Obamacare plans have shrunk payments to physicians so much that some doctors say they won’t be able to afford to accept Obamacare coverage, NPR reports.

Many of the eight million sign-ups in Obamacare exchanges nationwide already face more limited choices for physicians and hospitals than those in the private insurance market. But with low physician reimbursement rates, the problem could get even worse.

For a typical quick patient visit, Dr. Doug Gerard, a Connecticut internist, told NPR a private insurer would pay $100 while Medicare would pay around $80. But Obamacare plans are more likely to pay closer to $80, which Gerard says is unsustainable for his practice.

“I cannot accept a plan [in which] potentially commercial-type reimbursement rates were now going to be reimbursed at Medicare rates,” Dr. Gerard told NPR. “You have to maintain a certain mix in private practice between the low reimbursers and the high reimbursers to be able to keep the lights on.”

Narrow networks have become a hallmark of many Obamacare exchange plans, as one of few options left to insurance companies that allows them to save money by lowering reimbursement rates and covering fewer providers. In the health-care law’s first year, 70 percent of all Obamacare plan networks were either narrow or ultra-narrow, according to an analysis from consulting firm McKinsey.

But doctors are feeling even more financial pressure due to the changes and many believe there’s a risk that Obamacare insurance will go the way of Medicaid, where patients still struggle to find a doctor after low reimbursement rates led many physicians to stop accepting it.

“I don’t think most physicians know what they’re being reimbursed,” Gerard said. “Only when they start seeing some of those rates come through will they realize how low the rates are they agreed to.”

If Obamacare coverage continues on its current track, exchange customers could face a lower level of care than those who buy coverage in the private market.

“I think it could lead potentially to this kind of distinction that there are these different tiers of quality of care,” Connecticut Obamacare chief Kevin Counihan told NPR. “That’s been something, at least in our state, that we’re trying to work against. And the carriers are, as well.”

The problem is especially bad for private practices like Gerard’s, where physicians’ income is directly tied to reimbursements. But hospitals — especially top-tier ones that treat the most difficult diseases — are also increasingly rejecting the low reimbursement rates. The nation’s best cancer treatment centers are often covered by very few exchange plans in their states; if Obamacare customers end up with a difficult-to-treat cancer, they’re likely to face a lower quality of care right off the bat.

“You get what you pay for,” said Connecticut State Medical Society president-elect Bob Russo. “If you can’t convince [doctors] that they’re not losing money doing their job, then it’s a problem. And they haven’t been able to convince people of that.”

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