By Darrell Kirk

Journal contributor

San Juan County residents are confronting a harsh reality: The possible loss of Affordable Care Act subsidies is exposing fundamental flaws in America’s health care system that leave self-employed workers, people with disabilities and families choosing between medical care and basic survival.

“We have somehow decided to use the words insurance and healthcare as interchangeable words,” said Justin Paulsen, San Juan County councilman. “Healthcare and health insurance are two very different concepts, but we have allowed one to get in the way of the other. We have allowed the health insurance system to get in the way of the healthcare system.”

The human cost of a broken system

For Orcas Island resident Grey Tyson, 27, the health care system’s failures have been devastating. “I dropped coverage after years of severe symptoms. The cost was too high, and also I was being denied care and never knew when I was going to be covered or not,” Tyson explained. “I’ve been suffering without medical help for 7 years now. My disability caused me to lose housing and made me unable to work in my early 20s.”

Desperate for answers, Tyson started paying out of pocket. “I demanded MRIs from my primary care even though they said I was crazy. I paid out of pocket. Sure enough, there was something on the scan.” Now Tyson faces another frightening development: “I’ve also had a lump growing in my neck for about 6 months now, that I am worried about, but accessing care in time has been hard.”

The stakes couldn’t be higher. “My dad actually died because he could not access testing in time, due to the healthcare system sculpted around insurance instead of around the needs of the patient,” Tyson said.

Stigma and empathy in health care

Jim Glozier, former executive director of a Center for Independent Living who now lives in Eastsound on Orcas Island, has spent 40 years advocating for disability rights after his son Kyle was born with cerebral palsy in 1985. His transformation from civil engineer to activist was born of necessity. “To many Americans, people in poverty are invisible. Disabled people are invisible,” Glozier explains. “We were cast almost as second-class citizens, because now we had a son with a disability.” Regarding health care’s fundamental flaws, he’s blunt: “Insurance companies exist primarily to profit off the suffering of others.” His dental insurance paid just $245 of a $9,000 bill despite paying $150 monthly for 20 years.

San Juan Island resident Eva Luna describes feeling societal pressure around not having health insurance. “There’s a lot of stigma, I feel, around people who don’t have health insurance. And I’ve always felt when I tell people I don’t have health insurance that they think there’s something wrong with me,” she said. Luna believes this cultural attitude has been manipulated by large insurance companies. While acknowledging insurance can be important for those who really need it, Luna emphasizes her priority is being able to afford health care itself. When examining insurance plans through the ACA marketplace, she found the coverage promises misleading: “You look at what the insurance is gonna cover, but that’s not really what you’ll get. It’s kind of a bait and switch.”

Premium shock and impossible choices

Arna Robins-DeLappe, a nurse practitioner who owns Ancora Clinics on San Juan Island, faces an impossible situation. “We looked at our rates through Ambetter and they’re a little more than double. $2,800 a month is more than our mortgage. And frankly, it’s not affordable.” The irony is stark: “I’m a nurse practitioner. I own my own clinic here on the island and I’m about to have no health insurance.”

The gamble: Houses over health care

For Luna, a self-employed house cleaner and artist, the decision was clear.

“I’ve been uninsured the entire time and still am. I pay cash for medical care and put the rest into savings. That’s been a much better gamble than wasting my money on huge insurance premiums with little coverage.”

Luna’s strategy paid off unexpectedly. “I used to bill insurance. I paid over $2000 a year in fines because I wasn’t insured and yet that was still a better deal than getting medical insurance. Now after all this savings we finally own a home. If I would have paid the $6000-10,000 a year in premiums (which doesn’t include copays or any services because that’s extra) I wouldn’t now have a home.”

Sarah Carlson, a 40-year-old pediatric speech language pathologist with a private practice in Friday Harbor, represents another facet of this crisis. Her family’s Regence plan costs around $2,000 monthly with $5,000 deductibles per person. “As a 40-year-old who’s healthy and works out and eats well, there’s nothing aside from an emergency surgery or catastrophic injury that’s going to exhaust my $5,000 deductible. It’s November and I’ve only spent $2,000 and none of that was illness.”

Providers trapped in the system

Health care providers themselves are caught in this dysfunctional system. Carlson faces strict limitations: “I am unable to bypass a family’s insurance company and take a cash rate—that’s against the contracts that I have with the various insurance companies.”

Last year, she made an agonizing decision to drop Medicaid patients. “Medicaid over the past 16 years has dropped my reimbursement so much that I was actually losing money per session when I was seeing Medicaid patients. I had 12 families that when I dropped Medicaid, were affected. Two families, we had to part ways very amicably.”

The insurance system’s complexity creates additional barriers. “I charge out $160 a session for my speech services, but I get a range of $94 to $125,” depending on the insurance plan. Carlson hasn’t received a raise from most insurers in over a decade. “I have not received a pay raise from any insurance company except for one in the past 12 years. Last year, Primera gave me a $5 raise.” Meanwhile, “our subscriber fees have increased yearly, almost like 30%. But none of that is going to the providers directly.”

Robins-DeLappe sees the fundamental problem: “You’re trying to put for-profit insurance companies to fix a broken health care system. We can’t depend on for-profit insurance companies to fix anything.”

The dysfunction is uniquely American. According to an article from the Peter G. Peterson Foundation titled “How Does the U.S. Healthcare System Compare to Other Countries?”, the United States spends nearly twice as much on health care per capita compared to other wealthy countries, primarily due to higher prices rather than increased service utilization, with administrative costs alone exceeding $1,000 per person. Despite this significantly higher spending, America’s health outcomes are not better than other developed nations and actually perform worse in metrics like life expectancy, infant mortality and maternal safety.

Medicare telehealth crisis compounds problems

Adding to the crisis, Medicare has stopped covering telehealth services for most medical appointments, forcing elderly island residents to travel off-island for routine care.

Ellen Roberts from San Juan Island learned of the change firsthand. “I just learned that Medicare is no longer covering tele-health services for medical appointments other than for very specific things (behavioral health and substance abuse).” The impact is immediate: “This affects me personally because I now have to go off island just to get test results in Sedro Woolley. You know how that goes, as it means a whole day trip plus the ferry fare.”

Roberts emphasized broader implications: “More importantly, this will affect everybody on our island who is on Medicare. Since we have such a large population of people on Medicare, I think this would be an important investigative article for the Journal.”

Government response

The San Juan County Council has taken action. Jane Fuller, vice-chair, described meeting with Rep. Rick Larsen on Nov. 10, who wanted to know “what’s happening with regard to the reduction to one health insurance plan carrier for those who are self-insured in this county.”

Fuller offered a measured perspective on the political situation. While the outlook doesn’t “sound very positive that ACA is gonna be saved,” she noted that “those eight Democrats or one independent as well, who voted with the Republicans yesterday, they did accomplish extracting a vote on ACA subsidies explicitly. And what’s important about that is it’s not any longer buried deep in a big bill.”

The County Council’s letter to state and federal officials emphasized unique challenges: “We are now the only county in the State with only one carrier. Every other county has at least two, three or more, yet we are the only county that is an archipelago dependent on Washington State Ferries as our marine highway to the mainland for essential health care.”

Hospital district superintendents sent their own urgent letter Nov. 3, noting that “UW Medicine will leave Lopez Island Clinic in June 2026, and a new operator has not been identified. Ambetter does not contract with UW, and it is unknown if a future provider will.”

Alternative solutions emerge

Robins-DeLappe and her business partner at Ancora Clinics are pivoting their model. “We have also looked at establishing something like a direct primary care model and doing a hybrid model practice where people could pay for like a monthly subscription and get their medical care that way.” They’re also adopting a sliding scale for cash-pay patients.

Luna and her husband use Eventide, a membership-based medical practice in Friday Harbor, formerly owned by Dr. House and recently sold to Dr. Stacey Villendrer. Luna believes such membership practices offer better value than paying high insurance premiums that still require additional payments for visits and medications, noting similar models exist, like Country Doc in Seattle.

Eventide operates under the Direct Primary Care model, which, according to information on the Eventide website, eliminates insurance middlemen to restore direct patient-physician relationships. For a monthly membership fee, patients receive timely appointments where doctors have the time to address multiple concerns and increased access to their providers through email, phone calls and telemedicine appointments. Villendrer mentioned that the clinic has received increased interest from employers looking for alternative options for their employees as the ACA market has shifted.

An unexpected safety net

Councilman Justin Paulsen revealed an unconventional health care lifeline, The Orcas Island Fire and Rescue. “They are likely providing a lot of the service that would otherwise be provided by a health district or a health provider. If you get a cut and you go into the firehouse and they bandage you up and send you home, under an ideal medical provision world, you would go to a doctor for that. But we don’t do that. We go to our fire department. The benefit there is they don’t ask you if you have insurance when you walk through the door, they just do it.”

Ben Luna, Public Information Officer for Orcas Island Fire and Rescue, said that every chief and leadership group he’s worked with has consistently told residents to “call us anytime, anytime, day or night, no matter the problem.” And residents do exactly that. Almost daily, people come directly to the fire station with medical issues — sometimes calling 911 first to say they’re heading over, sometimes just showing up at the door. Luna said the issues range from minor needs like bandages to serious emergencies like heart attacks. While the fire department can’t officially call itself a clinic, Luna explained, “in some ways we serve in a capacity like an urgent care center might in a city because people just show up at the door, you know, with issues, yeah, with health issues.”

Luna described an innovative program that may expand this role further. The fire department is actively pursuing what is called a Mobile Integrated Health program, which would be broader in scope than the Community Paramedic System, as it would incorporate nurses as well as EMTs into the system, not just paramedics. His understanding is that the CPS program was never fully established. “It will be a huge contribution to community healthcare once it is formalized.”

Paulsen emphasized the significance: “In our community, we are fortunate to have an EMS provider who is able and willing to provide those services without regard to a person’s insurance status or being on the hook later. Our community has said, we believe this is an important piece of function on our Island. And so we have allowed them the funds to do that work.”

Looking forward

Public opinion on health care is shifting dramatically. In a Gallup Poll article dated Dec. 9, 2024, “More in U.S. See Health Coverage as Government Responsibility,” a survey shows that support for government-ensured health care coverage has increased across all political groups since 2020, with 90% of Democrats, 65% of independents and 32% of Republicans now believing the government should ensure coverage for all Americans. Public opinion on this issue has fluctuated significantly since 2000, dropping during the ACA’s passage but rebounding in recent years to make it the prevailing view.

For San Juan County residents, the possible loss of ACA subsidies isn’t just a policy debate — it’s a daily reality that forces impossible choices between financial survival and physical health.