June 29--Local medical providers Thursday expressed relief that the U.S. Supreme Court upheld the Affordable Care Act, saying they can begin addressing the estimated 30,000 people in Yakima County who will now have access to health insurance.

"This is a great day," said Anita Monoian, CEO of Yakima Neighborhood Health Services. "This ... marks the day when all Americans can look forward to having health-care coverage. That is huge."

The law's sweeping expansion of Medicaid eligibility and the establishment of a health-insurance exchange for the purchase of private plans will have the biggest impact on Yakima patients, providers say.

In Washington state, about 1 million people are currently uninsured; Yakima County has the highest rate at 27.5 percent of all county residents.

While coverage will expand, undocumented workers will continue to be excluded from Medicaid, as well as from the new insurance exchange.

"Given the demographics of the county, Yakima will be disproportionately affected by a continued high rate of uninsureds, even after January 2014" when the bulk of the reform law goes into effect, said Dr. Mike Maples, CEO of Community Health of Central Washington.

On the other hand, Maples said, "Yakima County will be disproportionately advantaged by the expansion of Medicaid to the low-income adult population, because we've got a lot of those, as well as undocumented."

Maples said the ruling gives providers a level of certainty they've been lacking that will allow them to plan for demands on the health-care system.

Yakima's federally subsidized health-care clinics are concerned that the existing system lacks the capacity to meet patient needs, particularly if previously uninsured people without a medical home flock to those centers. But providers hope that medical schools like Pacific Northwest University of Health Sciences will help by turning out more primary-care doctors to meet that need.

At the same time, capital grants like the $4.7 million awarded to Neighborhood Health last month under the Affordable Care Act will allow health centers to expand.

Washington is in a better position than many other states, providers say, because lawmakers have worked under the assumption that the law would go into effect. So far, the state has received more than $151 million toward the establishment of the insurance exchange, and several million patients are already enjoying coverage under other provisions.

The impact of the Medicaid expansion is hard to gauge at this point: Clinics and hospitals are already treating large uninsured populations, so they're not sure how much their current patient load will increase.

What will change, they say, is now they'll be reimbursed for providing that care, which in turn will allow them to improve patient outcomes and expand services.

For currently uninsured patients, the ruling could provide substantial financial relief.

Genoveva Alemn, 57, of Yakima was at the Yakima Valley Farm Workers Clinic on Nob Hill Boulevard on Thursday afternoon to pick up her blood pressure medication. She pays out of pocket for exams and medicine through a payment plan because it's too hard to cover the cost all at once from her wages cleaning houses.

"You've always got this fear that something serious is going to happen, and you'll have to go to the hospital without insurance," she said. "Imagine paying $10,000, $15,000 for a serious illness; it'd be really hard."

That's exactly what happened to Pascual Cabrera, 55, of Union Gap. Last year, the diabetic patient suffered from a blockage in his heart, and had angioplasty to re-open an artery. The hospital bill came close to $100,000.

Cabrera had been on the state's Basic Health Plan but said he lost coverage after his earnings exceeded the threshold to qualify. Yakima Valley Memorial Hospital wrote off about $90,000 of his bill as charity care, but Cabrera said he's still $10,000 in debt.

"That just caught me off guard. It was unexpected -- an expense I didn't anticipate," he said.

He's applied for Medicaid before but didn't qualify. He may try that route again under the new law or he may shop for private insurance in the exchange. But he's skeptical that the law will ever go into full effect, despite the Supreme Court ruling.

"They (opponents) say they're going to repeal it. ... I don't think it's going to work out later down the road. President Obama's been making a lot of bad choices," he said.

For now, Cabrera said he's working on getting his bills paid off and then he'll see what he can find. "It's a struggle," he said. "I take one day at a time."

The coverage expansion isn't the only major implication of the court's ruling.

Rick Linneweh, CEO of Yakima Valley Memorial Hospital, said a less-publicized part of the law significantly changes how providers are reimbursed for their services, moving away from fee-for-service and instead providing incentives for doctors who have better patient outcomes.

"Our effort now will really be to continue to work on accepting the fact that there's going to be a reimbursement redesign; it has to if we're going to get costs under control," Linneweh said. "We've got to design delivery systems to respond to that."

For that reason, Yakima Valley Farm Workers Clinic CEO Carlos Olivares said he's still cautious about the law's promise of reduced health-care costs.

"At the end of the day, we're still going to have to pay for this health care. ... It's a savings that are projected to be built around the implementation of an outcome-based system," Olivares said. And if the health-care system isn't responsive to the changes in the reform law, "we're going to be in financial crisis."

Focusing on preventive care has the potential to generate significant savings as patient health improves, he said, but it depends on a true overhaul of the system, which right now rewards providers based on all the procedures they perform rather than on how healthy their patients become.

"We can't keep doing what we've been doing," Olivares said. "Patients need to be actively involved in their health care. They cannot be passive any longer."

He knows a lot of people are unhappy with the court's ruling, or fear that the law represents a massive government intrusion. But he says it all reminds him of the reaction to the original passage of Medicare in 1965.

Back then, "Communism was going to take over the world, and Medicare was the first step," he said. "It's been a long time, and I still don't see Communists running around."

--Molly Rosbach can be reached at 509-577-7728 or mrosbach@yakimaherald.com.

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