Must MDs Serve Medicaid?*

S.Q. Lapius had decided to make one of his rare forays into the cold.  He spun two mufflers over his shoulders and wedged them tightly under his chin.  This hid the wool turtleneck, over which he had worn a sweater vest before donning his suit coat.  After struggling into his sheepskin great coat he ordered me to open the door, from where he trundled to the waiting and well heated taxi.  “Brrr,” said Lapius as he snuggled in.  “Thank God for thermal underwear.”

“Where are we going that’s so important that you must brave the cold wintry winds?”  I asked him.  “To have your thyroid examined?”

“On the contrary, Harry.  I am going to have my arguments examined.  I have been invited to a debate at the medical society, the proposition that all physicians must accept Medicaid patients.”

“Pro or con?”

“Pro.”

The taxi drew up in front of the gracious portico and I helped Lapius out of the cab.  He had as much mobility as a man suited up for a space fight. Dressed as he was for the cold weather I felt as if I was transporting a mummy.  After Lapius had rid himself of some of his outer garments we walked into the comfortable and surprisingly empty lobby, to be met by the tall, muscular Dr. John Hardline.  “Lapius,” he said.  “I tried to reach you but you had already left.  The meeting has been canceled.”

“How so?”

“The officers of the society were called to an emergency meeting at the state level.  Something about PSRO’s and utilization, and the HEW proposal that Medicare and Medicaid can no longer be admitted to hospitals on the recommendations of their doctor but the cases must be passed upon by a review board.”

“I wish I had known,” muttered Lapius, “It would have saved me a lot of bother.”

“Well, pull a chair to the fire,” Hardline said expansively.  “Come along, Harry,” he beckoned me.  “Let’s make the old man comfortable.  I think I have a bottle of brandy in my locker.”  We sat down and Hardline disappeared.  Being called an old man did little to soothe the ruffled Lapius, but he became somewhat appeased when Hardline returned with a bottle of Courvoisier. After he had poured he said, “You know, Simon, I’m glad for your sake the debate was cancelled.  You have taken a terrible unpopular position.”

“What position is that?”  Lapius asked owlishly.

“That you would want society to pass a resolution that all members should accept Medicaid patients.”

“If it was a popular position all doctors would see Medicaid patients.  I wouldn’t have to propose it.”

“Well, the fact is that some of the men feel very strongly about this.  They don’t see why the government should have the right to set a doctor’s fees.  The government doesn’t tell banks to lend to the poor at a lower interest rates, nor are landlords asked to lower their rents.  Why should the doctor be discriminated against?”

“That certainly is a point of view, John, but a weak argument.  Who will take care of the medical needs of the poor?”

“The medical profession has always done this in free clinics or their offices on a voluntary basis.”

Lapius mused about that for a while, cupping the brandy snifter gently.  Then he said, “I can’t see why you are up in arms just because you will receive a fee for what you always used to do for nothing.”

“But, Simon,” Hardline said trying to coddle Lapius, which was about as effective as trying to cook a soft boiled egg over an open grill, “it is the principle of the thing.  Where the hell does the government get off setting our fees?  No one else is asked to make the same sacrifice for the poor.”

“Every working person in America makes a sacrifice for the poor.  They pay taxes don’t they?  Or do you think that the money that supports Medicare and Medicaid is a gift from the Philadelphia Mint?”

“What are you, Lapius?  Some kind of socialist nut or something?” Hardline asked sneeringly.**

Lapius ordinarily wouldn’t let a petty remark like that interrupt his savoring a good brandy, but this time he put the glass down.  “The point is that government interference in medical practice encompasses more than medical fees.  It threatens the existence of the entire doctor-patient relationship.  Now when a doctor tries to fight the government by not seeing Medicaid patients he also threatens the doctor-patient relationship, and cuts the ground away from his own arguments.  The medical profession must speak out against government intrusion as a unit.  But to turn away the sick just because the government is setting the fee is a policy that will lead to moral bankruptcy.  You know damned well, Hardline, that when you are called to the hospital to see an emergency you don’t ask whether the patient is rich or poor.  So why turn the sick away from your office?”

“Well, Lapius, no doctor turns away an emergency.”

“I should hope not.  But the point is that from the patient’s point of view any illness might be an emergency.  They cannot always discriminate serious ills from minor ills.  Only the doctor can put them at their ease.  You are discriminating against the Medicaid patient just because you think that the government is discriminating against doctors.  An innocent party is getting hurt.  That is contrary to the tradition of the medical profession.”

“You make it sound like a priesthood.”

“It is in a way.  Aesculapius was called the God of Medicine by the Greeks and his sanctuaries for the ill became temples.  In western culture the first hospitals were established by religious orders, and the earliest nurses were monks and nuns.  The first great medical school grew out of the cathedral stadium of Salerno in the ninth century.  The profession of medicine is fundamentally a ministry to the sick, rich or poor.  Look here, Hardline, you are always complaining to me that the medical profession is getting a bad press.  You certainly won’t improve the doctor’s image by turning away a patient just because the government is paying you less than you would ordinarily charge.”

“Keep talking that way, Lapius.  Soon the government will take us over completely and put us on salary.  Would you like that?”  Hardline shuddered at the implications of his own statement.

“No,” Lapius said slowly.  “I wouldn’t like that.  As a matter of fact a great conflict might be brewing between the medical profession and the government.  The issues will be settled in the legislatures and the congresses, after the ballots have been counted.  I would hope that the medical profession develops a coherent policy and that all physicians join to formulate and support that policy.  I would hope, after all is said and done, that the doctor-patient relationship is preserved.  But none of this can be accomplished by turning away Medicaid patients.”

“You sound like a god-damned broken record,” Hardline said becoming surly.

When we left, Lapius draped his outer garments over his arm, and stood quietly, his hands dug deep into his pockets while we waited for a taxi to show up. 

“Why don’t you wear your coat and scarves?” I asked.

“I’m not cold any more,” he said heatedly

* In the mid 1970s the doctors of the New Jersey medical Society voted to accept Medicaid patients but not submit vouchers for payment because they believed that absent a minimum number of vouchers the State would not qualify for Medicaid reimbursement.

** As it turned out, the medical profession adamantly opposed to most government measures because they feared “socialization” by government, ended up being “socialized” by their purported allies, the business community. Enterprise was paying burgeoning medical costs won by the unions for employees which provided (as we see today re General Motors, almost bankrupted by its medical obligations) perpetual care for retirees living long past actuarial predictions.

Strange that the same government that fashioned Medicare apparently failed to take into account the fact that that same government was subsidizing science, and that medical science would increase longevity and that increased longevity would exhaust Medicare resources.