The Oklahoma State Medical Assn. has concerns about adding 200,000 residents to the state’s Medicaid rolls in 2014 and intends to work with the governor to assess whether such an expansion makes sense.

Part of the challenge is determining who these new patients are going to see for their care, said Kenneth King, the association’s executive director. The U.S. Census Bureau has ranked Oklahoma 50th in the nation in terms of physician-to-patient ratio, King said. With the work force already stretched to the limits, physicians barely are able to see the patients they have now, he said.

“One of the things we want is to have a dialogue with our governor on how the expansion [is] going to work,” he said. “It’s pretty cynical to say, ‘Yes, you’ve got coverage, but you can’t see a doctor for two years.’ So we’re worried about the work force issue.”

The effect an expansion may have on physician payments down the road is another issue the medical society wants to discuss with the governor, King said. The Affordable Care Act authorizes the federal government to pick up 100% of a state’s expansion costs for the first three years, with states taking on a modest percentage of those costs in future years. In Oklahoma, physicians are wondering what will happen when the state starts to cover 5% and then 10% of the additional costs, King said.

It’s possible that the states may look to offset these greater shares in the expansion by reducing physician payment, he said. “We’re very concerned about doing something that might impact how health care providers are reimbursed under the Medicaid system.”

In a letter to Gov. Mary Fallin, U.S. Sen. Tom Coburn, MD (R, Okla.), questioned whether the federal contributions to the Medicaid expansion even would be sustained. “Expanding Medicaid would inherently take the chance for our state that the federal government will follow through and keep its promises,” he wrote. Taking into account recent federal budget pressures, coupled with the projected insolvency of Medicare and Social Security, “a future Congress is likely to push expansion costs onto the states, leaving state governments with the unenviable position of picking up the tab for Medicaid’s unsustainable fiscal future,” he stated.

Dr. Coburn also said expanding Medicaid could shift working adults and their families from private to public coverage, thus “crowding out” private insurance options in the state. Medicaid’s original intent was to be a safety net for disabled and low-income patients, “not as an entitlement for single, working age adults,” he wrote to Fallin.

Other reports have pointed to the projected net savings states would realize from expanding Medicaid. In covering new individuals, states would incur some costs under the expansion, yet they also would gain from the federal government’s increased matching rate and by spending less on uncompensated care for low-income, uninsured adults, the Urban Institute concluded in an August report. More federal dollars for Medicaid also would boost sales tax and income revenues in states, it said.

Fallin for the time being is holding off on making a decision on expanding Medicaid. “She does, however, share Sen. Coburn’s concern that any expansion could result in additional costs to taxpayers and to the state of Oklahoma,” said Alex Weintz, the governor’s communications director.

King said the governor’s decision probably would come in January or February 2013. Other state executives also are mulling their decisions on expanding Medicaid and implementing other federal health system reforms.

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