Poverty, poor choices and not enough doctors.

That sums up why Yakima County struggles so much to improve its health, said Dr. Mike Maples, responding to Wednesday’s release of a national report that gave the county low grades on a range of health issues.

The Robert Wood Johnson Foundation and the University of Wisconsin’s annual County Health Rankings report, which compares counties nationwide on a variety of health outcomes and factors, ranked Yakima 37th out of the state’s 39 counties when it comes to behavior, demographics and environmental factors that lead to poor health.

Maples has headed up Community Health of Central Washington, a community health center, for 20 years, and says factors such as Yakima’s labor force, employment status and average income haven’t changed much in recent years.

Yakima’s rankings have held mostly steady over the four years the report has come out, often coming in the bottom five.

For 2013, the report pegs Yakima County at 38th out of 39 on the social and economic factors that influence health, such as unemployment, lack of education and inadequate social support.

The county ranks 37th of 39 for clinical care, highlighting that more than a third of adults in Yakima are uninsured and the ratio of patients to available primary care physicians is almost 1,400 to one.

Insurance status is probably the No. 1 hurdle in improving overall health here, Maples said.

“It’s a challenge for providers, it’s a challenge for patients, it’s a challenge to the system, it’s a challenge for health,” he said of the high number of under- and uninsured people. About 20 percent of patients at Community Health are uninsured, and health centers such as Yakima Neighborhood Health Services, Yakima Valley Farm Workers Clinic and both Yakima hospitals do not turn patients away for lack of insurance.

While people can still receive care, lack of coverage often discourages them from seeking health care in the first place, providers say. Conditions that could be caught early on or prevented entirely are not, and many low-income patients only seek care when they’re seriously ill.

“I’m sure that there are parents and patients that, if (health care) means taking money out of their pocket that they would be buying groceries to feed their children, then they’re going to choose to buy groceries to feed their children,” said Judy O’Neal, chief operating officer at Community Health.

Coupling that with a chronic shortage of primary care physicians can make it hard to find health care in the region.

Community Health’s Central Washington Family Medicine clinic is the only local residency program for training primary care doctors. In the past two years, the program has increased from six residents per year to 10, including a new program in Ellensburg. And Pacific Northwest University of Health Sciences, founded specifically to generate more primary care doctors in this rural community, is set to graduate its second class of medical students in May.

In the future, Maples said, he hopes more residency programs will be created, especially since demand for medical services is set to increase under the Medicaid expansion and health care reform.

“We’ve known for a long time that we needed to do more, wanted to do more,” he said.

Improving community health greatly depends on better education, providers say, so that people know how to avoid maladies such as obesity, diabetes, sexually transmitted diseases and teen pregnancy.

“One of the things is that these issues are preventable,” said Andre Fresco, head of the Yakima Health District. “We need to accept our responsibility to educate the community about making improved choices.”

The County Health Rankings are helpful because they show the wide range of factors — outside of direct medical care — that influence health outcomes, including economic status.

“It’s a reflection of the difficult times that we’re facing,” Fresco said. The task of providers, he added, is about “helping people realize that investing in themselves matters.”

While it’s unfortunate that Yakima hasn’t improved over the past few years, Fresco said he’s encouraged by strong partnerships among the health care community and a dedication to help people become healthier.

Still, he said, “It does take a long time to change people’s health, especially when the health of our community is so low.”

• Molly Rosbach can be reached at 509-577-7728 or mrosbach@yakimaherald.com.