Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The toxicity of Medicaid

Edwin Leap, MD
Physician
January 28, 2014
2K Shares
Share
Tweet
Share

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.

Prev

People with overt disabilities: Are we more forgiving of their behavior?

January 27, 2014 Kevin 7
…
Next

The truth about juicing

January 28, 2014 Kevin 1
…

Tagged as: Emergency Medicine

Post navigation

< Previous Post
People with overt disabilities: Are we more forgiving of their behavior?
Next Post >
The truth about juicing

More by Edwin Leap, MD

  • Hospitals at a breaking point: Lack of staff and resources leave ERs in chaos

    Edwin Leap, MD
  • Trapped in a cauldron of suffering, medical staff are weary

    Edwin Leap, MD
  • Vaccine hesitancy is complex

    Edwin Leap, MD

More in Physician

  • Tom Brady’s legacy and the importance of personal integrity in end-of-life choices

    Kevin Haselhorst, MD
  • The hidden truths of hospital life: What doctors wish you knew

    Emily Stanford, DO
  • The heart of a Desi doctor: Balancing emotions and resources in oncology

    Dr. Damane Zehra
  • The Iranian diaspora’s fight for liberty: Overcoming challenges in the largest women’s rights movement of our century

    Montreh Tavakkoli, MD
  • The harmful effects of shaming patients for self-education

    Maryanna Barrett, MD
  • The power of self-appreciation: Why physicians need to start acknowledging their own contributions

    Wendy Schofer, MD
  • Most Popular

  • Past Week

    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
    • Breaking free from a toxic relationship with medicine [PODCAST]

      The Podcast by KevinMD | Podcast
    • Revolutionizing COPD management with virtual care solutions [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • Breaking free from a toxic relationship with medicine [PODCAST]

      The Podcast by KevinMD | Podcast
    • Tom Brady’s legacy and the importance of personal integrity in end-of-life choices

      Kevin Haselhorst, MD | Physician
    • The hidden truths of hospital life: What doctors wish you knew

      Emily Stanford, DO | Physician
    • 10 commandments of ethical affiliate marketing for physicians

      Aaron Morgenstein, MD & Amy Bissada, DO | Finance
    • The heart of a Desi doctor: Balancing emotions and resources in oncology

      Dr. Damane Zehra | Physician
    • Safe sex for seniors: Dispelling myths and embracing safe practices [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 158 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Journal Shows Its Commitment to Exploring AI in Medicine
  • Do Away With 'Lockout' Period in iPLEDGE, FDA Advisors Urge
  • Cluster Headache, Migraine Linked to Circadian System
  • Smaller Liver Transplant Candidates Wait Longer, Less Likely to Receive Organ
  • A 'Double Whammy' for Gastric Cancer Risk

Meeting Coverage

  • Oral Roflumilast Effective in the Treatment of Plaque Psoriasis
  • Phase III Trials 'Hit a Home Run' in Advanced Endometrial Cancer
  • Cannabis Use Common in Post-Surgery Patients on Opioid Tapering
  • Less Abuse With Extended-Release Oxycodone, Poison Center Data Suggest
  • Novel Strategies Show Winning Potential in Ovarian Cancer
  • Most Popular

  • Past Week

    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
    • Breaking free from a toxic relationship with medicine [PODCAST]

      The Podcast by KevinMD | Podcast
    • Revolutionizing COPD management with virtual care solutions [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • Breaking free from a toxic relationship with medicine [PODCAST]

      The Podcast by KevinMD | Podcast
    • Tom Brady’s legacy and the importance of personal integrity in end-of-life choices

      Kevin Haselhorst, MD | Physician
    • The hidden truths of hospital life: What doctors wish you knew

      Emily Stanford, DO | Physician
    • 10 commandments of ethical affiliate marketing for physicians

      Aaron Morgenstein, MD & Amy Bissada, DO | Finance
    • The heart of a Desi doctor: Balancing emotions and resources in oncology

      Dr. Damane Zehra | Physician
    • Safe sex for seniors: Dispelling myths and embracing safe practices [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

The toxicity of Medicaid
158 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...