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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  • You make some good points, HOWEVER, in my neck of the woods, the massive hospital owned outpatient practices and Medical schools REFUSE to see medicaid patients in their outpatient clinics. Should I as a private practice physician shoulder the burden? My small business would fold quickly because I would soon become “the doctor that accepts medicaid”. After I fail, I’ll end up working for a large hospital group or university and then not accept Medicaid…

    I feel that the large hospital system and medical schools accept a lot of public funding and should accept medicaid patients. That would also indirectly help them as these patients wouldn’t clog up the ERs b/c of lack of adequate outpatient care.

  • I worked in hospitals &clinics until I became too ill to get out of bed & go to work fortunately for me I had an amazing doctor who took her own time to research my symptoms until she figured out what was wrong with me. During the time I was working I watched a doctor say that an elderly woman dying from lung cancer was a “smoked out choked out cigarette smoking old hag” who didn’t deserve my sympathy I watched as a surgeon had a problem with muscle tissue that “got in his way ” so he turned it into hamburger, a nasty man who told me that since he was a doctor it was okay to cheat on his wife with me because “he worked hard to get through medical school” maybe medical school would have been easier if he’d been more intelligent! Another who took Medicaid patients and then verbally abused them. And more than one who started their practice seeing Medicare/Medicaid patients and then when they had built up their practice they dumped all of the patients who were not private insurance! So it’s a misrepresentation that taking Medicaid or Medicare patients isn’t profitable otherwise how did you build up your practice on these people’s backs? There are many great, caring doctors who take Medicare/Medicaid, which most certainly does pay after Medicare pays! But there are also some people that think their name is God after going through medical school and your egos, obnoxious attitude and sense of entitlement doesn’t make you special it just makes you an idiot! There is a surgeon in Texas who thought he was god too he destroyed his patients lives, maimed and killed them until a brave decent doctor stopped him and now he’ll be spending his special life in prison! So really even though it might be inconvenient or even difficult to get to a doctor who doesn’t only care about how much money s/he’s making but also about their fellow humans and being able to make a difference in their patients lives, in the long run it might just save your lives!

  • It gets worse. Vets have become too many, mainly because of Caribbean school expansions. This results in employed vets with worsening situations, more dependent upon more testing.

    Nurse practitioner graduating classes have been increasing at 14 times the annual population growth rate since the 1990s with 6 to 10 times expansion rates for US MD, DO, and PA. This will not improve primary care or care where needed because the financial design already supports too few team members to deliver the care across generalist and general specialty areas. All this massive expansion will do is result in more graduates finding their way to areas better paid – subspecialty, hospital, procedural, technical.

    So if you think that there are any solutions to primary care, mental health, or basic services other than a financial design fix – think again.

  • My physician gets $35 from Medicaid for a visit. That’s a joke. I’ve made a 1/2 mill a year before as a hs dropout. I think drs should earn as much as a vet lol

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