Health-care providers have more questions than answers as they wait for a decision on whether Ohio will expand its Medicaid program under the auspices of the federal Affordable Care Act.

The biggest question is whether the expansion will happen at all. Gov. John Kasich and Lt. Gov. Mary Taylor haven’t said yes or no yet, but both have expressed concern that expanding coverage will add hundreds of millions in costs to the state’s already stretched budget down the line.

New Medicaid eligibility guidelines under the ACA could, if Ohio signs on, add up to 1 million additional adults to the state’s Medicaid rolls. The coverage becomes available in 2014 for states that opt to participate.

But while much attention has been focused on states, including Ohio, that aren’t taking any action yet, the law doesn’t set a deadline for states to sign up.

“There’s no deadline for a state to say whether or not it’s going to go ahead with the expansion,” said Judy Solomon, vice president, health policy, for the Center on Budget and Policy Priorities in Washington, D.C. “It’s not like the state insurance exchanges where the states have to tell the federal government whether they’re setting up their own by a particular date.”

A poll last month by the Kaiser Family Foundation found that 67 percent of Americans favor expanding Medicaid eligibility. Across the U.S., some states are moving forward with the Medicaid expansion. Some aren’t. The governor of Florida, for example, has said the state won’t participate.

“Most states, I would say the majority of states, are sort of in the category of studying the law, looking at all of the implications,” Solomon said. “I wouldn’t necessarily say Ohio is dragging it’s feet. There’s a lot of things to consider about the law.”

Governors of some states, including Oklahoma’s Mary Fallin, have said they won’t take any action regarding the expansion until after the November election. Mitt Romney, the GOP’s presumptive presidential candidate, has already vowed to repeal the Affordable Care Act if he wins the election.

“Everything we’re doing is kind of viewed within the frame of the elections,” said Ann Spicer, executive vice president of the Ohio Academy of Family Physicians.

The organization favors expanding coverage, arguing that increasing coverage for primary care services, in particular, saves money because it prevents the uninsured from needing to head to emergency rooms for costlier care.

One big debate is whether states will save big or spend big with Medicaid expansion. The Congressional Budget Office recently estimated that states will spend, overall, only about 2.8 percent more on Medicaid from 2014 to 2022 with the expansion.

But cost projections vary.

The federal government will pick up 100 percent of the cost for the additional coverage through 2017. Then their share will drop to 90 percent and continue to drop over the next several years. Once those subsidies begin to drop, states pick up more of the share for individuals new to Medicaid.

State leaders have said Ohio’s share of expanded coverage costs could top $400 million in 2017 and 2018.

An analysis released last month by the Urban Institute estimates that Ohio’s Medicaid spending will increase anywhere from $172 million to $1.3 billion in total between 2014 and 2019 if it adopts the Medicaid expansion, compared to leaving its system as is.

New York, on the other hand, would see spending decrease between $12 billion and $13.4 billion in that time frame, according to analysis.

Regardless of whether they accept expand Medicaid eligibility or not, states will spend more on Medicaid under the Affordable Care Act, experts point out. With so much information available about the program and who’s eligible for it, every state will see people who’ve always been eligible enroll, which will up spending.

And the law requires states to increase payments to doctors for certain primary care services beginning in 2013 and 2014.

Health-care providers have long complained that Medicaid payments don’t match the cost of care. The Ohio Hospital Association said that in 2010, total Medicaid reimbursements were $1.13 billion less than the cost of care provided.

For the Kettering Health Network, which operates seven hospitals in the Miami Valley, the difference between Medicaid reimbursement and cost of care was $20.7 million in 2010, said spokeswoman Elizabeth Long.

Hospitals say they lose millions every year in uncompensated care or bad debt. Those costs are often shifted to people with insurance in the form of higher charges, higher premiums and higher deductibles. Hospitals that treat a high percentage of uninsured or under insured patients get additional revenue from the state and federal governments.

In 2011, Premier Health Partners, which operates four hospitals in the region, reported $43.6 million in bad debt, according to spokeswoman Diane Ewing.

Expanding Medicaid would reduce uncompensated care, the Urban Institute analysis found.

In Ohio, the state’s savings would range from from $1.1 billion to $3.3 billion between 2014 and 2019, while the federal government’s savings would range from $3.4 billion to $6.2 billion, according to the Urban Institute.

The expansion would also mean Medicaid funding for mental health and other treatments not now covered by the program.

Many providers like the idea of expanding Medicaid coverage, but what they would really like to see is higher reimbursement. The Affordable Care Act increases payments for some primary care services to match Medicare reimbursements, said Dr. Deepak Kumar, a Dayton colorectal surgeon and president of the Ohio State Medical Association.

But reimbursements to specialists like Kumar are staying the same.

Right now, Medicaid reimburses him $40 for office visit, while Medicare reimburses him $70.

“If all I had to depend on was Medicaid reimbursement, I could not stay in existence,” he said. “I’d have to close my doors or someone would have to subsidize me. The financial reimbursement from the current Medicaid system is absolutely pathetic.”

And while health care reform puts the burden on providers to improve patients’ health while cutting costs, there’s no incentive for patients to follow their doctors’ orders, Kumar said.

“We’re happy to do our part. But what happens if the patient refuses to do so?” he asked. “They don’t show up for appointments. They don’t take their prescriptions. They don’t lose weight or change their diet. They just show up in the ER.”