Medicaid Patients and Healthcare Quality: Theory and Access
This paper examines the systemic barriers that prevent Medicaid patients from receiving high-quality healthcare in the United States. It identifies four primary factors—low physician participation rates, insufficient use of evidence-based practice (EBP) in Medicaid-accepting facilities, the complex health needs of Medicaid patients, and treatment delays—and analyzes them through exchange theory, which frames healthcare as a cost-benefit transaction. The paper then proposes patient-centered care theory and Sister Calista Roy's Adaptation Model as frameworks for improving care equity. Together, these theoretical lenses illuminate both why disparities exist and how holistic, individualized approaches could help Medicaid patients achieve health outcomes comparable to those of privately insured patients.
- Introduction: Overview of barriers to quality Medicaid care
- Lack of Physician Participation and EBP in Medicaid-Participating Facilities: Payment delays and resource gaps limit care quality
- Health Status and Treatment Delays Among Medicaid Patients: Poor health backgrounds and access barriers worsen outcomes
- How Exchange Theory Explains the Problem: Cost-benefit framing explains provider reluctance toward Medicaid
- Patient-Centered Care and Roy's Adaptation Model as Solutions: Holistic and individualized frameworks to improve Medicaid care
- Conclusion: Systemic inequity persists without structural and theoretical reform
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What makes this paper effective
- It organizes a multifaceted policy problem into discrete, clearly labeled causes, making the argument easy to follow and each section build logically on the last.
- It moves from diagnosis to explanation to remedy—first identifying the barriers, then applying exchange theory to explain their persistence, then proposing two constructive theoretical frameworks as solutions.
- The paper uses specific citations for each claim, grounding policy observations in peer-reviewed research rather than assertion alone.
Key academic technique demonstrated
The paper demonstrates effective multi-theory application: it uses exchange theory descriptively to explain why healthcare providers avoid Medicaid patients, then pivots to normative frameworks—patient-centered care and Roy's Adaptation Model—to prescribe improvements. Using one theory to explain a problem and different theories to solve it shows analytical flexibility and awareness of theory as a practical tool, not merely an academic exercise.
Structure breakdown
The paper follows a classic problem-analysis-solution structure across six sections. The introduction previews all key issues and names the theoretical frameworks. Two body sections catalogue specific barriers (physician participation, EBP gaps, patient health status, treatment delays). A dedicated section applies exchange theory as an explanatory lens. A solution-focused section then introduces patient-centered care and the Roy Adaptation Model. The conclusion ties the argument back to systemic inequity without introducing new claims.
Introduction
Why are patients with Medicaid coverage not receiving the best quality of healthcare? One reason is that physicians do not want to participate in the Medicaid program because the rate of payment from either the state or the federal government is slower than even that of private insurance (Brabury, 2015). As a result, access to quality care is limited for individuals enrolled in Medicaid. Another problem is that evidence-based practice (EBP) approaches to quality care are less likely to be utilized by physicians and nurses in facilities that accept Medicaid patients, thus reducing the quality of care those patients receive (Calvin et al., 2006).
Medicaid patients also tend to have poorer health and come from poorer backgrounds, which puts them at an additional disadvantage from the outset, as their health needs are more complicated and their outcomes less favorable—factors that further impact the perception of care received (Sastow et al., 2019). Finally, patients with Medicaid tend to experience greater treatment delays than individuals who are privately insured (Naghavi et al., 2016). Grembowski, Cook, Patrick, and Roussel (2002) have analyzed the healthcare system from the perspective of exchange theory, which posits that the benefits and costs of an interaction between two parties are weighed to determine risks and benefits. Such an approach helps to explain why Medicaid patients receive lower-quality care. However, patient-centered care is an approach that should be adopted regardless of how care is paid for (Connole, 2012). An even better theoretical framework for explaining how and why quality care should be delivered to all patients—including those on Medicaid—is the Adaptation Model put forward by Roy (2018). This paper discusses the reasons Medicaid patients tend to receive lower-quality care from healthcare providers, what theoretical approach explains this phenomenon, and what theoretical approaches can be applied to help address this problem.
References
Alligood, M. (2017). Nursing theorists and their work. Elsevier.
Bradbury, C. J. (2015). Determinants of physicians' acceptance of new Medicaid patients. Atlantic Economic Journal, 43(2), 247–260.
Calvin, J. E., Roe, M. T., Chen, A. Y., Mehta, R. H., Brogan, G. X., Jr., DeLong, E. R., ... & Peterson, E. D. (2006). Insurance coverage and care of patients with non–ST-segment elevation acute coronary syndromes. Annals of Internal Medicine, 145(10), 739–748.
Connole, P. (2012). Wireless data transfer from device to EMR. Provider Magazine, 1, 1–4.
Grembowski, D. E., Cook, K. S., Patrick, D. L., & Roussel, A. E. (2002). Managed care and the US health care system: A social exchange perspective. Social Science & Medicine, 54(8), 1167–1180.
Naghavi, A. O., Echevarria, M. I., Grass, G. D., Strom, T. J., Abuodeh, Y. A., Ahmed, K. A., ... & Caudell, J. J. (2016). Having Medicaid insurance negatively impacts outcomes in patients with head and neck malignancies. Cancer, 122(22), 3529–3537.
Roy, C. (2018). Spirituality based on the Roy Adaptation Model for use in practice, teaching, and research. Aquichan, 18(4), 393–394.
Sastow, D. L., White, R. S., Mauer, E., Chen, Y., Gaber-Baylis, L. K., & Turnbull, Z. A. (2019). The disparity of care and outcomes for Medicaid patients undergoing colectomy. Journal of Surgical Research, 235, 190–201.
Ursavaş, F. E., Karayurt, Ö., & İçeri, Ö. (2014). Nursing approach based on Roy Adaptation Model in a patient undergoing breast conserving surgery for breast cancer. The Journal of Breast Health, 10(3), 134.
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