What Does Health Care Ruling Mean to Oregon?

A narrow 5-4 ruling by the Supreme Court upheld President Obama's signature first-term achievement, not it is time to see how implementation and politics will proceed.There are probably as many interpretations as there are analysts looking at the words that Chief Justice John Roberts wrote for the Supreme Court in a historic 5-4 decision upholding major provisions of the Affordable Care Act.

It is tempting to delay comment because so much of what this landmark ruling means will play out over time, both in Washington, D.C. and around the country in states such as Oregon, where Governor John Kitzhaber has taken the lead in implementing reform measures.

Still, here are a few perceptions:

         *  Regardless of how the Court ruled, Oregon was committed to proceed with a number of reforms that emerged from the last two Oregon legislative sessions. That includes the governor's proposal to create Coordinated Care Organizations (CCOs) as mostly non-profit entities to handle the task of organizing and delivering Medicaid services to low-income Oregonians.

         From the governor's standpoint, the new CCOs — eight of which were approved this week to begin operating August 1 and a number of others are in the queue for a later start — will manage Medicaid closer to where people live, prompt providers to collaborate with each other for the benefit of patients and place a great emphasis on prevention, all (at least in theory) to save money.

         If money gets tighter and the CCO reforms don't work, the tough decisions — cutting recipients off Medicaid, cutting back on benefits or cutting provider reimbursements — will fall into the laps of regional or local CCO directors. In the past, these decisions would have been made on the Capitol Mall.

         *  The ruling does retain momentum toward the day, in late 2013 or early 2014, when Oregonians will have a chance to choose health insurance coverage through an online shopping center called an "insurance exchange."  Oregon already is a long way down the road toward starting its exchange and, arguably, would have continued regardless of how the court ruled. But the endorsement of an individual health insurance purchase mandate means the exchange will have a greater chance to succeed a year or so from now. With a few exceptions, those who now don't buy insurance will have to do so.

         *  It is not clear how the ruling will affect the politics of health care, though it is not likely to quell the lively and sometimes rancorous debate.  Opponents ranging from Republicans in Congress to the U.S. Chamber of Commerce to right-wing radio talk show hosts will continue to rail against the mandate and advocate that Congress repeal it. There also is little doubt that health care policy, notwithstanding the ruling, will continue to inflame the presidential campaign, even as the presumptive Republican candidate, Mitt Romney, says one of his first acts if he wins will be to propose repeal of the new law, regardless of what he did when he was governor of Massachusetts.  For his part, President Barack Obama didn't appear to crow about the result, even as he took it as a major victory, allowing him to move forward with the Court's blessing.

The Oregonian editorial today described an aspiration that many of us share:

         "The country spent at least four years bickering over mandates for health insurance. The question of whether the federal government can require people to buy a product, or penalize them for failing to do so, has overshadowed the health care debate since the last presidential race.   Finally, those days are over. The U.S. Supreme Court put an end to the endless civic parlor game on Thursday with its 5-4 ruling upholding most of the Affordable Care Act, President Obama's signature domestic victory. The landmark decision offers some much-needed resolution to the uncertainty surrounding reform efforts. It also compels Oregon — and Congress — to set aside the politics and drill deeper on the real-life challenges of cost, access and quality."

Here's hoping that policymakers in Oregon will be able to focus on improving the reforms in Oregon with the high court ruling in the rearview mirror. A lot rides on the Kitzhaber Administration's decisions — how to contract with the new CCOs, how to give them enough flexibility to operate without state or federal mandates, how to create the metropolitan Portland CCO that will have responsibility for about one-fourth of the Medicaid population in Oregon, and how to infuse the new system with an impulse to control costs.


CFM partner Dave Fiskum has represented health care interests at the Capitol in Salem for more than 20 years.