The Affordable Care Act (ACA) may make trips to the doctor more affordable, but even with an insurance card and extra money in your wallet, you might not be able to find a doctor to treat you.

A new research letter published in The Journal of the American Medical Association (JAMA) found that from 2005 to 2010 Medicaid patients in California visited the emergency department (ED) more often than any other group. The study found that many publicly insured patients were using the emergency room for non-emergencies.

“Increasing ED use by Medicaid beneficiaries could reflect decreasing access to primary care,” the study authors wrote.

The study also noted that the 2014 healthcare law changes, which extend Medicaid coverage in some states, will likely make the problem worse.

“A lot of people make the assumption that once someone is insured, they will automatically get access to a primary care physician,” study author Renee Y. Hsia, M.D., M.Sc., of the University of California, San Francisco, told Healthline.

“Many patients who are already on Medicaid have difficulty finding access to both primary care doctors and specialists. Newly insured Medicaid patients may likely experience similar—if not even more severe—problems, since even more people are now ‘covered,’ thereby placing further demands on an over-saturated system,” Hsia added.

Disappearing Doctors

The U.S. is in a primary care physician drought, and there’s little relief on the horizon. A senate report from earlier this year said the country is currently short 16,000 primary care physicians.

And many current primary care doctors are choosing to opt out of Medicaid care altogether.

“We know from other work that across the nation, over 30 percent of physicians are unwilling to take on new Medicaid patients; in California, this is even higher at 56 percent,” Hsia said.

Over the past few years, many states have decreased Medicaid reimbursement payments to doctors. This decrease in Medicaid dollars may cause them to sit out of the program.

That sends primary care patients to the ER window. A 2011 Centers for Disease Control survey found that nearly 80 percent of adults visited the ER due to lack of access to other providers.

“There is not one solution or cure for this problem,” Hsia said. “It will require a multi-faceted approach to address the deficiencies in our system.”

Hsia suggested finding creative ways to convince physicians to open their offices to Medicaid patients. She said that expanding primary care to include nurse practitioners could help as well.

She also noted that the ACA has a provision to increase Medicaid doctor reimbursement rates to match Medicare rates, though only for two years.

The Doctor Is Not In

San Diego doctor Ted Mazer told Healthline, “The JAMA article and the declining access to care under current conditions for Medi-Cal (California’s version of Medicaid) patients should be seen as writing on the wall.”

Mazer fought against a 10 percent cut to Medi-Cal reimbursement, but the state ultimately won, earning the right to cut payments as long as service remained sufficient.

Even without looming cuts, Mazer says payouts are already too low. “In San Diego,” he said, “Medicare pays about $75 for a routine follow up visit for both primary and specialty offices, while Medi-Cal pays $24, and as of now that will be further reduced 10 percent in the next month.”

Mazer doesn’t believe the federal Medicaid/Medicare matching funds supplied by the ACA will attract primary care physicians to work with Medi-Cal patients. “Even primary care physicians who might think of doing so fret over what might happen at the end of 2014 when the feds begin to reduce the payment and the state has to start picking up some of the costs,” he said.

“Just as we add 1 to 2 million new beneficiaries to Medi-Cal under ACA expansion, [the state] is going to sustain the program by increasing state payments? Not likely,” he added.

Mazer proposes some solutions, including the use of expanded primary care medical teams, including nurses, under doctor supervision. He believes tax incentives, liability protections for safety net care, and loan forgiveness for new doctors could also help. “And for goodness sake,” he adds, “cuts are not the way to go when we are already paid at the lowest rates in the nation.”

As care providers and public payers across the country work to balance their books, the Medicaid expansion nears. It will be up to Medicaid patients, who earn less than 138 percent of the federal poverty level, to decide where to go for care.

“It is crucial to remember that we cannot place blame on patients for seeking care in the emergency department,” Hsia said. “EDs are the only place where all patients can receive care regardless of their ability to pay.”

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