Medicaid puts strain on system

Expansion under health care law is keeping local providers busy

By Marissa Harshman, Columbian health reporter


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Medicaid enrollment

• Medicaid enrollment is open year-round, unlike commercial plans that have a specific open enrollment period.

• To apply for the Medicaid program, visit the Washington Healthplanfinder website,

• The Free Clinic of Southwest Washington is also holding enrollment events May 17 and June 21. To schedule an appointment for enrollment assistance, call 360-313-1390.

About Medicaid funding

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.

For those who were previously eligible for Medicaid but were not enrolled, the federal government will pay only 50 percent of the cost for providing care, which was the prior Medicaid funding structure in Washington.

The Urban Institute estimated in a May 2012 report the federal government would spend about $2 billion this year to provide services to new Medicaid clients in Washington. The total cost of providing services to existing and new Washington Medicaid clients in 2014 is estimated to be about $7.2 billion, with the state's share totaling $2.4 billion.

Estimated number of people enrolled in Medicaid in Clark County: 100,500.

Medicaid gives woman health care stability

For about two years, Gwendolyn Greene of Vancouver received her medical care from the Free Clinic of Southwest Washington. She enrolled in the clinic’s transitional diabetes program, which is designed to help people keep their disease controlled until they can find ongoing care.

In the program, Greene visited the clinic once a month to get her medications. The providers also monitored her glucose levels and helped her with her diet.

In December, the staff at the free clinic helped Greene to enroll in the Medicaid program. And in February, she visited her new primary care physician for the first time. She’s been in a few more times since then, working with her physician to get her high blood pressure and diabetes medications right.

“I’ve always wanted one doctor, and that’s the blessing of the new health plan,” said Greene, 53. “The free clinic keeps you up on being healthy with what they can do. This doctor is a little more.”

Since becoming insured, Greene has had blood work done, received a colonoscopy and mammogram and finally got glasses — all things she had put off before. Working part-time as a children’s aide, Greene has been without health insurance for about five years and could never afford the services on her own.

“I know that I’m healthy,” she said. “I don’t have polyps, that was really good. I don’t have any breast cancer. These days, it’s good to know.”

— Marissa Harshman

Health officials spread the word on Medicaid

While the Medicaid expansion has added 19,000 new adults to the Medicaid program, local health officials say their work isn’t done yet.

“We’re doing great, but we know we’re just scratching the surface,” said Lynn Johnson, community health specialist with Clark County Public Health.

Public health, the Free Clinic of Southwest Washington and other local organizations will now turn their attention to identifying those who remain uninsured and, if they’re eligible, getting them enrolled in the Medicaid program.

This summer, they’ll visit organizations that help the homeless, such as the Friends of the Carpenter and local churches, and summer events throughout the community to educate people about Medicaid. The free clinic will continue to help eligible patients to enroll in Medicaid when they come in for appointments and hold weekend enrollment sessions.

Public health workers will also continue to try to reach the Hispanic population and dispel misconceptions about the Affordable Care Act. One of the biggest issues health workers run into, Johnson said, is parents who are not legal residents and fear they’ll be reported to federal immigration authorities if they enroll their children in Medicaid. Only legal residents are eligible for Medicaid.

The goal is to get as many people who qualify for health coverage enrolled in the program.

“We’re closing the cracks in the ground people are falling through,” said Zac Sanders of the free clinic.

— Marissa Harshman

Clark County's Medicaid population has increased by about 24 percent in the last six months — an increase that translates to more than 19,000 new adults enrolled in the health program for low-income people.

The increase can be attributed to the Medicaid expansion implemented under the Affordable Care Act.

The medical clinics providing care to those new patients say many of them have been without regular care for a considerable amount of time. They have chronic conditions that may not have been properly managed in the past, and they've gone without preventive care and screenings.

All of those things mean the patients typically need more complex care requiring multiple appointments and more physician time than those who have had regular access to health care.

As a result, clinics are strained, primary care providers are busy, and waiting times are long. And all clinic patients are feeling the effects, not just those insured by Medicaid.

"We do our very best, but there are limits of how many patients you can safely see in a day," said Lynnette Pickup, clinic manager at Sea Mar Community Health Centers' Vancouver medical clinic.

Enrollment climbing

In anticipation of the expansion, state officials rebranded the Medicaid program last summer. All of the Medicaid programs now fall under one umbrella: Washington Apple Health.

Under the expansion, people ages 19 to 65 making up to 138 percent of the federal poverty level are eligible for benefits. For a single person, that's just under $16,000 per year. For a family of four, it's about $32,500 per year.

Prior to the expansion, Medicaid predominantly covered children, pregnant women and disabled people. Under the expansion, state officials expected to see an increase in single adults younger than 65, as most low-income kids were already eligible for the program and most people 65 and older qualify for Medicare.

The Washington State Health Care Authority, which oversees the program, doesn't yet know the precise Medicaid enrollment since the expansion went into effect Jan. 1. Getting an accurate count takes four to five months of data in order to account for normal turnover and retroactive coverage, said Jim Stevenson, spokesman for the Health Care Authority.

But based on prior enrollment figures and the number of people who enrolled through the state-based insurance exchange, Washington Healthplanfinder, state officials have a rough idea of the impact of Medicaid expansion in Clark County and across the state.

In October, Clark County had about 81,000 residents enrolled in Medicaid — about 51,000 of whom were children. From Oct. 1 to March 27, about 19,500 new adults enrolled in the program. That brings Clark County's total Medicaid population up to an estimated 100,500 people, roughly 22 percent of the county's total population.

Statewide, more than 268,000 new adults enrolled in Medicaid from Oct. 1 to March 27, nearly doubling the state's April 1 goal of 136,220 new adults. That brings the state's total Medicaid population up to an estimated 1.5 million people, Stevenson said.

Those enrollment numbers will continue to fluctuate because Medicaid enrollment is year-round.

Local impact

The two local organizations caring for the majority of Clark County Medicaid clients — and feeling the brunt of the increase — are The Vancouver Clinic and Sea Mar Community Health Centers.

The Medicaid population at the local Sea Mar clinics has increased by 77 percent since enrollment in the expanded program began Oct. 1. At that time, the clinics had 10,583 Medicaid clients. As of April 1, that number had spiked to 18,741.

"We're certainly at our limits," Pickup said.

To keep up with the need, Sea Mar has hired two new pediatricians and purchased a private practice in Orchards to serve as its new women's care clinic. Sea Mar hopes the changes will free up some of the family medicine physicians to care for the growing adult population, Pickup said.

Sea Mar also hired a cardiologist and is reaching out to other local specialists to form partnerships to care for the Medicaid clients who need care beyond what's available at Sea Mar. In addition, the clinic plans to bring in more physician assistants and nurse practitioners to support the physicians, she said.

In the meantime, waiting times are longer than the clinic would like. Currently, an adult making an appointment for a routine checkup can expect to wait about 60 days. Appointments for children are much easier to come by, about a five-day wait, Pickup said.

At The Vancouver Clinic, the number of Medicaid clients receiving primary care has climbed to about 31,000 people. In addition, the clinic's specialists see Medicaid clients who receive primary care elsewhere.

In January, once benefits went into effect, The Vancouver Clinic was inundated with phone calls. They received 10,000 more calls that first month. Those calls have tapered off but the call volume remains higher than normal, said Tom Sanchez, The Vancouver Clinic's chief operating officer.

"It's been a lot bigger than we expected," he said.

The clinic has added about 5,000 new Medicaid clients since the start of the year. Many of the new patients are adults in their 40s and 50s who have chronic conditions, said Dr. Alfred Seekamp, chief medical officer for The Vancouver Clinic. The acuity of the conditions of those patients surprised providers, Seekamp said.

Those with chronic conditions are now seeking care for their conditions and catching up on the routine preventive screenings they had put off in the past, he said. As a result, physician caseloads are being scaled back to give them enough time to see patients who need more services.

While the clinic has had the capacity to absorb the population increase, it is straining the system, said Ann Wheelock, chief financial officer at The Vancouver Clinic. The clinic is currently recruiting for new family practitioners and has a couple of providers starting later this year, she said.

PeaceHealth Medical Group and Legacy Medical Group are seeing increases in their medical offices as well.

Legacy's clinics were fielding 20 to 25 phone inquiries per day in January and February from people searching for primary care, said Bryce Helgerson, chief administrative officer at Legacy Salmon Creek Medical Center.

The clinics tried to ramp up for the increase, but physician staffing changes in some of the clinics made it difficult for them to handle as many additional patients as they had hoped, Helgerson said.

"The access for primary care is pretty limited," he said.

The number of Medicaid clients visiting the Legacy Salmon Creek Medical Center emergency department is also increasing. Last year, Medicaid clients accounted for about 18.1 percent of the hospital's emergency department population. During the first quarter of this year, that number is up to 21.5 percent.

Meanwhile, the number of uninsured people in the emergency department has dipped from 7.8 percent of the patient population to 3.4 percent.

Tom Haywood, chief financial officer at PeaceHealth Southwest Medical Center, said the hospital is also seeing fewer uninsured people and more people with Medicaid, but was unable to provide specifics. The PeaceHealth clinics are also seeing an increase in Medicaid clients, he said.

Kaiser Permanente, which has three primary care clinics and about 100,000 members in Clark County, has a small Medicaid population in Clark and Cowlitz counties, but that population has nearly doubled, said Lynn Barker, Kaiser's director of Medicaid and charitable programs.

Last year, Kaiser had about 1,400 Medicaid clients in the two counties. By the end of March, Kaiser's Medicaid population was up to about 2,500 people, most of whom live in Clark County, Barker said.

Kaiser has some room for growth in Clark County, primarily for children with Medicaid. Kaiser also has a policy to accept new Medicaid clients who had been established with Kaiser within the last year, Barker said.

Uninsured numbers drop

The medical clinics serving the uninsured in Clark County are changing as a result of the expanded Medicaid program. The Free Clinic of Southwest Washington has seen its patient population drop 34 percent since Jan. 1.

The clinic is, however, hearing from people covered by Medicaid but unable to get an appointment with a primary care physician. But the free clinic doesn't intend to become a Medicaid provider, said Barbe West, executive director.

"We will continue to be a free clinic serving the uninsured," she said. "We recognize that the volume will decline, but we know the uninsured will not go away."

The clinic's board of directors has, however, decided for the next year to provide urgent care for people who are insured — Medicaid, Medicare or unaffordable commercial plans — but cannot find primary care or cannot get in to see their provider, West said.

"We're going to see them. We're not going to turn people away," she said. "During this transition time, we don't want to slam the door in their faces."

The expansion has changed the way the clinic operates in other ways, as well. Historically, people would come to the free clinic and be treated for their immediate needs, but the clinic couldn't provide any help for ongoing care. Now, they can help to enroll people in Medicaid or at least let them know it's an option, said Zac Sanders, dispensary coordinator at the free clinic.

"The Affordable Care Act has allowed us to give them a solution to the problem," Sanders said.

Uncertain future

While local medical providers have been pleased with their ability to absorb additional Medicaid clients, they are cautious about the future.

As eligible Clark County residents continue to enroll in the program, the number of people turning to local clinics for medical care will continue to tick up. The Vancouver Clinic worries about the mounting strain on its system.

"If we see this pace continuing, that is going to be challenging," said Wheelock, the clinic's chief financial officer.

Wheelock hopes other local providers who are seeing fewer Medicaid clients will open their doors and take in more patients to help ease the burden.

West wonders how many more people are newly insured but haven't yet reached out to local clinics for care. And what happens when those people, in addition to the Medicaid clients already making appointments, need care?

"Just because you got Medicaid doesn't mean you're sick in January," West said.

Even with the future uncertainty, the local medical providers said the Medicaid expansion was the right move for Clark County.

"This is really positive for the people of our community," West said. "The hard part is getting through the change. Long term, this is the right thing to do."