Do the Poor Have Access to Medical Care?

Former President George W. Bush answered that question by saying they can always go to the ER.  Federal law, the Emergency Medical Treatment and Labor Act (EMTALA), guarantees that.  But what about primary care, which for many health care needs is what patients should be getting?  (That's why it's called primary care.)

The feds have decided to spend nearly $350,000 to conduct a survey to answer the question, according to an article just published in the New York Times.  The Times describes it as a "stealth survey," nice wording for a headline but inappropriately pejorative.  The government's contracted surveyors will pretend to be patients calling to get appointments with primary care doctors and will see what responses they get and whether those responses vary with whether patients have private insurance, Medicare (the federal program for the elderly), Medicaid (for the poor), or no insurance at all.  They will also call and identify themselves as performing a government survey, asking whether doctors accept new patients with public insurance or no insurance, and see how those answers compare with the ones given to the "mystery shopper" patients.

As reported by the Times, doctors expressed dismay that Uncle Sam is doing a "mystery shopper" survey to find out what's going on with access to care.  They don't like the idea that the government is "spying" on them.  That baffles me.  We (physicians, especially in emergency medicine) have been telling the government for years that Medicare and Medicaid pay doctors too little, compromising patients' access to primary care and leaving many with nowhere to go but the ER when they get sick.  They haven't been listening.  Maybe after gathering their own data, they will "get it."

Also interesting were some of the comments on another blog that reported this story.  Some of the comments were from people who thought doctors should be required to accept Medicare and Medicaid, and some clearly thought they already were and that physicians revealed by the survey not to be doing so should face heavy penalties.  In other words, they think the federal mandate under which emergency physicians practice should apply to all doctors.  We often refer to this as an unfunded mandate because it requires us to care for all patients without regard for the ability to pay, including those with no insurance.

What those commenters don't know - and, in fact, many physicians don't know, either - is that there is a provision in the federal Medicaid program intended to assure equal access.

Medicaid is a joint federal-state program, in that there are two sources of funding. The proportion of the Medicaid dollar varies, with a larger share coming from Washington for the poorer states.  But what the Medicaid program pays doctors is supposed to be enough to assure that patients on Medicaid can find doctors to care for them.  If rates (set by the states) are so low that too few doctors accept Medicaid patients, that violates the "equal access" provision of the law. Unfortunately, the federal government, which has the power to enforce that provision through the Department of Health and Human Services, has shown no interest in doing so.

Perhaps this new survey will define the problem of unequal access so clearly that the feds will realize they must address inadequate reimbursement.  The Patient Protection and Affordable Care Act (often called Obamacare for short) proposes to change the status of many Americans from uninsured to insured, and much of that will be accomplished by adding tens of millions to the Medicaid rolls by expanding eligibility.  How about fixing the access problem Medicaid patients face at the same time?  We've been singing this song for years: coverage does not equal access.



Update, 6-29-11:

The Times now reports that the Department of Health and Human Services has responded to criticism (from doctors and Republican lawmakers) of the planned survey by doing an about-face and shelving plans to conduct it. Illinois Republican Senator Mark Kirk is quoted as saying other "reputable studies" have already shown "many patients on Medicare and Medicaid cannot find a doctor to see them." The question remains whether the people who hold the purse strings have any intention of trying to solve that problem.