You’d think it would be easy to go to the doctor to get treated for a sprained knee from figure skating. I couldn’t, because I’m on Medicaid.

I’m required to declare a primary care physician, but after six months, I still hadn’t found one that takes Wellpoint, a Medicaid insurance provider.

At first I was frustrated, and then I was curious. Because I’m far from alone.

Nearly a quarter of Maryland adults report that they do not have a source of primary care. Perhaps that’s because there is only one primary care clinician for every 900 people in the state.

For Medicaid patients, the number of primary care providers willing to accept their insurance is even smaller, thanks to low reimbursement rates.

Without access to reliable primary care, patients may require more extensive treatment later, said Dr. Djinge Lindsay, chief medical officer of the Maryland Department of Health.

Since I didn’t have a primary care physician, I went to the emergency room at MedStar Union Memorial for my knee injury. Many people without primary care do the same.

Maryland already has among the longest emergency room wait times in the country, which could worsen if primary care availability shrinks even more.

More than a third of primary care clinicians nationwide are concerned about the financial viability of their practices in light of Medicaid cuts, according to a report by the Larry A. Green Center, a collaborative center based at Virginia Commonwealth University that focuses on primary care.

Primary care providers’ margins are already thin, thanks to the demands of insurance and efficiency that make the work of caring for patients more complicated.

Even while working part-time as a primary care physician in the Baltimore region, Dr. Julie Rich said she had a roster of about 2,000 patients.

She said she typically has just 20 minutes to take each patient’s vital signs, check their medical histories and screen for pain, depression and safety before addressing the reason for their visit, and creating a treatment plan.

Then she has to document the treatment with enough detail to comply with the patient’s insurance.

In some cases, insurance won’t cover the specific treatment that medical professionals determine they need.

“It’s demoralizing that there is someone else who isn’t seeing my patients and is trying to direct my patient’s care, and delays their care,” said Dr. Hannah Goldberg, an internal medicine physician in Baltimore.

Goldberg spends two hours a day — all unpaid — trying to get her patients’ care authorized by their insurance companies, she said.

Goldberg finds herself in “an infuriating state of perpetual anger at insurance companies,” she said.

Insurance companies can’t control the price they pay for care. But in deference to their bottom line, they can control whether a patient receives certain treatments or not by creating roadblocks for approval, said Howard Haft, a professor at the University of Maryland School of Medicine and primary care provider in Somerset County.

“You can’t blame a shark for being a shark,” Haft said. “Insurers will do what they can do to be competitive.”

Insurers do not have control over the price they pay for treatments and services because that power lies in the work of a little-known panel, the Relative Value Scale Update Committee.

The committee, established by the American Medical Association, is made up of health care providers who decide on the relative value of all medical care in the country. That value is what each insurance firm uses to determine how much it reimburses physicians for their work.

Very few people on the committee represent primary care. The majority are in medical specialties.

As a result, the work of primary care physicians is often valued less than the work of a specialist, Haft said.

In Maryland, Medicaid reimburses a dermatologist about $105 for a procedure using freon to remove bumps on the skin. A primary care physician gets reimbursed about $25 for an appointment that takes the same amount of time. While private insurance reimbursement rates are higher across the board, they are significantly higher for specialized care.

And while primary care physicians account for about half of all doctors’ visits in the country, primary care spending made up less than 5% of the trillions of dollars spent on health care, according to the most recent available yearly estimate.

Insurance reimbursements for primary care work must cover a physician’s salary, as well as the salaries of office staff and the costs of rent, utilities and an electronic health records system, Lindsay said.

So with all of those layered challenges, Lindsay said, “it’s likely that many primary care physicians can’t afford to see Medicaid patients.”

In rural Western Maryland, 70% of the patients at Meritus Health are insured by Medicare and Medicaid, said Dave Lehr, the system’s chief strategy officer and the chief operating officer of the Meritus School of Osteopathic Medicine.

Lehr said the hospital provides nearly $18 million worth of uncompensated care every year. With Maryland expecting nearly $2.7 billion in cuts to Medicaid, that means Meritus Health, and other rural hospitals, will lose a chunk of reimbursements.

The Maryland Department of Health has spearheaded initiatives to increase investments in primary care.

In 2019, Haft, a Somerset primary care provider and professor of medicine at UMD, became executive director of the Maryland Primary Care Program, the largest voluntary primary care program in the country. It was found to have saved lives and minimized overall spending on health care during the pandemic.

But the program is largely focused on improving the conditions of current primary care providers with the increasing demands and costs of their work. The program does not directly address increasing the number of primary care providers.

Maryland had the lowest per capita medical school matriculation rate in the country, Lehr said, before Meritus Health opened an osteopathic, or holistic, patient-centered medical school in Washington County this summer.

Their incoming class had more than 1,000 applicants for 90 spots.

The University of Maryland School of Medicine has tried offering free tuition to students who commit to practicing medicine in rural communities on the Eastern Shore.

Seven colleges in Maryland have programs for a nurse practitioner license that certifies a graduate to practice primary care independently.

While nurse practitioners are paid less than physicians, they make up nearly a third of the state’s practicing primary care providers, according to data from the state health department. But research suggests that their numbers won’t be enough to shore up the state’s shortage.

In answering my original question of why it is so hard to find a primary care provider, Lindsay, the state’s chief medical officer, said: “Our health care system is now held together with paper clips and gum. Putting more stress on it, I don’t know how much it can withstand.”

I never was treated for my knee injury — I just wrapped and elevated it until the pain thankfully went away.

Months later, I arrived at a long-awaited new patient primary care appointment and handed my insurance card to the medical assistant, Nicole Billings.

Turns out they don’t take my insurance. Billings said she could relate — she was two months into a wait for a new patient primary care appointment herself.