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.
For patients with insurance, Brigham is one of the highest priced facilities in the entire country. Their highway robbery collections allow them to easily subsidize care for Medicaid patients and still whistle all the way to the bank. Give me a Brigham level fee schedule and I’ll gladly open up to Medicaid patients.
In New Jersey, medical care centers in or near to the inner cities, end up with a undue balance of those that cannot pay, on where the medical center and cannot get fully reimbursed for their cost …. That in turn causes many medical centers to close, which then sent their clients to the next ring of service providers …. something need to be done to enable service providers in poor area to cover their cost!
Gerianne the issue is not uncommon. We have huge legal concerns about writing prescriptions for long-term use. Thank the legal system for this situation don’t blame the medical community. As far as I am concerned there are plenty of VERY responsible patients who could and should be allowed to have 6-month refills and or even longer BUT the system doesn’t make room for that option
Now that the Opioid epidemic is so rampant there is NO chance we are going to fiddle with the rules it is not worth losing our license over.
The $125 office visit for an Rx refill can be discussed and maybe a compromise reached. I would discuss the matter NOT with the office staff but with the doctor himself. The biggest issue your daughter is going to have is that many of us don’t take Medicaid for two reasons the first is poor payment but the second which was discussed is abuse by the Welfare patients. Instead of cherishing the fact that they can actually get cared for free they abuse the system with the attitude that they are entitled to care because the Gov says so and show up late, refuse basic hygiene, call at strange hours for non-emergent issues, cancel at the last moment and refuse to pay the minimal copays they sometimes do have to pay
So dumping Medicaid solves both issues but there are plenty of docs who would like to keep some of their better Welfare patients if they could be compensated fairly. In her case maybe the doc will reduce the fee for the months all she is doing is picking up a refill then charge full price when there is a counseling session
As far as us signing on to provide endless good to society I can tell you that NO ONE has done that in generations. Even the Physician’s Hypocratic Oath is now fully optional and most grads do not take it. When I graduated way back in the 80’s my class was the first class to be offered the oath as optional and many of us refused it. I never swore the oath as it prevents me from helping terminally sick patients to end their suffering so I never agreed to it (remember I am cancer doc)
With that I also don’t agree that our initiative is ANY different then any other job in the world except the priesthood and the nunnery we are all in our professions or jobs for the satisfaction of work and the compensation for our efforts NOT to simply open-endedly work for whatever society decides is fair at any given point. We have NOT agreed to poverty, chastity, etc.
Health is a right that once given away/abused is no longer a mandatory issue. Yes I am FINE with preventive care being somehow provided but once the prevention line is crossed and there is a disease then the care needed to return to or attempt to stabilize heath is open for bids
Society needs to accept that you are given a single body and if you take really great care of it then it will last you a great long time but if you abuse it then it will cost you a lot and will cause you heartache to maintain it from getting worse
We need to stop offering EVERY level of health care as a freebie and start to create tiers of responsibility that the higher you go the more it costs
There is NO reason why someone who smokes drinks and overeats should be allowed the same care at the same cost as someone who has followed all the rules of lifestyle and has an issue thru no cause of their own
THAT is the situation ignored by most
Dr. Dave
the responses to this article are terrific. would love to see a rebuttal from dr. agarwal.
Being in private practice, I learned that accepting Medicaid is a sure way to insolvency. $23 for an office visit barely covers my overhead.
In 2003, I helped found the Zarephath Health Center, where we provide care for the poor and uninsured for free with all doctors and nurses donate their time. Half our patients are on Medicaid and cannot find a doctor. The feds give us liability protection for what we do in the clinic via the FTCA.
We are proposing NJ S-239, where doctors donate 4 hrs a week in or through a clinic like ours with the state providing liability protection for our PRIVATE practices. This would assure that doctors of all specialties are available to care for those who cannot afford care. It would be a REAL contract with society.
My daughter was recently advised that he mental health provider no longer accepts medicaid. Her progress while under his care has been so gratifying and has helped her eliminate a number of previously prescribed psychotropic drugs and she was able to work and be productively employed. She now needs to save almost $125 dollars per month for each visit ( although she does not see the doctor) in order to refill the 2 prescriptions that she requires. No other physician in this field, certainly not in Somerset County, will accept medicaid either. Having been unemployed, due to her illness, for a number of years, she was so proud of herself, and felt self respect just by being able to work. Now, it is a constant struggle for her. Something is not right! $125.00, to drive two hours round trip just to refill prescriptions and no individual help from the medical professional. So frustrating! and sad. Without the medications, her symptoms truly debilitate her, and exacerbate the additional fibromyalgia issues. I am so worried for her!
It is discrimination. Doctors need to remember they are there to do the greatest good, without consideration for their incomes put above any other consideration. I was beyond shocked when I saw a sign in my doctor’s office about a year ago that no straight Medicare patients would be accepted. You must have a Medicare Advantage plan with, of course, the company thru which you receive the plan putting their profits above your health. No wonder people in this country are so unhappy and on the verge of civil war just to have someone to beat up on – maybe kill. All those guns in the hands of those vengeful fools deserve the highest consideration of all. Public health is important, get your priorities straight doctors or find some other line of work.
You expect someone who took out 200k in loans to see 30 Medicare or Medicaid patients a day when they can see 15 insured patients a day and make the same amount of money? Reverse the thought process, let’s pretend you worked an hourly job as a secretary- you could work 60 hours a week and get paid the same as 30 hours a week doing the same job, and you expect us to sacrifice our families time for the good of society? We are not priests and shouldn’t be forced to be paid less and work more- sorry. I’m not greedy but also value time off with my family and friends.
I’m afraid you are uninformed. Few if any of us put income above any other consideration. But we do consider it when making decisions about what insurance to accept. Such a decision is pure and simple a business decision for those in private practice. For the increasing number of doctors employed by large healthcare systems, the decision is out of their hands. If our country is actually committed to healthcare for the poor, doctors would be paid adequately to provide for them. Your argument that income should be no consideration at all equates to commercial insurors subsiding care for Medicaid patients.
Dr.Agarwal has not had to consider a budget in keeping a clinic open. With each Medicaid patient we actually lose money, considering the enormous overhead in a medical practice.
Would other businesses involved in health care also take a pay cut in order to care for Medicaid patients? How about a tax incentive or reduction in government fees to those that accept Medicaid? The health insurers, pharmaceutical companies, medical device companies, etc. continue to get full price for their services from Medicaid patients. Hospitals get a big kickback for their Medicaid services from the government. Why are doctors supposed to singly take a personal financial hit? I bet you get a salary no matter who you care for…..
My experience from 17 years in primary care in an internal medicine group is similar to Dr McAnelly’s. To see Medicaid patients, we would net nothing in take home pay and often would suffer a loss after overhead, in effect subsidizing the medical care of those patients. In addition to other bureaucratic hassles, referrals become more difficult as well.
Any private practioner must recoup enough to cover expenses and have what’s left for personal income. Income isn’t the main reason I went into or love practicing medicine, but I don’t want a pay cut. Also if I can work 40+ hours a week and earn x dollars, why would I willingly pursue less income for the same number of hours.
Dr. Agarwal’s moralizing is typical of those that have no hands-on experience &/or no financial responsibility for their practice, i.e. no skin in the game. If Dr Agarwal truly wants to understand the issues, he should leave academia and join a private practice for 5 years or so to become a LMD. Fellowship and MPH are unnecessary.
The foundation of healthcare in other developed countries, primary care in the US is both disparaged and expected to be the solution to every public health issue from guns to safety belts to spouse abuse to safe sex, ad infinitum.
More and more doctors are taking salaried positions. I’m told that locally most are subsidized by the large health centers for whom they work. Additionally many large systems are charging facility fees for primary care.
I believe in universal coverage. I don’t think finances should preclude good medical care. I think our system discourages primary care as a career choice and Dr Agarwal’s comments further that goal. When we as a nation effectively provide for universal coverage and do more than give lip service to promoting primary care, I will applaud those actions. But, no, Dr Agarwal, I do not feel personally responsible for the failings of the current system.
The author is passing moral judgment on his colleagues when he does not know them or their circumstances. This says more about the author than it does other doctors. But what speaks loudest is that STAT.com sees fit to print this propaganda.
Dr. Agarwal does not understand the financial realities in running a private practice. Every time I have ran the numbers to see if I could accept Medicaid, the reimbursement is less than my overhead costs, let alone any money left to pay myself a salary. I am a solo practice pediatrician, my wife is my receptionist and billing clerk, and I have one nurse that works 35 hours per week. I take my own call all the time, work Monday through Friday 8-5, with one hour for lunch, and close at 4 p.m. on Wednesdays. I take 10 days vacation every couple of years. I know how to run a practice efficiently. I have worked at practices that accept Medicaid, and the other issue has been a no-show rate of 50%. It is not something I can do.
George: that is so discouraging. Understood that it is the reality though. Working in a catholic system, we accept anyone regardless of the ability to pay. I did not realize the no show rate – on top of the abysmal reimbursement. The result is shameful and I keep coming back to the inevitable intervention: government takeover of healthcare.
George
Spot on sir! NOTHING in the “system” is going to change the mindset of the American towards his personal responsibility for his own care level. The top two nation on planet earth for healthcare and health outcomes are Singapore and Israel. As a former advisor to the US Senate on all things healthcare related I have been asked numerous times “so what do they do that we don’t and why can’t we simply follow their lead”
The answer is pathetically simple. We can’t follow their lead because our people don’t care!
Take a look at Israel. Everyone be it male or female must do their time in the Israeli military they have then engrained in the brain from birth. Same goes for health it is engrained in them that unless they take great care of themselves no one else will and then their life will simply be at their own disposal
Singaporeans are obsessed with eating correctly, exercising enough, not consuming tobacco, or excessive alcohol, and even taking time out of their day EVERY day to meditate, exercise, and soul search for solutions to things that Americans simply ignore
In Singapore, the entire society is based on a simple universal concept. If one is in need they have let down their neighbors and are a burden. So there if someone is sick the entire community steps up to prop them up until they no longer get results then if someone is still not able to be helped they make them comfortable and move on to the next person.
In the US we somehow feel like this pathetic article suggests that healthCARE is a moral ground. a place of moving responsibility from the individual to the entirety of society. It is SURELY not medicine’s responsibility that individuals are sick. It might be our JOB to help them but it is not our responsibility to help them
Doing so at the loss of income, peace, effectiveness, and the like only hurts the entire nation. Devoting so much time to the bottom-dwelling 7 million who refuse to cooperate all the while we lose focus that we are made up of 340 million total is a typical leftist approach to life in general
Make everyone feel guilty for the few so that we enter into a downward spiral that only ends when everyone is entrapped in a communist country and devoid of any passion or desire to excel
Look how well EVERY communist nation has ended over the last 100 years or so and that is the end we are heading towards if we don’t stop creating entitlements and a mindset that everyone must be responsible for the individuals. Sure it is fine to “support” each other that is how we succeed but to assume it is a societal responsibility is illogical and will end up in disaster. It is the time that individuals realize that they either fend for themselves or fail. Be it financial, medical, social, or spiritual the bottom line is that if it is to be done only the person can do it. It is not now and never was the community’s responsibility to care for the individual’s needs it is only the community’s availability to the individual who supports the community that society wins. When someone is given a freebie and then misses 50% of the appointments that demonstrates my assertion 100%. One would THINK they would be there 20 minutes early and willing to straighten up the magazines in exchange for being treated for free but NO they are entitled and feel outraged that they have to wait to be seen.
Dr. Dave
Liberal politicians never ask the people who take care of Medicaid patients why they have such deep reservations and disdain towards their Medicaid patients. As an ER physician for ten years here are the reasons:
1. When the government gives a group of people something for free, they don’t hesitate to race to the ER instead of their primary care for minor ailments. It’s not uncommon for momma to check in along with two or three kids at the same time. One is usually sick, the others just “need checked out”. Without a co pay or deductible, there’s zero incentive to not abuse the system.
2. Medicaid population are always victims that require someone else to fix their problems. At discharge, doctor you can’t send me home, I don’t have a ride or I need food. My mother would’ve been appalled if I asked someone else for basic needs but not Medicaid patients.
3. The expect and demand things and are ungrateful.
Over the years, I’ve realized there’s certain people who take responsibility and are appreciative but Medicaid patients are victims who refuse to help themselves- I’ve stopped trying to help them and frankly, wish I didn’t have to see another Medicaid patient- ever.