The hearts — and kids — at risk by under-funding primary care
The heart must feed itself first. Before pumping blood (and oxygen) to the body, the heart sends blood to itself, by way of the coronary arteries. If those arteries are blocked and unable to carry blood to heart muscle, a heart attack occurs. Without intervention, the heart will stop beating.
If you ask most physicians why they chose medicine, they will tell you about their heart. They love helping people. No one enters the medical profession to get rich. And those who do quickly learn there are many faster and easier ways earn money that sidesteps spending an extra decade in school.
Sadly, the healthcare system abuses the heart. Nearly 150,000 physicians hung up their stethoscopes for the final time in 2021-2022. The primary care specialties sustained the greatest loss, including internal medicine, pediatrics, and family practice. As a result, patients face more obstacles to accessing primary care services than ever before, particularly those on Medicaid.
Today, one in 4 Washingtonians receives health coverage through Medicaid. Most clinics limit the number of Medicaid patients they see to make ends meet. Healthcare professionals face a Faustian bargain: Either follow their heart and go bankrupt, or close your heart to keep your clinic going.
Financial incentive for physicians has been shown to improve access to care for Medicaid recipients. According to the Washington State Medical Association, “it has been decades since the last general Medicaid reimbursement rate increase in Washington state, resulting in reimbursement rates today that are nearly the lowest in the nation.” Improved access to primary care improves health outcomes for everyone, like this patient of mine.
“I don’t plan to live past my 18th birthday,” she stated, as if it was a fact. I was stunned. Eighteen. That was less than six months away. I could feel the tears coming. Before I could stop them, they slid down my face.
We first met at the Kitsap County Juvenile Detention Center, about a decade ago. At her intake appointment she asked for depo-Provera, an injectable birth control medication that lasts for three months. After updating her vaccinations and verifying she was not already pregnant, I gave her the shot and reminded her to see her doctor in 12 weeks for another dose.
Three months to the day after that first visit, she was back at the detention center asking for another shot. I obliged. She told me she did not have a doctor. She did not have health insurance either. Before her release from juvenile hall, social workers helped her obtain Medicaid coverage and connected her to the healthcare system. Before I knew it, I was her doctor.
By the time she shared her 18-year plan, I had been caring for her nearly 2 years. Looking back, until that day, I knew little about her. I never met her parents. They had both succumbed to drug overdoses before she turned 15. She always came to her medical appointments alone. I knew she traveled mostly by bus, because early one morning as I arrived to work, she got off at the bus stop more than an hour before her appointment. When I asked why, she explained it the last bus she could take to arrive at her appointment on time.
“Why are you crying?” she asked me. I was not sure. “What about dreams for the future?” I asked. She shrugged, as if never planning to have one.
She asked me what was so great about 19. I was a junior in college and applying to medical school that year. I told her my life began at 19. At least, my journey to become a doctor did. It was around that age my heart guided me toward becoming a pediatrician — so I could help as many children as possible throughout my lifetime. I realize how naïve that sounds now.
After referring her to a counselor, I assigned homework: to create a “bucket” list of things to do before she died. She returned two weeks later with her bucket list: 1.) become a beautician and 2.) move to New York City. She wanted to help young women feel better about themselves while living in a big city. I saw her every month until her 18th birthday, when she left for the Big Apple. She promised to write, and she has. Occasionally, a postcard with no return address comes in the mail. I recognize her handwriting instantly. I know our relationship made a difference in her life.
According to the National Health Interview Survey, for each $10 increase in payment rate parents are 25% more likely to report little to no difficulty finding a provider for their children when insured by Medicaid. That same $10 increase reduces school absences among elementary-aged Medicaid recipients by 14 percent, according to data from the National Assessment of Educational Progress. More importantly, with each $10 increase in payment rate, a Medicaid recipient is 1.1 percent more likely to report very good or excellent health across all age groups.
What happens when a physician must choose between her heart and her livelihood? I would love to tell you I chose my heart. But I did not. I chose my livelihood and to support my family. I have not accepted new Medicaid patients for the past five years. I hate knowing that. I hate writing it. And I hate acknowledging it to all of you. I hope sharing it serves as a call to action for Washingtonians to contact lawmakers and push hard this session for a long-overdue increase in Medicaid payments to all medical specialties.
Remember, even the heart must feed itself first, or it cannot keep beating.
Dr. Niran Al-Agba is a pediatrician in Silverdale and writes a regular opinion column for the Kitsap Sun. Contact her at niranalagba@gmail.com.
This article originally appeared on Kitsap Sun: Medicaid reimbursement rates that discourage doctors and patients
