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.

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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  • Okay well if things couldn’t get worse from losing my home, they did. I want people to hear what happens to us when we don’t resolve things because most of us don’t have time to waste here. I had been refused DNA testing and I knew if I could just get it I may have an answer and I got it very unexpectedly as I thought they would call and want to talk if anything came back wrong. So they tell me everything is good, two months had gone by and I finally go get the result and they act very oddly about it. I go into office and I am handed a letter and told well dr is busy so I know he will want to talk to you about a few things, call never came and I opened the letter and six years ago I had looked up some of my issues and found this article and I took it into my three year care PCP and he laughed at me, but you know in my gut I knew there was a connection but never did I think I’d find out I would have the defective chromosome and a different variant that has no documentation. I mean how lucky can I be. So then I’m thinking, okay, now they will treat me…. wrong…. I couldn’t get in to see anyone to explain the information in the letter. I would schedule with specialist and there was always a problem. So I call the doctors I have now, all have stopped returning my calls. Last week I go to try and address the neglect I was given at my last ER and I show them that I really needed treatments of very specific things if I wanted to at least slow down this process but they told me they didn’t understand genetics, which, that just can’t be; they employ hundreds of doctors and specialists. So after a very heated discussion to the point of meltdown because I was not just having a bad social day, I was having a really bad physical day. I couldn’t find my car, the security wouldn’t help me but that was because they were waiting for me to crash and unfortunately I was out of energy I had to fall to the ground so I’m laying in a dirty parking garage with a hospital right next door and someone stops and calls but to my surprise no one will get me to my car so I can get home to address things with medications, however my medication are even failing me now, it’s hit or miss. And all of a sudden there is that word again “Baker Act” this is the h.ll doctors send the chronically ill when they stop caring for patients. I panicked and I tried to get off the gurney all I know is a cop slapped cuffs on me fast. But then they raised my arms high to cause severe pain into my spine and back so I was losing control of my body and laughing at me as I’m screaming in pain they both let go and I fell forward striking my face into the hard metal of their footrail on their car. At first I thought my teeth were damaged but got lucky, did get a very nasty bruise. This is no way to treat the sick people, do you hear me, this is a very good way to strike fear into us and it was like pour fuel on a fire. So then I was left in a very hot car for quite some time, pain was escalating and as if it wasn’t enough, they drug me again on the ground by my arms by this time I had so much pain radiating down my legs my mind was a total blank. I had to listen to several cops and doctors enter my room and discuss how they would tell the judge a concocted story that would get me Baker Acted. I wasn’t suicidal so they had to concoct a story to show harm so they set up this deal where I supposedly hit a cop which of course never happened but they had to explain away the bruise and cut on my face. In total fear, I had to call attention to what was going on so I screamed as loud as I could, I kept repeating you are liars, you are corrupt. Between everything that happened, the pain, I’m sure I probably did look crazy, but you have to understand I’ve spent ten years watching my health deplete. I have been manipulated so many times by my doctors I can’t even remember all of it. The let downs after promise after promise and no one ever kept their word, no one even tried to follow what I always got told in the beginning and then if I questioned why, I was treated like a criminal for asking. So now I find out that my surgery last year where I though certain things had been done, well I’m finding out two things definitely are still there even though my report says he fixed it. On top of that I learn I have issues with my CBC and no one told me and it’s one thing to have two years of UTI’s but I felt this move from my bladder, to my upper ribs, to my lungs, up my neck and I am hurting pretty bad now. So yeah now the infection is showing up in my blood, and no PCP (she’s with same hospital) she cancelled my followup ER claiming she sent a letter last year, but I have a recent message from her office stating it was just sent and I doubt anything has been sent. Hospital could care less about what happened on my stay like refusing a patient to empty their bladder, refusing hydration even water and then coming in periodically with an IV bag and stating “oh my you don’t have an IV yet, what happened then walking back out never returning.” I’m sure it gets worse than that for some and I have to ask what has happen to you all, why are you so bitter towards a sick helpless patient. I mean this is just narsistic behavior and you have the edacity to push counseling on me. A counseler can’t possibly fix a defect in my DNA that is causing my body to attack itself and sad part is in all of this, there are things they can do for me. I just can’t get anyone to do it. The hope I had when I finally thought I was getting a surgery to fix everything and what I am left with now. At some point in time someone has to make this better or we are all going to suffer tremendously here. In my case I don’t know how long my body will hold out, I have my subpar days and my nightmare ones and more nighmares now then subpar. What I’ve learned in all this is you are totally alone folks, and if you aren’t persuasive to doctors you will lose the war and I live in h.ll every day now and not a thing I can do about it because not only was I not fixed but I got stuck with an infection that is getting worse and due to my diagnoses things could get real bad for me fast. It’s one of those things you kept asking God to just let you go because the disappointments in being here and the pain don’t allow you to function in life no matter how badly you wish it could change. To my doctors who deserted me every time I had infections that needed antibiotics I hope you never live to know what I have lived in for over ten years now because you refused to do your jobs. I’ve left multiple comments here so there isn’t much else to say, but you finally have broken me to the ground with the games, the constant gossip and laughter I’ve listen to you for a very long time make light as my life crumbled to the ground and there is no human being that deserves this for without our health we are nothing and we trust you to understand that, yet I watch how you rather gossip out in the halls of hospitals laughing at the screams of sheer pain all around you and you never once enter their rooms to help. This is sad what we have become. In the end it’s not about health insurance, it’s about being responsible human beings that want the best for each other and somehow that is getting lost in things that don’t really matter if you understood how precious life really is. It is only the sick that learn this and the pitfalls of human cruelty and how often you erase us from speaking until our bodies stop fighting and we are silenced into the cold ground as everyone cries at our funerals but never cared while we were still alive. It’s quality, not quantity and we have to do better or we all end up in loss.

  • Why is it so hard to see how badly people, caregivers, and families are being abused because of Medicare, Medicaid, both, or worst private plans? CMS or Medicare and Medicaid controls 120 million people directly and even more indirectly as it shapes the financial design.

    It is killing primary care – going, going, gone in more places. And the plans have narrowed networks and still require preapprovals.

    And the designers, totally unaware of what goes on in primary care, have done the worst thing possible. They have set up reforms. These reforms for decades, particularly the last decade, have resulted in little to no revenue increase with major increases in the costs of delivering care.

    Studies demonstrate that they are killing the doctor-patient time, the time for team members to interact, and the time that MD DO NP and PA have with their families.

    Follow the money. The Three Ms of metrics, measurements, and micromanagements have shifted more billions each year into the hands of consultants, corporations (new and old), and CEOs (many new and loving the feeding at the health care trough)>

    These entities are not delivering health care. They are killing it.

    Primary care is 50% of encounters. Most of what people see regarding health care – is primary care. Generalist and general specialty services are 70% of encounters and these are the lowest paid, paid even less where half of Americans have half enough. In these places, generalists and general specialists are 90% of local services.

    But that is not enough. The design drives most Americans to drive more and costs them more time and effort – and more die because of these changes impacting access and care and more.

    So we have had it. We have had it as family physicians – the ones who still distribute where needed and are most abused – along with our patients. Other specialties concentrate in concentrations – away from the majority of Americans struggling to get care.

    MD DO NP and PA in family practice are the only ones who distribute according to the population – but only when they can stay. And they are being driven out.

    Primary care, mental health, womens health, and basic surgical services are all dying – by financial design made worse with reform.

    AAFP is supposed to support family physicians and health access and patients in need of primary care, especially where needed. AAFP supports the financial design changes, hoping for some miracle that CMS will toss them a few dollars. It aint happening and has not been happening since the 1980s.

    Where were all of you in support of family practice, primary care, and care where needed?????

    It took most Americans to restore family medicine as a formal training specialty plus the hard work of practicing family physicians from the 1950s to the 1970s. Family medicine was restored at just the right time as Medicare and Medicaid were created and pumped billions into these counties where most Americans are left behind. Family medicine grew to 3000 annual graduates by 1980 and then essentially no more. A clear indication that the financial design no longer supported FM and neither does CMS. AAFP has worked countless hours and personnel – for no change in CMS, health access, primary care, and more

    Wake up. If you want health care, decent health care, decent team members, time with team members, and continuity of care – YOU MUST PROTEST

    You must tell AAFP to go jump somewhere and support you and your physicians – not promote additional burdens from meaningless use, additional costs of metrics measurements and micromanagements.

    A real family practice association would have rallied you long ago. It would have helped you fill out forms to send in to your state about health insurance abuses. It would have flooded your legislature with data about the demise of primary care and the abuses of Medicaid and other plans.

    Fight for a real future for family medicine and family practice of all types – because it is all that remains and the only population-based distribution.

    Family practice is even more important where hospitals and ERs are being closed – as they are what remain.

    36% of family medicine is found in 2621 counties lowest in MD DO NP and PA with 40% of the population. The primary care practices in these counties had 38 billion for primary care, but now each year about 8 billion is sucked out for metrics measurements and micromanagements.

    If you see health care dying – you are right. It is right in front of you. The designers have no clue and continue to send out more managed care, academic, technologic cures for primary care that make matters worse.

    Family physicians, their spouses, and their families have had it and they are packing up and having to do other careers.

    My mom was an RN in a family practice clinic and I grew up there. I really did not consider anything else. I started as a rural family doc and have continued to teach, deliver, and research basic health access for 37 years.

    They are killing all that I learned to value growing up.

    Do something, organize your complaints, make sure the designers here about what they have done and are doing.

  • “They lost her files, then if you have a few cents over the limit, you can’t get Medicaid.”

    This is what scares me about single payer: it’s run by heartless, often incompetent and sometimes power-hungry bureaucrats.

    I live in a country with single-payer. Appointment scheduling often involves calendar years, not months.

    “Your specialist can’t see you until after Christmas…”

    “OK, I guess I can wait”.

    “…2022.”

    Solve that plus the budget concerns and I’m all for it.

    The system is badly broken.

    And, after much upheaval to switch to single-player, it will still be broken.

    We need new ideas.

    • Agreed the system needs new ideas. I recently met a nurse who left the medical industry and went to medical insurance. She explained doctors are a huge problem here, as they are rude, they no longer care about their patients and they have gotten entirely greed hungry after Obamacare. Obamacare broke their reimbursement rates so now most are burnt out and don’t care and she told me the older doctors who are trying to carry the weight and burden as they entered into the profession mostly out of caring for the human race as opposed to new doctors who do it for statis and money. First of all biggest mistake of all is INSURANCE, it is run by the largest banking institutions in the country who not only own our butts but they regulate it too.
      In my lifetime I’ve never met one single investment individual who understood human compassion so this is one of the largest flaws in the system we have. Second, this is human health, without it life is horrible so we as human beings need to show some compassion to those who struggle as to those who do not. You do NOT bring in a hungry money gabbing finance institution as the middle man or you are just plain ignorant if you think this will benefit anyone. I feel patients should pay a monthly retainer to their doctors of choice not to any insurance company, however, we all know where money is so is greed so I feel that the medical society should be monitored appropriately and that means we need caring, honest individuals that take that part of this seriously that can not be bought out or manipulated to cover up mistakes. There should be a city/state tax of some kind that funds our hospitals and special health facilities that specialize in the more costly and difficult chronic issues that are plaguing our society in a growing number of increased cases and doctors who violate reporting the truth of the new issues need to face serious consequences and fines because how else are we suppose to know if there are environmental issues causing wide-spread problems. I want exclusions for labs to hide patients diagnoses, imaging and test results for social experiments on society stopped…. PERIOD!!! We are not your gunea pig test subjects and if you aren’t going to inform us this is a huge breach of life and liberty. I feel all patients should be able to view testing if there is question in how the lab is reporting things to stop all the mistesting that is currently happening that doctors are allowed to blame their own sick patients for. If a patient is having issues in which totally infringe on their live to be able to work so they are rendered without a way to place a roof over their heads or care for themselves we need to set up better area facilities to deal with this growing epidemic which is causing more homeless than I care to mention here and most of these people if properly cared for would never end up in this type of destitution. This has to start in the communities, to the city, to the state. While my doctors and congressional people continue to ignore this issue and make excuses, I can give you countless options if you care to even listen cause I am a resolver which is why anyone who knows me comes to me for help. Yet I can’t get any help and I am being wasted by my community when because I have had to struggle from health issues for a long time now, it opens you up to using every resource you have and I still am failing… why… cause the rest of the world won’t let you back in no matter what and this folks is why we will always have this problem because none of the haves want to do anything to help the havenots. I was a haves and now I’m am a havenot and believe me I know who is to blame here cause I most definitely did not subject myself to the toxicities that ended up in my body, I did not try to cover it up either, and I did not ignore the problems that needed addressing, I did not refuse anyone a necessary surgery and folks I had the money to pay for things, but instead ten plus years went by with all this flat out in front of my doctors faces who chose to waste my life, waste what they could do for me, waste my entire life’s savings and my families so you keep excusing yourselves but I know I’d be a way better doctor than all you who left me here drowning on total intent. The reason nothing changes is because none of the people who can change it are willing to do so.

  • We need what they have in every other country, single payer insurance that covers everyone equally. My daughter was divorced and had been for years on her husband’s insurance. They were married 23 years. He found someone younger. So the divorce. But she had paid into the system for years. Now she has Medicaid and has multiple health problems. Heart, digestive with hernias. It took awhile to get on Medicaid. They lost her files, then if you have a few cents over the limit, you can’t get Medicaid. So you go back and forth – living in the US is scary.

  • I have read many/ most of the comments here. From what I have seen, the problem seems to be that the governmental agencies ( medicaid and Medicare) do not reimburse doctors well enough. It sounds like it is medicaid and Medicare are the stingy ones, not doctors. It sounds like: if the government would allot more money for reimbursement of doctors and for diagnostic procedures and treatments, there would not be a problem. The people who have genetic illnesses, chronic illnesses but are low income would have their health care needs met.

    What I have encountered in the past 7 months is: I am a dual-eligible Medicare-medicaid patient/consumer. When I had a certain Medicare advantage provider, their reimbursement to doctors was soooo minuscule that no dermatologist in my county would see me for an ordinary skin-cancer screening! I got The same rejection from gastroenterologists!

    So, I wised up and switched to a different Medicare advantage plan. This second insurance does very good reimbursement of doctors. Now I can see a dermatologist and get that skin cancer screening…and MRI tissue screenings, etc.
    Medicaid rules and red tape varies from state to state. But the system of health care is broken when it comes to caring for people who:
    are low income because of genetic problems that are no fault of their own; and for people who are too ill to work; or people who are working but health care costs are too insanely costly for them to afford.

  • Again. The current healthcare system is broken. However, if physicians in high rent cities like NY accepted all insurances, they could not keep the doors open. It is not discrimination. It is reality.

  • I wholeheartedly agree with the above article’s information. Not allowing Medicaid recipients the basic rights to be seen for care, is wrong. It’s outright discrimination, nonetheless felt in other areas like race, gender, etc,. Everyone is entitled to superb health care, not just the affluent. I look at Canada’s
    Universal Health Care, seems to be working well, and I say, why not, America??? Well, I could go on and on, but I’m not… for I am merely a poor, disabled person, on Medicaid, who wanted to just speak for some of the voiceless,

  • I wholeheartedly agree with the above article’s information. Not allowing Medicaid recipients the basic rights to be seek care, is wrong. It’s outright discrimination, nonetheless felt in other areas like race, gender, etc,. Everyone is entitled to superb health care, not just the affluent. I look at Canada’s
    Universal Health Care, seems to be working well, and I say, why not, America??? Well, I could go on and on, but I’m not… for I am merely a poor, disabled person, on Medicaid, who wanted to just speak for some of the voiceless,

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