What would it mean for the Yakima Valley if Obamacare is repealed and replaced?

Yakima Herald-Republic (WA)

July 05--Local and state health care leaders are alarmed by the Senate's health care proposal, particularly the impact it would have on rural communities like the Yakima Valley.

Most troubling is the $834 billion cut facing Medicaid in the Senate's health bill, the Better Care Reconciliation Act.

"Overall, it's not a good policy. ... Right now, it's a lot of takeaways and not so much on the give-back," said John Gallagher, CEO of Sunnyside Community Hospital and Regional Health. "When it comes to the nitty gritty -- we took care of patients beforehand; we'll take care of patients after -- but it will be a challenge for the families involved."

In rural areas of Washington state, 53 percent of children and 21 percent of adults are covered by Medicaid, according to the Washington State Hospital Association. Both figures have increased since the Affordable Care Act was enacted and the state expanded Medicaid, giving new coverage to roughly 600,000 low-income adults and families.

The Senate bill also includes a provision that would lock patients out of health coverage for six months after their sign-up date if they've let their insurance lapse for 63 days or more. In theory, the lockout period is meant to encourage people to stay in the insurance market and not hop in and out of coverage, but providers fear it could mean life-threatening delays in care for people who drop their insurance because they can't afford it or because they lose or change jobs.

That provision applies to everyone, not just those on Medicaid. It would replace the ACA's individual mandate, which requires people to have health insurance or pay a penalty at the end of the year. (The penalty this year is the higher of either $2,085 per person or 2.5 percent of household income.)

Locally, hospital and health center directors say they will continue serving patients regardless of ability to pay. That's what they were doing before the ACA: offering sliding-fee-scale discounts to the uninsured and eating the cost in charity care and uncompensated care.

But the additional reimbursement from the expanded Medicaid population has allowed for the growth of services such as coordinated care, which help people receive more efficient, comprehensive health care by networking with different types of providers.

Across the country, community health centers saw their rates of uninsured, self-pay patients drop by approximately 50 percent, said Dr. Mike Maples, CEO of Community Health of Central Washington.

The uninsured didn't go away entirely, he said; there are still people falling through the cracks who are not eligible for Medicaid or subsidies on the exchange.

"But that was huge for us and other health centers, in terms of having a source of payment for their care so we could do things like expand integrated behavioral health services, for example," Maples said. "We've grown those services substantially since the Affordable Care Act."

They haven't yet looked at the "disaster scenario" of the Senate health bill actually going into effect, or what the rollback of those services would mean for patients, he said. They're waiting to see what progresses in the Senate, where the bill was put on hold until after the Fourth of July recess because Republicans couldn't get the necessary votes to pass it last week.

Prior to the ACA, Virginia Mason Memorial hospital in Yakima was spending 6 to 8 percent of its adjusted patient services revenue on charity care; it's now between 2 and 3 percent, said Tim Reed, Memorial's chief financial officer.

"The communities with the poorest socio-economic folks are going to be those hardest hit, and that's precisely what those (Medicaid) programs are for," he said.

Reed predicts that if Medicaid payments go away, the cost shifting from uninsured patients still using the ER will result in higher premiums for commercial insurance customers.

Pull Quote

"When someone doesn't have health insurance ... Heaven help them if they need a gastroenterologist or a specialist, or if there's gonna be a pharmaceutical regimen involved," -Julie Petersen, KVH Hospital CEO

"That will be the market or the system trying to equilibrate the shortfall in Medicaid," he said.

The major changes to health insurance exchanges and deep cuts to Medicaid in the Senate bill wouldn't go into effect until 2019 and later -- after the 2018 midterm elections. The overhaul of the entire Medicaid formula wouldn't happen until 2025, two presidential elections from now.

While community health centers may offer discounts, emergency rooms are required by law to treat anyone who shows up.

"When someone doesn't have health insurance ... Heaven help them if they need a gastroenterologist or a specialist, or if there's gonna be a pharmaceutical regimen involved," said Julie Petersen, CEO of KVH Hospital in Ellensburg.

Petersen has served on a national panel on vulnerable populations with the American Hospital Association, representing rural hospitals.

Hospitals may be forced to cut programs that helped reduce readmissions by ensuring safe housing, ensuring patients know how to take their medications and other factors that affect health after discharge from the hospital, she said.

"Those programs are part of health care reform," Petersen said. "But if (hospitals) go back to scraping by and working to keep their head above water, those are the sorts of things that we'll be sacrificing."

Expanded coverage has also allowed more people to find primary care providers, where they can go for preventive check-ups and screenings, as well as more everyday health care.

Brisa Guajardo lives in the Tri-Cities but often works with Yakima patients, encouraging people -- particularly in the Hispanic community -- to seek preventive care now that they have access to insurance instead of waiting until they're really sick or relying on home remedies.

She knows the value of preventive care firsthand: At age 24, she went to an urgent care center to figure out why she was feeling run-down all the time. The routine check turned serious when the doctor found a lump on her neck. She was diagnosed with thyroid cancer and scheduled for surgery within weeks.

"Since then, preventative care has been the focus, keeping up with my checkups," she said. "My doctors always tell me: Cancer will never hurt until it's too late."

The cancer came back in 2008, discovered during one of those regular checkups.

"I often wonder, 'What if I didn't keep up with those checkups?' Testing is so expensive; my medications today are expensive," Guajardo said. "I'm lucky to have insurance. ... What if my job was to ever go away? The first thing that I would think about is my health, because I have something that I have to take care of for the rest of my life."

Under the ACA, insurers are not allowed to refuse coverage to patients with pre-existing conditions, but under both the Senate and House health care proposals, states would be able to opt out of the "essential health benefits" of the ACA, which include coverage for pre-existing conditions.

One of the biggest concerns for hospitals around here is that, while the Affordable Care Act cut certain funds to hospitals, including disproportionate share (DSH) dollars that were initially given to make up for large number of Medicaid patients at those hospitals, the Senate bill both slashes Medicaid dollars and doesn't replace the DSH payments.

"That's really the double whammy you saw happen in a lot of the South that didn't choose to expand Medicaid: They took the cuts but didn't see any decrease in their uncompensated care," said Jacqueline Barton True, director of rural health programs at the state Hospital Association.

"Many of our rural hospitals operate on very thin margins," she said. If people's insurance goes away, their health care costs don't disappear; people often end up delaying care and showing up in the ER when they're more severely ill. "Those costs have to be absorbed by the system. ... Rural hospitals are less able to absorb that cost."

Nationwide, nearly 80 rural hospitals have closed since 2010 and hundreds more are vulnerable, according to the National Rural Hospital Association. Cuts to hospitals under the Affordable Care Act have not helped.

"But the things that are wrong with (the ACA) aren't really addressed in this (Senate) bill," Barton True said. "The forward-thinking things our hospitals are trying to do -- this bill doesn't help them do it."

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