Medicaid- the failed promise of Obamacare

“It is health insurance by sleight of hand”

Like many social programs, Medicaid, government subsidized health insurance for the indigent, was based on the laudable premise that the poor deserve good health care. Its implementation, however, has been less than stellar. In fact, I and half of my physician colleagues consider it a failed program. To us, having Medicaid is very much like having no insurance at all. I don’t really care if my staff file Medicaid claims. I know that when I see a Medicaid patient we will have to battle for payment and, when it comes, it will not cover my costs of practice for that care. It is less hassle to see them for free.

You see, I am in the trenches, seeing patients every day. Medicaid is not an abstraction; I deal with it constantly. It is telling that on Medicaid forms I am not a physician; I am a “vendor”. I do have one luxury. I am not a family physician, dealing with all comers. As a specialist, I am not called on to see many Medicaid patients. When I do, it is usually for an emergency situation. In those, insurance is moot since I will care for any patient regardless, if they are in urgent need. Most of my colleagues do the same. It is what we do as physicians. For elective care, it is different. Let me give you an example.

The most common problem for which I used to see Medicaid patients electively was for breast reductions. Large breasts are a legitimate medical problem, causing all sorts of misery to women who possess them- constant back, neck, and shoulder pain; rashes; nerve issues in their arms; limited ability to engage in physical activities, and social embarrassment. My breast reduction patients are probably, as a group, my happiest patients after their surgery. Because Medicaid paid so poorly for breast reductions, although I saw their patients for this problem, I had to limit it to no more than one or two a month. Most physicians who will see Medicaid patients ration how many they will see in a given period.

Some have opined that physicians have an obligation to see Medicaid patients and that not doing so is a breach of our responsibility as physicians. I counter by saying that a practice made up largely of Medicaid patients is likely not sustainable. Medicaid pays two thirds of what Medicare pays for care and many physicians regard Medicare as too low given all the costs of medical practice these days, costs which only seem to grow year by year. No, physicians aren’t starving but we are working harder and harder for less and less pay and physician burnout rates have skyrocketed.

My typical Medicaid breast reduction patient was both obese and huge; these were the largest breasts I saw, and the most difficult to reduce. One day, I was interviewing a patient and noticed that she came from Jacksonville, FL, over a three hour drive away. I asked her why she had driven so far to see me, bypassing literally dozens of plastic surgeons. Her answer shocked me. She said I was the only plastic surgeon within a three hour drive who would see Medicaid patients for breast reductions.

This led me to reflect on what I was doing by accepting Medicaid’s terrible reimbursement and constant battle to obtain payment in a timely fashion. Medicaid professes to be full insurance. So long as even a single plastic surgeon in the state accepts Medicaid’s payment for breast reduction, Medicaid can claim this as an offered service, even if patients have to drive hours to see a specialist. By participating, I was perpetuating the charade that Medicaid truly provided this service. That was the last time I accepted a Medicaid breast reduction patient.

This is the little known lie of Medicaid. Yes, patients on Medicaid have “medical insurance” but they will have difficulty finding participating physicians, wait long periods to be seen, and have to drive long distances. The last can be difficult for indigent patients if only for the cost of gas. A 2017 survey found that only 50% of physicians accept Medicaid patients and wait times are on the order of a month for new patients. It is eerily similar to what I saw in Venezuela. The government claims to provide all citizens with universal health care however, when you try to obtain health care, you cannot find a doctor, hospitals are bereft of necessary supplies, and patients find themselves without recourse. It is health care in theory, not fact.

When I heard that expansion of Medicaid was one of the central tenets of Obamacare, I could hardly believe it. This is what you get from politicians to whom something like Medicaid is an abstraction, all the while providing themselves with arguably the best health insurance on the planet. Medicaid as the answer to the uninsured is a sad, sick joke and those who uncritically promote this are either clueless or, worse, disingenuous. It is health insurance by sleight of hand: now you see it (when you sign up), now you don’t (when you need it).

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