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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  • CMS (Medicare and Medicaid) sets the health policy and payment design as per decades of legislative and administrative actions.

    CMS has long shaped half enough basic health care workforce for 40 – 50% of the population. Where CMS patients are concentrated, there are shortages because CMS does not support its patients or those who provide care for them in these counties.

    You should also blame associations, foundations, institutions, academics, and others who shape the payment design – and also claim that they can fix the shortages. But they cannot fix what is fixed in place by the financial design that they helped to shape. And they have made it worse.

    These counties left behind by CMS and insurance “payers” have 50% of Veterans, 45% of the elderly and poor, 40% of the population in 2010 (growing fastest to 50% by 2050), 26% of primary care workforce, 10% of health care dollars associated with physicians.

    If CMS, VA, IHS, and others pulled their weight and paid the cost of delivery – access would not be an issue. But they do not.

    The designers send more and more dollars to fewer places that have top concentrations of workforce – such as 1100 zip codes with 1% of the land area and 10% of the population and 45% of physicians with well over 50% of health spending. More and more lines of revenue are created and funded – but not where most Americans most need care.

    The designers say that primary care needs more – but are unwilling to cut the dollars for subspecialty and hospital services to pay more for basic services. So they oppose basic health access and true health reform. They use primary care in their areas as a loss leader – losing on primary care but gaining in the higher paid services.

    These counties made lowest in health care workforce are the counties where generalists and general specialists and basic hospital services are paid 15 – 30% less. CMS has also made the financial design worse. It has also forced these hospitals and practices to pay relatively more per physician for its constant shifting sand policies with much worse due to HITECH, MACRA, and PCMH. Billions more each year are stolen from the practices and hospitals where needed – as dictated by payer design. Billions less remaining defeats basic access – more each year.

    The payers do not understand the delivery of care and all that they do abuse the personal and professional lives of those who deliver care. And they help direct the blame to physicians – including the dedicated few (getting fewer) where care is most need.

    CMS not only diverts the local dollars to meaningless metrics measurements and micromanagements, it also diverts local dollars to health insurance meaningless for local health care.

    Most Americans have a right to be upset because of the designs – designs that penalize them, their local physicians, their local nurse practitioners, their local physician assistants, their local health care team members, and their local jobs, economics, and more.

    They need real health care dollars invested in real local care where most Americans have the least.

  • I’ll close my clinic and retire before I am forced to see Medicaid patients. Then see how many Medicaid patients or patients in general that will help. There is already a doctor shortage. I wouldn’t stir the pot. I am not going to be forced to see people who lose me money. most of you wouldn’t either if you knew the details. I am not going to be told how to run my business into the ground. There is no end to the madness. THE PROBLEM IS MEDICAID NEEDS TO BE COMPETITIVE IN WHAT THEY PAY AND NOT THAT DOCTORS NEED TO BE PHILANTHROPIC. Nothing is going to change until this happens. And if we’re forced to, many of us will quit. See how you like those apples. You entitled types brought it on yourself. I don’t see you out donating 25% of your job to the poor. And yes, that’s what we’re talking about.

  • Unless you KNOW how little Doctors get reimbursed to see Medicaid patients you can’t possibly understand.

    All the reasons are listed above, the regulations, paperwork, overhead and staffing.

    I can’t IMAGINE what would happen if we ever see a Medicare4ALL happen or universal healthcare. In my opinion, Obamacare was the preamble and the results of that speak VOLUMES !!! Guess who ended up taking the hit for that ?? The people that invested in themselves to take a job that offered GREAT benefits. BENEFITS were equally important as negotiating a salary. The COST of Obamacare was devastating. The people that HAD insurance LOST IT. Those that didn’t lose it, pay EASILY 3 to 4 TIMES more, get higher deductibles and less coverage.

    Only in the United States are people DEMONIZED for being successful.

    We already HAVE a doctor shortage. I’m absolutely POSITIVE there are first year residents truly scared right now. Seeing the work they’ve put in potentially go up in flames as this nation teeters on a universal healthcare nightmare.

  • I really do not understand the OH MY GOD! There is an entitlement in this country. I work every day – every single day for 30+ years so me and my family have health benefits. Dont give me OMG shit – there are 100s of jobs with medical insurance. If the Medicaid patients do not like the doctors and / or cannot work for whatever reason – then this is a CHOICE. I work for six doctors who would CLOSE their doors if they were forced to accept Medicaid. So instead, Alan Coker, of saying OH MY GOD! Take a class in insurance and life skills.

    • Consider me the 7th doctor who’d close his does if forced to see Medicaid. 2/3 of doctors already provide charitable care, often for free, to the uninsured. We do this willingly because we want to. But when we have to, as is the case with Medicaid (yes, it is charitable, based on lousy reimbursement), then it’s time to close up shop. I specifically provide 10% of my patient base with scholarships (free care). Most doctors do something like this too already. I wonder how many of the nimrods on this board provide the same amount of their income or work time to the poor. Probably none of them as they’re too busy running their mouths about things they know nothing about.

  • OMG what? not every doctor can take Medicaid nor should they? There are plenty who do. If it is not a doctor to a Medicaid patient’s liking – then they need to act on their behalf. I am STILL WORKING because of healthcare and I do not want Medicaid – so honestly, I have zero sympathy.

  • I’m tired of these ignorant comments regarding doctors who do not get paid what you think at all. There are plenty of doctors who accept Medicaid and if you’re so unhappy with your choice, get a job w private insurance or purchase the AFA

  • Never knew about this society or country like the USA! Medicaid /Medicare is issued by the Federal and State government – The so-called doctors do not accept it, What is a shame who called themselves physicians or doctors, how much they make money and still hungry for more money !! The USA is going down the hill because of these culprits………..!

  • More.

    That’s what everyone in this comments thread wants.

    And everyone can’t get enough of.

    More attention.
    More than 24 hours a day.
    More money to pay their admin staff.

    There are street urchins in Bangladesh who need just a few more pennies to avoid dying today.

    Anyone in this thread could give them what they need.

    But there are *millions* of them.

    Where do you draw the cutoff line? You have to, at some point, brusquely and rudely look away.

    Or, if you’re a doctor with only 24 hours and an admin staff payroll coming up, maybe you look away and stop accepting new patients.

    Perhaps if the government could eliminate paperwork by utilizing a ‘fixed firm price’ contract, doctors could afford to see, say, 50 patients a month.

    Or if the ‘Doctors’ Guild’ released some of their ‘sacred’ duties to nurse practitioners or physician assistants so that their 24 hours could be spent more productively.

    Maybe we could implement an Artificial Intelligence (AI) where we can (voluntarily) feed in all of our health care details (DOB, weight, height, 23andme results, blood test histories, supplements we’re taking, exercise profile, etc) and waive these constricting HIPAA requirements. Then a doctor could spend 20 minutes a week with us on FaceTime or Whatsapp Video and maybe 20 minutes a month in person.

    We must stop continuously whining about ‘doing something’.

    And start saying *specifically* what we’re willing to do!

    PS – Is there a non-proprietary AI already set up to receive my data?

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