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The cost of cutting care for our nation’s poor is far too high

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For months, we’ve watched Congress try to replace the Affordable Care Act (ACA), the most significant expansion of health-care coverage in the U.S. since the 1965 passage of Medicare and Medicaid. While Congress has thus far failed to pass a bill undoing the ACA, there remain efforts in Washington to weaken the law and to make it harder for citizens who need coverage under the ACA to access it. 

The fate of “repeal and replace” ultimately rested with a few Republican senators concerned about how their neediest constituents would fare under the proposals put forth by their GOP colleagues. They had reason to worry, because a common feature of those proposals was the gutting of federal spending on Medicaid, which now covers 40 percent of the country’s low-income adults and 76 percent of children in poverty. The Congressional Budget Office (CBO) estimated that spending reductions in the more draconian proposals would have forced about 15 million poor Americans off the Medicaid rolls by 2026.

{mosads}However, the number of vulnerable people who would have been effectively shut out of health care is almost certainly much higher than CBO projections. With Medicaid cuts that drastic, states would have few palatable options to rein in costs. States could change eligibility requirements to exclude more people, they could hollow out the benefits going to Medicaid recipients, or they could further depress reimbursement payments going to physicians and other health-care providers, an action that in some communities would be tantamount to denying patients care.


Medicaid is already a notoriously poor payer. In Maryland, Medicaid pays family practice physicians about one-third less per patient visit than commercial insurers do. Often the payment isn’t even enough to cover the cost of the visit. If reimbursement rates were forced down further, some providers — especially those running modest practices, where viability is won or lost on small margins — would be faced with limiting the number of Medicaid patients they see or refusing them altogether. Nationwide, 41 percent of primary care physicians choose one of these two options

I’m a pediatric gastroenterologist by training, and I lead a health sciences and human services university. One day a week, I see young patients in a clinic housed at the University of Maryland Medical Center in Baltimore, where one child in three lives below the poverty line. About three-quarters of the patients I see are covered by Medicaid or by the Children’s Health Insurance Program. With such a large share of the clinic’s patients on medical assistance, the practice’s viability rests largely on our five satellite clinics across Maryland, most of whose patients are covered by private insurance. This is the balance that providers across the country have to strike every day, using payments from private insurers and from Medicare to cover the cost of treating poor Americans. 

Of course, U.S. physicians aren’t obligated to see patients who can’t pay for their treatment. U.S. hospitals, on the other hand, are so obligated — and that treatment is expensive. The care delivered in a doctor’s office is often the same care the emergency department (ED) delivers at a cost that’s three to four times higher. EDs, fully staffed and equipped 24/7 for any conceivable emergency, have extremely high fixed costs. It’s not the place to access services for conditions that could be treated — or prevented — by a primary care provider, and taxpayers shouldn’t tolerate ED care as the first and last resort for the poor.

In fact, Medicaid works, and it should work for everyone who needs it. A three-state study suggests that Medicaid coverage increases the amount of care patients seek across multiple settings — the expensive emergency department, yes, but also the physician’s office. Compared to uninsured individuals, people covered by Medicaid are more likely to report that they have a usual (non-emergency) source of primary care, that they’ve increased their use of preventive health visits, that they take their medications as prescribed, and that they’ve experienced an improvement in their health. 

As a nation, we must work to expand — not shrink — access for those who need high-quality health care the most: the poor, the elderly, the disabled, people burdened with chronic disease. These patients deserve life-saving, life-enriching care, and they deserve providers who can afford to deliver it. 

There are real and significant costs associated with caring for the nation’s poor, but the cost of doing nothing for the most vulnerable among us is far greater. For that, we pay with our very humanity.

Jay A. Perman, MD, is president of the University of Maryland, Baltimore.

Tags Healthcare reform Medicaid Patient Protection and Affordable Care Act

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