coverage in the U.S. cannot be overstated. Medicaid provides health care coverage for millions of Americans, with enrollment increasing dramatically after the Affordable Care Act allowed states to expand eligibility. While there is a great deal of research on the impacts of Medicaid expansion on newly eligible adults, there is little research on negative attitudes towards people using Medicaid, or on Medicaid stigma. This study used qualitative methods to conceptualize stigma around Medicaid through discussions with individuals using Medicaid and enrollment assisters throughout Kentucky. Analysis was informed by Constructivist Grounded Theory, resulting in a framework for conceptualizing Medicaid stigma. The framework considered sites of stigma as health care settings, social service bureaucracies, and policy, and factors influencing exposure to these potential sites of stigmatization as household health status, availability of providers in a given specialty or geographic area, and complexity of the administrative case. Multiple participants in the study did not report experiences of stigma However,

others did have such experiences, and most described types of stigma resistance. One method of resistance included action and advocacy, particularly during the first phase of proposed Medicaid changes under the Bevin administration. Another response was the defense of deservingness, articulating the benefits of Medicaid and arguing for an expansive view of the policy, which often included support for some form of universal healthcare. Finally, while participants generally did not fully internalize stigma, assisters reported seeing this in some clients who were hesitant to enroll in Medicaid or chose to go without coverage altogether. However, even some who resisted Medicaid also struggled in some ways with messages they had received, struggled with shame and guilt for obtaining coverage, or concerns about what others would think of them. Many connections in this overall process remain to be further enumerated and understood. Still, this framework provides a starting point for future research that is embedded in the lived experience of people using Medicaid for their healthcare, situated in a unique historical, political, and geographic setting.

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