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Medicaid changes strain doctors

Millions joining program may find care scarce

Hector Flores, a primary care provider in East Los Angeles, treated Gloria Sanchez. More than a third of Flores’s patients are on Medicaid.

Emily Berl/New York Times

Hector Flores, a primary care provider in East Los Angeles, treated Gloria Sanchez. More than a third of Flores’s patients are on Medicaid.

SAN DIEGO — Dr. Ted Mazer is one of the few ear, nose, and throat specialists in this region who treat low-income people on Medicaid, so many of his patients travel long distances to see him.

But now, as California’s Medicaid program is preparing for a major expansion under President Obama’s health care law, Mazer says he cannot accept additional patients under the government insurance program for a simple reason: It does not pay enough.

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“It’s a bad situation that is likely to be made worse,” he said.

His view is shared by many doctors around the country. Medicaid for years has struggled with a shortage of doctors willing to accept its low reimbursement rates and red tape, forcing many patients to wait for care, particularly from specialists like Mazer.

Yet in just five weeks, millions of additional Americans will be covered by the program, many of them older people with an array of health problems. The Congressional Budget Office predicts that 9 million people will gain coverage through Medicaid next year alone. In many of the 26 states expanding the program, the newly eligible have been flocking to sign up.

Community clinics, which typically provide primary care but not specialty care, have expanded and hired more medical staff to meet the anticipated wave of new patients. And managed-care companies are recruiting more doctors, nurse practitioners, and other professionals into their networks, sometimes offering higher pay if they improve care while keeping costs down. But it is far from clear that the demand can be met, experts say.

In California, with the nation’s largest Medicaid population, many doctors say they are already overwhelmed and unable to take on more low-income patients. Dr. Hector Flores, a primary care doctor in East Los Angeles whose practice has 26,000 patients, more than a third of whom are on Medicaid, said he could accommodate an additional 1,000 Medicaid patients at most.

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“There could easily be 10,000 patients looking for us, and we’re just not going to be able to serve them,” said Flores, who is also chairman of the family medicine department at White Memorial Medical Center in Los Angeles.

California officials say they are confident that access will not be an issue. But the state is expecting to add as many as 2 million people to its Medicaid rolls over the next two years — far more than any other state. They will be joining more than 7 million people who are already in the program here.

The health care law seeks to diminish any access problem by allowing for a two-year increase in the Medicaid payment rate for primary care doctors, set to expire at the end of 2014. The average increase is 73 percent, bringing Medicaid rates to the level of Medicare rates for these doctors.

But states have been slow to put the pay increase into effect, experts say, and because of the delay and the fact that the increase is temporary, fewer doctors than hoped have joined the ranks of those accepting Medicaid patients.

“There’s been a lot of confusion and a really slow rollout, which unfortunately mitigated some of the positive effects,” said Lisa Folberg, a vice president of the California Medical Association.

Adding to the expansion of the Medicaid rolls is a phenomenon that Medicaid experts are calling the “woodwork effect,” in which people who had been eligible for Medicaid even before the Affordable Care Act are enrolling now because they have learned about the program through publicity about the new law. As a result, Medicaid rolls are growing even in states like Florida and Texas that are not expanding the program under the law.

Managed-care companies that serve the Medicaid population are still hustling to recruit more doctors and other providers to treat the new enrollees.

Molina Healthcare, which provides coverage to Medicaid patients in California and nine other states, has hired more than 2,000 people over the last year, said Dr. J. Mario Molina, the company’s chief executive. They include not just doctors, he said, but also nurses, case managers, and call center workers to help new Medicaid enrollees who may be confused about “where to go or what to do or how to access health care.”

Molina said the temporary rate increase for primary care doctors had helped his company recruit them to its networks. Recruiting specialists has been harder, he said, adding, “Rheumatology is difficult; neurosurgery is difficult; orthopedic surgery is difficult.”

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