Lobbying groups representing doctors have questioned the safety of some of the proposed changes, argued they would encourage less collaboration among health professionals and suggested they could create a two-tiered health system offering unequal treatment.
Bills seeking to expand the scope of practice of dentists, dental therapists, optometrists, psychologists, nurse practitioners and others have been killed or watered down in numerous states. Other states have proposed expanding student loan reimbursements, but money for doing so is tight.
As fixes remain elusive, the shortfall of primary care physicians is expected to grow.
Nearly one in five Americans already lives in a region designated as having a shortage of primary care physicians, and the number of doctors entering the field isn't expected keep pace with demand. About a quarter million primary care doctors work in America now, and the Association of American Medical Colleges projects the shortage will reach almost 30,000 in two years and will grow to about 66,000 in little more than a decade. In some cases, nurses and physician assistants help fill in the gap.
The national shortfall can be attributed to a number of factors: The population has both aged and become more chronically ill, while doctors and clinicians have migrated to specialty fields such as dermatology or cardiology for higher pay and better hours.
The shortage is especially acute in impoverished inner cities and rural areas, where it already takes many months, years in some cases, to hire doctors, health professionals say.
"I'm thinking about putting our human resources manager on the street in one of those costumes with a 'We will hire you' sign," said Doni Miller, chief executive of the Neighborhood Health Association in Toledo, Ohio. One of her clinics has had a physician opening for two years.
In southern Illinois, the 5,500 residents of Gallatin County have no hospital, dentist or full-time doctor. Some pay $50 a year for an air ambulance service that can fly them to a hospital in emergencies. Women deliver babies at hospitals an hour away.
The lack of primary care is both a fact of life and a detriment to health, said retired teacher and community volunteer Kappy Scates of Shawneetown, whose doctor is 20 miles away in a neighboring county.
"People without insurance or a medical card put off going to the doctor," she said. "They try to take care of their kids first."
In some areas of rural Nevada, patients typically wait seven to 10 days to see a doctor.
"Many, many people are not taking new patients," said Kerry Ann Aguirre, director of business development at Northeastern Nevada Regional Hospital, a 45-bed facility in Elko, a town of about 18,500 that is a four-hour drive from Reno, the nearest sizable city.
Nevada is one of the states with the lowest rate per capita of active primary care physicians, along with Mississippi, Utah, Texas and Idaho, according to the Association of American Medical Colleges.
The problem will become more acute nationally when about 30 million uninsured people eventually gain coverage under the Affordable Care Act, which takes full effect next year.
"There's going to be lines for the newly insured, because many physicians and nurses who trained in primary care would rather practice in specialty roles," says Dr. David Goodman of the Dartmouth Institute for Health Policy and Clinical Practice.
Roughly half of those who will gain coverage under the Affordable Care Act are expected to go into Medicaid, the federal-state program for the poor and disabled. States can opt to expand Medicaid, and at least 24 and the District of Columbia plan to.
In Ohio, which is weighing the Medicaid expansion, about one in 10 residents already lives in an area underserved for primary care.
Mark Bridenbaugh runs rural health centers in six southeastern Ohio counties, including the only primary care provider in Vinton County. The six counties could see some of the state's largest enrollments of new Medicaid patients per capita under the expansion.
As he plans for potential vacancies and an influx of patients, Bridenbaugh tries to identify potential hires when they start their residencies—several years before they can work for him.
"It's not like we have people falling out of the sky, waiting to come work for us," he said.
State legislatures working to address the shortfall are finding that fixes are not easy.
Bills to expand the roles of nurse practitioners, optometrists and pharmacists have been met with pushback in California. Under the proposals, optometrists could check for high blood pressure and cholesterol while pharmacists could order diabetes testing. But critics, including physician associations, have said such changes would lead to inequalities in the healthcare system— one for people who have access to doctors and another for people who don't.
In New Mexico, a group representing dentists helped defeat a bill that would have allowed so-called dental therapists to practice medicine. And in Illinois, the state medical society succeeded in killing or gutting bills this year that would have given more medical decision-making authority to psychologists, dentists and advanced practice nurses.
Other states are experimenting with ways to fill the gap.
Texas has approved two public medical schools in the last three years to increase the supply of family doctors and other needed physicians. New York is devoting millions of dollars to programs aimed at putting more doctors in underserved areas. Florida allowed optometrists to prescribe oral medications — including pills — to treat eye diseases.
The federal healthcare law attempts to address the anticipated shortage by including incentives to bolster the primary care workforce and boost training opportunities for physicians' assistants and nurse practitioners. It offers financial assistance to support doctors in underserved areas and increases the level of Medicaid reimbursements for those practicing primary care.
Providers are recruiting young doctors as they gear up for the expansion.
Stephanie Place, 28, a primary care resident at Northwestern University's medical school in Chicago, received hundreds of emails and phone calls from recruiters and health clinics before she accepted a job this spring.
The heavy recruitment meant she had no trouble fulfilling her dream of staying in Chicago and working in an underserved area with a largely Hispanic population. She'll also be able to pay off $160,000 in student loans through a federal program aimed at encouraging doctors to work in areas with physician shortages.
Place said the federal law turned needed attention to primary care as a specialty among medical students.
"Medical students see it as a vibrant, evolving, critical area of healthcare," she said.
Even so, many experts say the gap between doctors and those gaining care under the health reforms in many parts of the country will not close quickly. Access to care could get worse for some people before it gets better, said Dr. Andrew Morris-Singer, president and co-founder of Primary Care Progress, a nonprofit in Cambridge, Mass.
"If you don't have a primary care provider," he said, "you should find one soon."
