T

he 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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  • adults who ate cholesterol heavy foods, smoked, drank and sat on their rump for the past 40 years and now they want a bandaid …hmmm, nope doesn’t apply to me. I do none of the above, I got sick in my prime do not drink, smoke, was a very healthy eater (fruits, veggies, etc.), was an active athlete in twenties and very active even just before becomimg sick. The big elephant in the room is coverup environmental contamination as I did have overwelming lead and uranium! Some people claim to know it all but in reality they’ re brain dead to the realities of life. Sometime surgery saves the quality of life which is my only option because I didn’t get proper care before my damages fueled out of control,doctor refused this care. So until you are willing to look at facts appropriately you should be careful not to assume. No one deserves to get sick and to state such horrible comments not understanding human compassion for those struggling in such a inhumane way is why medical is failing us.

    • Everyone is going to die. Face that fact. Sorry you feel sick and had uranium poisoning, but I’m not responsible for that and you assume I should feel responsible or obligated to you personally. Meanwhile I’m not blaming you for my own health issues which also entitle me to imminent death, as do everyone’s eventually. So the news is, you’re not alone. So, there is the line, take a number. We’ll call you when it’s your turn.

  • It is the power structure no one wants to admit exists. There are doctors who disappear, lives ruined. Not many will talk about it, but none of them want to draw attention. AZ doctor is correct. Here is the problem, the top dogs in charge, most do not understand that financial guys own it all. Financial guys are not concerned about human life, they are concerned about money. If you look into every aspect of our economy and human life a financial investor is at the root of the problem.

    We have loans for everything but to save the only way we have life, our own healthy bodies… when this fails life is no longer worth being here yet we do not protect it, we don’t allow loans for much needed surgeries, but hey you want your nose, butt or breasts to look pretty you can get a loan anytime. This is doctors not wanting to deal with lower class people and this is a very big problem because we get sick too!!!!!

  • I’m a doc in AZ writing anonymously for various reasons. Personally, I accept Medicaid… for now. It should be noted that NOBODY is refusing service to medicaid patients. Any medicaid patient can walk in to just about any doctor’s office and receive service, they just have to pay for those services.

    Medicaid makes it illegal for us to charge an additional fee to make up the difference– to say “your ‘insurance’ only pays us half what we take for an office visit, pay the other half and we will be happy to see you.” Allowing this additional payment, the way EBT allows you to pay cash for additional groceries, would expand service to most offices.

    Moreover, MediCARE makes it illegal to charge cash pay patients — the true victims in this system — a reasonable rate. Reasonable, given that we do not have to write our notes in some absurd byzantine style to appease the billing Gods, get prior authorizations for medications/imaging, and obviously employ billers. We have to charge them what we charge Medicare, unless we jump through some dubious legal hoops which my office currently cannot do.

    In addition, Medicaid can do some pretty crazy things to doctors at any time. In AZ in particular, Medicaid decided to stop payment for radiology for a period of about 6 months a few years ago. No other insurer could get away with this.

    Finally, with all the new and ever-growing regulatory burden (MACRA, et al), overheads are getting insane, which is one of the many reasons doctors are becoming employed. My last practice actually had an overhead of over 60%. With medicaid paying 66% of Medicare, we literally could not support ourselves if we’d taken medicaid.

    It’s simple supply and demand with price ceilings: massive shortages are just part of the deal. Personally, I’d rather have Medicaid in the US than Canadian insurance in Canada where the same policies cause the same problems. You can complain about doctors being “greedy” but the fact is there are a ton of costs to becoming and maintaining licensure not the least of which is nearly a decade of training and massive debt. In addition, these are highly skilled workers who could literally do any job out there from engineering to law to whatever –most of which would net more by age 65 (or 70, when we typically retire). Ignoring basic economics does not lead to good policy.

    • Well stated, true, and entirely reasonable. What does it say when a person tells the truth, but must hide their identity in order to do so? It says that we are more comfortable with lies that make us feel good than the truth which will actually make things better.

    • The hypocritic oath

      Everyone talking about the costs of healthcare, and the social contract to providing it. No one talking about the elephant in the room of:

      1. All of us have a 100% chance of dying of health related injury or failure.

      2. Medicine is only a ward off death not a cure for it.

      3. Pharmaceutical companies cause a majority of referrals otherwise known as prescriptions. Many of these are for false “health issues,” especially “pain” related.

      4. Other methods could be employed to ward off death, including exercise, food based, and a trip to the beach.

      5. Many people avoid lifestyle changes and believe a doctor with a med or a scalple can cure death instead and fail to be remotely responsible for their OWN healthcare.

      6. Doctors have become daycare providers to keep pharmaceuticals in business.

      7. If “medicine” was preserved to the truly ill with a reasonable survival chance who have expended other options listed in #4, the system would not be bogged down with millions of whiny children who wish a parent can fix their self inflicted wound.

      8. The majority of people seeking said cures are adults, especially older adults who ate cholesterol heavy foods, smoked, drank and sat on their rump for the past 40 years and now they want a bandaid not children who broke their arm playing baseball.

      9. I fail to comprehend where a “social contract” implies we cure death or support adults in that overarching parental capacity.

      So, 10. They should give raises to morticians. They will always have a job where the doctor failed, 100% of the time. Seeking a career change.

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