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