Connecticut’s Medicaid program covers one in six state residents today, and in 2014 another 140,000 will join the program under national health reform. But this critical lifeline is suffering from a severe shortage of providers, limiting access to care and forcing members who need health care into expensive emergency rooms.

When asked, providers first blame low payment rates, but there is significant evidence that rates are only part of the problem. Despite a sizeable increase in payment rates in 2008, a study by the Connecticut Health Policy Project showed that provider participation, then and now at about half of the state’s doctors, didn’t improve. In comparison, a recent government survey found that three quarters of physicians nationally are accepting new Medicaid children.

So why don’t Connecticut’s doctors want to participate in Medicaid? To find out, we conducted focus groups, surveys, and interviews around the state. We got an earful. We heard about disjointed policymaking, contradictory oversight, delays in payment and rude, disrespectful treatment.

Poor communication was a constant theme. Providers and their staff waste hours on the phone with the Department of Social Services (DSS), which has Medicaid oversight. They report having extreme difficulty getting clear, consistent, up-to-date answers to questions, and can never get them in writing. One practice manager said, “It’s extraordinarily time consuming to get a straight answer out of them [DSS].”

We heard about inexplicable policies and procedures. For example, after being aware of and reimbursing a practice for staying open in the evenings for years, preventing emergency room visits and saving the state considerable dollars, Medicaid fined that practice triple damages of $75,000 for staying open after hours.  Practice managers from other states were amazed by this report, saying in their states the practice may have simply been asked to stop billing for after-hours care. Some states might have even issued a thank you. A practice manager noted, “Lots of good hearted souls are getting hammered.”

Practices also say they have no input into the rules they have to live with, are not given any rationale for rule changes, and are often told after the fact. DSS needs to listen more and talk less, doctors and their staff said.

Despite all this frustration, nearly everyone interviewed expressed a deep desire to participate in Medicaid. Connecticut physicians and their staff feel a strong responsibility to provide care to people who need it the most; for many, that is why they became physicians. Most were deeply pained by talk of leaving the program, and want to work with the state to fix the problems in Medicaid.

Some of the best solutions come from other states that have better provider participation despite, in many cases, lower payment rates. In those states, Medicaid is a “partnership” between providers and the state built on trust and mutual respect. While these programs aren’t perfect, there is an understanding that everyone is doing their best to make the program work.

To improve Medicaid provider participation we need to reorient agency attitudes and procedures, redesign provider systems from the perspective of practices, overhaul communications, establish fair and transparent policymaking and rate setting, and improve patient education tools. But most importantly, nothing will work if you still treat people badly.

The good news is that the new administration is listening. DSS Commissioner Roderick Bremby was receptive to our report and recommendations, he understood the issues immediately and is committed to correcting the problems. If we are going to make state government work better with less, Commissioner Bremby’s open approach to new information and ideas will go a very long way.

Ellen Andrews is executive director of the Connecticut Health Policy Project.