The doctor-patient relationship is not impervious to the financial stressors of the American healthcare system. With only 54.5 percent of Americans being covered by employer-based insurance, the country’s patchwork system serves almost two-fifths of its population on Medicare and Medicaid, with just under 1 in 10 Americans paying out-of-pocket insurance- a concerning uninsured population (Keiser-Starkley et. al.). Those on non-private insurance face a multitude of issues in securing consistent and competent doctor-patient relationships while also facing stigma from the doctors themselves. These struggles impact the duration and effectiveness of care while changing the patient’s attitudes toward seeking care, contributing to negative health outcomes for these populations. The issue of insurance for the poor and working-class however is not new, and the interesting ways that resilient patients deal with inadequate care are well documented in the oral histories from the Southern Oral History Project (SOHP). Analyzing these narratives with population-based research creates a better understanding of how insurance status contributes to increased stigma and worsened doctor-patient relationships.

An anonymous interviewee named Laura once said,

“And healthcare professionals treat you differently when you show up and you’re on Medicaid”.

This “difference” meant incomplete diagnosis, improper medications as quick-fix solutions, and a traumatic birthing experience that shattered the small trust she had in her OBGYN, whom she felt uncomfortable speaking to about her long-lasting post-surgery complications. In this and many cases, the difference seen with Medicaid patients is the doctor’s indifference. Rosenblatt outlines how the primary care case management system, which is currently still in effect in North Carolina, does not protect Medicaid users from inadequate care as the standard is judged in a “pre-paid, at-risk payment system” that incentivizes doctors to “contain costs” and therefore not go above and beyond at providing care to their patients (Rosenblatt et. al.). The medical ethics of Laura being given abnormally high doses of Pitocin while not being heard about her pain is a perfect example of how a pay-per-service mindset might have clouded her caregivers’ judgment. The broken trust in medical institutions as a consequence of Laura’s story is also not uncommon.

A study found that 80 percent of their interviewees on Medicaid felt that the stigma they faced was related to poor doctor-patient interactions (Allen, et. al.). Allen cites instances of security guards walking patients to appointments out of suspicion and unprofessional bedside manners from physicians being common, and their study was specifically designed for those who qualified for Medicaid expansion, which was supposed to help cover more of the 10 percent of Americans who fall through the insurance gap (Allen, et. al.). How is it that a program meant for social welfare could be causing harm? The answer to this question lies in stigma- which is shown through the reception of this insurance by doctors. A lesser-known cultural practice that impacts the doctor-patient relationship is that senior physicians will send patients on Medicare and Medicaid to junior physicians to receive care, ultimately limiting the quality of care these patients can receive and teaching physicians that these “types” of patients are not important (Brownstein). 

Carla Norwood, who was on what is colloquially referred to as “Pink Medicaid” as a pregnant PhD with twins, felt this stigma in her care, joking:

“People were like, ‘Oh, you’re on Medicaid, and here you are having a kid,’ kind of thing. I only meant to have one. [laughter] I didn’t mean to have two, for God’s sake”.

The judgment Norwood faced was directly because of the bias against her insurance rather than any other quality. Doctors’ bias towards certain insurances can have an individual impact on a patient’s trust and comfort in their doctor-patient relationship, making them less likely to seek care after negative doctor-patient interactions. 

This bias also extends to the uninsured community, where patients struggle with building consistent doctor-patient relationships. One study found that patients without insurance were five times as likely to report facing bias from medical providers. Within rural North Carolina, interviewee Ebony Talley-Brame has tried starting a medical transportation company in Warren County to help ease some of the non-medical costs that often stand as barriers to those without insurance from getting care. While her company has faced challenges in getting funding as there are cheaper, conglomerate bus companies in the area, her efforts are heading in the right direction to bridge the gap of care for uninsured individuals. When the effect of insurance coverage on the doctor-patient relationship in high-poverty neighborhoods was formally studied, it was found that having a regular healthcare provider made the impact of insurance null when considering diagnostic tests, a measurement of attentive care (Smith). Therefore by creating services that allow for less travel time, Talley-Brame is helping strengthen the doctor-patient relationship and possible health outcomes for her community.

The SOHP narratives that discussed insurance as a barrier to care, a source of stigma, and an overall negative stressor on the doctor-patient relationship made one thing evident: there is a need for doctors to rethink their biases and work to rebuild trust within alternative insurance communities through empathetically considering patient’s financial concerns and treating them with the respect granted to private-insurance patients. As Medicaid expansion and other initiatives like Talley-Brame’s are changing the landscape of healthcare, more efforts are needed to ensure that those on public insurance can use their insurance without fear of mistreatment or judgment from their doctors. In addition, doctors’ understanding that insurance is only a payment type and not a stereotype is crucial to having open and honest communication in the doctor-patient relationship. Through the narratives, I have learned that a myriad of people from different backgrounds use public insurance or are uninsured, and yet they all have unique health issues that deserve proper attention and care from doctors. Rethinking biases is truly the key to removing insurance stigma from the doctor-patient relationship. 

References

Keisler-Starkey, Katherine, et al. “Health Insurance Coverage in the United States: 2022.” United States Census Bureau, Sept. 2023.