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.


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.

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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  • Personally, I believe if a vision care professional, optometrist or ophthalmologist, doesn’t want to take Medicaid or Medicare clients that should be forced or shamed into doing so (and I have both).

    They should be under no obligation to go against their conscience or be forced to accept a patient that they have negative feelings towards. Nor should they be shamed, treated as unethical or doing a mis-service to society.

    Why? Because they will only treat the Client badly giving all involved an unpleasant experience. The eye care professional will begin to hate coming to work and his “poor” clients will eventually hate coming to his office and not return.

    If potential clients search for Eye doctors who freely accept Medicare/Medicaid, they can find one that freely chooses to work the “poor” clients, which makes a better experience for all involved. Just saying.

    PS: I respect all the opinions presented and think all are valid, but I do not want to work with an optometrist or ophthalmologist that is under pressure to take me on as a client.

    • Correction: I believe that the doctor Should Not be forced to work with clients that don’t want even if it’s Medicare/Medicaid.

  • The author obviously has never owned a medical clinic. Try paying the bills on Medicaid reimbursement. I wonder if the author is willing to work for pennies on the dollar. Where did society every get the idea that Doctors would work for free or take care of everything that walks through the doors. The author has no idea how much free care is given away in private practice. Reimbursement continues to be eroded by increasing expenses , insurance , employee pay electronic medal records etc. I would like to know what the author thinks the doctor should make, how many patients should be seen, how many hours should be worked in a day? The author sounds pompous and arrogant and has no insight in what it takes to keep the doors open and the lights on in a private medical practice.

    • I believe that no optometrist or ophthalmologist should ever be forced to take on clients. It should always be up to the Eye care professional who s/he accepts (and I have Medicare/Medicaid).

      I respect your honesty. Thanks for sharing.

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