House Calls

Medical and other musings of a plastic surgeon

Medicaid and the Emperor’s New Clothes

A Medicaid tale 1

The recent GOP failure to overturn, or even modify, the Affordable Care Act, popularly known as Obamacare, has again brought to the fore the issue of Medicaid as a solution to the uninsured. I have said it before and, at the risk of repeating myself, I will say it again: Medicaid is an insurance con foisted on those who don’t know any better and have no other options. It is the insurance version of the story of the emperor’s new clothes. I feel like the child in that story.


For those not familiar with the Hans Christian Anderson tale, here is a brief synopsis:


An emperor with a taste for fine clothes engaged two weavers to make a suit of clothes for him. The weavers were actually con men who convinced the emperor that their cloth was not only the finest but their technique of weaving gave it the unusual property of being invisible to those who were stupid or unworthy of their position in life. The weavers took the money and materials they were given to make the clothes and pocketed this, all the while weaving on empty looms. Everyone the emperor sent to inspect their progress was unwilling to admit that they saw nothing on the looms for fear that they would be admitting they were too stupid or unqualified for their post. On the day the clothes were unveiled, the emperor, having heard one glowing report after another on the magnificence of his new clothes, discovered to his horror, that he couldn’t see them. Like all the others, he was unwilling to admit this and for the same reasons. He donned the “magnificent” new clothes and paraded through the streets to show them off. The crowd had heard repeatedly over the preceding weeks about the wonderful clothes and their unusual property so no one was willing to admit that the emperor had nothing on. No one, that is, until a small boy shouted out, “the emperor has no clothes!” Despite the dawning realization of the crowd, and the emperor, that the boy was right, the charade continued as the procession moved through the city. No one wanted to be the first to admit that the emperor had no clothes.


The situation with respect to Medicaid is the same; Medicaid insurance is no insurance at all.

Medicaid 7

Medicaid is the government health insurance for the medically indigent. If you cannot afford private health insurance, even through the Obamacare insurance exchanges, and you do not qualify for Medicare, you can apply for Medicaid. Medicaid is provided by each state, with funding assistance from the Federal government.


The problem with having Medicaid insurance is that, once you have it, what does that really get you? Unfortunately, very little. The reason is that so few doctors accept Medicaid that getting to see a physician, especially one geographically close to you, or seeing a specialist, is often an exercise in futility. Ask yourself this. If you have health insurance and no one will accept it and see you, do you really have insurance at all? I would submit that, no, you do not.


The statistics are misleading. A 2013 National Electronic Health Records Survey undertaken by the Office of Management and Budget (OMB) of the Federal government is often quoted as showing that two thirds of physicians accept new Medicaid patients. First off, this means that one in three doctors do not accept Medicaid patients. That’s a big number to write off immediately. As to the other two thirds, if you look at the survey questionnaire, it asks if the physician accepts new patients. Then it lists all the possible types of payers, of which Medicaid is one, and physicians check off all the ones they will accept payment from.


The problem with using these two questions to determine access to medical care for Medicaid patients is that they are too limiting and nonspecific**. I accept new patients and I will accept Medicaid’s payment so, according to this survey, I am a provider of Medicaid services. In reality, I see very few Medicaid patients because Medicaid payment is so low and is such a hassle to collect that it just isn’t worth it. I would just as soon see a patient with no insurance and not charge for it. There is less hassle and I feel it is my obligation to provide some portion of my care to those who cannot pay. Many physicians are like me. They will see only limited Medicaid patients even though they answer “yes” to both seeing new patients and accepting Medicaid payments. I would bet big that if anyone actually looked into how many doctors are actually seeing Medicaid patients and how many they will see in any given year, the number is a lot smaller than two thirds.


Medicaid 6

I constantly hear from Medicaid patients that finding a physician to see them involves a lot of searching and, as often as not, when they find a doctor, they have to travel a long way to see him or her. I have this problem myself when I try to get a Medicaid patient seen for something I do not treat; I can’t find a doctor within a reasonable geographic distance who will accept them. The only physicians who make their living on Medicaid patients are those who will run massive numbers of patients through their practice, often at the expense of quality care. There are certainly exceptions, but that is what they are: exceptions.


The numbers provided by the OMB make politicians feel good, undergirds some of the assumptions used to craft Obamacare, and give lie to the assertion that Medicaid is a legitimate form of insurance to be used to solve the problem of access to health care. Other countries do the same thing. The Venezuelan government, for example, claims to provide universal health care to its citizens. Try to get care through government clinics and hospitals, however, and you will find that there are too few physicians and resources are so limited that medical care is that in name only, kind of like the emperor’s new clothes.


If you doubt what I am saying, try this little experiment. Call a dozen doctor’s offices randomly. Tell then you have Medicaid insurance and ask if the doctor will see you. I believe you will find the results instructive.


** The 2015 National Electronic Health Records Survey suffers from the same limitation.

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