When Paul Lyons opened a primary-care practice in the Palm Springs area for low-income patients, the need was clear.

“We went from zero patients to 30,000 within six months,” he said.

The clinic, which opened in 2015, continues to swell with patients who now have coverage due to the Affordable Care Act.

Since the federal health reform took effect, California has insured more people who were previously uninsured than any other state. The uninsured rate has dropped from more than 20 percent in 2010 to less than 7 percent today. The state’s low-income health program, Medi-Cal, has nearly doubled in size under the ACA, and now covers nearly 14 million people, or one out of every three residents in the state.

But this public-policy success has created a conundrum.

While the number of Californians with health coverage has surged, the state is struggling to provide enough physicians to care for them.

While the number of full-time physicians serving Medi-Cal enrollees increased 9 percent between 2013 and 2015, the overall proportion of doctors serving the population shrank significantly. According to the California Health Care Foundation, in 2013, there were 59 full-time primary-care doctors per 100,000 Medi-Cal patients. But by 2015, the ratio had dropped to 39 doctors per 100,000 patients.

The ratio of non-primary-care physicians per 100,000 Medi-Cal patients also dropped during the same time period, from 91 to 63. And the percentage of the state’s doctors willing to participate in Medi-Cal during those years fell too. In 2013, 69 percent of California doctors saw patients in the low-income program, but by 2015, 64 percent did.

Strains Across the State

The drop in doctors has put pressure on some of the major Medi-Cal operators in California. According to John Baackes, chief executive officer of L.A. Care Health Plan, which covers 2 million Medi-Cal enrollees in Los Angeles County, shortages of primary-care physicians in parts of the county are especially severe.

For example, the area around Martin Luther King Community Hospital in South Los Angeles is about 600 primary-care physicians short of what is needed.

“It’s been a challenge meeting the demands of the Medi-Cal expansion,” Baackes said, noting that the ACA added about 600,000 new Medi-Cal enrollees to L.A. Care’s numbers. He added that the plan has also been under pressure from the placement of dual-eligible Medicare and Medi-Cal enrollees into managed care. L.A. Care also added about 70,000 commercial enrollees through Covered California.

Similar strains are being experienced in Northern California. Joy Melnikow, professor of family and community medicine at UC Davis and director of the university’s Center for Healthcare Policy and Research, recently co-authored a yet-to-be-published “secret-shopper” study of Medi-Cal managed-care physicians in eight counties in and around Sacramento. On a countywide basis, the proportion of doctors not accepting new Medi-Cal patients ranged from 30 percent to 60 percent, according to Melnikow. Those that were able to offer an appointment had wait times of about a month on average, despite state rules requiring patients obtain appointments within 10 business days.

“I think it takes a lot of perseverance to find a doctor,” Melnikow said.

Newly minted primary-care physicians also have hard economic choices to make. According to Lyons, big providers such as Kaiser Permanente can offer signing bonuses in the mid-five figures, and offer salaries that are $50,000 higher than those of safety-net providers. If those doctors have debt from medical school to pay off, they are more likely to gravitate to higher salaries—and far more likely to treat commercially insured populations.

Meanwhile, the shortage of physicians in California—which is most acute in primary care—is only expected to worsen over the next decade. A study released last year by researchers at UC San Francisco concluded that the demand for primary-care physicians will be 12 to 17 percent higher than the supply by 2030. As a result, the state will be short 4,700 primary-care doctors by 2025 and as many as 8,800 by 2030. That’s despite the fact the supply of nurse practitioners and physician assistants is rising rapidly and will comprise nearly half the primary-care providers by the end of next decade.

“California needs to closely monitor the supply of primary-care clinicians and to develop strategies to fill potential gaps,” the study said. It noted that “new graduates will be more likely to pursue opportunities in specialty fields,” which are often more lucrative than primary care.

Lyons noted that there is also a significant “maldistribution” of primary-care doctors in California as well. In many of the coastal areas, it’s easier to find a doctor, but that’s often not the case in the inland and rural parts of the state.

‘Like Rowing a Boat’

California universities and in health plans are scrambling for solutions.

UC Riverside’s medical school focuses on producing a large number of family practice and primary-care physicians. It offers about three-dozen full scholarships to graduates who are dedicated to becoming managed-care physicians. According to Lyons, nearly a quarter of the current graduating class is entering family-medicine residencies, one of the highest rates among allopathic medical schools in the country.

And, in eastern Los Angeles County, the Keck Graduate Institute, affiliated with the Claremont Colleges, said in June it would open a new medical school in the next several years focused on producing more primary-care physicians.

Meanwhile, L.A. Care is making a potential nine-figure financial commitment to develop and recruit primary-care physicians. The insurer has about $600 million in reserves, and Baackes wants to spend a significant chunk of that to beef up the primary-care numbers. The health plan is investing $31 million over the next year in an initiative called Elevating the Safety Net. L.A. Care may spend an additional $124 million more on the program over the next five years, Baackes said.

The money is being deployed in numerous ways. Among them are $125,000 grants to various clinics and medical groups in Los Angeles County to boost the annual salaries of new hires, offer moving expenses or other financial incentives. As many as 100 such grants will be made in the coming months.

A second group of funds will be used to forgive medical school loans in lieu of working for a safety-net provider.

Other money will go toward full scholarships to medical school students who pledge to work as primary-care physicians. L.A. Care recently announced the first eight recipients, who are students at the David Geffen School of Medicine at UCLA and the Charles Drew University School of Medicine. They’re receiving full-ride scholarships of $350,000 apiece, meaning they will not have the burden of repaying student loans or financing their living expenses, removing the financial pressure on them to select a medical specialty more lucrative than primary care.

The money L.A. Care is putting into Elevating the Safety Net is expected to satisfy relatively modest goals: Baackes projects it will produce 300 to 400 new primary-care physicians to treat low-income patients in the county over the next several years.

However, Lyons believes that the multi-pronged approaches could make a difference.

“I think this is like rowing a boat,” he said. “The more arms pulling in the same direction, the faster we’re going to go.”