In the next year, the state of Washington expects to have more than 600,000 newly insured residents.
A significant portion — about 330,000 people — will receive medical coverage through the state's expanded Medicaid program.
The Washington State Health Care Authority, which oversees the state's Medicaid programs, began work three years ago to implement the expanded program offered through President Barack Obama's Affordable Care Act.
One year ago, expanded Medicaid was still considered a dream, said Manning Pellanda of the Health Care Authority.
"And now that we're less than three months out until we start, our vision is becoming a reality," he said.
In Clark County, where about 60,000 residents are on Medicaid, that reality means an estimated 28,600 new Medicaid clients. It also means new concerns about the program's sustainability, the local physician workforce and the state's method of enrolling clients.
As local physicians, medical groups and health plan administrators try to prepare for the patient surge, they're left with a number of unknowns.
"It's like building an airplane in the air," said Dr. Alfred Seekamp, chief medical officer for The Vancouver Clinic. "You don't know how it'll turn out, but you'll do your best."
Under expanded Medicaid, people ages 19 to 65 making up to 138 percent of the federal poverty level will be eligible for benefits.
For a single person, that's just under $16,000 per year. For a family of four, it's about $33,000 per year.
"This will be a big change," Pellanda said. "It's a positive change."
The way people apply for Medicaid has also changed.
Washington residents will apply for Medicaid benefits using the state's online health insurance marketplace, Washington Healthplanfinder. Open enrollment begins Oct. 1, but coverage won't go into effect until Jan. 1.
Residents will go to the website and input their basic demographic information. From there, the system will connect to a new federal hub that stores information from the Internal Revenue Service, Social Security Administration and Department of Homeland Security. The system will also draw information from state offices, such as the Washington State Employment Security Department, which handles unemployment claims.
That information will verify the person's citizenship (only U.S. citizens are eligible for Medicaid) and household income. The results will be displayed on the screen for the consumer to approve. Once the applicant clicks "OK," he or she will be added to Medicaid, Pellanda said.
"Instead of 45 days for an eligibility decision, you will find out in probably 45 minutes if you're eligible for Medicaid, which is fantastic," he said. "There's no waiting. There's no pending eligibility."
Since the system relies on data that could be outdated, such as annual income tax returns, applicants have the opportunity to edit the information gathered through the data match to reflect their current circumstances, Pellanda said.
If the person reports income below 138 percent of the poverty level, he or she will be declared eligible for Medicaid, he said.
The state will run additional data searches afterward and will conduct random audits of about 20 percent of the total Medicaid population to ensure people aren't misrepresenting their circumstances, Pellanda said.
"Our data from many years experience is when you're thinking of people trying to fraud to get coverage, in the Medicaid world, we don't find that as a very large number," he said.
New Medicaid clients will automatically be enrolled with a plan in their region. In Clark County, clients will be assigned to either Molina Healthcare of Washington or Community Health Plan of Washington, which contracts with Vancouver-based Columbia United Providers.
Auto enrollment raises concerns for many in Clark County.
If Clark County residents are assigned to a plan without a robust network of providers and specialists, they'll struggle to get access to care and will likely end up back in the emergency department, said Tom Sanchez, director of clinical operations at The Vancouver Clinic. Clients can request to be switched to a different plan, but the requests take time to work through the state department and result in delays in care, he said.
"That's happening now, and it'll continue to happen," Sanchez said.
In the last year, health care providers and Columbia United Providers officials say Molina hasn't contracted with enough specialists to meet patients' needs. As a result, many patients are requesting to be switched to the Community Health Plan/Columbia United Providers plan.
Molina Healthcare issued a statement saying it has been preparing for Medicaid expansion in Clark County and across the country since the Affordable Care Act was passed and is open to working with additional providers.
"In addition to expanding our network of providers, we are adding member services representatives to help members find primary care and specialty physicians as well as other social services they need to access health care and to stay healthy," the statement said.
The Health Care Authority regularly evaluates network adequacy and is currently evaluating the Clark County plans, said Preston Cody, HCA deputy director. Based on his initial review, Cody said he's pleased with the results.
"Provider networks are growing," he said of the plans. "Their capacity continues to be able to serve Clark County."
A small percentage of plan switching always occurs, and Cody said he hasn't noticed an unusual increase in Clark County. However, the state will continue to monitor plan adequacy, Cody said.
Preparing for the influx
Local officials believe many of the people who will be added to the state's Medicaid rolls are receiving medical care now, even though they're uninsured.
Physicians are serving the uninsured at free clinics, in the emergency department of hospitals and in their own offices when insured patients lose medical coverage, said Ann Wheelock, Columbia United providers chief executive officer.
"I think it might not be the train wreck people think it will be," Wheelock said of the expansion. "These people are already getting some care."
But it's unclear how many of those patients and other new Medicaid clients will be assigned to — or will request to be switched to — the Columbia United Providers plan. As such, providers who contract with Columbia, such as The Vancouver Clinic, don't know what to expect come Jan. 1.
But Duane Lucas-Roberts, Vancouver Clinic's chief executive officer, thinks the clinic can handle an increased patient load.
The Vancouver Clinic has more than 1 million visits to its medical offices each year. With 200,000 people seeking care at the clinic annually, even an additional 10,000 people would only be a 5 percent increase, Lucas-Roberts said.
"We think we have the capacity," he said.
Still, the clinic has taken steps to prepare for the influx.
Throughout the last year, The Vancouver Clinic has implemented several initiatives aimed at improving patient access, and by the end of the year, the clinic hopes to have hired an additional 10 to 15 physicians.
Sea Mar Community Health Centers — which provides medical, dental and behavioral health care to the insured and uninsured — is also taking steps to prepare for more patients, said Mark Carlson, Vancouver Medical Clinic manager.
Sea Mar is further developing its care teams by assigning case managers to people with chronic illnesses and hiring trained peer advocates — many of whom have or have had their own chronic illnesses — to work with patients, Carlson said.
In addition, the clinic is recruiting more physicians and specialists. The clinic is hiring its own specialists since accessing specialty care in Clark County has been a challenge, Carlson said.
Primary care concerns
Carlson fears the expansion will exacerbate the specialty care access problems. Wheelock believes the access problem is bigger than just specialists.
"I think there's a big primary care access problem with all of health care reform," Wheelock said.
The state Office of Financial Management issued a research brief in June 2012 about the availability of primary care physicians to serve the expanded Medicaid population. Nearly all urban areas in the state have enough capacity, according to the report.
The one exception: Clark County.
The researchers suspect a portion of new Clark County Medicaid patients will seek primary care in Portland. They based that conclusion on unpublished hospital discharge data that showed 19 percent of hospital stays by Clark County residents in 2010 occurred in Oregon hospitals.
That won't likely happen, Wheelock said.
"We have for years tried to work with Portland providers," Wheelock said. "They've got Oregon Medicaid patients and no-pay patients and Medicare patients to take care of. They're not interested in caring for Washington's Medicaid patients."
The state hopes increasing the Medicaid reimbursement rates will give providers incentive to take on more clients.
Through the Affordable Care Act, the state is increasing rates for family practice, internal medicine and pediatric physicians.
The reimbursement for a new adult patient's office visit will increase from $57.56 to $114.21. Reimbursement for an established adult patient's office visit will increase from $38.63 to $76.86.
The higher rates went into effect this month, but the reimbursement is retroactive to Jan. 1. The federal funding for the enhanced rates expires Dec. 31, 2014.
Wheelock questions what will happen once that federal funding is gone.
"If we're banking on federal money to save the day, I think we all need to be realistic," she said.
The uncertainty surrounding reimbursement rates is only one concern local officials have about the future of the program. Many are also concerned about the sustainability of the state Medicaid program.
"Costs are going through the roof," Wheelock said. "This (expansion) is going to add pressure."
Under the Affordable Care Act, the federal government will pay 100 percent of the cost to cover the newly eligible Medicaid enrollees for the first three years. After that, the federal contribution is scheduled to decline to 90 percent by 2020 and remain at that level.
But many are skeptical the federal government will continue funding the program at those levels. Add in the state budget concerns, and the picture grows murkier.
"Somewhere there's going to be a point where all of this crashes," Wheelock said. "I think we're heading over a cliff."
Despite the uncertainties, Wheelock is confident local providers will pull together and do their best to accommodate patients come Jan. 1.
"I think Clark County is probably as well-prepared as any other county in the state," she said.
At the state level, the Health Care Authority is committed to make the new Medicaid program successful, Pellanda said.
"We do not want to see this fail in any way," he said. "And we will do whatever it takes to ensure the citizens of this state have access to care through the system we have put in place over the last three years."