But those payments were delayed, with the first checks going out to physicians in November 2013. That delay could cost the state in physician participation.
"I think the longer it takes to implement that, the less likely it is that it will affect any decisions about whether to participate more fully in the program than you would have otherwise," said Christopher Perrone, deputy director of the health reform and public programs initiative at the California HealthCare Foundation.
And the temporary nature of the pay increase adds to the problem, Mr. Perrone said. "I don’t see California sustaining that increase on its own and I haven’t heard anyone suggest that the federal government would sustain it after the 2 years."
Mr. Perrone said it’s more likely that physicians who are already committed to participating in Medi-Cal will use the money to invest in electronic health records and other telemedicine features, and hire medical assistants.
But with so many small and solo physicians shying away from Medi-Cal because of low payments, community clinics and health centers will have to pick up the slack.
"All these issues together really point to the importance of the community health centers and the role we are going to be playing in ensuring access," said Carmela Castellano-Garcia, president and CEO of the California Primary Care Association.
Federally qualified health centers are in a better position financially because they are paid an enhanced Medicaid rate and won’t be subject to the coming Medi-Cal cuts, Ms. Castellano-Garcia said. And the ACA has directed an influx of cash to these centers as well – more than $500 million in California alone to establish new sites, expand services, and support major capital improvement projects, according to the Health and Human Services department.
Texas: No expansion means doctors will keep feeling pressure
Texas has the highest number of uninsured residents in the United States – a quarter of its 26 million residents lacking coverage – but Gov. Rick Perry (R) refused to expand Medicaid, which could cover as many as 500,000 to 1 million Texans.
The governor’s decision will stay in place at least until 2015, when the state legislature reconvenes.
Some physicians in Texas are not upset by the decision – they consider Medicaid to be low-paying program and full of bureaucratic hassles.
Others – including many of the primary care organizations – disagree.
The Texas Medical Association, the Texas Academy of Family Physicians, and the Texas chapter of the American Congress of Obstetricians and Gynecologists all support the expansion of Medicaid allowed by the ACA.
In April, Gov. Perry reiterated his position. "Medicaid expansion is a misguided, and ultimately doomed, attempt to mask the shortcomings of Obamacare," he said in a statement. Instead of expansion, he favors flexibility for the state to manage its Medicaid program.
State Rep. John Zerwas (R-Simonton), an anesthesiologist, introduced H.B. 3791 that would give that flexibility, but it did not get consideration by the full House before the legislature adjourned in May.
The TMA supported Dr. Zerwas’ proposal, but also is in favor of expanding Medicaid, said Dr. Stephen L. Brotherton, TMA president. More people would have some type of insurance, but they might not necessarily have good access to care, he said.
That’s because Texas has a shortage of primary care physicians. The number of primary care physicians per capita is lower than the national average – at about 70/100,000 in 2011, compared with 80/100,000 nationally, according to the Texas Department of State Health Services, in the publication "Supply Trends Among Licensed Health Professions, Texas, 1980-2011. In rural areas, it’s even lower – about 50/100,000.
Then there’s the question of just how many physicians will take Medicaid. A 2012 TMA survey found that only 31% of doctors in the state were accepting new Medicaid patients.
Medicaid payment rates are so low that Dr. Brotherton, who practices in Ft. Worth, said that he treats Medicaid patients as charity care. "It’s much less expensive for me to do it for nothing as donated time," he said.
Dr. Moss Hampton, chairman of District XI of ACOG, added, "Medicaid doesn’t cover the cost of taking care of the patient."
For Medicaid expansion to eventually be successful, "there would have to be a better payment rate and less of a hassle factor," said Dr. Hampton, chairman of the obstetrics and gynecology department at Texas Tech Health Sciences Center at the Permian Basin in Odessa.
"It’s hard to get doctors to accept Medicaid because of the rates they pay," agreed Dr. Clare Hawkins, TAFP president, who added that Texas physicians also feel that it’s hard to comply with differing rules among various Medicaid managed care programs.