Brenda Morgan didn’t think she had the heart to take another assignment as a Tri-Cities home health care provider after she lost her client of 17 years in December.

But then she saw a message from the family of a young, autistic adult.

Sam has a heart condition, uses a feeding tube for meals and medication, and thrives on structure to help her remain calm. Her family needs the help that Morgan is now providing.

Now Morgan and Sam are worried about the future of Medicaid — called Apple Health in Washington state — that pays for her care.

“Why aren’t people thinking about us? Do they not know I cannot survive without Medicaid?” Sam told Morgan to ask at a recent news briefing held by Sen. Maria Cantwell, D-Wash., at Kadlec Regional Medical Center in Richland. Morgan only used Sam’s first name.

It’s not just people like Morgan’s client who need to be concerned about deep cuts to Medicaid that Congress may approve.

The program provides free or low-cost medical care to nearly 300,000 in Washington’s 4th Congressional District, which includes the Tri-Cities.

The district is the most dependent on Medicaid/Apple Health in the state, with 70% of children and 24% of adults relying on the government program.

Covered patients include children, the elderly, those with disabilities, young families and people who don’t have health insurance benefits at their job.

Steep reductions to the Washington Medicaid, or Apple Health, would impact services for other residents, according to health care officials.

They could mean even busier emergency rooms, the closure of rural hospitals and loss of community doctors, and fewer medical services for everyone as hospitals lose Medicaid revenue.

“When hospitals are forced to cut services to remain financially viable, those cuts affect everyone, not just Medicaid patients,” said Reza Kaleel, chief executive of Providence Southeast Washington Service Area, which includes Kadlec Regional Medical Center in Richland and Providence St. Mary Medical Center in Walla Walla.

“When a service becomes financially impossible to maintain, access disappears potentially for the entire community,” he said at the briefing.

To meet a budget resolution passed by the U.S. House, $880 billion over 10 years would be cut from programs overseen by the House Energy and Commerce Committee.

With Congress reluctant to touch Medicare — which primarily provides care for people 65 and older after money was withheld from their paychecks during their working years — the bulk of the cuts are expected to come mostly from the Medicaid program and possibly a few much smaller programs.

“This is a tsunami of cuts coming at the people of Washington and the United States of America,” said Cantwell in a series of news media briefings around the state.

Children, elderly, expectant mothers

Those who rely on Medicaid/Apple Health include elderly residents who have exhausted their life savings since moving into nursing homes and now rely on Medicaid to pay for their care.

They include people with disabilities, such as those who Morgan has cared for, who can live at home because of in-home helpers, often at less cost than at live-in care facilities.

Medicaid is the single largest payer in the nation for mental health care, said Megan Cole, associate professor at Boston University School of Public Health, speaking at a SciLine media briefing.

Apple Health also is widely relied upon by young families. About a third of childbirths in Washington state, plus postpartum care, are covered by Apple Health, said Cantwell at the Richland briefing.

Tri-Cities residents might be surprised at who relies on Medicaid, or Apple Health, said Dr. Richard Meadows, a Richland doctor in the Kadlec network and chief medical officer for Providence Clinical Network.

He sees small business owners without money for health insurance who rely on Medicaid.

The program for low income residents of Washington state is free or low cost.

“Many of our neighbors on Medicaid are working multiple jobs or caring for family members with complex medical needs,” Kaleel said.

All but 8% of adults enrolled in Medicaid nationwide are working, caretakers or in school, says Megan Cole, associate professor at Boston University School of Public Health, speaking at a SciLine news media briefing.

The cuts would destabilize care for people across the state, regardless of their insurance status, according to the Washington State Hospital Association.

“It would take the lifeblood out of the system here,” Cantwell said.

Hard decisions would have to be made, including by hospitals like Othello Community Hospital with 58% of patients paying through Medicaid and Astria Toppenish Hospital with 41% of patients relying on Medicaid.

Even Kadlec officials are nervous, with about 20% Medicaid patients overall, but more than half of patients relying on Medicaid in its women’s and children’s programs.

Congressional delegation divided

Sen. Patty Murray, D-Wash., says $880 billion is more than all of federal Medicaid spending in 2023.

“Republicans need to stop listening to Donald Trump and Elon Musk who want tax breaks for their billionaire buddies, and start listening to their constituents who just want to stay on their health care,” Murray said at a news briefing.

But Newhouse says fearmongering is needlessly causing public panic.

“It is not a forgone conclusion these cuts are going to happen,” he said.

Targets have been set for committees as cuts must be made to reduce federal spending and eliminate waste and abuse, but there will be compromise, he said.

He will not support denying any eligible American access to Medicaid, Medicare or food stamps, he said, as calls pour into his office calling for Medicaid to be saved.

But a coalition of health, business and community organizations in the 4th Congressional District, represented by Dan Newhouse, R-Wash, is concerned enough to form a nonprofit, Central WA Families, urging residents to contact Newhouse about the importance of Medicaid or to sign its online petition asking him to vote against cutting Apple Health.

The coalition includes organizations supporting hospitals, people with disabilities, nursing homes and home health care.

It’s telling that the health care community has come together to warn about possible deep cuts to Medicaid, Cantwell said, as she stood at Kadlec with its executive director, doctors, a home health care provider and the executive director of Blue Mountain Heart to Heart, which helps those addicted to fentanyl.

“People would not be able to afford the cost to even fly across the state for things like (Seattle) Children’s Hospital,” Cantwell said. “We would not be able to help support those patients fighting for their lives on important things like cancer treatment.”

“Now is the time to be aggressive” or by the end of April the proposal to decimate Medicaid spending could be successful, Cantwell said.

“I guarantee you this is not a drill,” she said.

Tri-Cities largest hospital

More than 50,000 Medicaid patients each year come through the doors of Kadlec Regional Medical Center in Richland, the largest hospital in the greater Tri-Cities area.

That’s enough patients to fill the Toyota Center five times, Kaleel said.

Kadlec is back to operating now on a very thin positive financial margin post-pandemic and needs to grow that not only to keep services it offers now but to plan for serving the rapidly growing Tri-Cities, he said.

Not only are its women’s and children’s programs highly reliant on Medicaid payments, but Kadlec is seeing more Medicaid patients from around the region for trauma care since in 2023 it joined the Providence hospital in Spokane as the only two hospitals in Eastern Washington to be approved to care for level 2 trauma patients, or more severely injured patients.

One way to make up for potentially lost Medicaid patients is by increasing costs to private insurers, but more than 70% of patients rely on Medicare and Medicaid, with rates that are not negotiable, Kaleel told the Tri-Cities editorial board.

Other options would be to cut services to stay in the back or to just not keep up with growth needs even for basic services, he said.

Kadlec and other health care providers in the Mid-Columbia have grown, but have struggled to keep pace with the growing population already, he said.

“Many of you have experienced this firsthand, waiting weeks or months for an appointment, spending hours in waiting rooms or traveling for specialty care,” Kaleel said at Cantwell’s news briefing.

Now a third of the patients who come to Kadlec’s emergency department rely on Medicaid, said Dr. John Matheson, Kadlec chief medical officer.

When people lose medical coverage, they don’t stop needing care — they postpone it until small problems become emergencies, Kaleel said.

Hospital emergency departments are the only place in the U.S. health care system that must treat everyone regardless of ability to pay.

That safety net is already frayed, Matheson said.

Patients who lose Medicaid will delay or forego care, he said. The result will be more severe illnesses and worse outcomes, including lives lost, he said.

But the impact would reach beyond Medicaid patients.

“If the emergency department becomes more crowded with patients who have higher complexity illness, the delays affect everybody,” he said.

“A lot of people are concerned, but I don’t think people understand how dire it is,” he said. “Yes, the emergency department will be open, but it can’t be the entire system.”

Smaller hospitals at risk

Some hospitals in the 4th Congressional District would close if deep cuts to Medicaid go through, Cantwell said.

“They just wouldn’t be able to support themselves without the Medicaid reimbursement for uncompensated care,” she said.

Others likely would be faced with tough choices, such as potentially closing labor and delivery units, Cantwell said after talking to the Grand Coulee Medical Center chief executive.

Astria Toppenish Hospital already has closed its Family Maternity Center, a decision driven by declining Medicaid rates in 2021 and rising costs. The next year it ended MRI service.

“We don’t have anything left to cut,” Cathy Bambrick, administrator of the Toppenish hospital told the Tri-City Herald editorial board.. “Currently we are fighting to keep our acute care and emergency services for our community,” she said.

Over the last two decades hospitals have absorbed primary care medical clinics because doctors have not been able to operate medical clinics on their own without losing money, Bambrick said.

“If you lose hospitals, you lose primary care,” she said.

‘Just left to die?’

Medicaid is the single largest payer for long term care, including adults who exhaust their savings after moving into a nursing home.

Three in five nursing home residents rely on Apple Health, according to Cantwell.

“Seniors will be cut off from home care services and forced out of long-term care facilities” if deep cuts to Medicaid spending are approved, Murray said.

“So, are we just left to die?” asked Gail Halverson of Spokane, who relies on Medicaid and Medicare, at a roundtable discussion held by Cantwell.

Already finding placement for an elderly person who needs live-in nursing care or memory care can be a challenge in central and eastern Washington if Medicaid is being used to pay.

Regency Canyon Lakes Skilled Nursing Facility in Kennewick used to fill half its space with Medicaid patients, even though Medicare covers only 85% of costs.

But with the increased costs of staffing the center, it has had to reduce that to a quarter of its space, Parker Rieckelman, administrator of Regency Canyon Lakes told the Tri-City Herald editorial board.

“Everyone’s story is different, but typically our Apple Health residents have no other places they can go to receive round-the-clock care to keep them healthy and thriving,” he wrote in an op-ed for the Herald. “They are often with us because they have no family able to house them and take care of them.”

When a family called him recently, looking for rehabilitation care for a woman who had broken her hip while traveling to California, he had to say no when they said she relied on Medicaid. She ended up having to go out of the Tri-Cities for care.

Hospitals already may struggle to find a place that will accept a Medicaid patient they are ready to discharge but who needs 24-hour care.

Cuts to Medicaid will further reduce the number of Medicaid patients who can be accepted by skilled nursing facilities and increase stress on hospital discharging, he said.

Watching and waiting

Among the 300,000 people in Central Washington who depend on Medicaid in the Tri-Cities is Adelita Martinez.

Heavy braces support the weakened muscles of her legs, even as she uses a wheelchair.

She’s one of the three in eight people with disabilities who are covered by Apple Health, according to Murray.

When Martinez was a baby there was confusion about whether she had been vaccinated against polio at the same time her young cousin was.

Unhindered by vaccine, the virus attacked her body at 8 months old.

But she was one of the children of Zenaido and Angélica Martinez, honored with the Mid-Columbia Ag Hall of Fame Pioneer Award, for advancing from a laborer to a landowner and business owner. They raised their children to work hard and dream big.

As an adult Adelita Martinez traveled to Israel, spent a year as a missionary in South America and taught kindergarten and high school classes in Pasco and Basin City.

But decades after contracting polio, the weakness is back.

Now she is one of nearly 300,000 people in Central Washington dependent on Medicaid.

Asking for help from the government program was difficult for her, she said. But now it is her lifeline.

It pays for the therapy she needs to regain her leg strength enough to walk and drive again.

Household aides paid for by Apple Health help her with tasks of daily living, including getting her ready for the day each morning.

Now she is watching and waiting to see if her Medicaid coverage continues.

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