If Florida’s Medicaid program doesn’t expand in 2014, hospitals stand to lose more than Medicaid funds. That’s particularly true for Jackson Health System, which gets tens of millions of dollars in special federal payments to make up for caring for the uninsured.

The reform act provides for eliminating or scaling back such payments, as the number of uninsured is reduced. Bruce Siegel, president of the National Association of Public Hospitals and Health Systems, said government hospitals in some other states are facing similar problems and he’s hoping the Obama administration will maintain uninsured funding for places like Jackson. “But it may still be a very bumpy road ahead.”

Linda Quick, president of the South Florida Hospital and Healthcare Association, said that the nation’s hospitals agreed to more than $150 billion in payments under Medicare over a decade during negotiations leading to the Affordable Care Act. They did so assuming they would make up for the loss with revenue from patients newly insured under the federal act. But if Florida doesn’t expand Medicaid, the hospitals are unsure where that leaves them.

Steven Ullmann, a health policy expert at the University of Miami, said Medicare has required many tweaks over the years and he’s certain that the 2,000-page Affordable Care Act will need modifications as it goes along. But political experts say that may not be possible with a Republican-controlled House of Representatives opposed to the reforms.

The most immediate challenge facing Florida is the Jan. 1 change so that Medicaid primary care doctors will get better rates of compensation. Many doctors have avoided taking Medicaid patients because of the low pay, and virtually all healthcare analysts, both liberal and conservative, believe that the best way to cut healthcare costs is to provide more primary care on the theory that early treatment will reduce expensive trips to emergency rooms.

The federal government will cover all the costs of the increased payments, but because Medicaid is a state-federal program, the state pays the doctors and then is reimbursed by Washington. That means the Legislature must approve the change.

Mobeen Rathore, president of the Florida Chapter of the American Academy of Pediatrics, said Florida doesn’t have any choice because “the state has to follow the federal law.”

Nan Rich, a former state senator from Broward and a Democrat, said that since the Legislature doesn’t meet until next spring, the increased doctors’ payments would have to be recommended by both the governor and legislative leaders, then approved by the Legislative Budget Commission.

“It’s a no-brainer,” Rich said. “That’s our tax dollars. If we don’t use them, they’ll be going to other states.”