My former TNR colleague Suzy Khimm had a nice piece yesterday about a familiar but hugely important issue: poor Medicaid reimbursement rates that lead primary care doctors and specialists to avoid treating poor people. This issue was only partly addressed in health care reform. No one doubts it will fester, becoming a sore point between providers and policymakers and between the states and the federal government.

By chance, the electronic version of Pediatrics also arrived yesterday. It includes a depressingly clarifying essay "Has leisure time become Medicaid's new competitor?" by Indiana professor Samuel S. Flint. Flint briefly describes the ways that states have induced the past generation of pediatricians to take Medicaid patients:

Historically, state Medicaid programs have counted on the immutable economics of private practice. The vast majority of practice overhead costs are fixed (e.g., nonphysician personnel, rent, malpractice insurance premiums), but the marginal cost of treating each child is minimal. Consequently, it makes economic sense for physicians to accept some patients with Medicaid, because Medicaid fees for an otherwise unused appointment exceed low marginal treatment costs.

The problem with this strategy is that it is predicated on the notion that leisure time has little value, and that is changing, particularly among young physicians.

That's standard fare, but what gets interesting is Flint's effort to put dollars-and-cents numbers behind the argument. He notes that 38% of pediatric residents sought (and 21% accepted) a part-time position as a first job. This proportion surprised me. At least partly, it reflects the striking gender mix across the medical profession. Almost 70 percent of pediatric residents are women. Many pediatricians are working mothers, whose job schedules must accommodate work-family balance concerns.

Anyway, Flint calculated that such part-time positions would shorten doctors' annual work output by 2,094 visits, while reducing income by about $34,000. Doing the long division, Flint finds that pediatricians willing to work part-time vote with their feet to forego about $18.50 per visit.

You can pretty much guess what comes next.

This value ($18.50) exceeds the Medicaid payment for a brief office visit (Current Procedural Terminology [CPT] code: 99212) in Indiana and subsequent newborn care (CPT 99433) in New York, Florida, and Pennsylvania. It is greater than the Medicaid reimbursement for an emergency visit (CPT code: 99282) in 5 states, a subsequent hospital visit (CPT code: 99231) in 7 states, performing a venipuncture for a child under the age of 3 (CPT code: 36400) in 21 states, performing an arterial puncture (CPT code: 36600) in 16 states, reading a chest radiograph (CPT code: 71010) in 20 states, and performing developmental testing (CPT code: 96110) in all but 9 states.

Although the phobic in me would happily skip that arterial puncture, this overall pattern isn't healthy. We want pediatricians to regard children on Medicaid as desirable, paying customers. Right now, these kids are often viewed as charity cases for whom a pittance will be paid--late—after a load of paperwork is done. Not surprisingly, health economists and clinical researchers document the large proportion of doctors who won't take Medicaid. More disturbing than the implicit tiering of American medical care is the evidence that Medicaid patients receive lower-quality care. Sandra Decker documented, for example, that doctors devote less time and attention to Medicaid patients. Low Medicaid reimbursement has also been linked with higher infant mortality.

You get what you pay for. Seniors who worried that their options would be constrained by the public option should ask themselves what their lives would be like if they relied on Medicaid. And don't forget: Primary care for kids is probably the easiest and cheapest problem in this entire area. Imagine that your family depended on Medicaid. Now imagine that you, your son or daughter, or your spouse had a serious cardiovascular, psychiatric, or orthopedic problem, or a high-risk pregnancy. For millions of Americans and more than a few TNR readers, this is no hypothetical concern. They face this every day.

This problem needs to be fixed.

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