In the Middle: Experiencing Medicaid as a Texas Healthcare Provider

In this study I investigate how healthcare workers, involved in the Texas Medicaid program as healthcare providers, cope with four workplace constraints. Healthcare workers are constrained by: 1) the policies and practices of the Medicaid program, 2) their own individual and professional values towards indigent care, 3) the rules and policies of their own organization and business type, and 4) the Medicaid patients with whom they interact. I use structuration theory and sensemaking to better understand how these professionals cope with these challenging constraints.Using in depth interviews of 36 private and public healthcare professionals from four unique fields of service (i.e., dental, optical, pediatric, mental health) I applied a modified grounded theory approach to understand: 1) how professionals make sense of the four Medicaid constraints described above, 2) how sensemaking strategies help or hinder professional performance, and 3) how sensemaking communication shapes professional identity and work perceptions.

Healthcare workers viewed Medicaid support staff as "flippant", "rude", incompetent, unhelpful, and unreliable. However, providers believed Medicaid was equal to or better than other insurance companies for speed and reliability of payment. While they unanimously identified with providing indigent healthcare, they also clashed with the Medicaid program as a vehicle for those services. Private practices framed Medicaid as a liability while public non-profit organizations relied on Medicaid as a primary source of revenue. Providers agreed that Medicaid patients had poor follow-through, a high no-show rate, were undisciplined, and crowded provider offices with unscheduled family members. Healthcare workers enacted self-reliance as individuals, by networking with other Medicaid providers, and by relying on in-house experts. They also engaged in discursive strategies by minimizing, blaming, and detaching. They viewed themselves as disciplinarians, problem-solvers, advocates, and benefactors.

Theoretically, this study develops the concept of identity regions and reframes workplace constraints as necessary identity structures. It also suggests that how Medicaid patients behave may have a more damaging impact on whether providers are willing to work with Medicaid than low reimbursement rates.