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.

advertisement

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.”

advertisement

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.

  • Wow! This is an awesome informational article about doctors and the Medicaid system. It sounds like both sides need to make some improvements and requirements to at least lead to decreased discrimination in health care.

  • I have a daughter who is 22 years old and unable to work full-time because of a medical condition called dysautonomia. Our insurance dropped her when she turned 21 and she’s had to take on Medicaid / Humana. We have had so much difficulty finding good doctors. See with her medical chart that includes autoimmune conditions as well as autonomic conditions she needs specialist. In specific right now she needs to see a specialist that is in Mayo Clinic, they finally called it’s been 5 years that we’ve waited for this call only to find out that they won’t take Medicaid although they had an opening for her. There are few doctors that treat dysautonomia, he is the only one in this area. What do we do? We can’t afford to give her private insurance unfortunately. We are at with ends and I know that if my daughter doesn’t get the proper care that she is only going to get worse. The scheduler at Mayo Clinic said that we could call the insurance and ask them to pay for it, I just don’t know how to go about it he also said that the doctor can put a referral out to the insurance stating that this is the doctor she needs and that there is no other close to us. Does anybody have any idea how we go about? She needs to see this specialist.

    • Rose:
      I am not sure which location you are at Mayo is both in MN and FL so if you are in MN they have strong patient advocates at Mayo Clinic that may be able to tell you about programs offered. Call the clinic and ask for their patients advocacy. Also try your local health department, they sometimes can also help get you to the proper area. Sometimes local churches donate to certain people with financial issues for medical, go online and look for different programs online as well as ever state is different, a bit surprised the doctor she needs to see didn’t offer anything but certainly not shocked as they don’t make our doctors like they used to which is unfortunate for many. They are tied up with red tape now so we don’t get the kind of care we need anymore.

  • Yep David sounds like you did get really good doctors and my comments aren’t towards really good doctors they are towards the corporate business docs who have no ethics or standards in the care they offer and unfortunately in the care system there are many more of those then what you describe. Mine have had no issues with harming me and do it gleefully. Secondly from the years of paying attention closely to things in multiple offices as you start to wonder what is going on so you pay a lot more attention, there is a huge discrepancy with how doctors treat men and how they treat woman, you may have had a bit better luck due to you being a man and I hate saying things like that but there are multiple things that play in to why they help some and not others. I have been shoved into a category that is destined for total abuse no matter what I do for reasons I will not go into here, but I am very glad to hear a positive story like yours, it gives me hope not all has failed in the system.

  • There are no, not understandings here from me… let’s make this very clear. I know very well what goes on as I grew up with a good friend who was a very good doctor and I watched him see countless patients in his private facility. This man worked around the clock he fell asleep just to eat his dinner which was probably all the sleep he actually got at times. I worked in medical several types of positions, but I also worked in multiple types of companies and what I see going on here is doctors beating up the sick for reasons of mismanagement of their own practices as I have too much experience here to fool. I am not young, and you guys always blame something it’s just amazing. First hire more people, get transcribers to ease the paper and electronic loads, granted for those of you not familiar each employed person cost a business quite a bit of costs both salaries and then you also have other issues of insurances, social security. If you are smart in business you can figure it out. Whoever is saying I don’t know I do know (Bystander well bystanders only watch system fail so I take your criticisms as ignorance). I also owned several businesses over the course of time as a matter of fact infringement of regulations and laws have several times cost me a career I loved to where I could not survive and I had to change course not because I wanted but I was forced to so beware who you point at as not knowing as I do know very well. So I ask here do you think it is fair to take ten years of false diagnosing of a patient, force this on them when the patient knows your dishonest, your correspondence to feel the need to push your own opinion onto another; as this issue is becoming very alarming now through the electronic system so patient can’t begin to get a fair assessment once the first doctor makes this wrong diagnoses. Do you really thinks it’s fair to blame your patient for mistakes you are making to the point it ruins their lives or is damaging to them through dangerous medications? Do you think in any other profession you would not be fired for lack to resolve any issue or even brought into a court system for questioning? Doctors are the entitled and you carry your power with no regard to the destruction of your helpless sick patients and I am done with defending what is just plain inhumane rational to a very destructive disease of thinking your profession now has. The only reason you keep beating me down is the truth is something you don’t want to hear nor accept and your oath is first not to harm.

    • CAID Patient: With all due respect, I am really trying to understand your point of view here, but unfortunately it sounds like you are simply angry and dislike doctors in general because you have had some bad experiences. I feel that you are unfair by overgeneralizing a group of people by saying “they ruin lives” or “use damaging medications” or “destruction of helpless sick patients”. I would caution you that it is never a good idea to use blanket criticism for the deeds a few bad apples.

      My story is quite different. My body would have been ravaged by my kidney cancer if it wasn’t for the generous actions of several doctors. I had no insurance. My primary care doctor found my cancer when I started peeing blood one day. He obtained a CT of my belly and was able to get me a discount. The CT showed a kidney tumor. He spoke with a surgeon and the surgeon actually removed my kidney. The tumor was very large. The surgeon actually wrote off his bill. The hospital was another story. My PCP wrote off his bill as well as he knew I was struggling. The point is, these two generous individuals knew I needed help, and they did what they could. It saved my life. I will be forever grateful to the medical community. The doctors I know do far more charitable work for their community than any other professions.
      And the kicker, neither of these doctors take Medicaid any longer. Nor do I qualify for Medicaid, yet cannot afford insurance. My doctor says he is happy to help those in need and does, but when Medicaid stopped playing fair, he said the practice could not afford to. You can take what you will from this, but rather than just assume that “whatever” amount one would get paid should be “enough” is a bit disingenuous about trying to understand the problem.

      By the way, the end of the story, the doctors wrote off my bills. I am now well and happy and cancer free! To this day, I am still paying an ungodly amount to the hospital and cannot get Medicaid or afford insurance. My beef is with the government and corporate medicine, not the doctors. They are taking as much abuse from all of this as most of us patients. You should at least be grateful you have Medicaid. I am grateful to all the doctors who were there for me in my time of need and were never concerned about the money.

  • The author of this article, it should be pointed out, graduated medical school in 2014 and has never owned, administered, or managed a health care facility or clinic. In short, he is an academic. While he may be a fine doctor, he has no business lecturing physicians who have much more experience making payroll and keeping the lights on. This is pretty typical of the young Left these days. They take a simpleton view of things and propose drastic change with no knowledge of the unintended consequences. I propose he run a clinic from the ground up before he spout off from his public health “ivory tower” about “social contracts” doctors have. “Social contracts” are fine, but remember, they always go two ways. Many more doctors used to accept Medicaid that they do now. Do you really think it is because doctors now are less altruistic, or do you as logic should suggest, want to see the truth, which is Medicaid reimburses so poorly. Both the author and the doctor bashers here would do well to target their disgust with the real cause of this, the reimbursement system (CMS, Medicaid, to lesser extent managed care, and finally the large hospital systems). Lastly, few doctors remain in private practice these days and most are employed by big hospital systems. Little input into the decision to take Medicaid is even made by the overwhelming majority of doctors. Please get your fact straight folks!

    • Poor people can reimburse even less than Medicaid; that’s why they’re on it in the first place.
      Are you saying poor people don’t deserve healthcare? (Before you deny it, yes, you very much are saying that. )

    • Are you kidding? My doctors bailed out of Medicare and Medicaid programs as the ACA was rolling out. I am left with foreign doctors who have Sheepskins on their walls from 3rd world countries and a short history with some charity hospital in some S-hole city. I had one doctor who was a cardiologist I was referred to in my area who had three relatives working in the same office. To this day I do not know which was my doctor and they all vanished. I was put in a chair and with shoes and socks off the bottoms of my feet resting on a strip of metal, this box diagnosed my entire body (supposedly) then told them what my health issues are. You said Medicaid reimburses slowly. If you think it reimburses slowly now wait until everyone in this country is on Medicare and Medicaid. Tell me doctor. When a patient comes to a doctor with a referral or not your staff makes sure he or she is covered by something. Right? If they have Medicare you check. Part of your query to Medicare is the infamous yearly deductible. Yes? And if you find out the patient has not met his deductible you ask for half or more? Yes. You do. So the patient coughs it up and then you or 9 out of 10 of you can hold that check or payment for up to 364 days. Why? Because of taxes and interest. That’s why. You or those who do this don’t care that this messes up the patients. Do you? You whine about slow payments from Medicare and Medicaid but you sand bag tens of thousands a year and draw interest on it. Invest it and let it and hundreds more make you rich. So don’t play high and mighty. You are not a doctor who believes in your oath to do no harm. I’ve been harmed many times by sanctimonious doctors. Your comment sounds like you are one of them.

  • My correspondence friend and rural family physician is done. For years he has supported his full time practice with a second job in ER. He and his NP wife have been giving countless additional hours to keep the practice afloat. They cannot. He has had the chance to talk directly to CMS Directors – and primary care associations and more – and no support. When he and others point out the financial situations and worsening – there are those on family medicine leader list serves that tell them they should stop complaining.

    They want us to work with CMS despite the fact that CMS has continually made the situation worse. Why would you work with someone who smiles and shakes your hand and acts like you are listening while the dial away whatever salary that you had remaining after paying for practice expenses.

    Family medicine leaders want to deceive more and encourage more. Why? Only half of recent graduate family physicians are remaining in office family medicine.

    One recent graduates gives you and idea of what they must do to pay off debt and have a job. He works in a clinic with substantial homeless and HIV. He has 15 min to deal with one or two problems and they have 8 to 20. Some of the other problems could be addressed – if there were resources and more team members and more time. Their time has been taken away by meaningless use (EHR, metrics, measurements, micromanagement). He was never interested in making a ton of money as with most who choose family medicine. But he did not sign up for worsening conditions for team members and patients with worsening support.

    He and most family physicians do not deserve to be abused by so many here and across the various media outlets.

    Who would put up with the blame of poor patient outcomes when you cannot shape those outcomes?

    Who would put up with running a practice that runs you and your finances and your family into the ground – especially you patients and your family that you love?

    Stick a fork in most needed primary care. It is dead. The governments (federal, state) and associations and corporations and foundations have killed it.

    You might be upset with the way your life turned out. Guess what. I am too. Despite this I have to take the abuse of disgruntled patients when my patients are disabled, depressed, discouraged, abused, or otherwise shaped into poor responses and communications.

    And what happens when patients cause any fuss is even more abusive to us who work the front lines.

    I can only ask for some level of understanding of the situation facing primary care team members – especially the family practice positions filled by MD DO NP and PA that are on the front lines – and are being most abused from all directions.

    After 35 years of steadily worsening situations, you would think that there would be more than blame and shame. Sadly, there is not.

  • I am a Medicaid recipient due to leaving a lucrative career in order to take care of a beloved parent suffering from memory disorder. Most people on Medicaid are caretakers who are saving billions of dollars in medical costs and other government services in order to ensure their loved one receives all the care they need as they transition, eventually die. Every person who wrote their two-cents regarding the above article will someday face either becoming a care giver for a parent, spouse, child—or face a catastrophic event which causes a cessation of employment checks and need for medical care that will land on a physician who either cares or gives lip service because the insurance one once had no longer exists when a catastrophic event occurs.

    At least Medicaid allows a person who undergoes a catastrophic event to maintain a longer hospital, rehab, nursing home stay before the usual two week cutoff Medicare or other insurance enacts. Bet you didn’t know that after a very short time any and all kinds of insurance is stopped, dropped, goes kaput after a catastrophic event and these hospitals, rehabs, nursing homes go after your bank account no matter how poor or rich, no matter your station in life. After insurance is dropped in less than a month, bills arrive which demand between $8-to-$10,000+ per month depending on the cost of living in the State you reside. And as far as thinking you’re safe and everything is A-okay because you bought into special care, aging, nursing home insurance you’re misinformed and will receive no better care than anyone else. Nursing homes are notoriously understaffed with primarily untrained workers who don’t often speak fluent English. Their overworked employees may be the salt of the Earth but if you’re suffering from dementia or other conditions which impair your ability to communicate, expect to lie in your own waste for days—actually, expect to not live for very long because no one will take their precious time on their low wage to hand feed you or check/change your diapers on a regular, hourly basis.

    From my experience, too many people are becoming doctors for the prestige and money only to become disenchanted because they actually have to touch people. As a caregiver, I eventually became ill and MRIs, blood tests prove disease and serious conditions exist but because of these things which disable and keep me on Medicaid, after many years of lip-service whether kindly or rudely stated by physicians who accepted Medicaid, I’ve still not received any surgery or service which can help cure or alleviate conditions except lots of conversation which pretty much means No, I’m not going to help you any further because you’re a Medicaid patient but I’ll keep shuffling you off to other doctors in the field who will do unnecessary tests and try to squeeze any nickel out of Medicaid/Medicare like I do especially because you’re a Medicaid patient.

    Someone’s health—life—is of no real concern to Liberals or Conservatives yet it seems this important personal matter has become contingent on political agendas and how much a party platform gives it value (based on their shortsighted knowledge that they’re only human, too, and if they live long enough will face a partisan greedy elitist doctor who doesn’t give a shit about you or your politics).

    Doctors who won’t accept Medicaid patients and those that do and only pay lip-service to their patients ought to be identified via their local media and shamed for not helping the millions of caregivers who conscientiously brought their loved ones in for treatment for years, then scorn those caregivers who became on Medicaid simply because they desired to ensure their loved one received the best care possible and couldn’t be two places at once (simultaneously at work and at home with a demented parent). I’ve not encountered one physician yet who hasn’t acted cold hearted (but smiled as they denied further service) while on Medicaid. Only thing that keeps me from going bonkers in this predicament is knowing some day as we live long enough we will most likely find ourselves in the very same predicament yet much worse—everything earned will be depleted by insurance, doctors, greedy heirs who will most likely put an aging parent in an understaffed and cheap nursing home so they can get every penny from an estate. That’s right PhDs— you face this future, too—your life won’t end up any different the way this current system of healthcare keeps on getting more greedy and less humanitarian.

    • Where in the Constitution does it say you have a right to medical care? If you think it should be a right, then you should petition Congress to set up a system to pay for someone to go to medical school in exchange for signing a lifetime contract to see patients for no fee but a fixed salary like any other civil servant

  • I live in the state of Florida and Medicaid patients are treated like dirt. I live in a rural area but the only primary care I had is 50 mins away I can’t physically drive there my right leg is paralyzed from a brain stem stroke I have had to get a medical ride the office was wonderful only there for a half hour great doctor it took me 6 months to find less than 6 months later I’m sick with a uti I find out he quit with no warning the med ride takes me away from home for 5 hours we pick up several patients I tried to tell them I can’t ride that when I have to stop at every gas station They even told me when I asked if I could do the lab work at my local hospital and have them send the results they told me no I had to ride out there I ended up having to use the er Even urgent care will not except Medicaid Well after all this my uti turned into a kidney infection my side is paralyzed so I dont feel it until it’s too late I have often said they want to kill us and I may have well stayed home and die I also have a Down syndrome 32 year old who has no doctor forget seeing a specialist I have had no stroke care since I left rehab no neurologist I’m divorced all I get is Ssi I cannot afford to move to another state I’ve never seen healthcare as bad as Florida and so lack of caring for disabled people something simple like a uti turned into a kidney infection that didn’t need too thanks for letting me vent

  • 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.

    • I have insight and experience with keeping a practice afloat and still accepting Medicaid patients. It is not easy but it is the right thing to do. It ought not be so much about the money and more about the ethics of healthcare. Incidentally, I’ve never met a doc that didn’t make a decent living.

Comments are closed.

A roundup of STAT’s top stories of the day in science and medicine

Privacy Policy