Medicare: The Architecture of a Public Health Crisis

07/02/2010 01:06 pm ET | Updated Nov 17, 2011

For a while, I thought my worries were irrational. One by one, I saw physician colleagues close their practices and open boutique medical concierge services. They decided to stop taking insurance and opened businesses designed to serve the wealthy. Many physicians I have previously referred to now take only cash-paying patients, and have decided to exempt themselves from insurance altogether. This had me worried about how medicine might soon be reduced to a state in which only the most economically privileged can actually seek out and receive medical care. But then I started to see what I had feared most; physicians are slowly and insidiously ceasing to be Medicare providers.

Who can blame them? Reimbursements have declined in recent years and although there have been halts to the "SGR" (standard growth rate) cuts until next November, in which Medicare reimbursement will possibly be cut again--the continued voting in Congress (every month) to put off the cuts feels akin to a stay of execution. The end is going to happen, though it is not clear when. Health care clinicians have been dealing with the threat of these cuts for many months now, and although they have not happened, the ominous threat of yet another income decline seem to have scared a number of providers into no longer taking Medicare. Has the Obama administration not noticed this?

Though Medicare might not seem to be a big issue for those of us under 65, it does, in fact, impact us all. Insurance reimbursements are often based on the Medicare standard rates. So if Medicare cuts reimbursements, this actually impacts most insurance rates. And if doctors don't get paid enough, they limit the amount and kinds of insurance they take.

The unrest for those who accept Medicare is not knowing if and when these cuts will dramatically change the ability to pay overhead for practices. Potentially, those who accept Medicare are going to have to decide if they want to provide very low fee services or if they should save themselves and get out of the system altogether. Indeed, many clinicians are already out. Some of the recent news coverage has included USA Today as well as a British Medical Journal Article published this week.

Physicians seem to be getting out of the Medicare system, and fast. The Medicare issue is a time bomb ticking away under the radar screen of those who can do something about it. If doctors continue to stop accepting Medicare, then what will happen to the millions of people who rely on Medicare for their health benefits? This is not just a question of class, but also a question of public health. What the Obama administration did so brilliantly last fall regarding the H1N1 flu and helping to prevent a wide outbreak might be a purely empty victory in the fall of 2010. If there are less providers accepting Medicare, then fewer seniors and others with chronic medical conditions will be less likely to receive routine medical care such as influenza vaccinations. This could lead to an increase in frequency of influenza outbreaks and preventable deaths.

And with boomers turning 65 (and thus eligible for Medicare) in greater numbers, this hardly seems to the time to experiment with what will happen when increasing numbers of doctors are getting out of the system. While healthcare reform will take care of the very disadvantaged, the middle class is at risk. People who are eligible for Medicare have paid into the system and expect to be rewarded. But if doctors continue to stop taking Medicare, where will this leave people who are neither poor nor rich? And more importantly, if we enter into the flu season in the fall of 2010, and some people cannot find providers because their doctors have decided to stop accepting Medicare, then we are really facing a public health crisis, and one the Obama administration may not be able to solve.