The notice on the clinic’s website, “We do not accept Medicaid,” might as well say, “Poor people aren’t welcome here.” It’s an unfortunate practice that is sadly all too common and affects the lives of millions of Americans. My patient, Gerald, is one of them.

A retired school bus driver, Gerald and his wife make do on a meager income. For health insurance, he relies on Medicaid — insurer of the aged and disabled, pregnant women and children, and the poor. Gerald drives 50 miles into the city to see me for his diabetes. There are clinics closer to his home, of course, but he makes the long journey to see me because the clinics in his area won’t see patients with his insurance. In our health care system, beggars can’t be choosers.

The blanket refusal of many physicians to see patients with Medicaid is unjust. It contributes to a health care system of separate but equal based on social class. The medical profession must fix this glaring breach in our contract with society — all physicians should accept Medicaid.

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An oft-cited study showed that 31 percent of physicians nationwide were not willing to accept new Medicaid patients. The rate was even higher for orthopedic surgeons and dermatologists, two of the highest-paying specialties in medicine. The Affordable Care Act led to some modest improvements, particularly in access to primary care, but the acceptance rate of patients covered by Medicaid remains dismally low.

Yet these patients need us. One in 10 have cancer; 1 in 5 have diabetes; 1 in 3 have mental illness. As Paul Farmer has written, disease has a “preferential option for the poor.”

To explain why some physicians do not accept Medicaid patients, physicians and administrators frequently blame the bureaucratic hassles of Medicaid, particularly its subpar reimbursements. Nationally, Medicaid reimburses providers for their services at 66 percent the rate of Medicare and at even lower than that compared to private insurance. So the business argument goes like this: To maximize revenue and margins, prioritize patients with private insurance and turn away those with Medicaid.

Patients with Medicaid are also often psychosocially complex, requiring more attention and resources than the average patient. Gerald, for example, can’t read, which complicates and frustrates his care. So the job satisfaction argument goes like this: To minimize encounters with difficult patients, prioritize those with private insurance and turn away those with Medicaid.

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What this means for patients with Medicaid is what Seema Verma, administrator for the Centers for Medicare and Medicaid Services, decries as a “card without care.” In truth, that’s a bit misleading. Gerald does have access to care — he sees me. A survey of Medicaid enrollees found that 84 percent were able to get the care they needed. Yet to do that Gerald must drive past dozens of other clinics that will not accept Medicaid and get to a safety-net clinic that will.

Although Medicaid helps bridge the gap between those who have private insurance and those who have no insurance, physicians drive a wedge into the health care system and propagate the structural inequities of separate but equal when they turn away those with Medicaid.

A modern version of the Hippocratic oath, called “Medical Professionalism in the New Millennium: A Physician Charter,” demands that we work to “eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.” That’s only fair. In recognition of the integral role that physicians play in society, the U.S. government invests $15 billion each year in the training of doctors, or $150,000 per year on each and every resident physician. No other profession enjoys this level of public support.

To rebuff Medicaid, the insurer of society’s most underprivileged and vulnerable, is to reject our moral responsibility as physicians and to worsen the very disparities in health care we have been charged with eliminating.

While policymakers continue to work towards improving Medicaid, physicians can and must do their part to live by our collective professional ethics and help those most in need of our services. Doing so would not bankrupt our practices. Each physician can decide what level his or her practice can sustain — the answer is not zero.

Over the last few years, Medicaid and health care have become increasingly politicized. But physicians must remember that behind all the double-speak, pretense, and charades are real people like Gerald who need care. Refusing to see them is nothing less than discrimination by another name.

Sumit Agarwal, M.D., is a fellow in internal medicine at Brigham and Women’s Hospital and is pursuing a master’s degree in public health from the Harvard T.H. Chan School of Public Health.

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  • There is no such thing as a social contract. There is no moral obligation to bend over backwards to do stuff just because the government says so. There especially isn’t an obligation to work for someone else for free just because they’re broke. This is leftist nonsense.

    • “Statist Destroyer”? Are you a statist/rightist who seeks destruction, or somebody who seeks the destruction of the State? Your “logic” is as flawed and confused as your name…. Yes, of course there’s something called a “social contract”. MOST PEOPLE believe it to be the very thing YOU deny the existence of. The Declaration of Independence, the Constitution, and the Bill of Rights together form the American “social contract”. Whether YOU acknowledge reality or not…. There’s no “moral obligation” for your continued existence, and no “moral obligation” preventing me from, say, murdering you because I think you’re a waste of perfectly good food, water, and air. That’s how “logical” and “rational” your rightist nonsense is. Even if I had the money, I don’t want *you* working for *me*, you’re obviously a mental defective, and un-American. We were talking about the low reimbursement rates of Medicare & Medicaid, and how that hurts smaller medical practices, and restricts healthcare access. And yes, it began long before Obamacare. Obamacare just made a bad situation worse. And your continued DELUSIONAL belief in the “left/right paradigm” is the bulk of the problem…. Besides, all Federal money is FUNNY MONEY anyway, so who cares?….

  • I am a single 40 yr old doctor. I came across this article because it has been over a year since I have earned any income as a physician. Increasing red tape with insurance plans have made it take forever for an employer to credential me this year. I have gotten on food stamps and am about to give up hope. Insurance plans don’t want to pay me as a provider because I “don’t have a speciality”. I just want to work as a general practitioner. I did 3.5 yrs of residency. The affordable care act really messed up the medical system. Insurance wants any excuse to not pay me. So I just wasted 20 years of my life, family, dreams only to scrape by hopefully at a non-insurance type accepting place. Medicaid approved me 4 months ago when I was hired by an employer. But I can’t start work, till insurance will pay for my service.
    This also has far reaching effects across the industry. Small town hospitals are having major doctor shortages due to these increasing regulations. My mother is a nurse, she was informed her unit will close in August 2019 because of this credentialing nightmare. I would be homeless right now if my parents were not paying my rent. They are close to 63-65 and will probably work themselves to death.
    I can’t imagine life at age 65. My grandparents are in their 80’s and I’ve missed so much holiday time due to medical career stuff. All of my life efforts are in vain. If I work at a grocery store until I’m retirement age, the IRS will be docking my pay for all I own. It is really hard to want to stay alive.

    Be happy if you got healthcare or insurance at all. With healthcarel.gov for a 40 yr old female earning teacher wages, the cost is 15K a year in Wisconsin. I give up.

    • Thank you for information it is exactly what I thought was going on. Can I be really blunt here. In 1980 someone came to me and told me a really far out story, he did some work for g officials. I have been watching everything this man told me would take place ever since and this problem is not just people sick who aren’t getting cared for, it is doctors also not able to survive under the scrutiny of a third and fourth party. When ObamaCare came in it changed the power of structure which was the whole point folks and you all need to wake up cause many of us are not going to find care if this continues. I have never understood why medical was not set up where doctors were payed directly by patients rather than insurances who actual are the biggest reason none of us are doing so well. So you have to understand the structures that form both insurance and medical tier systems. What this really is about is social classes and we have all been bamboozled for a very long time. Who own insurance companies and makes the regulations for them (look it up and then you will understand why insurances never get addressed into the health problems of unaffordable care!). I really believe that both doctors and patients… those who really care about the total neglect and abuse that is going on for both parties… should join forces and fight for a better system that does exist, it’s just we are being told otherwise by the very people who are cashing in on how they manipulate it. I just learned I was lied to about my surgery, a surgery I thought would take me off the system and give me back my own stability to choose again, to make my own way. I broke down today as I have never healed right from this surgery only to learn the two years I fought to get the right surgery done was a painful waste of suffering, as I am learning I got lied to, played manipulated by the same doctors who tried to block any surgery from happening. They won, I now am chained to a lifetime of health issues because the worst of my circumstances are still unfixed. They waited until after my surgery to let me know and I could of gotten a surgeon to fix it all but they blocked one of them by calling them to fill their head up with bogus information and the other one I didn’t end up using due to long delays after the one who tricked me promised it all was going to get taken care of immediately. I kind of knew I was taking a chance on sticking to someone who had obvious ties to those all involved in stopping things, but I just spent too many ER’s in sheer agony to wait things out any longer. I felt trapped to just take the first one who would take me for what I was asking to have done never thinking he would lie to me all the way up to five minutes before surgery. So this doesn’t happen to anyone else please note: All procedures of what a surgeon is doing must be listed on your surgical operative notes, if it is not, even if he tell you not to worry about it or states I am going to do that… DO NOT BELIEVE THEM!!!! Secondly, be sure you understand what type of surgeon is able to do what type of procedures. I found out my surgeon was not able to do two procedures I thought would be corrected in my surgery because I believed in my surgeon and my surgeon was dishonest and fed me lip service. Because of what these people have done, I will be lucky to ever get off the nightmare system, lucky if anyone will fix the remaining problem as none of them really wanted to help me in the first place. This is a two way street and I sometimes wonder if the people who really care about their patients are people like this gentleman above. Ever think there was a bunch of red tape thrown at you because you didn’t have the popular, creepy doctor syndrome where you cash in on ten year intensional misdiagnosing to ruin your patients life because it creates better cash flow to keep them sick. What if our hospitals aren’t being run by compassionate people anymore? What if a corrupt system was put into play all the way to the training of our doctors and the reason I say this is because I witnessed some very shady business through all this and I am dumb founded there is no one who will look into it, investigate it, and folks I ‘ve got some pretty bad stuff I can’t even discuss here. I hear this doctor’s story (above) and I am wondering if this is a recreated system of selection for both doctors and patients. It is in this that then you will understand what Obamacare was really about and why it got shoved down everyone’s throat. If you think your doctors can’t threaten you, use you as a human lab rat and get away with it scot free to do this to many… you better think again. We live in communities, towns, cities… you need to start fighting… please start supporting one another and bring the ugliness of what is really going on in the country out of the silence it’s been in for way too long. Doctors deserve to be paid for their time and they put in years of devotion, outside of those who ruined my health I am very grateful they exist. It is up to our communities to protect them as much as we expect them to protect us. It is insurance that leaves many destitute and it is insurance that needs some serious re-evaluation along with the leaders in the industry who are operating in a less than professional manner these days. We have no human rights anymore guys NONE! There is noone really defending them(g.800 number for human rights was disconnected in 2014) and this is why our most important issue is being collapsed into a distant memory, except for those who feel they are more important than the rest of us, but in the end we all reside on the same ground because we all have nothing without our health and this is why it is so important we understand patient suffering and the needs for our doctors to be given a reason living for their sacrifices they make to keep us alive and healthy because life is nothing when you wake up unable to move, in chronic pain, sick. Patient should be able to pay doctors directly without the worthless insurance companies that always make excuses why you have to live in chronic pain and illness, and why doctor have to pay excessive costs to protect them from patient law suits or injuries; they are the biggest reason we all suffer and will continue unless we in our communities let them know we have had enough empty care for extraordinary costs. Our doctors are not perfect, mistakes happen and I think like in my situation, I could of forgiven all the mistakes had I not been subjected to total ridicule, torture during unnecessary experimental attempts I did not agree to but rather forced to comply with, reinjury from lack of concern of my already present issues, and totally bullying when I looked out for my best health option. It IS my body and it is ME who should decide WHO and WHAT doctors do to me. When doctors are NOT honest it steals these very important trusts away from a patient and it is why it should be handled with very serious and strict measures. A lot of legal matters would not even arise if doctors understood that leaving them injured and uncared for from their actions to ruin their lives was a terrible decision but a common one of today and that a board to discuss the issue WITH THE PATIENT and not closed door which is a total insult, to resolve a solution that both patient and doctor could agree to would be a much better avenue for all involved. As it stands today a patient needing a very highly trained surgeon due to misdiagnosing and neglect until the patient has compounded health problems is a growing and troublesome future of today, in that they no longer will even associate themselves with common societies health demands and in it, people suffer for life or they die. This is a shared effort by all in both directions and until everyone understands it we will never have a decent health care system and doctors as the one above who had dreamed of a career and wasted years and much income to benefit the rest of us will just stop dreaming and we will be left with no good doctors anymore and if you want what I just had, you will get it in the droves folks and that is a very scary thought coming from one who just had their health ruined in a very torturous style. I would not wish what I have been through on anyone, it has devastated me.

  • Not much worth discussion anymore. The financial design is so bad for public and private plans that practices are dying. They are dying out most where the patients with the concentrations of the worst plans are found – elderly, poor, Veteran, disabled, chronically ill. The practices dying most are smaller practices, the practices in rural areas, the practices in areas lowest in workforce, and the practices doing basic (cognitive, most prevalent, office) services. Each of these results in lower payment and comes with higher costs of delivery per primary care physician (or practitioner).

    So those who have been incensed versus physicians as is more and more common, why not turn your anger on the designers and payers – the ones who have truly made your lives miserable and less healthy in more ways than can be counted.

  • Simply stating that it is every doctors responsibility to take Medicaid oversimplifies the issue. What about the responsibility of Medicaid to pay a livable rate of reimbursement so that doctors can spend the time to provide the proper level of care? What about the responsibility of the patient to show up for their appointment and the costs incurred to the doctors when a patient does not show?

    Many doctors around the nation would be glad to take Medicaid, if Medicaid would first pay a livable rate of reimbursement and reduce the logistical nightmare of signing up with and being reimbursed by Medicaid.
    Most doctors want to provide care but they can not and should not have to do it for so little that they very often lose money. They are the ones who have sacrificed years and spent thousands of dollars in education. Let’s face it the Medicaid system is broken and until that changes doctors will not be wanting to participate in any great numbers anytime soon.

  • As a Billing Manager for a private practice, I can tell you why we stopped taking Medicaid. We stopped taking it because no matter how many patients we see, we was not being paid in a timely manner or we did not get paid AT ALL and if we did it was with much less reimbursement than other insurances. Also, the highest number of no shows are Medicaid patients since we are not allowed to charge them for a no show appointment per our contract. If you sit and just spew out all these unkind words about Dr’s, Maybe you should do some real research and not just try and satisfy the left agenda. We were also told that per our contract, that we MUST see Medicaid patients for 90 days after we terminate the contract. We did as we were told and guess what?? WE WERE NEVER PAID for any of those patients..

  • This is a very narrow view of why clinics are forced to not accept Medicaid. One it doesn’t pay nearly what the cost of the treatment, you lose money treating anyone on Medicaid. More importantly, it forces you to give certain services but not others that are in fact needed and should be paid for. I work in the addiction industry and most people on Medicaid, in my field are spending between 50-100 a day on drugs. They can easily afford private insurance or could get a job that affords them a plan but won’t quit using drugs long enough to get a good job. Medicaid is great for hospital visits although I don’t think they get treated nearly as well as somebody with private insurance and that is where the real issue is. Stick to that.

  • There are so many over-simplifications and misleading arguments in this opinion piece I hardly know where to begin.

    Let me start off by saying I do see Medicaid patients and I do accept new Medicaid patients. But to criticize other doctors who do not is the height of arrogance.

    Most doctors do not refuse to see Medicaid patients because if reimbursement issues. They refuse because the Medicaid system in mist states is overly bureaurocratic and adhering to all of their special requirements is extremely time consuming to the physician and his staff. In addition, Medicaid in many states have actually cut reimbursement in the past 2 decades. In Oklahoma where I practice reimbursement has been cut 3 timed since 2008. What kind of logic insists on engaging in an action that will eventually lead to financial hardship if not outright bankruptcy if you kniw how the reimbursement issue will play out ?

    Essentially, state governments and the burearocrats who administer these programs share most of the responsibility of the dysfunctional nature of the Medicaid system.

    Adiitionally, in regards to the “massive” financial support the state’s give to physician training it needs to be pointed out that most of the support goes to training residency training programs that provide an enormous amount of medical care for the poor and indigent population of this country so the government is actually getting a huge return on their investment unlike so many other government sponsored programs.

    It seems the author is planning for a career in one of government burearocracies that regulate medicine. I suggest he concentrate his efforts on correcting the deficiencies and problems stemming from poor decisions coming from that area before he accuses physicians if being immoral. In fact, his article is a perfect example of the arrogant, authoritarian attitude that pushes physicians away from government funded programs.

  • Nice article to the uninformed. I can’t believe you would write a piece like this inciting more divide between patients and doctors. This paper is nothing more than a liberal leftest view on our healthcare system.

    Please do not blame Doctors for the current health crisis! $150k per year for each resident? Come on, you’re a resident! You know the average salary for a resident is $50k and has NOT gone up in the past 20 years (AAMC) to adjust for inflation. You also know that any hospital that accepts residents are operating at a loss right? The government pays the hospital $150k per resident, residents get paid $50k, the other $100k goes to overhead and malpractice insurance.

    After residency MDs are forced to pay $500k in debt. How are we suppose to do that in our 30-40s when Medicaid only pays $15 for a level 3 code (99213) for a 10 minute slot? After overhead you probably see like $3 per 10 mins. That’s $18 an hour assuming you see a patient every 10 mins!

    So… you wrote a fantastic article worthy of publication but have no solution. Typical leftist mindset. You just say… the answer is not zero. Well, no matter the answer, whether that is 5% or 90%, the practice will still turn away Medicaid to some degree. You offer no solution and just complain.

    If you want solution talk to your state senator. This needs to be changed by the federal government. Perhaps forgive MD loans. Perhaps pays more or be as competitive at reimbursements as private insurance. We live in a capitalistic society. I know the government does not have enough money to be competitive as private insurance so somethings got to go so that we spend more on healthcare. Shall we cut spending on military? Education? Infrastructure? Perhaps we should limit spending to legal residents? Who knows. Regardless, the middle and upper class need medical support too.

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