LINCOLN, Neb. (AP) - Dr. Michelle Seller starts her mornings with inpatient rounds at the local hospital in Central City, then visits a health clinic, followed by emergency room duty and a bevy of meetings with other doctors. She checks in with a nursing home on her days off.
 
     "There's a lot going on," said Seller, 33, who returned to her rural roots after finishing medical school in Omaha. "But that's why we like it. I think that's what drives people into family practice. They like variety, and they like a little unpredictability."
 
     Seller is among a declining number of Nebraska doctors who work full-time in rural areas, a key point of debate for Nebraska lawmakers when they address the federal health care law next year.
 
     Lawmakers will decide whether to extend Medicaid coverage to more residents, an idea that Gov. Dave Heineman staunchly opposes. But amid all the debate, Nebraska faces a more immediate problem with no easy answers: The state doesn't have enough doctors to treat all the new patients who will become insured when new pieces of the law take effect in 2014.
 
     "My concern is that the system will be so flooded that it could bring it to some degree of collapse," said Grand Island Sen. Mike Gloor, a retired hospital administrator who has worked extensively on Nebraska health care issues.
 
     Doctors and health care researchers said insured patients are much more likely to seek care, which helps catch health problems earlier and can potentially lower the overall cost of care. But it also means a surge of patients who wouldn't otherwise seek care, at a time when the number of rural primary-care physicians has dwindled.
 
     For rural patients, the doctor shortage means longer for an appointment and longer drives to clinics or doctor offices.
 
     Data released by the University of Nebraska Medical Center shows that the state lacks primary care physicians, and the shortage is worse in rural areas.
 
     Nebraska has 1,410 primary care doctors, but the study projects that the state will need at least 1,685 to meet the increased demand when new provisions of the federal health care law take effect in 2014.
 
     At the same time, rural doctors and their patients are both aging. The number of physicians older than 65 has grown by 78 percent over the last five years. As those doctors retire, the statewide shortage is expected to grow.
 
     Eleven Nebraska counties - Arthur, Banner, Blayne, Grant, Hayes, Keya Paha, Logan, Loup, McPherson, Sioux and Wheeler - have no primary care physicians, said Jim Stimpson, director of the Center for Health Policy at the university's College of Public Health. Stimpson was one of the report's authors.
 
     Stimpson said the number of counties designated as federal "health profession shortage areas" has grown to 65 this year, compared to 51 in 2009. And many rural counties that do have doctors only see them part-time, he said.
 
     "The deeper problem is the distribution," Stimpson said. "There is a shortage, and that's certainly a concern. But this isn't necessarily a problem in cities. This is a problem in rural areas, where they aren't able to attract physicians."
 
     Nebraska health care providers have taken steps to try to attract more rural doctors, with loan forgiveness programs and doctor residencies in smaller Nebraska cities. But such programs add only a handful of primary care physicians each year, not enough to address the shortage.
 
     Stimpson said many rural counties rely on physician assistants and nurse practitioners to help fill the void, but Nebraska is one of 36 states that require a doctor's supervision to prescribe drugs, and the state imposes other limits on the medical care they can provide.
 
     Roughly 237,000 Nebraska residents - about 13 percent of the population - are uninsured, according to 2011 U.S. census estimates. Nationally, 49.9 million Americans, or 16 percent of the country, are not covered.
 
     Another study by the University of Nebraska found that the number of residents with employer-based health insurance fell 9.3 percent between 2000 and 2010. Meanwhile, the number who bought insurance directly - usually at a much higher cost - increased by 16 percent.
 
     In Grand Island, Dr. Richard Fruehling has spent his 40-year career in medicine watching uninsured patients lose their homes and their farms. Doctors would indeed face a surge of patients if Medicaid was expanded, he said, but the strain on physicians would likely ease as more doctors begin to practices. He pointed to rising medical school enrollments nationwide.
 
     "My bottom line is, it's going to be difficult in the next five years," Fruehling said. "But my hope is that five years from now, 10 years from now, everybody has coverage and everybody has access."

(Copyright 2012 by The Associated Press.  All Rights Reserved.)

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