Table 3.

Four Archtypes Illustrating the Theoretical Layers of Stigma (Presented in Figure 1)

Qualifying for Public Insurance

This family qualifies for public insurance, but they only obtain employer-sponsored insurance when they can afford it. Other times, they pay out-of-pocket, and care is rationed, delayed, or neglected. During hard times, all family resources are rationed, including food. At these times, getting injured or sick is feared the most. For them, health insurance is a coveted luxury—they wish their family could have private insurance “forever.” This family lives in fear, every day, of losing their private coverage, especially since mom’s coworker just lost her job.

They understand that no insurance is perfect. Their private plan has more options but at higher cost; public insurance would offer them fewer services but at minimal cost. For them, it is important to have access to providers based upon trust and experience, rather than type of insurance. They desire a simpler system with better continuity of care. Although they qualify for public coverage, they are too proud to apply. They have become accustomed to having access to the system while insured but to forego care while uninsured.

Applying for Public Insurance

This family is frustrated with the public insurance application process. Last year, mom had to find a second job, so they lost their public insurance but could not afford private. Now, no one is insured, including the kids. Their kids may again qualify for public insurance, but repeating the onerous application process would take time away from work, which is top priority to be able to afford basic needs. Rationing of food and clothing is a daily reality.

They use alternative means of accessing health care. Sometimes, they borrow from family, which increases family tensions. Other times, they negotiate payment plans or shop around for cheaper options. Mostly, they wait until it is absolutely necessary to seek care, which heightens anxiety. They worry about a child falling ill, feel disempowered with few options for care, and live with the guilt of not being able to insure their children. Recently, their kids have been healthy, so the burden of applying for public insurance has not been worth it.

Accepting Public Insurance

This single-parent family struggles every day to stay afloat. In the past, mom and her two kids were covered by public insurance; however, mom lost coverage last year after Medicaid eligibility rules changed. Mom worries about the limited access to providers with public insurance and is grateful that her children’s physician continues to accept Medicaid. She takes comfort in knowing she can bring her kids to their doctor whenever necessary but still worries about not being able to access dental care.

She believes accepting public coverage is worth it to her family because she has experienced the stress of being uninsured. In fact, she recently declined a $1.50/hour pay raise, for fear of losing her children’s insurance. She is frustrated that getting pregnant again would be the only way for her to access public coverage for herself.

Using Public Insurance

This family desperately needs health insurance—of any type. Currently, the entire family is covered by public insurance, for which they are grateful. Several months ago, mom was diagnosed with a terminal illness. The “silver lining”: she now qualifies and has successfully obtained public disability and health insurance benefits, which have helped immensely with financial stressors.

Mom has a master’s degree, and dad was a high school dropout; both are confused by the processes to obtain health insurance and the fragmented way in which health care is delivered. They are frustrated by limited access to providers, and they wish their children had more options. Their insurance only covers some care, so they opt out of recommended treatments to avoid out-of-pocket costs, especially dental care and prescription medications. For them, however, the need for the public insurance outweighs the frustrations with using it.