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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  • This is an easy article for a resident to write – someone who hasn’t yet faced the struggles of managing a practice. The key word not emphasized is that many physicians are not accepting *new* Medicaid patients. It’s financially inept to build a practice wherein an overwhelming majority of your patients have the same time of insurance (i.e. a majority that would devestate your practice if the insurers decided to remove the physician from their network). That is true for any insurance provider. I’m not going to try to suggest there isn’t a monetary component driving a physician to potentially stop taking Medicaid but at the end of the day, working as a physician is also a person’s livelihood. Building a practice with small (or even negative) margins is not sustainable. So who is committing the a bigger social disservice, a physician that caps the number of Medicaid patients they see in a given month or the physician that is so fiscially irresponsible that they lose their practice/job and can’t see any patients?

  • Again it’s at the top. We keep ignoring this. In history misery is center around top few let’s be honest here. Doctors are trapped and patients are trapped. Doctor can’t fill patient obligations because heads they answer to hokd this power. We as communities need to re-evaluate why we continue to put people in charge that don’t value human life. I have greedy doctors who injured me knowingly, but I also had very sympathetic physician who I could tell felt guilty with their gands tied from a system gone wrong. Our government uses this to their advantage. In my state we had a major big corporation catastrophy, this effected many lives and I’m pretty positive the state is keeping track of thoseharmed I saw my back file by accident when oddities began showing up with my records. Point blank, top of the chain in our healthcare system is CMS and a very highly notable hospital I dare put here because these individuals are aboutas ruthless as they come, they have no problems using their Medicare patients as human lab rats, they have no regard for the harm they bring to thousands of patients they silence from tge lives they destroy. How did our local representitive react. Well they put in charge a bull dog attorney who headed the bar association so injured patients will never find attorneys to protect them,they put in place a head of the state health dept. who came from the same county that injured people who probably knew the extent of the damages so hey could hide it some more. Fact is, the dishonestyfactor goes up the more you reach the power structures who make these God forsaken rules for the rest of us. We can talk about this all day, unfair to patients, unfair to doctors… doesn’t matter, cause those creating the cess pool we have to live in are still untouch and continue to leave us vulnerable.

    • Im a medicaid patient. You can easily say I’m a nobody in our society-a single mom who escaped a severly violent abusive relationship 8 years ago. This is my little take on this dilemma in our country. I worked full time and was continuing my education full-time with 2 semesters away from my bachelor’s degree until I could not continue on with symptoms. My fulltime job did not pay well but it was flexible around my school schedule. I couldn’t afford health insurance. I refused to pursue child support because the state never protected me from severe abuse even when I had a protective order again my 11 yr old son’s father.
      Years have gone by with me suffering symptoms of illness with little help. The doctors who accept Medicaid mostly treat me like I am dirt and dismiss most of what I tell them. I am 47 years old and have been suffering with kidney disease for a long time. One kidney is now atrophic and the other has glomeronephritis. My GFR is not yet below 60 or stage 3 and although the renal artery stenosis was identified, I’m told it’s not severe enough for a stent.
      I had a hysterectomy for something that was misdiagnosed last year. In the year I suffered with pain prior to surgery I was not prescribed anything sufficient for pain due the opioid crisis. Now I suffer excruciating pain in my hips and lower back. Xrays show bone loss, sclerosis, arthritis in my lower lumbar and hips. Nothing strong prescribed for pain. My new pcp tell me arthritis does not cause pain.
      A year now after hysterectomy and I go on the hospital portal and take a look at the pathology report again. The doctor who did the surgery was a new gynecologist and she accepted my medicaid. After surgery she dismissed me as a patient because I complained of symptoms of infection. Although after her refusal to do a swab test, a nearby hospital diagnosed the infection. They released me and gave me antibiotics because they said they had no open beds. My pcp told me to give it time, that the surgery was still recent. Five months later, my doctor diagnosed a staph infection and I was given a shot in his office for it. So I came across the pathology report again and this time it’s updated. This new doctor told me she wanted to do a vaginal hysterectomy because it was easier. She left my ovaries intact and removed my cervix and uterus. I’m upset now after reading the updated report. It shows transitional cancer cells in my uterus, and transitional cancer cysts on my fallopian tubes. I am just seeing this one year after surgery.
      I have been traveling 3 hours to a university clinic to get medical care from mostly doctors dedicating time once a week or from internists. They diagnosed me with gluten intolerance I’ve suffered for years, refer me to doctors willing to see me but not willing to do surgery for me.
      I was able to recently find a new pcp where I now live but on our 2nd visit he told me he only treated a few things, was unfamiliar with any of my problems and that I was welcome to get a second opinion.
      However I did ask he run lab for me for rheumatoid arthritis. Two weeks now and his office tells me last Friday when I called that he has to review my results first.
      In the meantime I am struggling financially, meaning I have no income and living by the grace of God for one year now. My firmer employer forced me to take medical leave, which extended longer with my ongoing problems. I applied for disability in January and told with the ckd it would be 60 day decision. It ended up taking 9 months to be denied and now I have an attorney and am still wait for a hearing date.
      I have huge concerns for our country. How do we call ourselves a Christian nation? Only God could say if we truly ever were one. To live in a day and age where healthcare is only for the wealthy is an abomination. Maybe that’s fine for many but looking at the future I imagine we will have many more disabled unable to work because doctors do not care. Only the weathly have value. This article is accurate and true. Thanks for being vrave enough to publish it.

  • the article mentions that a large part of physician education (graduate medical education programs) are paid for by the government. I believe it is approximately 80% of the cost of resident training. It is more accurate however to say that most of the 80% comes from the trust fund which is the money all of us taxpayers provide to the government. Much of the remaining money is the interest the government makes on the money it holds in trust for the citizens of the US. We also pay fees for services. So when a third of physicians choose not to accept the reimbursement from Medicaid for providing medical care to Medicaid, perhaps a third of us should withhold that amount from the cost of their training. Patients should remind the doctors their training was paid for by the people they now refuse to see. Physicians who turn down Medicaid patients after accepting the cost of their training from those people need to rethink their point of view. What do you think?

    • Barry:
      You did the math, so let’s do THE MATH. In my 6 years of training, I averaged $26,000 per year in pay. I also averaged 92 hours per week in direct patient care, which was worth over $125/hour to the hospital. So, cost to the hospital for my services=$5.52 per hour and value to the hospital was $125/hour. AND, the hospital was getting money from the government, which WAS NOT accruing to me.
      Now, help me figure out where the taxpayer helped ME. I think you are confusing the taxpayer helping the hospital with the taxpayer helping the doctor.

    • Jay is correct in his statement. Hospital Administrators make far more off the taxpayer than do Resident Physicians. Hospital Administrators also commit all kinds of crimes against patients when they: understaff their hospitals, which exacerbate the burgeoning rate of Hospital-Acquired Infections and the overwhelming number of unreported Medical Errors, most of which are preventable. Moreover, if one peruses various publications, including many medical journals, the number of Hospital Administrators that are being investigated and charged in criminal cases of fraud and criminal misrepresentation of charges, the priority of income over patient care becomes electrifyingly clear. Furthermore, in almost every case, the people who are on Medicaid roles are either paying no taxes at all, or paying very minimal taxes. It is not they who have paid for the majority of the education for physicians, but middle and upper class people who have paid for that education.

  • I was a patient at my hometown rural health clinic (Montana). I am a disabled oil worker and I receive Social security disability insurance NOT SSI. I also receive Medicare A, B, and I have part D prescription drug assistance. The largest part of copay is met by the state QMB program. My out of pocket copays per visit amounted to approx $20 each outpatient visit.
    I was never charged any money at my outpatient visits. I was billed by mail and the bills were sent to some address in a town I have never lived in. I eventually discovered this plain error and that I owed approx $110 in outstanding copays. I went to their business office to settle my bill and to sort out the issue of my bill being sent to an address other than mine. I paid my copay and advised the billing clerk of my correct address.
    After paying my outstanding copays and showing evidence of my 20+ year same mailing address I was advised I was terminated as a patient at their facility. I was advised I could by law still use their ER. (I already know that) Approx a year later I was issued a check in the exact amount I gave them for the outstanding copays. I know this is about medicaid not medicare but
    Im wondering what’s going on here.

    • @Bill S.: Obviously, I can’t say for sure about your case. But I’d say you saw a peek behind the curtains of Medicaid & Medicare FRAUD….. The bills get “submitted”, and “paid” by Uncle Sam. Or they get bundled into other bills, and converted to a “debt asset”. Any debt is ALSO an “asset” that can then be bought and sold. “CMS”, the Federal Center for Medicare services, estimates there is $150Billion per year in Medicare FRAUD, alone. Yes, that’s “$Billion.” with a “B”. Obamacare created 70,000 “diagnostic codes”. Etc.,etc., The TRUTH is something THEY do NOT want you to know….

  • 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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