By Harrison Hayes
Introduction
“A cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid and discriminate against people… Stigma is about disrespect. It is the use of negative labels to identify a person living with mental illness. Stigma is a barrier” (University of Texas).
There is a substantial issue with how stigma interacts with patients in the healthcare system. Healthcare provider’s stigma towards certain marginalized or socioeconomic groups instantly comes to mind, as well as stigma towards mental health or HIV/AIDS (Moyce; Lloyd et al 3-8). However, there is also a structural stigma towards the healthcare system and a perceived stigma towards providers. It stems from a number of issues in the industry that serve as barriers towards care, such as no perceived need, bad experience with a provider, lacking insurance (Taber et al 1), or high costs (Kearney et al; Thomas et al). Some fall into one category, and some fall into both. Just like the other stigmas present in the healthcare system, substantial effort should be placed toward acknowledging and addressing the stigmas against providers and the healthcare system that impact the quality of healthcare patients receive.
Causes of Stigma
As previously mentioned, one of the sources of structural stigma is monetary. High costs and lacking insurance is not a new concept, but the stigma created by these is unmistakable. A qualitative study by Taber et al (1) found that 24.1% of participants listed high costs and another 8.2% listed no insurance as the reason they did not pursue care. Another study, by Kearney et al for the Kaiser Family Foundation found that half of adults find it difficult to afford medical care, and that 25% struggle with paying for prescriptions. As William Donaldson put it,
“I’d make the medicine cheaper. And the whole healthcare system is too expensive for most people. If they can’t afford insurance, they’re in bad shape” (Efird, 26).
This cost creates extensive impact in groups of lower socioeconomic status or of historic marginalization. According to the surveys conducted by Kearney et al, 12% of individuals interviewed stated that medical bills had a major impact on their household, with an additional 11% saying that they had a minor impact. Burdening costs and avoidance of care are also more likely to occur in Black and/or Hispanic households as well as those with less than $40,000 in income, as well as to the mentally ill (Mejia-Lancheros et al) or those with chronic conditions (Thomas et al; Carrol 2-5), with those groups experiencing higher levels of impact. The system of healthcare is stigmatized when people cannot reliably afford care without large burdens being placed upon them and their households.
Other barriers exacerbate this structural stigma and develop a perceived stigma too. These include negative experiences with healthcare providers and organizations (33%) alongside some patient’s lack of perceived need (12.2%)(Taber et al 1). Negative experience with healthcare providers is exemplified in Anna Freeman’s interview with Nefertiti Byrd and Darius Scott’s with Barbara Brayboy. Byrd describes how her doctors, due to a lack of communication, had prescribed medications that did not work well together. This had only been discovered due to the patient’s family member asking, not due to the doctors finding it. Similarly, Brayboy belabors the lack of familiarity that doctors have with their patients nowadays–that they prefer to type on a keyboard than talk with you. Byrd also sheds light on how patients may perceive their need for medical care.
“I just feel like I think people are smart enough to know that even though they are not a doctor, they understand their body, and they know when something is wrong…”
Impacts of Stigma’s Growth
All these barriers in unison serve to undermine healthcare in communities that may need it most. As mentioned, these barriers tend to crop up in areas of marginalized groups or lower socioeconomic status. It does not help when other barriers, such as time constraints (Taber et al 1), get in the way as well. Not to mention, avoiding healthcare can elicit disastrous results for patients who choose to ignore their medical needs. A study by Thomas et al in the Journals of the American College of Cardiology found that patients of heart failure with delayed or forgone medical care had a number of monetary burdens. Not only have higher inpatient and overall costs, but they also had more emergency room visits (Thomas et al).
While these conclusions may be for a specific group of patients, they apply to other patient populations as well. As seen in Damon Tweedy’s novel Black Man in a White Coat, the chapter Charity Care demonstrates how an inability to receive care can put people in serious danger. The character Tina avoids getting treatment for her unusually harsh periods because her Medicaid coverage ran out soon after the birth of her daughter, only to discover that she will likely need a hysterectomy due to how long a fibroid progressed inside–not helped by how fibroid are more likely to appear in black women as well as appear harsher and faster (63-68).
When so many barriers to care are erected in front of patients, it becomes easy for stigma to grow. A bitterness and lack of confidence forms as individuals find more reasons to avoid healthcare. Patients may not be confident in the system or its providers, especially when faced with accruing medical bills. Stigma in the medical field comes from many different sources towards many different groups. However, one big step that healthcare systems and providers can take to limiting stigma is to address the stigma against them that stems from their greatest flaws. Not only would it help the marginalized that find themselves unable to pay their bills, but it would also lead to more equitable care outcomes. Addressing the stigma generated by patients towards healthcare means creating a better healthcare landscape.
References
Tweedy, Damon. Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine Picador, 2015.
Efird, Caroline. “Y-0059 Interview with Donald Williams.” Southern Oral History Program, 2018, https://dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/27915/rec/58
Freeman, Anna. “Y-0012 Interview with Nefertiti Bryd.” Southern Oral History Program, 2018, https://dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28292/rec/12
Kearney, Audrey, et al. “Americans’ Challenge with Health Care Costs.” Kaiser Family Foundation. Dec. 14, 2021, https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/
Mejia-Lancheros, Cilia et al. “Trajectories and mental health-related predictors of perceived discrimination and stigma among homeless adults with mental illness.” PloS one vol. 15,2 e0229385. 27 Feb. 2020, doi:10.1371/journal.pone.0229385
Scott, Darius. “Y-0011 Interview with Barbara Brayboy.” Southern Oral History Program, 2018, https://dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/27918/rec/11
Taber, Jennifer M. et al. “Why do People Avoid Medical Care? A Qualitative Study Using National Data.” Journal of General Internal Medicine, vol. 30, no. 3, 2014, doi: 10.1007/s11606-014-3089-1
Thomas, Alexander, et al. “Forgone Medical Care Associated With Increased Health Care Costs Among the U.S. Heart Failure Population.” Journals of the American College of Cardiology, vol. 9, no. 10, 2021, https://doi.org/10.1016/j.jchf.2021.05.010.
University of Texas. “What is Stigma?” Mental Health Promotion Committee, University of Texas, 2022, https://utexas.instructure.com/courses/1211434/pages/what-is-stigma