The major expansion of Medicaid coverage for low-income Americans under the Affordable Care Act is proving to be a double-edged sword for patients and the medical profession.

Nine million uninsured people, many older and with complicated medical problems, will likely receive health insurance coverage in the coming year, according to the Congressional Budget Office. Under Obamacare, the federal government will pay the entire cost of expanded health care coverage for the first three years and then 90 percent of the cost thereafter, with the states covering the rest.

Related: Obamacare Creates a Two-Tiered Medicaid System

Only 25 states and the District of Columbia have signed on so far, however, as Republican governors and GOP-dominated state legislatures in most of the remaining states have opted out of the expanded program – either to protest Obamacare in general or out of fear that their states may end up having to pay a much larger share of the expanded Medicaid costs than the Obama administration promised. The result is a disturbingly stark dual system health care system determined largely by where people live and the political leanings of their home states.

Now there’s an even more challenging problem: Qualifying for expanded Medicaid coverage is one thing; finding a doctor who will even accept new Medicaid patients is another.

Familiar Red Tape

For years the Medicaid program has struggled with a shortage of doctors willing to accept its low reimbursement rates and red tape, forcing many patients to wait for care, especially care from specialists. With the advent of Obamacare, the problem will get even worse starting early next year, as physicians across the country warn they’ll have to turn away Medicaid patients they can’t afford to take on, according to a report by The New York Times on Friday.

“It’s a bad situation that is likely to be made worse,” Dr. Ted Mazer of San Diego, one of the few ear, nose and throat specialists in southern California who treats low-income Medicaid patients, told The Times. Dr. Hector Flores, a primary care doctor in East Los Angeles who has a huge Medicaid practice, said that at most he could accept about a tenth of the additional 10,000 Medicaid patients he expects to turn up at his office for treatment.

Related: The Hidden Costs of Rejecting Medicaid Expansion

Medicaid patients aren’t the only ones at risk. Across the country, there are growing signs doctors are turning away new Medicaid patients as well as seniors covered by Medicare. Forbes reported earlier this week that “patient access to doctors is approaching a perfect storm of decreased physician supply, more demand for medical care – especially after Obamacare kicks in – and doctors increasingly refusing to see low-paying Medicare or Medicaid patients.”