Low-income women in the Maryland suburbs are finding it increasingly difficult to obtain routine medical care because doctors are refusing to take Medicaid patients and short-staffed public health clinics have long waiting lists.

In Prince George's County, for example, women needing prenatal care can wait 10 weeks for an appointment. In Montgomery County, none of the county's private gynecologists will take new Medicaid patients, and public health clinics do not provide routine women's health checkups, county officials said.

Carol W. Garvey, a physician who heads the public health committee for the Montgomery County Medical Society, said doctors are reluctant to participate because the reimbursement rate is relatively low, the state is slow with payments and the procedure is cumbersome.

"Although Maryland has worked very hard to bring reimbursement levels closer -- they are up to about half of private insurance -- that covers {the physicians'} malpractice insurance but they don't earn anything," Garvey said.

The waits in the Maryland suburbs are not unique in the Washington region. In the District, patients who seek appointments at public health clinics usually wait three weeks or more to get in, a recent Washington Post review of the city's health department showed.

There also are delays in the Virginia suburbs; poor women in Alexandria have to wait six to nine weeks for prenatal appointments and even longer for routine gynecological care.

We are just overwhelmed," said physician Anne J. Albertson, Alexandria's health officer. "We are the sole provider of obstetrical care in the city of Alexandria for women who are poor or on Medicaid."

For poor women in Montgomery, such as Annette Offutt, who discovered a nickel-sized lump in her breast two months ago, almost all avenues to medical care have been closed.

None of the county medical clinics are set up to treat such problems, and Offutt, 29, who has a medical assistance card, has been told by the Medical Society's referral service that none of the county's private gynecologists will take her. She was referred to a doctor in Lanham and one in the District, but Offutt, who has no car, said it would be difficult for her to get from Gaithersburg to those appointments.

"If you have money, you can get in to see the doctor today, but if you don't you can't see one," Offutt said. "What do they expect us to do?"

Late last week, Offutt went to the emergency room of Shady Grove Adventist Hospital where, after a three-hour wait, a doctor checked her and recommended her to a specialist.

Health officials and physician organizations want fundamental changes in the way Maryland reimburses doctors who treat Medicaid patients, as well as moves to shield physicians from malpractice claims from those patients. The state is poised to begin a new program that will pair Medicaid recipients with primary-care doctors or clinics, but physicians, especially specialists, have been slow to volunteer to participate.

"It's one of the huge gaps that exists right now for health care delivery" for people like Offutt, said Sharon Martin, director of the Family Health Services Division of the Montgomery Health Department.

Montgomery County Medical Society and health department records show that none of the estimated 121 private obstetricians and gynecologists in the county will take new Medicaid patients. Montgomery County runs family planning, prenatal and sexually transmitted disease treatment clinics, but does not offer routine health care for women.

In Prince George's, only three of the 23 obstetricians and gynecologists in the county will take Medicaid patients, and then only with the condition that they not be high-risk patients.

The clinic wait for family planning and routine checkups ranges from two to four weeks in Prince George's. But at the county Health Department's Cheverly and Hyattsville prenatal clinics, the wait for an initial appointment averages eight to 10 weeks. This is a critical period for most pregnancies, especially for teenagers, drug abusers or women with illnesses such as diabetes or high blood pressure.

"It's a mess. We can't keep up," said Helen McAllister, Prince George's health officer, whose clinics have a shortage of doctors.

Maryland officials are trying out a new program they hope will help. Maryland Access to Care will assign low-income patients, two-thirds of whom are women, to a doctor who will decide when the patient needs to see a specialist such as a gynecologist, or go to an emergency room.

The program is designed to save money by reducing Medicaid patients' reliance on emergency rooms. It offers as an incentive to physicians an increase in the Medicaid reimbursement rate from 25 to 30 percent to as much as 50 percent of the cost of care. Specialists in some instances would be reimbursed at a lower rate, Garvey said.

The initiative is similar to an eight-year-old Virginia program that tries to manage care for Medicaid patients by assigning each to a doctor and pharmacist. Virginia officials are considering expanding the program to other low-income people, particularly the working poor. About 65 percent of all doctors in Virginia accept Medicaid patients, but in some specialty areas, including obstetrics and gynecology, the percentage is much lower, said Bruce U. Kozlowski, director of the state's Department of Medical Assistance Services.

In Maryland, physicians have been slow to volunteer to participate. Doctors said they are concerned that the reimbursement rate from the state will not cover their costs, particularly for liability insurance.

"If you brought reimbursements up and eliminated the paperwork . . . almost every physician will see" Medical Assistance patients, said physician Jeffrey F. Witte, president of the Montgomery County Medical Society. But he added that the responsibility for health for low-income people is not just on physicians. "We need a commitment on society's part to say these people deserve care and it costs X. Society has got to pay."