Doctors in the US are steadily opting out of treating Medicare patients. Mounting pressures, including new restrictions imposed by the Affordable Care Act (ACA), are prompting a growing number of physicians to no longer accept patients in the government-run health insurance program.

Medicare currently serves about 50 million seniors and disabled persons. The drop-off in available doctors means that Medicare patients, many of whom already have difficulty finding a doctor that accepts the program, will find it even harder to obtain affordable, needed care.

While some physicians are getting out of the program altogether, others are limiting the number of Medicare patients or not accepting new ones. A survey by the American Academy of Family Physicians found that the proportion of family physicians that accepted new Medicare patients fell from 83 percent in 2010 to 81 percent in 2012. The same study found that 4 percent of family doctors now run cash-only practices, or “concierge practices,” where patients pay a monthly or annual fee to obtain access to a doctor.

According to the Centers for Medicare and Medicaid Services (CMS), the government agency that administers the program, the number of physicians opting out rose from 3,700 in 2009 to 9,539 in 2012. There were about 685,000 doctors enrolled as Medicare participating physicians last year, according to the CMS. Last year’s opt-out rate of about 1.4 percent is statistically significant, especially when considered in relation to the rising trend.

The move by doctors to stop accepting Medicare patients comes in the context of an assault on Medicare orchestrated by the Obama administration through the health care bill signed into law in 2010. The legislation aims to slash $700 billion from the program over the course of a decade. The ACA cuts expenditures, in part, by linking doctor pay to costs as well as by taking aim at the fee-for-service system, in which Medicare pays doctors and other providers for individual services they provide.

One of the factors pushing doctors out of the Medicare program is a punitive and arbitrary process for evaluating doctors that is being implemented as part of the health care overhaul. Under the ACA’s Physician Value-Based Payment Modifier Program (VBP), Medicare physicians, hospitals, nursing homes and other providers will be evaluated for quality and performance, i.e., how effective they are at cutting costs and rationing care.

Under draft regulations released by CMS officials last month, by 2017 the VBP will be expanded to include about 500,000 Medicare doctors working in group practices. Doctors will be evaluated not only on the services they provide, but on the services of any other doctor who provides treatment to patients under their care. Bonuses and penalties will be calculated on quality measures varying by specialty.

As early as 2015, doctors judged according to the VBP to be high-cost providers will face penalties of as much as one percent of their Medicare reimbursement and will miss out on incentives. In addition, Medicare participating doctors who do not comply with new regulations requiring them to switch to electronic medical records and to send data on quality measures to the government will also face penalties beginning in 2015.

Another reason doctors are abandoning Medicare are current low reimbursement rates and threats of more cost-cutting to come. Doctors can be reimbursed as little as $58 for a 15-minute office visit, often pressuring doctors to cram 30 or more patients into their schedules to cover overhead costs.

Doctors are also wary of the possibility that Medicare reimbursement rates could face cuts of as much as 30 percent in 2014, unless Congress overrides cutbacks mandated by a budgetary formula enacted in 1997. While Congress has consistently intervened to delay the cuts, this is by no means guaranteed.

Doctors who opt out of Medicare can charge patients whatever they want, and Medicare patients must pay out of pocket to be seen. The Medicare Payment Advisory Commission, an independent congressional agency, found that 28 percent of Medicare beneficiaries looking for a new primary care physician last year had trouble finding a doctor who accepted Medicare.

Increasing numbers of physicians dropping out of the program will force millions of seniors to either pay wholly for their doctor visits, utilize emergency rooms for treatment, or forego care altogether. In a growing phenomenon, some doctors in mostly affluent urban and suburban areas have stopped participating in both Medicare and private insurance, charging hundreds and even thousands of dollars per visit.

Working class patients will be the most severely affected by this. In a cruel twist, even if a Medicare patient chooses to visit a non-participating doctor, he or she will still be required to maintain premium payments, as failure to do so could result in a cut-off of Social Security benefits.

An estimated 10,000 Americans reach the age of 65 every day, and a projected 25 million new Medicare recipients will be enrolled in the program by 2020. The Obama administration and both big business parties cynically maintain that slashing billions of dollars from the program can actually result in an improvement in care for America’s senior population.

The exit of growing numbers of doctors from Medicare demonstrates that the combined effect of a massive reduction in spending and policing of the physician workforce is rationing of care and a reduction in its quality. Ultimately, the ruling elite is taking aim at the Medicare program with an eye toward privatization, making the right to decent health care the sole province of the wealthy who can afford to pay out of pocket.