Perhaps more than any other state, the expansion of Medicaid to give thousands of Louisiana residents no-cost health insurance stands to have a profound impact on health care — whether it’s better or worse than the system that was already established to take care of the needs of the poor.

Louisiana on Friday is set to become the 31st state in the country to expand Medicaid under the federal Affordable Care Act. About 375,000 people — mostly the working poor — are expected to get free health insurance coverage through the new program, which is mostly subsidized by the federal government.

But the transition to having so many more people on Medicaid, rather than relying on Louisiana’s unique “charity” hospital system when they can’t afford health care, is expected to be bumpy — to put it lightly.

“There’s going to be a journey we have of people learning what it actually means to have insurance and have primary care,” state Health Care Secretary Dr. Rebekah Gee said.

The Affordable Care Act, frequently referred to as “Obamacare,” left many questioning what would happen to Louisiana’s unique health care delivery model. Under the direction of then-Gov. Huey P. Long, Louisiana established its statewide charity hospital system in the 1930s, offering hospital care to those who could not afford it.

Bobby Jindal, as governor, reshaped the system during his tenure to set up public-private partnerships under which the hospitals would operate to get LSU largely out of the responsibility of providing health care to the poor. But Jindal staunchly opposed expanding Medicaid — a program that has traditionally in Louisiana provided health care coverage to pregnant women, the disabled and children — to cover more people.

Gov. John Bel Edwards campaigned on the fact that he would expand Medicaid to give free coverage to thousands of people quickly after he took office. One day after taking office in January, Edwards signed an executive order to set the wheels in motion.

Adults who make below 138 percent of the federal poverty level — about $33,500 a year for a family of four or $16,200 for a single adult — are among the newly eligible population.

Benefits are slated to kick in July 1, and enrollment will continue year-round.

“This isn’t just about expanding health care coverage or saving money,” Gee said. “We want healthier people in Louisiana. We want more productive people in Louisiana.”

The old charity system encouraged the poor to seek out hospital treatment, rather than primary care. Often they waited weeks or months for an appointment under what was called a “rationing” of care. By entering into partnerships with private entities that now run all but one of the old charity hospitals, Louisiana stepped back from its responsibility of covering health care costs of the poor. Now, those entities do so on a contract basis, but recent budget cuts have dipped into their payments, often threatening the relationships.

Louisiana has repeatedly faced state budget shortfalls — the most recent of which led to large tax increases and cutbacks to state services to bridge a nearly $2 billion gap.

The fight over Louisiana’s public-private partnerships was well illustrated during the most recent legislative session and the following special session on the budget.

The contracts were funded at the level that Edwards’ administration had said they needed to be funded, but the hospital partners had asked for more.

The private partners say they aren’t profiting off the state, and many take offense to the assertions that they could be.

“It infuriates me to say, ‘Let’s go back to the state,’” Dr. Peter DeBlieux, chief medical officer at the University Medical Center in New Orleans, said of negotiations over getting more money and fights at the State Capitol. “I was about to come out of my chair ... The thought that the partners are somehow getting fat off of this.”

“The education of the legislators on this very complex topic is tough,” he added.

The old system had led to a so-called “rationing” of care, under which people could wait weeks or even months before seeing a doctor.

“I’ve personally seen women who have put off a mammogram because they couldn’t afford it,” Gee said.

Warner Thomas, president and CEO of Ochsner Health System, said hospitals want to build partnerships with community health centers to try to build a network of care that the state hasn’t seen before.

“The expansion, we think, is a good thing for Louisiana,” he said. “It’s a good thing for the communities and the folks in our communities.

“Hopefully we will have very few people uninsured in Louisiana thanks to Medicaid expansion,” Thomas added.

The ACA’s Medicaid expansion plan is partially paid for by the scale-back of federal Disproportionate Share Hospital payments, commonly called DSH and pronounced “Dish” payments. Those funds have typically gone to hospitals that treated the uninsured who were unable to pay for care they received.

Whether states adopt Medicaid expansion or not, those DSH payments will go away, which could leave some hospitals with facing uncertain futures.

“That’s not a place you want to be,” said Pete November, executive vice president of the Ochsner Health System. “(Expansion) is also the right thing to do for patients.”

The new $1.1 billion University Medical Center, which was built to replace the old Big Charity hospital in New Orleans that shut down shortly after Hurricane Katrina, offers lush waiting rooms, reminiscent of upscale hotel lobbies, as well as state-of-the-art treatment amenities.

The long-term goal is to drill it into the heads of people who have private insurance and otherwise would have never thought of seeking treatment at “Big Charity” in New Orleans that UMC is a legitimate option for their health care needs.

“That’s how we become less reliant on the state,” said DeBlieux.

On top of the public-private partnerships, the state struggles to pay other providers who cover Medicaid patients at a level that they will accept. The result: Many patients are turned away because doctors and other providers don’t accept Medicaid. Many have wondered whether adding more to the system that already has struggled to get providers on board will be helpful or hurtful.

The goal is to get more people seeking treatment through primary care providers in medical offices and clinics, rather than the hospitals.

The Edwards administration has insisted that increased provider rates will come.

“We don’t have a plan and a timetable (but) it’s as soon as possible,” Edwards said. “It’s something we’re talking about. We’re going to do it at the very first possible time. We’ll do it our first opportunity.”

Gee is similarly vague but optimistic.

“That’s my long-term goal,” Gee said, when asked about provider fee increases.

“Primary care I’m not as worried about, but specialty care is always a challenge when you have lower rates,” she added.

But she stressed that the increased rates are coming.

“This is not a resource rich time in our state,” Gee said. “There are pools of money we can look to and we’ll be addressing sooner instead of later.”

Gee said that the hospitals were instrumental in getting expansion into a meaningful posture.

“The hospitals were a huge part of this,” she said. “These hospitals are, for many of these communities, very economically critical.”

And leaders say the Medicaid managed care providers will be crucial to ensuring that coverage works.

Louisiana has contracted with five providers who facilitate Medicaid coverage: Aetna, UnitedHealthcare, Amerigroup RealSolutions, Louisiana Healthcare Connections and Amerihealth Caritas.

The benefits differ from company to company — they range from monitoring emergency room visits for intervention to providing memberships to Boys & Girls Clubs or Boy and Girl Scouts for kids, and in some cases even swimming lessons.

The managed care providers also have put pressure on clinics and doctors to expand hours that they will treat people.

“We see that as a positive for the state and the population,” said Jamie Schlottman, chief executive officer of managed care provider Louisiana Healthcare Connections.

Schlottman said that the providers are intimately aware of the problems with getting providers into the Medicaid network. “There’s a lot of questions about access for the Medicaid expansion population,” he said.

But he thinks that the estimated 375,000 people won’t even overwhelm the existing system.

“You have to change your business model,” he said. “We see it as a positive for the state and the population.”

Follow Elizabeth Crisp on Twitter, @elizabethcrisp.