D

ear Secretary Price,

Boston Medical Center, where we work, is New England’s largest safety net hospital. Nearly 60 percent of our patients come from medically underserved populations. Many of them rely on Medicaid and the Children’s Health Insurance Program (CHIP), which in Massachusetts are combined into one program called MassHealth.

Gary, a patient of ours with diabetes, is an example of how well such programs can work. Gary became unemployed and homeless last year. He stopped taking his diabetes medications because he couldn’t afford them. His inability to keep his blood sugar under control eventually triggered a heart attack, for which he was hospitalized. Because we were able to enroll Gary in MassHealth after his heart attack, he was able to see one of us for primary care to help him manage his diabetes and blood pressure. He is no longer homeless, and credits MassHealth as “the reason I was able to take control of my life.”

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Many of us who choose to do our residency training at Boston Medical Center do so because of its stated mission to provide “exceptional care, without exception” — a motto we take extremely seriously, especially when we find ourselves taking care of Boston’s sickest, poorest, and most vulnerable citizens.

We fear, Secretary Price, that the policies the Trump administration is proposing would cut funding to programs like MassHealth. That would endanger patients like Gary and our ability to provide them with the exceptional care that every American deserves.

You grew up in Dearborn, Mich., in a county in which today 16 percent of residents do not have health insurance, 10 percent are unemployed, and 35 percent of children live in poverty. You stayed in Michigan and went to medical school at the University of Michigan, where your fellow alumni have raised concern over the direction the Trump administration is taking in health care policy.

Like us, when you graduated from medical school and became a physician, you took an oath to help the sick and to do no harm.

Like us, you did your residency at a hospital (Grady Hospital in Atlanta) that prides itself on being able to care for everyone, including the city’s most vulnerable. You eventually joined the faculty at Emory University in Atlanta, and directed Grady’s orthopedic clinic, serving Atlanta’s sick, poor, and vulnerable citizens.

Like us, you have seen firsthand what Medicaid programs do for Americans in need. Surely you have also seen the harms of lapses in health care coverage.

Yet you have joined an administration that is determined to dismantle legislation that has improved access and care for millions of vulnerable Americans — the same vulnerable Americans you dedicated years of your professional life to helping.

You and your colleagues in the new administration have proposed repealing the Affordable Care Act’s Medicaid expansion despite its clear gains in coverage and despite the American Medical Association supporting its expansion. Instead, you support measures like Medicaid block grants despite nonpartisan analysis showing they would severely jeopardize vulnerable patients’ access to care.

We ask, Secretary Price, that you stand with your fellow physicians who know that these changes are wrong for our patients.

We ask that you stand with residents like us who will spend our lives practicing in the systems that are under construction today. Being a physician is not just prescribing medications and doing surgery — we must advocate for policies that help our patients, not harm them.

While it is clear our current system is broken, we ask that any new solutions not jeopardize coverage that is already in place for millions of vulnerable Americans.

Finally, Secretary Price, we ask you to remember the oath we took as physicians:

“… Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption. … So long as I maintain this oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of men for all time. However, should I transgress this oath and violate it, may the opposite be my fate.”

Yuvaram Reddy, MD, and Christopher Worsham, MD, are resident physicians in internal medicine at Boston Medical Center and members of the Committee of Interns and Residents, the largest union representing interns, residents, and fellows in the United States.

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  • I have a gut feeling politics is sneaking into the response concerning the viability of block grants vs. improving traditional Medicaid. I’m a retired registered nurse (open heart recovery and cardiac critical care) from the South (on Medicare anx dread them getting their hands on it), and things are a tad different down here. Even though the medical community, especially the rural hospitals begged our state to accept the Medicaid expansion, it was useless. Of course since then in roughly a 120 mile radius (including our community) at least 6 or 7 of these small rural hospitals have closed, just as they said would happen without the expansion. Even when the first ones started going and the others begged harder, no go. Strictly for poltics so they could blame Obama. Our insurance commissioner even tried to make it so the people who answered the phones and signed folks up for the ACA had to be licensed insurance agents. When asked why he’d do something so ridiculous he just laughed in the reporter’s face. They don’t care if people die in the streets, it’s about power.
    Anyway, block grants are going to provide less money per person. As the population grows that pie is going o be sliced even thinner because it’s not indexed to population growth and the increase in healthcare costs, it’s indexed to the CPI + 1%. Healthcare costs have been far outstripping the CPI (Consumer Price Index). As a matter of fact, my Social Security check went DOWN this year because the cost of living increase is tied to the CPI, but the amount they take out for all the parts of Medicare (reflecting the increased cost in healthcare) was more than the cost of living increase via CPI.
    A great blog or report. I too came across many patients on our intake evals who ended up there because they ran out of their meds and couldn’t afford more. My heart hurt for those people. Keep the same attitudes y’all have now as residents and y’all will have long careers as fantastic docs.

  • Dear Drs. Reddy and Worsham:

    Thank you for writing an opinion regarding Secretary Price’s position on Medicaid. You both have allowed me to expand on a personal experience with Medicaid – more specifically, the State Children’s Health Insurance Program (SCHIP) arm of Medicaid.

    I grew up in a below-the-poverty-line household, in which my sister and I were covered under SCHIP. Due to our poverty, my parents could not afford the mortgage payments, food, clothes, and our utilities. We spent many winters with periods of no heat; because of this, I contracted pneumonia several times as a child. When I went to search for a doctor to treat my pneumonia, however, I came to find out that several doctors in my area did not accept Medicaid; or, when the doctors did accept SCHIP, the coverage was not vast enough, and the cost-sharing components (co-pay and deductibles) made it unaffordable for my parents to take me. In fact, my mother told me several times that ‘we couldn’t afford the doctor because our insurance didn’t give us enough.’
    The several times I had pneumonia, I ended up in the same state: I could barely breath, sleep, function, or eat. I ended up going to the ER each time, because due to the fact that Emergency Medical Treatment and Active Labor Act requires hospitals to screen and treat patients with or without coverage. Obviously, as you both know, the ER costs are higher than those of the outpatient costs; however, since my parents couldn’t afford them, these costs were just transferred to other patients of the hospital (mostly private insurance carriers).

    It was not until I received a private donation from a local church that I received sufficient treatment. While this may not happen for everyone, it helps convey my message: Medicaid, and its components, do not adequately cover the treatment needs of the poor.

    While I understand that I only provided one data-point as my evidence, your opinion did, too, by only mentioning one patient’s (first) name. While I understand that patient’s personal health information and right to privacy are important, and that you would need to obtain the patient’s consent to publish his full name, I would posit that my data-point is a bit more trustworthy, because I am writing my personal experience: I am disclosing my medical past and you have my first and last name; but, I, and the other readers of your opinion, do not know whether your data-point is true, because you only provided a first name. Moreover, my story is one of a personal experience with Medicaid; yours is just a story of treating those with Medicaid. Forgive me if I am mistaken, but unless you have personally been on Medicaid, I don’t think it is fair for you to assess it. Providing care and receiving it, as you know, are very different.
    My experience with Medicaid is not the only reason I disagree with it; however, my experiences with Medicaid, private charity, and private insurance, all lead me to the same answer: Medicaid does not, as you have said in opinion, provide adequate care. In the name of those who endured experiences similar to my own with Medicaid, reforming Medicaid is what needs to be done.

    • Thank you for your thoughtful comment.

      I wholeheartedly agree with you that as someone who does not receive Medicaid benefits, I certainly lack the insight that you have into what it is like to be a Medicaid beneficiary. My thoughts above are based on my experience as a provider at an institution that cares for many MassHealth beneficiaries. While we do only tell the story of one patient (and yes, we have changed his name for privacy), we felt that this patient’s story shared common threads with many others.

      I also agree with you that Medicaid (in its various state-run forms around the country) is far from perfect, and we did not mean to imply otherwise in this article. Even with Medicaid payments, many clinics and hospitals around the country still need to find other sources of funding to be able to provide the best care for their patients.

      We argue that cutting funding to Medicaid by switching to block grants, as Secretary Price has proposed, is not the first step toward improvement. Rather, let’s find ways to make Medicaid better without putting its current beneficiaries in jeopardy of losing the care they do have.

    • This is what you typed “the several times I had pneumonia, I ended up in the same state: I could barely breath, sleep, function, or eat.” I think you meant to say breathe. Other than that I enjoyed learning your story.

    • Dr. Worsham,

      I appreciate the reply and the clarification around your opinion post.

      I do certainly agree that ensuring that current Medicaid beneficiaries are not in jeopardy in losing coverage is imperative. As you mentioned, the current Medicaid system is not working – which is precisely what I meant in my previous post.

      From personal experience and reading economic analyses, I would argue that the current Medicaid structure has actually provided less quality care than it has more. Health care providers, state regulators, and even patients are bound by numerous caveats which prohibit the offering and receiving of quality care. Not only that, but, in our current structure, as I’m sure you know, MassHealth is approximately 37% of our State’s fiscal budget – this is the largest budget item.

      If we moved away from the current Medicaid system, and went to a block grant system, I have seen studies (which I’m happy to share) that demonstrate that there might be fewer barriers causing a dearth of quality for low-income beneficiaries.

      I will also add that my personal experience of receiving private donations for my health care has influenced my view on solutions for low-income beneficiaries. Prior to Medicaid, health care providers and facilities provided much more care for free; now, however, that happens less frequently (there are some non-profit hospitals which still provide this care, obviously) because the burden has been shifted to the federal and state governments. Before, private charity from churches, associations, and other groups helped fund these kinds of expenses. I was personally a beneficiary of this in 2001, when I was nine-years-old. An interesting essay that shows that private charity has gone down since government has took some of it over is “The Tendrils of Community” by Charles Murray. It shows a graphical representation of what I have just described.

    • Ivan Del Rio:

      Thank you for pointing out my typo.

      I am a passionate writer and, as most humans do, make mistakes when I think faster than I can type. I noticed my typo after I submitted, but, as there is not an ‘edit’ option, I was unable to fix it.

      Nevertheless, I appreciate the comment and the fact that you enjoyed my post.

    • Jonathan,

      I am sorry that you have had difficulties engaging in care with the health care system in the past. As an individual health care provider, it is upsetting that we are unable to help people when they are most vulnerable.

      I hear your frustrations with Medicaid and I agree that it needs work. However, I find it difficult to argue that a fixed block grant would result in improved access and health outcomes. I would be happy to read any of the information you have to share about it. In the meantime, I believe I should continue to advocate for increased or maintained federal reimbursements to MassHealth in order to allow for it to be an affordable and accessible form of health insurance.

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