I have noticed over the years that physicians who write about medicine, particularly for the general public, are limited to specific discussions. It is perfectly acceptable, for instance, to write about the plight of the poor and uninsured. It is always reasonable to advocate for a single-payer system. It is fine to discuss how one downsized to earn less and give back more. And it is praiseworthy to hold forth on the absolute necessity of primary care.
It is reprehensible, however, 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 unpleasant.
To write any of these negatives is to incur a blizzard of angry letters and suggestions that one leave medicine to the truly compassionate and seek mental health care.
I will boldly violate these rules, though, and say that emergency medicine is becoming ever more difficult in part because of Medicaid. This is extremely relevant because the Affordable Care Act 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. But it is hurting medicine — primary care and emergency care.
Look at the recent study out of Oregon that clearly showed that Medicaid increases emergency department use. (http://bit.ly/1l0NbPU.) It's an interesting study with mixed results: no change in controlling patients' hypertension, diabetes, or cholesterol, but a decrease in depression and financially catastrophic health care costs.
The problem is multifaceted, but at the heart of it is that our Medicaid population has no ownership of its health care dollars. They're told by government functionaries that they have insurance. I have insurance, but 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 makes everyone else look bad. They come to the ED 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 are unemployed, and have no schedule restrictions. So coming to the ED at 3 a.m. is not an impediment to going to the pediatrician the next morning.
And 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 nonemergent.
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 redirect 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, cigarettes, drugs, jewelry, and vehicles that some of our Medicaid patients sport. Medicaid primary care patients sometimes have a co-pay, but EMTALA ensures that will never happen in the ED.
The problem isn't just this abuse. It's that this population of patients, who use the ED extensively for any and every problem, crowd the department 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.
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 the Oregon study), it demoralizes those who treat the patients with it (and costs us money because we are hardly excused from expensive liability insurance while accepting it), and it adds so much hay through which we must sift to find the needle.
I know. Bad doctor. Hateful doctor. Let the name-calling begin. But if nothing else, honest doctor.