In a for-profit healthcare environment, we are constantly in a balancing act between doing what’s right for our patients and what’s profitable for the company. This becomes even more of an issue when we start differentiating patients based on insurance plans. Someone on Medicaid [funded by the U.S. government] brings about half as much revenue as a patient with private insurance. Should we treat both patients the same? More than half of our patients are on Medicaid.
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Ethical Decisions 
Professional obligation is a central factor in this case. Joining a profession means that you promise to live up to expectations the profession has created in the public mind. This is, in fact, why we have professions: so the public will know what to expect and can rely on competent and ethical conduct. Breaking this promise is not generalizable. If medical professionals always broke their professional promises whenever it is profitable, no one would trust hospitals with their health, and the government certainly wouldn’t pay hospitals to provide care.
So we have to think about expectations for medical professionals. They are clearest for physicians, who often take an explicit oath (maybe some form of the Hippocratic Oath), but they extend to hospital management professionals.
The most basic professional promise is that treatment decisions will be governed by the health consequences to the patient, and not by extraneous factors. This may not imply a promise to supply any particular level of care. A doctor in a poor country isn’t unprofessional if she fails to use the best medical technology due to the high cost. But it does imply a promise to make treatment choices based solely on medical criteria, subject to overall resource limitations. It would be unethical to shift greater resources to someone you know or someone from a particular ethnic background — or to someone who can pay more. The professional approach is to ask people to pay what they can, and then distribute these resources to patients based on medical criteria. The same principle applies in a U.S. hospital with Medicaid patients.
There may also be expectations for a particular level of care, especially in a wealthy country like the U.S. Delivering substandard care in order to take on 90% Medicaid patients might be seen as unprofessional, even if it created more total benefit than delivering Cadillac care to a smaller patient body with 10% Medicaid patients. It is hard to define what counts as minimally acceptable care in a given context, but Medicaid regulations may help define it for a U.S. hospital. A for-profit hospital may have to limit the number of Medicaid patients to deliver care that meets expectations.
What to do if there are too few beds for Medicaid patients? This obviously a public policy problem, and there is not a great deal that individual medical professionals can do about it. One possible option is to work for a nonprofit charity clinic for below-market wages, a clinic that may not have the latest hi-tech equipment but meets expectations because everyone knows it is a charity clinic.
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