The Supreme Court's validation of President Barack Obama's landmark health law set off a scramble across California to find enough primary care doctors and other professionals to serve an estimated 3 million newly insured patients by 2014.
California rates below average in the number of doctors per capita. But the state, and rural counties in particular, will face additional shortages as health reform slashes the ranks of its 7 million uninsured.
California has an unusually large number of doctors heading into their retirement years. It expects a higher-than-average rise in the health-intensive 65-and-older population. And it has one of the lowest reimbursement rates in the country for Medi-Cal, the state's primary program offering health coverage for the poor.
Especially for communities that are struggling with doctor shortages, the court's somewhat unexpected endorsement of the Affordable Care Act suddenly presents a steep challenge.
"The Affordable Care Act will add hundreds of thousands of people to the rolls of the insured. That's good," said Dr. G. Richard Olds, founding dean of the UC Riverside School of Medicine. "But where are the primary care physicians going to come from to serve that population?"
In Merced County, there are an estimated 13,400 people who will be newly eligible for Medi-Cal in 2014, according to a UCLA study, said Alan McKay, executive director of the Central California Alliance for Health, a nonprofit that manages the county's Medi-Cal care.
There are about 12,000 people in the county who are eligible for Medi-Cal but haven't enrolled, he said. Also, about 10,000 county residents would be eligible for health coverage through the Health Exchange.
Nearly one-third of Merced County's 250,000 residents are without health insurance because of high unemployment and a drop in income, according to a 2010 report by the UCLA Center for Health Policy Research.
McKay said these are people in the community who are putting off health care. Sometimes they're going to the emergency room for care, he said.
It is likely that large numbers of people will go to a primary care doctor once those individuals get health coverage, McKay said.
"All health care providers are kind of bracing for that wave," he said. "There will be a lot of people who will have coverage and we need to make sure that the medical work force is ready to meet that need."
His nonprofit is offering incentives to providers to be open on evenings and weekends to help them get ready for the increased demand for health care services, McKay said.
According to a 2009 study by the California HealthCare Foundation, only 16 of 58 California counties had sufficient primary care doctors, as measured against standards set by the American Medical Association. The Association of American Medical Colleges has warned that the nation could reach a shortfall of nearly 100,000 doctors by 2020.
Many of California's most acute shortages are in the Inland Empire and the San Joaquin Valley, where communities struggle to attract and retain doctors. These areas have some of California's highest uninsured rates -- exceeding 30 percent of residents in some counties, according to a 2009 UCLA study.
Dr. Jaipal Reddy, a primary care physician at Family Clinic of Merced, said there are many uninsured people who can't afford a primary care physician, but will be able to do so in 2014.
He said there definitely will be an increased demand. "How much it will be? I don't know," he said.