The great thing about expanding Medicaid coverage in Maine is that not only do more people get health care but the federal government pays for two-thirds of the cost. The danger of this coverage is that it can outrun Maine’s ability to pay physicians a fair rate, pushing the physicians cut off service. The many well-intentioned advocates of expanding Medicaid currently lobbying in Augusta should recognize the seriousness of this situation and that further expansions without improving some of the pay rates could actually make the problem of coverage worse.

The doctors at Portland Urologic Association grew exhausted with trying to keep a practice going with 40 percent of their cases qualifying for Medicaid, which pays the practice an average of just less than 20 cents on the dollar based on a reimbursement unchanged for 28 years. Because the association needs 25 cents of every dollar just to pay overhead costs, every time a Medicaid patient is seen the group loses money. For instance, Medicare reimburses a urology procedure called a cystourethroscopy, with biopsy, at $310.73; MaineCare, the state’s Medicaid program, pays, $74.99. Doctors in the association said last week that they would no longer accept new Medicaid patients, an unhappy decision because the statewide practice was among the few that offered this specialty to Medicaid patients.

Other specialties face similar financial pressures from Medicaid. A surgeon at Bangor Ear, Nose and Throat reports that his practice receives only 17 cents on the dollar. An appendectomy under Medicare could pay $568; under MaineCare, it pays $297. Medicare reimburses a tonsillectomy procedure at $290.69; MaineCare, $156. Reimbursement rates for dentists in Maine traditionally have been poor enough to keep many from providing Medicaid service.

Advocates of expanding Medicaid to a larger portion of the uninsured might look at physician salaries and at the long-standing practice of charity care within medicine and assume that while physicians complain, they are unlikely to cut off care, but for a few exceptions. That is neither a fair assumption nor one that Maine should be willing to risk. When doctors say they have had enough, they do not simply refuse to take new Medicaid patients that recently were included under an expanded state plan, they also cut off people who would have received care if not for the load of newly qualified patients.

Supporters of a single-payer health care system should equally be concerned because their plans count on Medicaid money as part of the mix of funds to reach universal care. Making up the shortfall in Medicaid payments falls even more heavily on other sources under single-payer than it does under the current system.

While lawmakers properly work on ways to expand care, they must also balance the use of limited dollars with the clear need to reimburse physicians at a level that keeps them from shutting out Medicaid patients.