When people ask family practitioner Ray Ward if he does charity care, he likes to joke, "Yes, I take Medicaid."

It means making less money, but the Bountiful doctor does it out of a sense of duty.

"I still come out OK at the end of the year," he says. "So far, I haven't had to turn anyone away. I still accept [Medicaid] patients."

Physicians like Ward, however, are in increasingly short supply.

In Utah the number of doctors who accept Medicaid has shrunk 25 percent in 11 years. This year, 3,166 doctors are certified to bill the low-income health program, down from 4,210 in 2000.

That's just over half of the state's 5,844 practicing physicians. Meanwhile, Medicaid enrollment, now at about 244,470, is swelling with no immediate end in sight.

Health officials say the dropping numbers haven't reached a crisis. Medicaid patients have the same, or better, access to quality care as privately insured patients, according to the state Department of Health.

Patients may have to hunt for a doctor willing to see them, or wait for an appointment, said agency spokeswoman Kolbi Young. "That's not new."

But managed care groups that administer the joint federal-state program say staying ahead of the problem is getting tougher.

Come 2014, under federal health reform, Utah's Medicaid rolls are predicted to expand by 110,000.

"We are going to have to increase our network by that proportion," said Richard Sánchez, chief medical officer at Molina Healthcare of Utah, which is responsible for 30 to 40 percent of the state's Medicaid patients. "We are in the process of doing that now with people out there on a daily basis recruiting doctors."

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Problem of pay • So far, Molina has been able to find willing providers, said Sánchez. Shortages are most acute in rural areas and some specialists are hard to find, including rheumatologists, neurosurgeons, endocrinologists, psychiatrists and pediatric cardiovascular surgeons.

Sánchez says Molina makes do by busing patients to urban health centers and marshaling non-Medicaid doctors to treat patients in a pinch. Like most insurers, it also leans more on mid-level providers such as social workers, physician assistants, nurse practitioners and midwives.

But, he says, "something needs to be done to close the reimbursement gap."

States on average pay Medicaid providers about 72 percent of what Medicare pays. Utah's rates are among the lowest in the country.

Health industry leaders have high hopes for a reform plan pitched by Sen. Dan Liljenquist, R-Bountiful, which would steer Medicaid patients into Accountable Care Organizations or ACOs, new and improved HMOs designed to keep costs in check.

The idea is to pass savings along to providers in the form of higher reimbursements, said Sánchez.

The plan needs federal approval and could take years to reap dividends. Until then, providers and patients say the status quo, while not perfect, will suffice.

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Quality questions • Medicaid has become a favorite political target of conservatives who chafe at President Barack Obama's signature health care overhaul.

Some paint the program as a cushy, free ride for people with a heightened sense of entitlement. Others label it a "health care gulag," arguing the care it provides is questionable.

Such was the gist of remarks recently delivered by Utah Republican Sen. Orrin Hatch at the Heritage Foundation, a conservative think tank.

"Those who are the biggest advocates for Medicaid ... are happy to consign America's poorest and sickest patients to a health care gulag," said Hatch, referring to a study by researchers at the University of Virginia that showed Medicaid patients had poorer outcomes than those with zero health coverage.

The study is among others to find fault with Medicaid but was criticized for failing to account for patients' underlying health differences. The uninsured tend to be younger and healthier.

But there's plenty of contradicting research underscoring the health benefits of Medicaid.

"It's not perfect, but it does a necessary job. People will argue all kinds of things about it, but it's what we've got," said Salt Lake City pediatrician Louis Borgenicht.

From a paper-pushing perspective, dealing with Medicaid is no more onerous than dealing with private insurers, Borgenicht said. "And for patients, it's a lot better than being uninsured."

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Making do • Last year, Borgenicht unsuccessfully lobbied the Utah Medical Association to adopt a resolution urging doctors to accept a certain percentage of Medicaid patients.

"Because some docs won't take Medicaid, more of the burden falls on those of us who do. But for me, it doesn't matter," said Borgenicht. "I look at it as a social responsibility. We make enough money to cover our overhead so the economic issues from my perspective aren't major."

Ward agrees while acknowledging, "If you sat people down and gave them a choice of plans, most wouldn't choose Medicaid."

Part of that is due to stigma, but also to hurdles in finding specialists.

Ward pinch-hits on some cases. He says he recently aligned a boy's broken arm that he would have preferred to have an orthopedist handle. "We put a cast on and it will probably be fine," he says. "None of the orthopedists in Bountiful take Medicaid."

Debbie Christoffersen looks forward to finishing college and landing a job as an actuary with full benefits. But for the time being, the 31-year-old mother of four can't imagine life without Medicaid.

The Midvale woman hasn't encountered delays in care and complains only of a shortage of eye doctors in the valley. The one she found was a disappointment, she says. "The clinic was dirty and smelled funny."

But Medicaid keeps her kids current on their immunizations and makes it possible for her son to get the medication he needs to focus at school.

Bottom line, she says, "It means my kids can see a doctor."

kstewart@sltrib.com