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Why do some eligible families forego public insurance for their children? A qualitative analysis.

BACKGROUND AND OBJECTIVES
Central to health insurance reform discussions was the recurring question: why are eligible children not enrolled in public insurance programs? We interviewed families with children eligible for public insurance to (1) learn how they view available services and (2) understand their experiences accessing care.


METHODS
Semi-structured, in-depth interviews with 24 parents of children eligible for public coverage but not continuously enrolled were conducted. We used a standard iterative process to identify themes, followed by immersion/crystallization techniques to reflect on the findings.


RESULTS
Respondents identified four barriers: (1) confusion about insurance eligibility and enrollment, (2) difficulties obtaining public coverage and/or services, (3) limited provider availability, and (4) non-covered services and/or coverage gaps. Regardless of whether families had overcome these barriers, all had experienced stigma associated with needing and using public assistance. There was not just one point in the process where families felt stigmatized. It was, rather, a continual process of stigmatization. We present a theoretical framework that outlines how families continually experience stigma when navigating complex systems to obtain care: when they qualify for public assistance, apply for assistance, accept the assistance, and use the public benefit. This framework is accompanied by four illustrative archetypes.


CONCLUSIONS
This study provides further insight into why some families forego available public services. It suggests the need for a multi-pronged approach to improving access to health care for vulnerable children, which may require going beyond incremental changes within the current system.