Do doctor shortages affect a state’s decision to opt out of Obamacare?

November 20, 2012

The media have focused on the recent Affordable Care Act (ACA) deadline for states to decide whether they will create health insurance exchanges. It’s an important issue, but if a state does not agree to build an exchange, the federal government will step in and create one. So either way, all 50 states will end up having health insurance exchanges.

But the other ACA choice that states have to make is whether to expand Medicaid in their states to include more beneficiaries. According to the ACA law, states will not have pay for the expansion until later years:

States that refuse to cover more poor people will do so despite the fact that Uncle Sam will pick up most of the tab. From 2014 to 2016, the federal government will pay 100 percent of the cost of covering newly eligible people, after which the share will gradually go down to 90 percent in 2022 and later years.

So what is stopping the eight states whose governors have declared that they will not expand Medicaid? Oklahoma’s Governor Mary Fallin makes her case (emphasis mine):

“I have also decided that Oklahoma will not be participating in the Obama Administration’s proposed expansion of Medicaid. Such an expansion would be unaffordable,” Fallin said. Oklahoma and seven other states have declared they won’t expand Medicaid to their poorest residents[.]

One reason for not expanding Medicaid may be that states do not have enough infrastructure to support more beneficiaries. Oklahoma is pretty thin on primary care physicians, with 141 active practitioners per 100,0000 of the population, according to the Association of American Medical Colleges (last page). This number is far lower than the national median of 203 active primary care physicians. Most other states that have declared their intent not to expand Medicaid have similar shortages of physicians.

The only state opting out of Medicaid expansion with more active primary care physicians than the national median is Florida, with 207.

The Affordable Care Act does raise reimbursement for physicians serving Medicaid patients to equal the fees for serving Medicare patients, but this still doesn’t address the physician shortages.

What is the current port of entry for those who receive public heath care? Often it is a health center program. The Health Resources and Services Administration has data for 2011, saying they:

  • Served 20.2 million patients
    • 93% below 200% poverty
    • 72% below 100% poverty
    • 36% uninsured
    • 1,087,431 homeless individuals
    • 862,808 farm workers
    • 187,992 residents of public housing
  • Provided 80 million patient visits in 1,128 organizations across more than 8,500 service sites
  • Employed more than 138,000 staff including
    • 9,900 physicians
    • 6,900 nurse practitioners, physicians assistants, and certified nurse midwives

The physician shortage across America is an estimated 52,000 with the changes in ACA. It could be that governors worry as much about a shortage of health care providers as the chronic shortage of funds for their existing populations. The lack of training and certification for additional primary care physicians is the least examined part of the ACA, but it seems the most critical.


Bloomberg – “Hospital Medicare Cash Lures Doctors as Costs Increase”

No comments so far

We welcome comments that advance the story through relevant opinion, anecdotes, links and data. If you see a comment that you believe is irrelevant or inappropriate, you can flag it to our editors by using the report abuse links. Views expressed in the comments do not represent those of Reuters. For more information on our comment policy, see