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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.”

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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.

  • I mean if I could laugh out loud on this post you would hear uproarious laughter emanating from your computer! Contract with Society?!! Physicians?? Really? I have worked in the medical profession for over 15 years and, since you seem to be delusional about human motivations, I will gently but truthfully explain to you what drives physicians. Almost all of them. 1. As much money as they can possibly accrue. 2. Doing Whatever It Takes to ameliorate their Liability in any given situation. Everything else is ancillary, including patient care. Patients are a means to an end. That end is money. I’ve worked for, befriended and socialized with dozens of physicians over the years. And I could count on far less than one hand the number of them who cared, really cared, about anything else. In more cases than I would like to recall, that axiom also included their family. The medical profession, excuse me please and I hate to say it, is a cesspool.

    • Well atleast you used your real name so all the doctors you claim are your friends can actually know how you really feel about them
      PATHETIC that you had no problem working in the greed mongering money grabbing cesspool but I didn’t notice you saying your salary was excessively high for your efforts and time spent.
      My plumber just charged my wife $200 to show up and to put 3 rounds of Teflon tape on a pipe fitting that started to drip around our water heater. No accusation of greed or the like towards him although at that rate he SURELY makes more than any of us.
      Supply and demand! Don’t need us don’t pay us but if you do then write a check and stop bitching. As I said everyone can lower their own medical costs by lifestyle alteration but they refuse to knowing that society will pay the costs when the need arrives.
      Why does someone have to work for anything other than money? Why do we see medical like we see clergy? We don’t take vows of poverty as no one else in society does. We ALL work for income, not altruism and that is perfectly fine. The problem is when some are accused of wrongdoing for it
      I am proud I have earned enough to now do surgery for free but if I still charged I would surely be more then proud of earning a good living for helping others do what they can’t on their own
      Dr. Dave

    • Well, Dr. Dave, I’m happy you are so proud of yourself. And I see you announce your real name as well. How much would you have charged for wrapping up an arm in the OR if the person were paying with a check instead of an insurance card? I do not deny your right to make a living in concert with your skills, but I very much resent, deny and am disgusted by physicians – and surgeons are particularly prone to do this – who either commits a medical error – oh, I’m sorry, did I mean “adverse event” – or witnesses a colleague commit one, which then turns into a chain of errors and eventually, because it wasn’t stopped, kills someone or disables them, sometimes for life. And then that physician “doctors” (that means lies to any lay people reading this) the medical record to ameliorate his/her liability and and makes it difficult if not impossible to get restitution. Don’t give me this high-brow argument about having the right to make money. Nobody deny’s that; I certainly did not. What disgusts me is the pervasive nature of physicians who take “make a living” past the point of unethical behavior and make their way to immoral livelihood. When people like you fail to report a destructive medical error by anyone and then lie to cover it up, that is closer to the definition of PATHETIC than the one you tried to label on me.

  • Dr. Dave- Brilliant response. After ten years out of medical school, I’ve treated more than my fair share of no pays and don’t owe society anymore free care. I need to feed my family and the day, I am forced to take Medicaid is the day I start looking for another job.

    • ABSOLUTELY agreed
      It is one thing for us to pick and choose who we donate our time to but to be forced to donate our time is simply not going to happen in reality
      The concept of greed is obviously posted by a layperson who somehow thinks we are overpaid morons and what we offer to society can somehow be replaced by another entity altogether
      Social scenarios are ALL based on two things: supply and demand and level of expertise
      When there is more supply than demand the costs drop to balance the issue. In medicine we are in severe demand and suggesting that we make too much money for our time spent is FINE with me I am MORE than willing to retire again (for the 3rd time) and I am even willing to give every head and neck cancer patient a 30 minute course on surgical oncology and let them use my instruments on themselves to see how well they do. So far none have taken me up on the deal but I don’t know why not since they totally open to the world on our provision is not essential.
      When I hear from people who somehow see us as greedy or overpaid I then ask both myself and them why do they simply not take better care of themselves to lower their need for us and save the money?
      Since over 80% of ALL US diseases are lifestyle based all they need to do is shift their lifestyles and avoid us altogether
      Cancer, diabetes, hypertension, cardiovascular disease the list goes on and on are ALL based on lifestyle choices. Sure somethings “just happen” but the rest are purposefully caused and can, therefore, be purposely avoided. I avoid my colleagues by avoiding alcohol tobacco excessive carbohydrates sedentary lifestyles etc. Although I have a genetic type of cancer the rest of me is over-aggressively well treated by attention to my lifestyle.
      SO many of the screamers that accuse us of greed are the same ones who over-need us because they refuse to live in toleration and moderation
      It is the time we start to point the right finger at the right party. Society would be much better off if instead of blaming the healthcare system it blamed the population for its part in CAUSING the diseases, to begin with, and charging a duty for anyone who refuses to participate in a national healthy cleanup campaign. No different then we used to have back in the 70’s only now for body wellness, not city clean ups. Make everyone with a bad lifestyle and refusal to cooperate with medical advise financially responsible to the rest of us who are and who are tired of paying more to carry them thru their diseases and time off and lack of productivity etc
      Dr. Dave

  • I guess I missed the lecture that said after spending 15 years and over a quarter of a million dollars in education expenses I have ANY “social commitment” to the entire society.
    SURE I get it that we are healthcare providers and I get it that some people will simply be locked out but how does this differ from any other aspect of life? Are lobster fisherman discriminating because they fish only for animals that cost upwards of $20 per pound? Don’t even think about suggesting that health is an entitlement since we allow Welfare recipients to buy beer with food stamps and cigarettes which SURELY are not healthy and or entitled to items
    When the profession of medicine becomes a mandatory state of affairs then it will be time for me and thousands of like-minded other docs to hang up the shingle and return to our workshops, dens, sofas, and baseball fields/golf courses
    I have never taken Medicaid or for that matter Medicare but then I have not charged for a single surgery in almost 20 years. Yes I am unique in that I do all my work for free and work only on patients I choose to but we can’t be forced by mores or laws or ethics to be funneled into the “everyone must be cared for” mentality
    If that is true then we need to ship most of us docs to Africa and other third world places because they surely need services more then any US area
    Time we wake up and realize that healthcare is a business and not a calling
    Dr. Dave

  • With all the paperwork the government requires from physicians who see Medicare people, who can afford to see them and still try to break even? Doesn’t surprise me that many physicians simply don’t treat them any longer. I have both Medicare and a paid-for BC/BS policy to cover the costs. Because I worked for them and respect the physicians’ time and learning.

  • As a physician, why would any doctor be forced to accept 66 percent less per patient? We’d have to see 50 percent more patients per day and most Medicaid patients have complicated medical histories with history of non compliance and no shows which distracts from the patients who pay more.

    • Greg
      I learned a lesson a LONG time ago from a POTUS candidate decades ago. H.Ross Perot said it best. You can’t make up in volume what you lose in profits. Medicaid pays less than the minimal expenses for most providers that means for every patient we see, regardless of how many of them we do see we lose money the more we see the more we lose. Medicare atleast we break even on so that our efforts pay the bills and not come off of our dinner tables or clothes closets but Welfare is a losing proposition and there is no amount of volume of patients or cost cutting in time or efforts that can EVER return us to taking home anything for our efforts for treating them. Some areas use state-funded offset programs to add a bulk check or some added revenue to super clinics who treat lots of them but still the overall process is a financial loser and suggesting it be required for all of us is tantamount to slave labor
      Dr Dave

  • Look, all us providers should help those who don’t have all the bells and whistles. And, yes we should go after the fat cats. We took an oath. I don’t remember saying I would only treat private insurance. Remember KARMA is waiting for us!

  • I have heard, and this may be wrong, that the bureaucratic process unnecessarily makes “the juice not worth the squeeze”. I have experience dealing with invoicing the government and at times the process was so time-consuming as to require the creation of a “govt invoicing specialist” position.

    Doctors should take Medicaid patients (perhaps some of that $150,000 per physician could be in the form of IOUs where the recipient owes the government medical services on behalf of Medicaid patients).

    But lazy, incompetent bureaucrats (not *all* bureaucrats) kill people! That needs to be addressed too.

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