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My Turn: Medicaid doesn’t provide enough to be called insurance

I am responding to the My Turn by Jay Smeltz (“Medicaid expansion is good for business,” Monitor editorial page, June 23) from my perspective as a small-business owner in New Hampshire.

The conversation about Medicaid expansion has been shaped by the acceptance of the false assumption that Medicaid is insurance. The old adage of, “if it is said or printed often enough, it must be true” seems to apply well here.

By definition, insurance means the equitable transfer of the risk of loss from one entity to another in exchange for payment. But Medicaid does not meet the cost of providing care for many physicians; it essentially does not cover overhead expenses. As a result, Medicaid is not equitable and therefore is really not insurance.

The truth is that this would be an expansion of subsidized charity with all of the legal trappings of a state and federal program. Expanded Medicaid will put a card in the pockets of more people that is supposed to signify “health insurance” and therefore coverage for treatment – coverage that relies on treating physicians’ participation in the expanded, subsidized charity program even though it does not meet their overhead and comes with strings attached.

This is how it really works: Some private-practice physicians accept involvement with Medicaid and others don’t. Hospital-based and or owned physicians generally do take Medicaid because their employer, the hospital, usually participates in the program for various reasons. (Until recently, hospital employers have been getting federal money to further subsidize Medicaid and uninsured care as well as enjoying facility fees and potential tax advantages that are not available to private-practice physicians.)

A 1986 law requires hospitals to provide emergency services to anyone who needs them, regardless of their ability to pay. Hospital bylaws require even private-practice physicians to take emergency call and patient assignments, including Medicaid and nonpaying patients. Although the bylaws require private physicians to provide these services, they are not compensated for the work.

It’s no wonder that private physicians try to reduce their exposure to Medicaid and nonpaying patients, because it is unsustainable. It weakens the solvency of private practice businesses, and thus contributes to the trend of hospitals buying private practices – deals negotiated from a position of weakness for the private practice to the hospital’s position of strength.

If you think that this is a good idea, try to find examples when a consolidation of industry resulted in more choices, better quality, better service and reduced price.

For many of us, accepting Medicaid as payment for services is simply not feasible. Buying apples for 8 cents, then selling them for 6 cents and trying to make up the difference on volume is not a sound or sustainable business practice.

I, for one, do not want to expand this unsustainable, non-equitable situation under the guise of “insurance.” I will be forced to do as any business owner and reduce my exposure to this risk and loss.

I see the issue from the perspective of an end provider. Expanding this charitable entitlement program to working Americans because they are not covered by their employer as Mr. Smeltz suggests actually demonstrates a clear failure of the business community to provide coverage to their employees. When, under the proposed expansion of Medicaid, end providers are mandated to incur additional losses, no one is really insured.

The short answer on the proposed expansion of Medicaid from a provider standpoint is the following: Call it Medicaid, call it federal or state subsidized health care plan, call it Plan Q, or call it pumpkin seeds. Whatever the name, it still pays providers too little to be considered “insurance.”

(Dr. Paul DeGregorio is an ophthalmologist at the Eye Center of Concord.)

Legacy Comments4

The best healthcare at the lowest costs is provided by institutions that operate like the Mayo Clinic. Doctors are salaried, and a collaborative, outcomes-based approach is used. By contrast, the places with the highest costs, like McAllen, Texas, rely on a for-profit model, in which physicians, paid by the fee-for-service model, stand to gain financially by ordering more tests. Very often, these physicians in for-profit models invest in or own the technologies they use, giving them an added incentive to drive up costs. The key point: despite the higher cost and greater number of tests, patient outcomes are not better in places like McAllen, in fact they're often worse than those in areas with the Mayo Clinic model.

Dr. DeGregorio provides some valid points. What he doesn't provide is a solution. The uninsured are still going to get emergency medical care and someone's going to have to pay for it. In the long run it's cheaper to provide preventive medical care to keep people healthy and productive.

Dr. DeGregorio is not after a solution. He is just after a bigger paycheck. It is obvious he feels doctors/hospitals should just pick a number out of the sky for a procedure cost and then pass it on for the government (taxpayers) to pay. The government is doing the right thing telling the hospital they (taxpayers) will not just keep raising the payments. Where is the incentive to control costs if the doctor/hospital just gets a bigger payout every time they feel like it. And yes it is going to get worse as more private companies drop insurance for their employees during work and for retirement. These companies just push the cost onto the government and then complain they want lower taxes. The solution is to change the broken system.

Agreed.

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