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Originally published Thursday, June 28, 2012 at 7:59 AM

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Supreme Court health-care ruling means Washington state can move quickly

Now that the Supreme Court has ruled in favor of President Obama's health-care law, Washington state will begin working to bring many of its 1 million uninsured onto Medicaid or private health insurance.

Seattle Times health reporter

What now?

Two conferences gather policymakers, health leaders and concerned citizens

Washington Policy Center: Bill McCollum, who as Florida attorney general initiated the constitutional challenge to the Affordable Care Act, will be a featured speaker at the Washington Policy Center's 10th Annual Health Care Conference. The event, open to the public, will be held 7:30 a.m. to 1:30 p.m. July 10 at the SeaTac DoubleTree Hotel, 18740 International Blvd., Tukwila.

More information: washingtonpolicy.org/events/details/10th-annual-health-care-conference.

Legislative summit: State Sen. Karen Keiser and Rep. Eileen Cody, chairwomen of their chambers' health committees, will lead a summit for lawmakers, policymakers and others to develop a response to the Supreme Court's decision and to plan health-reform initiatives for the next legislative session. The event, which is open to the public to observe, will be 10 a.m. to noon July 25 on the state Capitol campus, in the ABC conference room of the John A. Cherberg Building, 198 15th Ave. S.W., Olympia.

Read the decision

U.S. Supreme Court: www.supremecourt.gov

Federal law's provisions

Children up to age 26: State law now allows children up to age 26 to stay on their parents' insurance plans, similar to the popular provision in the Affordable Care Act (ACA). But the federal law also covers self-insured companies — most of the state's large employers.

Children with pre-existing conditions: The federal law prohibits insurers from refusing to cover children up to age 19 with pre-existing conditions.

Insurance for high-risk patients: Washington has two insurance pools for state residents with pre-existing health conditions who have been denied insurance. The state high-risk pool, established in the 1990s after insurers stopped offering individual plans in the state, will still exist. The federal pool, created by the ACA for people who had been without insurance for at least six months, will vanish in 2014, when such patients become eligible for other coverage.

Lifetime limits: Insurers typically impose lifetime limits on medical expenses; the federal law removes those limits.

Independent review of denials: People denied a particular treatment by commercial insurers already have the right of third-party review in Washington, which adopted a patients' bill-of-rights law in 2001. The federal law extends that to all insurance plans, including those offered by self-insured companies.

Canceled coverage: The federal law bars insurers from canceling coverage after a patient gets sick, unless there is outright fraud on the patient's part.

Preventive services: The federal law removes patient co-pays for many preventive services, including those covered in Medicare plans.

Seniors on Medicare: Those with large prescription-drug expenses received a check for $250 after the law passed, and now get a 50 percent discount on brand-name drugs if they hit the so-called "donut hole," where they must pay their own way until out-of-pocket costs trigger coverage again; the law calls for the gap to be eliminated by 2020.

Medical-loss ratios: One of the most controversial parts of the law requires insurers, starting in 2011, to spend most of what they collect in premiums on actual care or quality-improvement efforts. Some states, such as Washington, have similar — but less stringent — requirements. The ACA's spending requirement, which a Forbes magazine columnist predicted would amount to a "death panel" for some for-profit insurers, was 85 percent for large groups, 80 percent for others.

Help for small businesses: Tax credits in the ACA, which began in 2010, aim to help small businesses with low-wage employees afford health coverage.

Patient safety provisions: Those include a new patient-safety center, regulations requiring more reporting of hospital-acquired infections and other injuries, and incentives for providers to improve care.

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State lawmakers and health leaders say they're grateful that Thursday's U.S. Supreme Court decision upholding the federal health-care law has ended the legal limbo they've all been stuck in since last year.

"This whole case has caused chaos," said Democratic state Sen. Karen Keiser, chair of the state Senate health-care committee. "Over the last six months, we've had nothing but chaos and confusion."

Now the plan is to move quickly to start bringing a good part of the state's 1 million uninsured onto health insurance, either public — through a major expansion of Medicaid — or private.

The ruling clears the way for the state, beginning in 2014, to add up to a 500,000 uninsured to Medicaid rolls, and to enroll an additional 300,000 people with low-to-moderate incomes in private insurance, with the help of federal subsidies.

But those implementing the law have reasons to worry.

Federal funding, in a time of political uncertainty, never is totally secure, particularly when the law's opponents in Congress have vowed to try to dismantle it.

And there are questions whether the primary-care system, already overloaded in many areas, can absorb hundreds of thousands more patients. A state survey of primary-care doctors, done late last year, showed that nearly half said they would not take new Medicaid patients.

Medicaid rolls to grow

Under the expanded eligibility, Medicaid will for the first time insure adults without dependent children or severe disabilities, with incomes up to 138 percent of the federal poverty level.

This influx of patients won't happen all at once, but it will be huge.

Most of the new Medicaid enrollees, who must be U.S. citizens or have resided legally in the country for more than five years, will be newly eligible for the joint federal-state insurance program, which now covers about 1.2 million in the state. The state estimates Medicaid also will enroll as many as 170,000 others, mostly children, who already have been eligible but not signed up.

For those newly eligible for Medicaid, the law calls for the federal government to pay 100 percent of the costs for three years, phasing down to 90 percent by 2020, with the state picking up the remaining 10 percent. For those already eligible and new to sign up, the state immediately will take on a share of the cost.

Nearly 33,000 people are on the state's Basic Health program, under a federal waiver. They, too, will be folded into the expanded Medicaid program.

In all, state officials expect the Medicaid rolls to grow by up to 42 percent, and they offer no predictions on the extra cost.

Subsidies for others

In addition, moderate- to low-income people who don't qualify for Medicaid will receive federal subsidies to help them buy private insurance on the soon-to-be-ready state Health Benefit Exchange, envisioned by the federal law as the marketplace where people can compare benefits, something nearly impossible to do now.

Subsidies outlined in the federal law, given as refundable tax credits, are aimed at people with incomes between 139 percent and 400 percent of the federal poverty level. The federal poverty level, which changes each year, is now $23,050 for a family of four, meaning a family earning up to $92,200 would be eligible for a subsidy, though it would be considerably smaller than those given to lower-income families.

The calculation for the subsidy includes caps on the percentage of income people would have to spend on premiums and on out-of-pocket costs.

The state's Health Benefit Exchange, which has received federal money to get up and running, plans to be open for "shopping" next fall.

Who'll treat them all?

Then, when all those folks have their insurance cards and are ready to get some health care, will there be somewhere for them to go?

Many private clinics and doctors now limit or don't take Medicaid patients, saying reimbursement levels are too low. Beginning next year, the federal law boosts Medicaid reimbursements to doctors to somewhat higher Medicare levels for at least two years.

Washington state has 5,971 primary-care doctors active in patient care — which works out to one doctor per 1,143 state residents — and ranks 13th best among states, according to the Association of American Medical Colleges' 2010 tabulation of the physician workforce.

But a state survey counted only 5,498 primary-care doctors, and found wide geographic differences in access. About 40 percent of the state's primary-care doctors practiced in King County, and more than half were age 50 or older.

Aaron Katz, a health-services and global health expert at the University of Washington's School of Public Health, said if coverage provisions envisioned by the ACA stay intact, "A fair number of people will face a struggle getting access to primary care for a few years while the system adjusts to the 'new normal.'

"There's widely held concern adding so many people in short order, even if it's two to three years, will strain the capacity of primary care providers and organizations (like community and migrant health centers) to serve them," Katz said in an email.

In Massachusetts, visits to emergency rooms and to community health clinics went up after a similar law was enacted statewide, Katz said. ER visits have leveled off, he said, but visits to the community clinics have stayed high.

Community clinics, which provide care regardless of ability to pay, "have a strong track record at providing high-quality, efficient basic health services," Katz said.

Even so, hiring staff to see potentially hundreds of thousands of new patients "is a serious challenge we face," said Steven Wish, director of public policy for the Washington Association of Community and Migrant Health Centers, which represents 26 clinic organizations that together run 170 clinics and cared for more than 770,000 patients last year.

Mark Secord, executive director of Neighborcare Health, which runs seven primary-care and five dental clinics in Seattle, as well as school-based clinics, said gearing up won't happen overnight. "It takes time," he said. "But we've been thinking about it for some time now."

Carol M. Ostrom: 206-464-2249

or costrom@seattletimes.com

On Twitter @costrom

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