Sunday, February 18, 2024

Should Medical Doctors Be Required to Accept Medicare and Medicaid $$$ as a Condition of Licensure? Can the Gods be humble and care for their lowly helpless subjects?

Should Medical Doctors Be Required to Accept Medicare and Medicaid as a Condition of Licensure?





By Donald H. Marks, MD PhD, FACP   physician and scientist
Reason, ethics, health equity, 3rd generation Veteran

Medicare and Medicaid are two government programs that provide health coverage to millions of Americans. Medicare covers 67 million citizens ages 65 and over, as well as 8 million younger adults with certain chronic conditions or disabilities. Medicaid is a joint federal-state program that provides health insurance to low-income individuals and families. To date, 41 states (including DC) have adopted the Medicaid expansion, and as of June 2023, approximately 94 million persons are covered by Medicaid and Children’s Health Insurance Program CHIP.  


Having insurance coverage is not the same as having access to care,  because not all doctors accept Medicare and Medicaid patients. Are you shocked, surprised or offended? According to a survey by the American Medical Association, in 2018, 90% of physicians accept new Medicare patients, while only 72% accepted new Medicaid patients. The main reasons cited for this discrepancy are the low reimbursement rates and the high administrative burden of dealing with these programs. I have faced this very frustrating situation in my own medical practice and in my own personal life as an over 65 medical patient, turned away by a large local hospital-affiliated orthopedic surgery group which does not accept Medicare.

Interesting discussion of medical equity and access to care, on Star Trek https://youtube.com/shorts/MNbADGu_0Z0?si=e3owA2sTyhy7GliE


Some healthcare equity advocates argue that all medical doctors should be required to accept Medicare and Medicaid as a condition of their medical license. They claim that this would ensure access to quality health care for all Americans, regardless of their income or age. They also point out that medical doctors have a social responsibility to serve the public good, and that accepting government insurance is part of their professional duty.


Some opponents contend that medical doctors should have the freedom to choose their patients and their payment methods. They assert that forcing medical doctors to accept Medicare and Medicaid would violate their autonomy and their property rights. They also warn that such a mandate could reduce the supply and quality of doctors, as some would retire early, relocate to other states, or opt out of the system altogether.


Public Funding of Physician Training

All physicians in the United States receive some form of public funding during their training. This funding can come from a variety of sources, including:

  • Federal funding: The federal government provides funding for medical schools, residency programs, and other healthcare training programs through a variety of programs, such as the National Institutes of Health (NIH) and the Health Resources and Services Administration (HRSA). Another form of federal funding, which I benefited from, is military sponsorship.

  • State funding: Many state governments also provide funding for medical schools and residency programs.

  • Local funding: Some local governments also provide funding for healthcare training programs.

In addition to government funding, many physicians also receive financial assistance from private sources, such as scholarships and loans. However, even these private sources of funding often rely on government support in some way. For example, many student loans are guaranteed by the federal government.

Obligation to Accept Medicaid Patients

Because all physicians receive some form of public funding during their training, many healthcare equity advocates argue that medical doctors have an obligation to accept Medicare and Medicaid patients.

There are a number of reasons why physicians should accept Medicaid patients. First, it is a way to repay the public for the investment that was made in their training. Second, it helps to ensure that everyone has access to quality healthcare, regardless of their income. Third, it can help to reduce the burden on the uninsured healthcare system.

Challenges

There are a number of challenges that physicians face when accepting Medicaid patients. One challenge is that Medicaid reimbursement rates are often (but not always) lower than those of private insurance companies. This can make it difficult for physicians to cover the costs of providing care to Medicare/Medicaid patients.

Another challenge is that Medicaid patients often can have more complex medical needs. This can make it more time-consuming and difficult to provide care to Medicare/Medicaid patients.

While it's important to encourage healthcare providers to participate in government healthcare programs like Medicaid and Medicare, denying medical doctors a medical license solely for not accepting these programs may not be the most effective or ethical approach. Instead, it may be more effective to incentivize their participation through other means, such as matching Medicare Medicaid to BC/ BS or Kaiser rates. Here's why:

1. Ethical Considerations: Denying medical doctors a medical license based solely on their participation in specific insurance programs could be seen as discriminatory and heavy-handed. All licensed medical professionals should be treated equally, but their primary commitment should be to provide quality health care to patients, regardless of their insurance status.


2. Access to Care: Restricting access to care by revoking licenses may be counter-productive, by exacerbating the shortage of healthcare providers, especially in underserved areas. A better approach may be to encourage more doctors to accept Medicaid and Medicare patients by offering realistic reimbursement rates which also represent the cost of providing care, and lowering administrative barriers.


3. Focus on Quality of Care: Licensing should primarily ensure that medical doctors are qualified and capable of providing high-quality care. Accepting or not accepting specific insurance should not be the sole determinant of a physician's qualifications.


4. Individual Choice: Doctors often have valid reasons for not participating in government insurance programs, such as administrative burdens or low reimbursement rates. Some hold that it is essential to respect their professional judgment and provide incentives for participation rather than punitive measures.


5. Incentivize Participation: Instead of punitive measures, it may be better to create incentives for medical doctors to participate in Medicaid and Medicare. These could include improved reimbursement rates, reduced administrative burdens, or offering tax incentives for providers who accept a certain percentage of patients from these programs.


6. Patient Choice: Patients should have the freedom to choose their doctors. Forcing doctors to accept specific insurance could limit patient choice and interfere with the doctor-patient relationship, which is crucial for effective healthcare.


Of course it's crucial to encourage medical doctors to participate in Medicaid and Medicare without resorting to revoking medical licenses, although the alternative of denying access to healthcare to the sick is even more onerous, IMO. By addressing the issues that deter doctors from participating and providing incentives, we may perhaps ensure that more healthcare providers accept patients from these programs while upholding ethical standards and individual choice.


From a health equity and ethics standpoint, are medical doctors who refuse to accept Medicaid or Medicare simply greedy? 

Health equity is the principle that everyone should have a fair and just opportunity to attain their highest level of health, regardless of their income, race, ethnicity, gender, disability, or other factors that may affect their access to health care (CDC What is Health Equity? | Health Equity | CDC). By electing not to accept Medicaid or Medicare patients, even though these programs provide essential life-supporting health insurance for millions of low-income, elderly, and disabled Americans (https://www.who.int/health-topics/health-equity), those non-participating medical doctors are actively and intentionally denying patients the right to health and contribute to the health disparities that result from their unequal access to quality health care.

One might argue that doctors who refuse to accept Medicaid or Medicare are greedy because they prioritize their own financial interests over the health needs of their patients. According to a report by the Medicaid and CHIP Payment and Access Commission (MACPAC), the average Medicaid payment for 18 selected conditions was 6 percent higher than Medicare in 2012 (https://www.cdc.gov/nchhstp/healthequity/index.html ). Moreover, the average Medicaid payment for all but two of the conditions was higher than Medicare. This means that doctors who reject Medicaid patients are not only discriminating against poor and needy patients, but also losing out on potential revenue.


Another reason why doctors who refuse to accept Medicaid or Medicare might be considered greedy is that they are ignoring the social determinants of health that affect their potential patients’ well-being. Social determinants of health are the conditions in which people live, learn, work, play, and worship that influence their health risks and outcomes (https://www.cdc.gov/healthequity/whatis/index.html). These include factors such as discrimination, racism, poverty, education, employment, housing, transportation, economic status, and environment. By turning their backs on Medicaid or Medicare patients in favor of better paying patients, those doctors are failing to address the root causes of poor health and perpetuating the cycle of disadvantage and disease.

Therefore, from a health equity standpoint, doctors who refuse to accept Medicaid or Medicare could be considered greedy because they violate the principle of fairness and justice in healthcare. They also miss the opportunity to improve the health outcomes of patients and reduce the burden of preventable diseases on society.


The American College of Physicians, the internal medicine professional society to which I belong as an Emeritis Fellow, has a vision for improving healthcare access in America. ACP provides a comprehensive, interconnected set of policies for a better U.S. healthcare system for all. 


The first of ACP comprehensive recommendations is that USA should transition to universal coverage, which includes essential benefits, which I and most US citizens and healthcare providers agree. Prior US presidents, including FDR, Nixon and Clinton have agreed. 


ACP vision challenges the U.S. not to settle for the status quo, but to implement systematic health care reforms. An additional set of ACP policy papers, published in Annals of Internal Medicine, address issues related to coverage and cost of care, health care payment and delivery systems, barriers to care and social determinants of health, and more. 


Although essentially a commendable set of proposals, I look forward to ACP giving more attention to the "essentially uninsured", meaning those with unaffordable premiums, high deductibles, and poor access to providers. Not being able to afford healthcare is equivalent to not having access to healthcare. For many, it's essentially not available. In addition, if a drug is priced in a way that results in it being unaffordable, it is essentially not available to those in need, and in that sense of no efficacy. Drugs found to have no efficacy should have their approval from FDA revoked.

 

Solutions

The issue of whether medical doctors should be required to participate in Medicare and Medicaid is a complex and controversial one. It involves ethical, economic, and legal considerations that affect both doctors and patients. 


I look forward to your comments on all these issues.




References


Physicians who refuse to accept Medicaid patients breach their contract with society https://www.statnews.com/2017/12/28/medicaid-physicians-social-contract/


What is Health Equity? | Health Equity | CDC

https://www.cdc.gov/nchhstp/healthequity/index.html

https://www.cdc.gov/healthequity/whatis/index.html


Health Equity. WHO. https://www.who.int/health-topics/health-equity



Personal blog of Donald H. Marks, where one can find most of my personal and professional writings, and links to my podcases. www.DHMarks.blogspot.com


Reducing the influence of politics in healthcare. Donald H. Marks https://dhmarks.blogspot.com/2023/08/reducing-influence-of-politics-in.html


Better is Possible: ACP's Vision for the U.S. Health Care System. My comments.  https://dhmarks.blogspot.com/2020/04/httpsannalsorgaimfullarticle2759528envi.html




UBI: a Basic Income floor be established public policy and should it be Universal. My personal take, as a non-economist.

Universal basic income (UBI) is a proposed government program in which every adult citizen may receive a set amount of money regularly. Most models of UBI advocate payment that is not based upon need, a detail that makes no sense to me and certainly will lead to both rejection by voters and will inevitably lead to corruption and waste of money. The proposed use and justification of UBI is to help offset the cost of basic expenses including minimally adequate housing, food, certain essential medications, child care, and others, for those who have an established need and do not have their own adequate resources to survive, i.e. need and resource-dependent.

Much of the renewed interest in UBI appears to be from a fundamental change to the economy—namely, the growth of automation—that threatens to leave many Americans without jobs that pay a subsistence wage = a livable wage, as opposed to the more often cited, but in practice inadequate, minimum wage.

The end goals of a basic income system would seem to be to alleviate poverty and potentially to replace other need-based social programs that require greater bureaucratic involvement. The world economies seem to be repeating past major changes in the economy (see works of Ray Dalio, Thomas Piketty, Neil Howe and the social scientist Peter Turchin), specifically during the industrial revolutions, the great depression, and world wars. The idea of UBI has gained momentum in the U.S. as automation and AI increasingly replace workers in manufacturing and other sectors of the economy. I have noticed increasing discussion of UBI in recent years, and I have attempted to assimilate for my personal use a position paper on this seemingly reasonable concept. Following are my thoughts, as a non-economist, on the overall issues.

The impact of the rapidly accelerating AI on the need for UBI

The advent of AI is laying a strong foundation for increased productivity and GDP growth, setting the stage for a future where UBI becomes not only possible but necessary. As technology continues to evolve and societies adapt to this 'new normal', we probably will witness a profound transformation in our global economic model.

What will ultimately be UBI's impact on economic inequality is a subject of much debate, and certainly resolves around implementation. Proponents argue that UBI can help reduce inequality by providing financial support to low-income individuals and families. However, critics contend that the effectiveness of UBI in reducing inequality depends on its design, funding, and UBI’s interaction with other social policies. For a comprehensive approach to addressing economic inequality, some experts suggest combining UBI with other policies that focus on wealth redistribution and asset-building programs. Leading economist thought-leaders in this area include Thomas Piketty (Capital in the 21st Century, and Gorbis 2017). In essence, UBI alone may not be a comprehensive solution to increasing economic inequality, and UBI’s effectiveness would depend on how it is implemented and integrated into broader social and economic policies.

How will UBI be applied specifically to those dealing with substance abuse issues?

Implementing UBIfor people in the throus of substance abuse and other addictive behaviors will definitely require a thoughtful, careful, and holistic approach that utilized current social and rehab services coupled with the cruel reality of drug dependency. Here are some considerations:

1. Identifying appropriate recipients: It's essential to identify individuals who are struggling with drug addiction, enlisting the help of healthcare professionals, addiction treatment centers and a wider outreach.

2. Tailored support: Customize the UBI program to address the specific needs of drug addicts. This could include additional funds for addiction treatment, counseling, and rehabilitation services.

3. Education and awareness: Invest in education and awareness programs to inform recipients about the importance of seeking help for their addiction and how the UBI can support their recovery.

4. Monitoring and evaluation: Continuously monitor the progress of recipients to ensure that the UBI is being used for its intended purpose only and that individuals are making efforts to overcome addiction. See my following comments on specific areas for appropriate and inappropriate use. Enabling should not be tolerated.

5. Collaborate with addiction treatment centers: Partner with organizations and facilities that specialize in addiction recovery to provide comprehensive support to recipients.

6. Prevent enabling: Ensure that the UBI does not inadvertently enable drug and alcohol addiction, destructive and anti-social compulsive behavious, violent aberant behaviors, and other by offering essential adequate support in the form of goods and services, rather than cash.

7. Access to mental health services: Many drug addicts also suffer from underlying mental health issues. AI will play an increasing role here. Provide access to mental health services alongside the UBI to address these co-occurring problems.

8. Rehabilitation and reintegration: Encourage and support drug addicts to seek rehabilitation and help them reintegrate into society with vocational training and employment support.

9. Social services: Make available social services like housing assistance and food programs to ensure that the basic needs of recipients are met.

10. Evaluate and adjust: Continuously assess the UBI program's effectiveness and make adjustments as necessary to improve outcomes and help recipients on their path to recovery.

Remember that addressing drug and alcohol addiction and compulsive,, violent or socially destructive behaviors is a complex issue, and UBI alone is unlikely to be the sole solution. It should be part of a comprehensive strategy to provide realistic support and opportunities for recovery.

An important issue is what exactly should be covered by UBI? To start this conversation, I offer the following list of areas appropriate for UBI funds:

  • Essential medication and access to basic essential healthcare for all citizens,
  • Access to basic safe food and shelter

Equally important, and to increase its acceptability by policymakers and citizens, we need a consensus on what should not be covered by UBI.

  • Non-essential medications and medical procedures,
  • Certain vaccines not already covered by government programs or mandates,
  • Sex reassignment,
  • Addictive drugs, including heroin, cocaine, methamphetamine, repurposed drugs without established benefit in humans, including xylazine and ivermectin, marijuana,
  • Alcohol,
  • Weapons,
  • Elective recreational activities.

UBI, being universal, certainly has its critics and drawbacks:

  • Cost and Sustainability: Critics argue that providing a universal income to all citizens can be prohibitively expensive for governments. Funding a UBI program could lead to substantial increases in taxation or divert resources from other essential public services, potentially straining national budgets [See the commentary by CBPP].
  • Inequity: Some believe that a universal approach doesn't effectively target those in greatest need. UBI may provide unnecessary financial assistance to individuals who are already well-off while not providing enough for those facing severe economic hardships, potentially exacerbating income inequality.
  • Workforce Participation: Critics argue that a universal income might disincentivize people from working, as they would receive money without the requirement of employment. However, studies have shown mixed results regarding the impact of UBI on workforce participation [UBI, U Chicago].
  • Budget Allocation: Allocating resources universally to all citizens may not address specific societal challenges effectively. Critics suggest that targeted social programs could better address the diverse needs of different demographics and address specific issues, such as healthcare, education, or poverty reduction, more effectively [Money for Nothing. Brookings].
  • Political Feasibility: Implementing a universal income may face significant political challenges and resistance due to concerns about its cost and potential economic consequences. This can hinder the feasibility of enacting UBI policies

Everyone asks: Where will all the money come from? Potential sources for UBI include:

  • Redirecting the interest on national debt
  • Diminishing foreign wars and military aid
  • Expenses through the Military-industrial complex
  • Revising the payment for pharmaceutical and healthcare complex
  • Addressing Income and asset redistribution and maldistribution
  • Collection of taxes from hidden assets
  • Maybe a “needs test” for social services including social security, Medicare, and retirement before 65.

Criticisms of UBI

Despite its promise to curtail poverty and cut red tape, UBI still faces an uphill battle. Perhaps the most glaring downside is cost. According to the nonprofit Tax Foundation, former Presential candidate Andrew Yang’s proposed $1,000-a-month “Freedom Dividend” for every adult would cost $2.8 trillion each year (minus any offsets from the consolidation of other programs).

Yang, ever the dreamer, proposed covering that substantial federal budget expense, in part, by reciprocal shrinking the size of other social programs and imposing a 10% value-added tax (VAT) on businesses. He also proposes ending the cap on Social Security payroll taxes and putting in place a tax on carbon emissions that would contribute to his guaranteed UBI.

Whether that set of proposals is enough to fully offset the cost of the Freedom Dividend remains a contentious issue, however. An analysis by the Tax Foundation concluded that Yang’s revenue-generating ideas would only cover about half its total impact on the Treasury.

Among the other criticisms of UBI is the argument that an income stream that’s not reliant on employment would create a disincentive to work. That, too, has been a subject of debate, although certainly seems reasonable. Yang has suggested that his plan to provide $12,000 a year wouldn’t be enough to live on. Therefore, the vast majority of adults would need to supplement the payment with other income.

While UBI has its merits, including poverty alleviation and simplification of social welfare systems, there are valid concerns regarding its universality. Critics argue that it may strain government budgets, not effectively target those in need, and potentially discourage workforce participation, among other challenges. The decision to implement UBI in a universal or targeted manner depends on the specific policy goals and the economic and political context of a country.

Basic Income support for eligible needy citizens should, in my opinion, be universal for several compelling reasons:

  • Simplicity and Efficiency: UBI should serve to simplify social welfare systems by providing a fixed, unconditional minimum sustainable floor income to every eligible citizen, reducing the need for complex means-testing and administrative overhead. The devil is of course in the details, centering around the words Eligible and Equitable. This simplicity may reduce bureaucratic inefficiencies and lower administrative costs, as discussed in the World Bank's guide on UBI.
  • Poverty Alleviation: UBI should help reduce poverty by providing a financial safety net for citizens in need, especially those in vulnerable or low-income groups. It ensures that no one would fall below a certain sustainable safe basic livable income threshold, contributes to poverty reduction, and improves living standards (as mentioned by a recent Brookings Institution report).
  • Economic Stability: UBI can stimulate economic activity by increasing consumer spending. When everyone has a guaranteed basic floor livable income, they are more likely to spend money on essential goods and services, thereby boosting demand and supporting businesses, as indicated by Investopedia.
  • Flexibility: UBI provides eligible citizens with the freedom to choose how they allocate their funds, whether for education, healthcare, starting a business, or covering basic needs. This flexibility empowers people to make decisions that align with their unique circumstances, as noted by UNC College.
  • Social Cohesion: UBI promotes social cohesion and reduces income and asset inequality by ensuring that everyone benefits from economic progress. It helps bridge income disparities and fosters a sense of inclusivity in society, as emphasized in the cited World Bank's guide.
  • Future of Work: In a rapidly changing job landscape with automation, AI, and gig work, UBI can provide a safety net for individuals facing job disruptions, as discussed in CNBC's article on UBI in the USA.

In summary, a universal approach to UBI is an interesting, stabilizing, equitable approach to simplify welfare systems, could at least contribute to the alleviation of poverty, stabilize the economy, empower individuals, enhance social cohesion, and address the challenges of the evolving job market, making it a compelling policy option for the USA and many countries

UBI may provide a working solution to mass unemployment caused by AI-driven automation by offering financial support, promoting inclusive growth, stabilizing the economy, encouraging innovation, and allowing for policy adaptation to changing circumstances. However, the success of UBI in this context depends on its design and implementation alongside other supportive policies and programs.

This is a subset of my more complete discussion of UBI - a non-economist view. The complete article can be found on my personal blog https://dhmarks.blogspot.com/2024/02/should-basic-income-floor-be.html

Your comments are always welcome


References that I have found helpful.

Marina Gorbis, 2017. To fix income inequality, we need more than UBI—we need Universal Basic Assets (qz.com)

Ray Dalio, Principles For Dealing With The Changing World Order: Why Nations Succeed And Fail.

Thomas Piketty, 2017. Capital in the Twenty-First Century

Neil Howe and Peter Turchin). The Fourth Turning is Here.

How do I get to UBI and post labor economics? Decentralized ownership and the new social contract, by David Shapiro. https://youtu.be/T3O_BNexdEg?si=PUqs0fe9g2V0VLAk







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Donald Harvey Marks is an American physician, scientist, author and advocate for improved healthcare access. He is a husband, the proud father of three children, and a grandfather of 5. He is a believer in reason, ethics, and is a 3rd gen veteran.

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