The toxicity of Medicaid

I have noticed over the years that physicians who write about medicine, particularly for the general public, are limited to very specific discussions.  For instance, it is perfectly acceptable to write about the plight of the poor and uninsured.  It is always reasonable to advocate for a single payer system. It is perfectly acceptable to discuss how one downsized in order to make less and “give back” more.  And it is praiseworthy to hold forth on the absolute necessity of primary care.

It is reprehensible to discuss money unless it has to do with intentionally making less of it.  It is judgmental to suggest that patients might, in some way, bring their ills upon themselves.  It is cruel and heartless to advocate for more market solutions.  And it is symptomatic of burnout to suggest that one no longer enjoys practice, or finds dealing with the public to be unpleasant.

To write any of the above negatives is to incur a blizzard of angry letters and suggestions that one leave medicine to the truly compassionate and seek mental health care.

However, I will here boldly violate the above the rules and say that emergency medicine is getting ever more difficult, in part because of Medicaid.  This is extremely relevant since the ACA is dramatically increasing the Medicaid rolls.

By way of disclaimer, many of my favorite patients are dependent on Medicaid.  I love them and I am happy to see them, whether for their child’s earache or their own pneumonia or injury.  Many people truly need the program, and it helps them … at least in the short term.  However, it is hurting medicine — both primary care and emergency care.

(Look at the recent study out of Oregon which showed clearly that Medicaid increases emergency department usage.  It’s an interesting study with mixed results … no change in patients in terms of control of hypertension, diabetes or cholesterol, but there was a decrease in depression and in financially catastrophic health-care costs.)

The problem is multi-faceted. But at the heart of it is the fact that our Medicaid population has no ownership of their health care dollars.  They’re told by government functionaries that they have insurance.  But I have insurance.  And as such, I try my best not to use it because the co-pays are very expensive.  Medicaid patients suffer from no such disincentives.

The problem is, of course, that a relatively small number of “bad eggs” make everyone else look bad as well.  They come to the ER at night with a sick child. I treat the child and say “see your doctor next week if he isn’t better.” “Oh, we have an appointment with him in the morning anyway,” mom responds.  Many of them, unemployed, have no schedule restrictions.  So coming to the ER at 3am is not in any way an impediment to going to the pediatrician the next morning.

Furthermore, some are extremely demanding.  One told me, “I have the right to whatever treatment I want.  I checked it out. And I demand to be admitted until this is figured out!” Well, no.  It was a long, loud discussion over a problem that was non-emergent.

In addition, our Medicaid population has no emergency department co-pay.  Likewise, the Medicaid reimbursement rates would be comical if they weren’t insulting.  (Some years ago our Medicaid rate for a cardiac arrest resuscitation was somewhere around $100.)  A $5 co-pay would truly re-direct a great deal of traffic. And the argument that it would be oppressive is ludicrous in the face of the expensive cell-phones and plans, the cigarettes, drugs, jewelry and vehicles that some of our Medicaid patients sport.  Alas, while Medicaid primary care patients sometimes have a co-pay, EMTALA ensures that will never happen in the ED.

But the problem isn’t just the abuse as listed above.  It’s that this population of patients, who use the ED extensively and for any and every problem, cause the department to be ever crowded with patients who do not deserve the name patient. And yet they complain of things we must evaluate.  They call ambulances for fever, they complain endlessly of chest pain when they have anxiety (with attendant dyspnea, diaphoresis and nausea, of course, all of which direct us to work them up for heart attack.)  Their headaches are always the worst and their depression is frequently suicidal … knowing as they do that commitment to a mental health facility raises the likelihood of the “holy grail” of disability.

In the end, I want to help the sick and injured; especially the poor and their children. But I fear that Medicaid is only growing more toxic to those who have it and those who are paid by it.  It offers little advantage to those who have it (well demonstrated in a recent study from Oregon), it demoralizes those who treat the patients with it (and costs us money since we are hardly excused from expensive liability insurance while accepting it) and it adds so much hay through which we must daily sift to find the needle.

I know. Bad doctor.  Hateful doctor. Let the name-calling begin.  But if nothing else, honest doctor. Deal with it.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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