December 28th, 2009
12:53 PM ET

A restaurant-style view of reform

By David Martin
CNN Medical Senior Producer

Imagine you’re hungry and someone gives you a coupon for a free meal at what’s been touted as the best restaurant in the world. The only problem is the restaurant is never open.

This could be the case for some of the estimated 15 million new Medicaid patients created by the congressional health care overhaul.

These patients are hungry for health care, but they may not be able to find a doctor who will serve them.

Almost half of the newly-insured under the congressional health care legislation come by expanding Medicaid. In the Senate bill, for example, a family of four earning up to $29,326 would be eligible. The House bill provides subsidies for families of four earning under $88,200.

Two problems: A shortage of primary care doctors and a shrinking number of doctors accepting Medicaid. According to the Association of American Medical Colleges, there are about 256,500 family doctors - about 16,000 fewer than we need. As for accepting new Medicaid patients, one recent survey found only half of all doctors accept all or even most new Medicaid patients. Among family and general practice doctors, who should be the front door for health care for the millions of newly-insured patients, 35 percent said they accept no new Medicaid patients.

Medicaid reimbursements to doctors are simply so low there is little financial incentive to take these patients. Some doctors say they actually lose money on Medicaid patients. To continue with the restaurant analogy, doctors are asked to serve up steak but are paid for a Big Mac.

As one primary care doctor told me in an e-mail, “I have concerns about where these 15 million will find a medical home … will it be existing practices, community health centers, ER’s, Wal-Mart or urgent care centers? How will rural settings or inner cities be able to meet the demand? We in primary care are already pushed to see increased numbers and this will ask us to spend less time with established patients and see more numbers. Is that good medicine?”

I visited a free clinic this year. The volunteer doctors were busier than ever, treating everything from colds and the flu, to asthma, diabetes, tooth decay, and on and on. Many of the patients belonged to a group we generally call “the working poor,” and most had put off seeking treatment as long as possible. They were uninsured and couldn’t pay, or insured and couldn’t afford the co-pay. One woman couldn’t afford a $40 inhaler. A diabetic who had recently lost his job as a pizza cook couldn’t afford the test strips needed to manage his condition. Another woman, who worked at a fast food joint, had lived for months with the pain of two teeth broken off at the gum line. The visit was a grim testimonial to the painful gaps in our health care system.

Some of these folks will likely be among the new Medicaid recipients. Unfortunately, they may not be able to find a family doctor. And that could mean they won’t get screened for diseases, will wait to get treated and may well be back at the emergency room. The only difference now is they will not get an enormous bill they can’t pay.

Will the health care reform change the way you get health care?

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Get a behind-the-scenes look at the latest stories from CNN Chief Medical Correspondent, Dr. Sanjay Gupta, Senior Medical Correspondent Elizabeth Cohen and the CNN Medical Unit producers. They'll share news and views on health and medical trends - info that will help you take better care of yourself and the people you love.