When they were first issued 11 years ago, the plastic Medicaid identification cards were designed to open the doors of the city's private practice physicians to the District of Columbia's poor.
But it hasn't$13.9 million that the program paid to private doctors last year.
Their earnings last year ranged from $25,000 to $462,415.
"The theory behind Medicaid," said Andy Schneider, an attorney formerlly with the Health Law Project, "was that the problem of health care for poor people was that they didn't have money, and if you put a card in their hand, with a government promise of payment on that card, they would find their way into main stream care."
According to interviews with some Medicaid patients, physicians in and out of the program did not work as planned for four main reasons:
There has been little or no education of Medicaid recipients to encourage them to seek out the services of private doctors, rather than use expensive hospital emergency rooms for non-emergency medical care.
Medicaid pays physicians often half the going rate for a given service -- and requires additional paper work.
Hospitals often encourage Medicaid patients to use the hospitals' out-patient departments -- rather than private physicians -- because it is profitable for the hospitals to do so. Unlike private physicians, who are paid fixed rates which have varied little since 1968, hospitals are paid on an ever increasing cost-of-treatment basis.
Physicians are no more willing today than they were when the Medicaid program began, to set up practice in the poor, medically under-served areas of the city.
The chief complaint that physicians make about the program is the low payment rates.
Dr. Barrington Barnes, chairman of the District of Columbia Medical Society's Medicaid liaison committee -- and an internist who last year received $26,825 for treating Medicaid patients -- said Medicaid pays $20 to have a patient transported one way to his office, "but they only pay me $13 for a basic office visit. Maybe I should get into the transportation business."
A physician treating privately insured patients would charge from $18 to $40 for the visit and, said Barnes and other physicians, such disparities in payment discourage physicians from caring for the poor.
"There is such a marked disparity between the fees paid by Medicaid and the other programs, even Medicare, that the physicians feel put upon. They feel they're expected to do something extra," said Clarence C. Edwards, a District obstetrician-gynecologist who received $367,896.44 in Medicaid payments in 1978.
According to Dr. Leroy Jackson, a member of Mayor Marion Barry's Blue Ribbon Task Force on Infant Mortality, "most people who handle about 30 percent Medicaid have to have an additional clerk" to handle the paper work.
"In order to break even you have to see twice as many patients as a non-Medicaid physician," said Jackson.
Although most of the 118,513 District Medicaid recipients who went to private physicians last year went to specialists -- 44 percent of the 107 big money makers are either obstetrician-gynecologists or pediatricians -- the general state of the city's health has changed little since the beginning of this decade.
The District of Columbia is still a national leader in the areas of infant mortality, tuberculosis, sclerosis of the liver deaths, cancer deaths among blacks and veneral disease.
"The primary problem is not the availability of service, but the utilization," said Jackson. "We have patients walking into our private offices in the 6th and 7th month [of pregnancy rather than the first or second]. I haven't seen an appreciable change" in that in the 11 years of the District's Medicaid program.
The major area in which the poor have made use of the Medicaid program as it was intended to be used has been in gaining admission to private hospitals in the city.
Since fiscal 1974, admissions to, and surgery at, D.C. General Hospital -- which serves only the poor -- has dropped by more than one third. Use of the hospital's emergency room, however, has remained fairly constant at 95,000 to 105,000 visits a year.
According to officials at D.C. General and other hospitals, 80 to 90 percent of those emergency room visits are unnecessary, such as cases of Medicaid being charged $40 and more to have a patient told to take aspirin for the flu -- advice a private physician could provide without charge over the telephone.
According to Victor Kugajevsky, director of the federal Department of Health, Education and Welfare's office of Medicaid program development, Medicaid recipients continue to use emergency rooms out of habit.
"It's convenience," he said. "The patient's mother went there, or his brother went there. "It's what he's familiar with. Or somebody else went there and he's familiar with them."
"People throw a lot of brickbats at the program," said Kugajevsky, "but it's providing health care. I think the financial barrier
to good health care have been removed."
But whether or not those barriers have really been removed is a matter of debate.
In the District, 10 percent of those below the poverty line -- or about 8,600 persons -- have no health insurance, including Medicaid.
And while the Carter Administration says that about 11 percent of the American population does not have health insurance, and needs to be included in a National Health Insurance program, 22 percent of all Americans with incomes below $3,000 a year do not have any health insurance, according to 1976 federal statistics.
One of the major reasons for that, says a high HEW official, is that up to 70 percent of the rural poor in America do not qualify for Medicaid in most states.
"A lot of people think Medicaid has covered the poor," said the official, "but even in urban areas there are a lot of two-parent families that don't qualify."
A common complaint among those patients who do qualify for participation in the District's $119 million Medicaid program is that no one every explained their rights and privleges to them.
"Instead," said Connie Barnes, a 22-year-old D.C. Medicaid recipient," you go to the public assistance office, tell them you want Medicaid. They might send it in the next month or two and you have to read what's on the back of [the card]."
There is a phone number listed on the back of the card for those having any questions "on services covered by this pass."
But a caller asking if the city has a list of physicians who accept Medicaid is told "No, we don't. We had one three years ago. You'll have to go through your Yellow Pages" for the name of a doctor, and then call to see if he accepts the yellow-and-white card.
Peter Coppola, director of the city's Medicaid program, said those receiving Medicaid are given a booklet outlining the system, but acknowledged that welfare workers are too overburdened to supply patients with detailed information.
However, Coppola said, starting this October -- 11 years after the Medicaid program here was begun -- District officials plan to begin a new effort to fully explain the use of Medicaid cards to the people who carry them. worked that way.
Instead, the health insurance program, which cost the city and federal government $119 million here last year, has created a new medical specialist -- the Medicaid physician -- and the poor are still being served by a handful of doctors.
In 1978, ten years after the District launched its Medicaid program, only 18 percent of the city's estimated 8,500 physicians were treating Medicaid patients.
And of those choosing to participate in the program jointly funded by the District and federal government, just 107 physicians earned almost half the