Medicaid

Brown’s Budget Focuses on Education, Human Services

Fresh off her successful re-election, Governor Kate Brown unveils her $23.6 billion General Fund budget that includes a $2 billion revenue challenge to state lawmakers to eliminate structural deficits in public education.

Fresh off her successful re-election, Governor Kate Brown unveils her $23.6 billion General Fund budget that includes a $2 billion revenue challenge to state lawmakers to eliminate structural deficits in public education.

Governor Kate Brown released her 2019-2021 budget recommendations that roll out ideas to shore up state health care funding, continue to invest in affordable housing and pay for initiatives she announced in her re-election campaign.

Proposed budgets are also notable for what they don’t include. Brown’s $23.6 billion budget proposal omits any mention of Public Employees Retirement System (PERS) cost-cutting or investing to restart bi-state conversations about an I-5 Columbia River Bridge replacement.

Her proposed budget did contain a $2 billion revenue challenge to legislators to bolster Oregon’s public education system. The challenge coincided with the rollout of the Coalition for the Common Good, consisting of Oregon public employee unions, a group of long-term care providers and Nike, in support of a major tax package.

“We want to bring a sole focus into revenue reform,” said James Carlson, president of the Oregon Health Care Association. “The reality is we can’t afford to waste another five years chasing a deal that may or may not happen” on cutting government costs.

Major business groups are positioned to resist a major tax overhaul without steps to reduce the $22 million unfunded PERS liability, which poses a drain on local government and school district budgets.

The $2 billion in new revenue would go to extend the school year, decrease class sizes, expand access to preschool and decrease college tuition at public universities. Brown faced sharp criticism in her re-election campaign for Oregon’s low high school graduation rate and failure to provide all of the funding voters authorized to expand career and technical education statewide.

Brown’s budget is heavy on aspiration and revenue projections. It also is very readable, has a reasonable amount of detail and is backed up by economic and revenue analysis. For example, it shows that $19 billion in revenue comes from Oregon personal income taxes, which represents 80 percent of the budget. Corporate income taxes and lottery proceeds contribute 4 and 5 percent, respectively. Roughly 50 percent of Brown’s proposed spending would go to education and 27 percent to human services.

Even though state lawmakers will have around $1 billion more in revenue than the previous biennium, Brown included tax increases in her budget, much of it to plug a funding hole for Medicaid. She proposed raising tobacco taxes by $2 and expanding taxes or assessments on hospitals, insurers and some employers.

In her budget, Brown proposes to shut down the Oregon Department of Energy and allow the state’s Chief Education Office to end. She asks for creation of an Oregon Climate Authority that would administer a “well-designed, market-based program to achieve our state climate emissions reduction goals at the least possible cost, while protecting our manufacturing industry and mitigating impacts on low-income and rural communities, communities of color, and Tribes.” 

Brown devotes substantial funding to her Children’s Agenda, including $285.8 million to provide preschool for an additional 10,000 children, $20 million for housing stability for homeless families, $13.8 million to integrate disorder treatment and behavioral health programs for families and $10 to increase “quality, affordable” child care. Brown wants to ensure 100 percent of Oregon children have health care access and proposes $47.1 million for a comprehensive child welfare system “based on positive human development” and that reduces the need for foster care.

Another campaign promise that showed up on Brown’s budget is incorporating standards from the federal Clean Air and Clean Water acts into state law. She also wants to fund an effort to eliminate a backlog in pending air quality permits.

Brown recommended expanding Oregon’s automatic voter registration system by including other public interactions with state agencies, such as applying for a hunting license, as triggers and sending voters ballots with return envelopes with pre-paid postage. 

After a gubernatorial election that broke state spending records and involved independent expenditures funded with dark money contributions, Brown committed to work on campaign finance reform.

The budget proposal sets aside money for earthquake preparedness, firearm safety, a university program dealing with threat assessment and immigrant defense. Some $5 million is earmarked for funding rural broadband infrastructure and $10 million for remediation of rural brownfields so they can be redeveloped.

Brown titled her budget proposal, “Turning Point: An Agenda for Oregon’s Future.” Here is the opening paragraph of the budget document:

“Oregon is at a turning point. Hundreds of thousands of people have moved here in the past 20 years, and a million more are on their way. We’ve done some good things over the years, but our state is changing, and changing rapidly. With the aging of Oregon’s baby boomer generation, and the impacts of recent dramatic federal tax changes and burgeoning federal deficits exacerbating these changes, one thing is clear: we can no longer do things the way we have in the past. We must grow up as a state, and we need to decide – together – what we want to be over the next 20 years. The challenges of affordability, of educating our kids, of mitigating the effects of climate change, and of maintaining a strong democracy will not get better unless we change our approach.”

She says Oregon must renew faith in democracy, spend money wisely, address affordability, prepare for the future and “finally fix our underfunded education system.”

 

Short 2018 Session May Have Less Drama

No single issue is likely to dominate the Oregon 2018 legislative session that begins Monday, but lawmakers will still be busy with issues ranging from reconnecting to the federal tax code to gun restrictions. And there will be some political jockeying in advance of the Oregon primary in May and general election this fall.

No single issue is likely to dominate the Oregon 2018 legislative session that begins Monday, but lawmakers will still be busy with issues ranging from reconnecting to the federal tax code to gun restrictions. And there will be some political jockeying in advance of the Oregon primary in May and general election this fall.

Voter approval of Measure 101 and Senate Democratic cold water on cap-and-invest legislation may remove much of the anticipated drama at the 2018 Oregon legislative session, which convenes Monday. Of course, any legislative session during an election year can have outsized political tensions.

Without a focus on patching a big budget hole or trying to thread the needle for a compromise on cap-and-invest provisions, there isn’t an apparent single issue that will dominate the session with an adjournment deadline of March 11.

One of the sleeper bills likely to draw attention is legislation to connect Oregon’s personal and corporate income tax system with federal tax changes enacted by Congress late last year. Oregon lawmakers have tended to favor connecting Oregon’s tax provisions with their federal counterparts for the ease of taxpayer filing. But there may be other considerations this time around, including how the new federal limitation on state and local tax deductions will affect Oregon taxpayers.

The Oregon business community wants to see substantial progress on reducing the unfunded liability of the Public Employees Retirement System, but that appears unlikely in the short 2018 session and during an election year. Governor Brown will ask lawmakers to create an Employer Incentive Fund to provide matching money for public employers that accelerate their contributions to PERS. The pressure to act also was relieved by the Oregon State Treasury’s announcement that the PERS fund posted a 15.3 percent gain in 2017, which is good news, but not enough to stem rising costs.

Other priorities for Brown in the short session include a measure to encourage construction industry startups in rural areas that can access low-rate loans from Business Oregon to build affordable housing. Licensing requirements also would be relaxed and grants would be available to defray the costs of apprentices.

Brown wants all licensed opioid prescribers in Oregon to register with a Prescription Drug Monitoring Program to generate information about opioid use and identify illegal prescribers. Her proposal also would provide for mentors in emergency departments to counsel people who have overdosed.

Another Brown priority is to create a reverse auction for state procurement as a way to squeeze more value and less cost for state expenditures. Her concept is to generate more competition among state vendors who benefit from the $8 billion Brown says state agencies spend every biennium. 

The governor is seeking a bill to prohibit people convicted of domestic violence or stalking from purchasing firearms. Oregon lawmakers approved legislation last year to empower courts to order the confiscation of guns owned by people deemed at risk of suicide or hurting others.

Passage of Measure 101, which secures funding for Oregon’s Medicaid program through this biennium, prompted Rep. Mitch Greenlick, D-Portland, to propose a constitutional amendment that declares health care is a right of every Oregonian. He has attracted 40 cosponsors for his referral that would appear on November 2018 general election ballot.

Likely GOP gubernatorial frontrunner Knute Buehler, R-Bend, is pushing legislation to force coordinated care organizations to repay up to $74 million in Medicaid overpayments and address transparency and management issues by the Oregon Health Authority. Buehler has called for bipartisan action, but his measure will invariably have a vapor trail of politics following it.

Some familiar legislative faces will be missing. Long-time Senate Minority Leader Ted Ferrioli and Senator Richard Devlin, the Democrat’s budget guru, have moved on to appointed posts on the Northwest Power Council. Cliff Bentz, who has served in the Oregon House since the 2009 session, assumed Ferrioli’s seat and Senator Jackie Winters was chosen to succeed Ferrioli as minority leader. Rob Wagner, a Lake Oswego School Board member, was appointed to fill Devlin’s seat.

Oregon Voters Give Overwhelming Support for Measure 101

Governor Kate Brown told Measure 101 supporters at Tuesday night’s victory party that voter approval of the Medicaid funding plan shows Oregonians support a GSD (Get Stuff Done) agenda.

Governor Kate Brown told Measure 101 supporters at Tuesday night’s victory party that voter approval of the Medicaid funding plan shows Oregonians support a GSD (Get Stuff Done) agenda.

Voters in yesterday’s special election overwhelmingly approved of Measure 101, which leaves in place the Medicaid funding plan approved by the 2017 Oregon legislature. It also lifts a huge fiscal burden off the shoulders of lawmakers in the short 2018 session that begins February 5.

The die was cast when, early in the evening, results indicated nearly 80 percent of Multnomah County voters approved Measure 101. Even though half of Oregon’s 36 counties, many of them rural, voted against Measure 101, they were heavily outvoted with strong support among higher population centers across the state.

In a low-turnout election, the side that wins is usually the side that can motivate voters to cast ballots. The pro-Measure 101 campaign had the broad coalition support, cash to advertise and the foot-power to get out the vote. Measure 101 opponents had none of those things. More than 180 organizations, both large and small, came together in dozens of advocacy events to show support in protecting healthcare coverage funding approved during the 2017 legislative session.

Referenda usually start as political quarrels in legislative sessions, which was the case for Measure 101. Whereas in recent sessions, funding mechanisms paying for Oregon’s Medicaid program had enjoyed bipartisan support, the enhanced tax proposal in 2017 met with partisan objections from some Republican lawmakers.

Led by Rep. Julie Parrish (R-West Linn/Tualatin) and Rep. Cedric Hayden (R-Roseburg), opponents called it unfair and declared it a “sales tax on health care.” Similar messaging was used successfully during last year’s M97 debate and opponents were trying to drum up support from Oregon voters who reacted to that rhetoric.

Supporters of the admittedly complicated Medicaid funding mechanism fought back, saying it was the best bipartisan plan to raise the money necessary to attract federal Medicaid matching dollars. They said opponents raised objections, but offered no politically viable alternative funding plan.

In the end, the $3.6 million campaign drowned out the opposition campaign, which reportedly spent less than $150,000 (a significant chunk of that raised in personal loans from Rep. Hayden). While TV ads provided air cover, the real difference was in the get-out-the-vote drive, aided by union and hospital supporters of Measure 101.

A key takeaway from this election may be the impact on future efforts by minority legislators or interests who seek to alter agreements they oppose. With M101 receiving more than a 6o percent majority, those parties may think twice before attempting similar fights on other legislative packages. Oregon’s referendum process is there for a reason, but legislators already have a mechanism for debating the validity and appropriateness of these type of budget and policy issues. Through the election process, voters can hold their elected leaders accountable for their work.

More than 1 million Oregonians are covered by Medicaid, which represented a fertile target audience to turn out to vote. In a relatively low-turnout election, a motivated group of voters can make the difference.

This was an election decided by urban Oregon voters. Majorities in big counties for Measure 101 ranged from 79 percent in Multnomah County to more than 65 percent in Benton and Lane counties. Jackson County in Southern Oregon went 58 percent for Measure 101. Suburban Washington County favored Measure 101 by more than 60 percent and Clackamas County, which Parrish represents, gave the measure a 58 percent plurality. Marion County went for Measure 101 by a 55 to 45 percent margin.

Oregon’s last special election was in 2010 when the state debated M66/67, which raised personal income tax revenue on the state’s highest-earning individuals and corporations. In that election, 1.28 million Oregonians cast ballots, representing 62.7 percent of eligible voters. Final numbers for M101 are yet to be released, but estimates are significantly lower.

The victory for Measure 101 was declared at 8 pm when the first batch of ballot totals were released.

Oregon Health Plan Goes from Secure to Shaky

 Congressional inaction to continue funding for the Children’s Health Insurance Program is just the latest financial challenge facing Oregon policymakers and putting Oregon’s health plans on shakier ground.

 Congressional inaction to continue funding for the Children’s Health Insurance Program is just the latest financial challenge facing Oregon policymakers and putting Oregon’s health plans on shakier ground.

When the 2017 Oregon legislature adjourned in early July, the state’s health care exchanges and Medicaid program seemed secure for at least another biennium. A lot has changed since then, and the stakes continue to grow.

The funding package to sustain the Oregon Health Plan faces a likely referral vote in January. Congress allowed federal funding for the Children’s Health Insurance Plan (CHIP) to lapse as it debated, but failed to repeal and replace the Affordable Care Act. The Trump administration continues to threaten actions to undermine the Affordable Care Act.

No matter how you spin the situation, Oregon could feel a financial pinch as early as mid-November when its funding runs out for health insurance for thousands of children in the state. The legislature won’t convene until February, so a potential gap in coverage could lead to a reduction in benefits and new enrollments.

Oregon Senator Ron Wyden is working with Senate Finance Chair Orrin Hatch on a bipartisan funding plan for CHIP, but House GOP leaders want to tie continued funding to spending cuts for Medicare, community clinics and grace periods for Affordable Care Act payments.

Oregon policymakers could have an even bigger problem on their hands if voters reject the $320 million funding package that includes a health insurance tax and a new hospital tax. While the majority of the $320 million will shore up the state’s Medicaid program, it also would fund a reinsurance pool that limits individual insurers’ financial exposure for high-cost patients.

The Oregon Reinsurance Program calmed Oregon’s market and paved the way for 6 percent lower insurance premiums. The shaky status of the reinsurance program could affect Oregon’s pending application for a waiver from the Centers of Medicare and Medicaid to administer its programs flexibly. If Oregon’s funding package is rejected, the waiver request could be in jeopardy – along with lower insurance premiums.

According to the Portland Business Journal, Alaska requested a similar waiver, which was approved. However, waiver applications by other states have been rejected or withdrawn. The Washington Post reported Trump intervened to block a waiver request from Iowa, which was seeking ways to increase competition and bring down premiums. Oklahoma withdrew its application after CMS inaction. Minnesota was granted a waiver, but CMS reportedly cut a low-income enrollee program.

The longer-term view isn’t any better. The US House has approved a budget resolution that will be used as the vehicle to move a major federal tax cut and that calls for massive cuts over the next decade to Medicare and Medicaid.

Latest ACA Repeal Measure Would Punish Oregon

CNN posted a map showing how the latest Senate GOP effort to repeal and replace the Affordable Care Act would affect states such as Oregon and Washington that expanded their eligibility for Medicaid coverage. Other states that are billion-dollar losers under the GOP proposal include California, Ohio, Pennsylvania and Michigan.

CNN posted a map showing how the latest Senate GOP effort to repeal and replace the Affordable Care Act would affect states such as Oregon and Washington that expanded their eligibility for Medicaid coverage. Other states that are billion-dollar losers under the GOP proposal include California, Ohio, Pennsylvania and Michigan.

The US Senate is taking another stab at repealing and replacing the Affordable Care Act (ACA), this time with a plan that could disproportionately hurt the Medicaid programs in Oregon and Washington. Oregon could be one of the hardest hit states, with more than a $3 billion loss over the next decade.

Along with 18 other states ranging from New York to North Dakota, Oregon and Washington expanded Medicaid eligibility under provisions of the ACA. The latest version of the Cassidy-Graham bill in the Senate would effectively scrap discrete federal funding for the expansion as part of a plan to give states Medicaid block grants.

“The revised version of the Cassidy-Graham plan would disproportionately harm certain states,” according to the Center of Budget and Policy Priorities, a nonpartisan research and policy institute that analyzes how federal budget priorities impact low-income Americans. “The block grant would not only cut overall funding for the Medicaid expansion and marketplace subsidies, but also starting in 2021 redistribute the reduced federal funding across states based on their share of low-income residents rather than their actual spending needs.”

The Center says states that expanded Medicaid eligibility, including Oregon and Washington, could end up receiving 35 to 60 percent below what they get now from the federal government under current law. That would exacerbate Oregon’s budgetary challenge if the Medicaid funding package approved in the 2017 legislative session is referred to and rejected by voters in a special election next January.

After a dramatic Senate floor showdown in August that failed to approve a previous GOP proposal to repeal and replace the ACA, it seemed as if congressional Republicans had decided to move on to other issues, including tax reform. The proposal by GOP Senators Bill Cassidy and Lindsey Graham seemed to come out of nowhere and has sparked speculation it could get enough votes to pass.

Senate Republicans only have until September 30 to approve an ACA repeal and replacement measure with 50 votes under complicated budget reconciliation procedures. That means Senate Republicans, who hold a slim 52-member majority, can only afford to lose two of their members on the repeal vote. A 50-50 tie vote would be broken under Senate rules when Vice President Mike Pence cast a vote. The Trump White House has signaled it would support the Cassidy-Graham bill. GOP Speaker Paul Ryan has indicated he would push for House passage.

Opponents say the Cassidy-Graham measure also would destabilize the individual health insurance market by eliminating ACA subsidies and allowing states the flexibility waive essential benefits and weaken the pre-existing condition provisions in the ACA.

“While insurers would still be required to offer coverage to people with pre-existing conditions,” the Center says, “insurers could charge unaffordable premiums of thousands or tens of thousands of dollars per month, effectively resulting in a coverage denial.”

Insurers also could offer plans with large benefit gaps such as maternity care, substance abuse treatment and mental health services, which a Kaiser Family Foundation analysis was a common pattern in health insurance before passage of the ACA.

The impact could be even greater as the Cassidy-Graham bill reduces the per capita allocations in block grants for all states starting after 2026. “Many states would likely cut home and community-based services, which allow people needing long-term services to remain in their homes rather than moving to a nursing home,” according to the Center.

If Senate Republicans are unable to muster the necessary 50 votes for Cassidy-Graham in the next 10 days, then all the dire predictions will be put aside.

Another casualty of Cassidy-Graham has been the bipartisan effort in the Senate Health Committee to find politically acceptable ways to stabilize the individual health insurance marketplace and reduce pressure on higher premiums. Senator Lamar Alexander, the GOP chairman of the committee who was working with Washington Senator Patty Murray, said no consensus was reached. The effort was undercut when Ryan said the House wouldn’t consider a bipartisan stabilization bill.

A group of 10 governors representing Medicaid expansion states sent a letter to Senate leaders urging a continuation of bipartisan efforts on the ACA, saying that the way to “achieve true, last reforms.” One of the governors is John Bel Edwards of Louisiana, which is the home state of Senator Cassidy.

Louisiana Secretary of Health Dr. Rebekah Gee sent a letter directly to Cassidy that said, “In its current form, the harm to Louisiana from this legislation far outweighs any benefits. Therefore, I must register our deep concerns and hope we can find a better path forward toward fixing the broken parts of our healthcare system.

State, Federal Health Care Debates Remain in Flux

Oregon legislative leaders Tina Kotek and Peter Courtney want voters to know the fiscal risks of rejecting a tax package to sustain funding for the Oregon Health Plan, as federal lawmakers begin hearings on ways to stabilize coverage and premiums for the individual health insurance market under the Affordable Care Act.

Oregon legislative leaders Tina Kotek and Peter Courtney want voters to know the fiscal risks of rejecting a tax package to sustain funding for the Oregon Health Plan, as federal lawmakers begin hearings on ways to stabilize coverage and premiums for the individual health insurance market under the Affordable Care Act.

On the same day Oregon lawmakers prepared for a January vote on funding to maintain the Oregon Health Plan, a US Senate committee held the first hearing on how to stabilize the individual insurance markets under the Affordable Care Act. Both reflect the unsettled and unsettling condition of key parts of America’s health care system.

Legislators worked Tuesday on a ballot title for a referral sought by GOP Rep. Julie Parrish that could result in voter rejection of a tax package to sustain current spending levels for the Oregon Health Plan, the state’s Medicaid program.  If the tax package is voted down, state officials could face a budget hole of between $300-$500 million to plug during the short 2018 legislative session that starts next February.

An opinion from Legislative Counsel added more potential confusion to the issue that voters could be asked to decide in a January special election. The opinion says the way the referral is written would only eliminate the additional 0.7 percent assessment on hospitals from October 6, 2017 until January 1, 2018. The referral wouldn’t have any effect on the previously approved hospital assessment.

The draft ballot title clearly attempts to raise the specter of the impact of rejecting the tax package on low-income families, children and insurance premiums.

PROVIDES FUNDS CURRENTLY BUDGETED TO PAY FOR HEALTH CARE FOR LOW-INCOME INDIVIDUALS AND FAMILIES AND TO STABILIZE HEALTH INSURANCE PREMIUMS, USING TEMPORARY ASSESSMENTS ON INSURANCE COMPANIES, SOME HOSPITALS, AND OTHER PROVIDERS OF HEALTH CARE COVERAGE.

On Capitol Hill, GOP Senator Lamar Alexander kicked off the first hearing of any kind this year on the Affordable Care Act by declaring, "To get a result, Democrats will have to agree to something – more flexibility for states – that some are reluctant to support. And Republicans will have to agree to something – additional funding through the Affordable Care Act – that some are reluctant to support." Alexander said his priority is on lowering health insurance premiums.

On the day of the hearing, Washington Senator Patty Murray said in an op-ed in The Washington Post that Democrats are willing to work on a bipartisan approach to stabilizing insurance markets. In the op-ed, Murray raised the issue of creating a “public option” to ensure competition to hold down premiums in the individual health insurance market. Capitol Hill observers said that is an unlikely outcome in what already is viewed as a chancy legislative venture in the wake of the Senate’s failed attempts to repeal and replace Obamacare. Conservative groups have already launched a digital ad campaign slamming Alexander’s effort.

A more likely provision may be some kind of reinsurance program to broaden the base to pay for high-cost individuals, which tend to spike overall premium rates.

Alexander expressed hope his committee can produce compromise legislation by the end of September, which is a critical deadline for insurance companies that have to submit plans and prices for individual health insurance markets around the country. Skeptics doubt whether Alexander’s target date is realistic, especially in light of other looming congressional debates to raise the debt limit, approve a disaster relief funding package and approve some kind of FY 2018 appropriation.

For now, the Trump administration is continuing, with reluctance, to make subsidy payments to medical providers as called for by the Affordable Care Act. Insurers have warned that cutting off those subsidies, which essentially compensate for high-cost care for a few individuals, could lead to as much as a 20 percent increase in premiums, effectively forcing some people to drop their policies.

There also isn’t any clear indication how much or perhaps in what form Congress will authorize for Medicaid reimbursement to states in FY 2018. The Obamacare repeal and replacement bill that narrowly cleared the House earlier this year would have slashed $800 billion from federal Medicaid reimbursements over the next 10 years.

Gritty Issues Teed up for 2018 Election

Hot button issues such as PERS, Medicaid, immigration and taxes are already heating up long before the 2018 Oregon election starts in earnest and are sure to bring into focus questions over who can provide the political leadership to address these issues.

Hot button issues such as PERS, Medicaid, immigration and taxes are already heating up long before the 2018 Oregon election starts in earnest and are sure to bring into focus questions over who can provide the political leadership to address these issues.

The 2018 election is more than a year away, but the issues that will animate campaigns are getting exposure now. As Republicans challenge monolithic Democratic control of the lever of powers in Oregon, the issues center on PERS, Medicaid and immigration. And more will follow.
 
In a news release Monday, the Senate Republican office deplored a “time bomb” decision by the PERS board that had the effect of inflating the unfunded liability of the public employee pension program to $52 million. With breathless prose, the release said, “Taxpayer-funded pension systems are combustible by nature, but Oregon’s ticking time bomb known as PERS is one of the brink of exploding.” Legislative Republicans pushed for steps to corral PERS funding but were unsuccessful.
 
The Oregonian added fuel to the Medicaid debate by reporting over the weekend that more than 37,000 Oregonians were extended health care benefits under the program even though they exceeded the earnings threshold – at a cost to the state of $191 million. The Oregon Health Authority reportedly has another 30,000 enrollees to check, so the number of ineligible Medicaid recipients could grower higher. A bipartisan majority agreed to a tax package in the 2017 session to sustain the core and expanded Medicaid program. Rep. Julie Parrish, R-West Linn, is pursuing a referral of the Medicaid tax package.
 
The potentially most explosive issue could be the call by Republican senators for Governor Brown to veto legislation declaring “sanctuary state” status. Their call follows violent attacks by Sergio Jose Martinez, including a sexual assault on a 65-year-old woman, who has been deported 20 times. Efforts by the Trump administration to step up deportation of undocumented immigrants has sparked public demonstrations both for and against the action.
 
The PERS and Medicaid issues have been stoked by Oregonian reporting. The PERS unfunded liability and sanctuary state issues have been fanned by Jonathan Lockwood on behalf of Oregon Senate Republicans. The Medicaid story’s fuse was lit by Secretary of State Dennis Richardson, who is the leading GOP gubernatorial candidate, largely due to his higher name familiarity.
 
Gubernatorial campaigns serve as referenda on how the state is doing and its most vexing issues. But few campaigns are so issue-centric before the front-running candidates have a chance to chisel out the political debate fault lines.
 
Brown is expected to seek re-election, but there is no consensus GOP challenger and the threat of a third-party bid can’t be ruled out. Political leadership is sure to be a major issue in the campaign. Republicans and even some Democrats will charge that Brown ducked out on leading toward a solution to the state’s $1.6 billion budget deficit. Brown can claim her leadership helped to push through a major transportation package that included funding for public transportation.
 
Oregon has become a reliably blue state, where Democratic statewide victories are pretty much a sure bet. That probably won’t change, but foul winds are blowing. Brown hasn’t alienated many core Democratic constituencies, but she hasn’t necessarily wowed all of them either.
 
Pointing to growing PERS liabilities, ballooning Medicaid costs and an immigrant bad boy may make headlines but aren’t the same as alternative solutions. This also could be a year where the politics of blame isn’t a big winner. But it is undeniable that gritty policy issues will consume oxygen in the 2018 campaign regardless who runs.
 
One final issue likely to emerge is whether to pursue revenue reform next year, despite Democratic leaders indicating it should wait until the 2019 session. Brown, Senate President Peter Courtney and Speaker Tina Kotek released statements arguing that reform wasn't possible until 2019, but a union-backed 2018 initiative similar to Measure 97 may spark interest in trying to head off another divisive and expensive battle at the ballot box. 
 
The question is who will take the lead and convene a working group. Senator Mark Hass, D-Beaverton, attempted compromise legislation in 2017 and may do so again. Brown could build off her transportation win and try to do the same on revenue reform. Brown's new Chief of Staff Nik Blosser showed an aptitude for such negotiations in 2017 and may be the person to do it again next year. A Republican candidate may jump into the fray with a plan and a strategy. The political risks are palpable, but the intensity of the issues may make the risk worth it.

Adjournment May Seem Like Only an Intermission

The Oregon legislature is on track to adjourn by July 10, but adjournment this time around may seem more like an intermission as corporation taxation, PERS, Medicaid, education funding and political leadership remain as hot griddle issues that won’t wait until the next election or next legislative session.

The Oregon legislature is on track to adjourn by July 10, but adjournment this time around may seem more like an intermission as corporation taxation, PERS, Medicaid, education funding and political leadership remain as hot griddle issues that won’t wait until the next election or next legislative session.

Oregon lawmakers appear on the road to adjournment by July 10, but with an air that the journey is just beginning, not ending on big issues such as taxes, transportation and long-term cost containment.
 
Last week, Governor Brown, Senate President Peter Courtney and House Speaker Tina Kotek hoisted the white flag on an attempt this session to revise Oregon’s corporation taxation and raise additional revenue. They said corporate tax changes would have to wait until the 2019 session. However, public employee unions want to move up the schedule. They are already airing TV ads saying “big corporations” should pay their fair share of the tax burden in Oregon, which appears to be a bombing run to soften the ground for another revenue-raising ballot measure.
 
The Senate and House approved an $8.2 billion K-12 funding bill, which Republicans and Democrats said was not enough, even though it represents 11 percent increase over the current biennium. Republicans blamed Democrats for trying to ram through a tax hike without cost containment. Democrats blamed Republicans for refusing to budge on revenue, even though it meant serious budget cuts. Education advocates are furious and may push state leaders to do something before the 2018 general election or the 2019 legislative session.
 
The Oregonian published an editorial lambasting the lack of leadership in Salem, pointing a particular finger at Brown, who faces another re-election battle next year, with GOP candidates already salivating at the chance to unseat her. More than one Capitol wag suggested that Beaverton Democratic Senator Mark Hass showed more leadership on a corporate tax compromise and a more substantial cost containment proposal that included the Public Employees Retirement System. Hass and others have pointed to a growing fiscal crisis in Illinois that is faltering under the weight of huge underfunding of its public employee retirement fund.
 
There is still time for lawmakers to act on a transportation funding package, which was a bipartisan priority before the session started. However, its fate continued to hang in the balance, despite an announcement by Brown that a deal has been struck. Key players are still working hard to tie down final details, which could surface today.
 
But the major hiccup is an 11th-hour threat by Rep. Julie Parrish, R-West Linn, to refer the transportation package and Medicaid tax measure to voters. Democratic leaders scrambled to write legislative language in Senate Bill 229 that would allow legislators to write ballot titles for the referrals and schedule them for a vote at a special election January 23.
 
While the legislature cleared a tax increase on hospitals and a new tax on health insurers to patch the state’s Medicaid budget hole for the next two years, stomachs are still churning while Congress considers health insurance legislation that, in versions so far, make drastic cuts in federal support for the program vital to low-income Oregonians, children and the elderly housed in nursing homes. Whatever Congress does, it probably won’t have much of an effect on the 2017-2019 biennium, but its shadow will cast a pall over the program moving forward into subsequent biennia. Voter approval of a referral of the tax increases would turn the shadow into a serious rain cloud.
 
In fact, the issue of health care could be at the center of policy and political debates for the foreseeable future. Congressional Republicans seem hell-bent on reining in a fast-growing entitlement program and lowering insurance premiums, even at the expense of reducing what’s covered in health insurance policies. Democrats are defending the Affordable Care Act, while conceding it could use some repairs to remain viable. Meanwhile. Voices such as Providence St. Joseph Health CEO Rod Hochman deplore GOP legislation that slashes federal support for Medicaid when states have little financial ability to pick up the slack. Hochman said he and others in the health care industry hoped federal legislation would address some of the issues making health care delivery unaffordable for many Americans, including households with health insurance.
 
The interim – the time between legislative adjournment and the next session – is usually fairly quiet, with a few hearings, some work groups and early stirring for ballot measures. The looming interim may be anything but quiet and may make it seem like adjournment was just an intermission before the final acts.

Kitzhaber Makes National Waves

Governor Kitzhaber went from a face in the crowd in the First Lady's State of the Union box to a news media headliner talking about Oregon's bold venture into transforming the health care delivery system to deliver better quality at less cost.

The former emergency room physician told national audiences this week he couldn't accept budget cuts that forced low-income and working poor families to access their health care in the ER. He told The Washington Post he still vividly recalls an elderly man who was culled for budgetary reasons from the state's Medicaid rolls, but who showed up at his emergency room after suffering a stroke. "These people don't disappear," Kitzhaber said.

Appearing on NPR's Here and Now show, Oregon's third-term governor explained the approach the state is pioneering to "bend the cost curve" of health care by creating incentives to keep people healthy rather than just treat them when they are sick. 

Kitzhaber focused on the care of patients with chronic illnesses who can avoid hospital admissions and additional prescription drugs through more personalized care, often in the form of a Registered Nurse. He said helping to manage chronic illnesses can result in better outcomes for patients and drastic reductions in medical costs. Another cost driver is untreated mental illness, which can result in frequent, costly medical incidents that are treated, but without getting to their root cause.

A Grand Bargain on PERS, Public Safety

Oregon lawmakers settle in for real Monday and will quickly see, if they haven't already, that the 2013 session pivots on the outcome of two tough political decisions — modifying PERS and public safety reforms.

The legislature's only absolute duty is to approve a balanced budget and Governor Kitzhaber has teed up that task on the backs of saving a lot of money on PERS and new approaches to managing public safety. He also wants to slow the rate of growth of Medicaid and save $400 million in projected health care costs in the next biennium.

Squeezing money out of Medicaid rests on the ability of hospitals, doctors and health systems to, in Kitzhaber's words, "bend the cost curve" of the health care delivery system. But squeezing money out of PERS and Oregon’s public safety system falls squarely on the shoulders of legislators.

If there ever was a need for a grand bargain, this is it.

That's undoubtedly why legislative leaders have created a bipartisan, bicameral committee with equal numbers of Democrats and Republicans to address the public safety reforms — or, in legislative parlance, to provide both parties with political cover on what surely will be tough votes.

Leaders know there will be hell-no votes on both issues in both Democratic and Republican caucuses. Bipartisan majorities will be required if PERS and public safety changes are going to pass this session.

Reforms Will Push Up Premiums

Implementation of health care reforms in Oregon and America are beginning, but may occur in the backdraft of rising insurance premium rate shock.At the end of the 2011 and 2012 legislative sessions, headlines crowed about the progress Oregon had made on health care transformation as a result of bipartisan legislation from both sessions. In fact, Oregon has become a national leader on the topic with leadership from Oregon's governor, Dr. John Kitzhaber. From the establishment of Coordinated Care Organizations (CCOs) to the establishment of one of the first exchanges nationwide, Oregon took major steps forward in implementing health care reform.

As CCOs have begun to spring up in different communities throughout the state and details of the health insurance exchange have become more clear, a surprise that legislators didn’t anticipate is beginning to bubble-up to the surface: Major increases in health care costs will hit consumers just as the exchange debuts early next year.

Many of the causes of these cost increases are outside the control of Oregon legislators, but they nonetheless have the potential to unravel public support for reform as front-line consumers come face-to-face with the true cost of health care for the first time. 

Oregon Emphatic on Expanding Medicaid

While some states have debated whether to expand Medicaid as part of implementation of the federal Affordable Care Act, Oregon appears not even to have considered the possibility of saying no.

Led by an activist governor, John Kitzhaber, Oregon has proceeded as if health care reform was a foregone conclusion.  In fact, the governor, a former emergency room physician and one of the country's acknowledged health care policy experts, has taken action to put the state ahead of almost all others, contending there is no choice but to reform a system that could threaten to bankrupt the state budget.

Kitzhaber encouraged the state to develop an online health insurance shopping center before there were any federal rules on such health insurance exchanges. He proposed a new approach to delivering health care to Medicaid recipients through "coordinated care organizations" and prodded the legislature to go along with him. In the new budget Kitzhaber unveiled for 2013-15, he continued moving down the road aggressively toward reform.

Lawmakers, even with a nearly even split between Democrats and Republicans in the 2011 legislative session, went along with the governor in large numbers. The vote on the underpinning of reform, Senate Bill 1580, passed on a party line vote in the Senate, but cleared the House by a wide margin, 53 to 7.

Few legislators went on record with statements in opposition to reform, though a couple Republican voices in the Senate asked whether the state wanted to get linked up with Obamacare when so little was known about long-range costs.

Last week, one Republican said he was concerned that the governor had included Medicaid expansion population in his Oregon Health Plan budget recommendation, exposing the state to unfunded costs down the road.

Meanwhile, other states have moved more slowly than Oregon. An Associated Press story this week reported several governors have resisted submitting to the federal directives.

Governor Rolls Out "Education Budget"

Governor Kitzhaber unveiled a budget proposal today that he called "first and foremost an education budget."  He said his budget "creates space for front-end investments in education and early learning by cutting back-end spending on health care and corrections." 

His 2013-15 budget, which was previewed by The Oregonian and Salem Statesman Journal today, puts controversial changes to the Public Employees Retirement System (PERS) squarely in the center of an effort to carve out more money for schools. And that could bump into political resistance from the newly Democratically controlled House.

Despite that, the atmosphere in the state Capitol was markedly different than in Washington, DC, where partisan wrangling continues over how to avoid plunging over the so-called fiscal cliff. While there is no looming fiscal cliff here, the governor's budget will only serve as the framework for the 2013 legislature to hash out a final budget with Democrats at the controls in both the House and Senate.

Senator Richard Devlin, D-Tualatin, already named to be Senate co-chair of the Joint Ways and Means Committee, was charitable toward the governor, as quoted in the Salem Statesman-Journal.  "I appreciate the governor's candor about the specific challenges we face in funding education and the Oregon Health Plan in the next biennium," Devlin said.  "With his recommended budget, Governor Kitzhaber has provided a good starting point for the budget negotiations ahead of us."

New House Republican Leader Mike McLane, R-Powell Butte, praised Kitzhaber for addressing PERS, but questioned the rosiness of revenue projections and the lack of any fund reserves to cushion the budget in case the economy falters in the next two years.

The governor's plan for more money for K-12 schools rests on the premise that the legislature will accept his recommendations to reform PERS in two ways:

• By limiting cost-of-living increases to the first $24,000 in retirement income; and

• By closing a benefit loophole for out-of-state retirees. 

What Does Health Care Ruling Mean to Oregon?

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.

Surprise Decision Strains Reform Support

The decision caught almost everyone by surprise last week. The Governor's Office and the Oregon Health Authority said they would not make any of the $2 billion in new federal money obtained by the Administration available for the first year of health care reform in Oregon.

"Members of the new groups (Coordinated Care Organizations, CCOs) are crying foul," reported The Oregonian, "after a directive Thursday that they'll receive no new funds for the additional responsibilities they've agreed to take on — mental health care, prevention efforts, quality measurements and new patient-care staff, among others."

In fact, managers of the new, still-not-yet-approved CCOs have been told they will have to live with last year's rates, which themselves represented an 11 percent cut. Leaders of the new groups say their success relates directly to the new money to fund them. They say it takes money to revamp care for more than 600,000 Oregonians covered by Medicaid, the joint federal-state program that provides care for low-income citizens.

In touting health care reforms such as CCOs and the Health Insurance Exchange, Kitzhaber has stressed the need to control costs through competition and innovation.

For many in the health care reform orbit, all of this conjures up images of the original Oregon Health Plan more than 15 years ago, also designed by Governor Kitzhaber in his earlier service as Oregon Senate President and as governor in his first term. A key tenet of the plan then was that providers would be paid close to their costs for delivering services. The clear objective was to limit the cost shift onto the backs of private health insurance payers.

Well, that tenet apparently has been lost in the intervening years.

Today, those with private health insurance pay about 20 per cent more in premiums as they bear the "hidden tax" of paying for Medicaid underfunding. In a 2008 study, the Milliman Group estimated underfunding of Medicaid and Medicare amounted to more than $90 billion annually.  Though four years old, the study is still applicable today.

Kitzhaber Brings Home Bacon

The big news last week revolved around Governor Kitzhaber's successful, last-minute trip to Washington, D.C. where he negotiated final terms of a deal that will bring Oregon almost $2 billion in federal money over the next four years to finance health care reform. The first installment — $620 million — is expected to arrive in Oregon by July 1.

As The Oregonian put it in its lead story on the successful trip: "Kitzhaber saves Oregon budget and his reputation in health care deal with Obama Administration." Both points are true. Oregon needs the money to fund reform. And, Kitzhaber, a former emergency room doctor who thinks, lives and breaths health care policy, had almost no choice but to succeed in D.C.

What remains is a question about whether the new federal money can be used to fill budget holes or must be devoted to new health care reforms. But that question, as important as it may be to budget analysts, ignores the basic policy point — the money will go to reform and that will mean that the reforms have a better chance for success here.

The Possibility of a Nuanced Ruling

Most media focused last week on oral arguments before the U.S. Supreme Court on the controversial federal health insurance mandate for individual Americans. However, justices also heard arguments on other aspects of the legal challenge to what has become known as ObamaCare that could lead to a more nuanced decision and perhaps even more complexity for states.

Justices listened to arguments on whether the constitutional challenge of the individual mandate is ripe because it hasn't gone into effect yet. Commentators expressed doubt the court would effectively punt a big decision for this reason. They also considered the severability of the federal health care reform act. They wanted to know if voiding the individual mandate would void the popular ban on excluding health insurance because of pre-existing conditions. 

A ruling isn't expected until late June, which will allow for a lot of media speculation, political bombast and unease by state officials who will play a key role in implementing health care reform in whatever form it survives from the court case.

Based on the intense questioning by justices and the balky performance of the U.S. attorney arguing the government's case, you could easily conclude the federal individual health insurance mandate is in trouble. The court seems clearly split, but the split echoing from the questioning suggests at best a 5-4 rejection of the mandate.

However, the mandate underpins a grander bargain. Creating the largest possible pool of people with health insurance coverage gives health insurers the ability to absorb and spread costs, including from new insureds who may be combating cancer or suffering from a chronic disease. Dispatching the mandate could put even more pressure on health insurance premiums, which are continuing to rise. That, in turn, could erode the quality of existing employer-provided health insurance and, in some cases, cause employers to drop coverage for employees altogether.

The unspoken part of the story crowded out by commentary on the mandate is what happens if we return to the status quo before Congress approved ObamaCare. The truth is, that status quo has disappeared. 

  • The exclusion of pre-existing conditions and expansion of family coverage to children up to age 26 are very popular provisions, which few would want to lose — especially in an election year.

  • Many employers facing stiff domestic and international competition are looking for ways to trim their health insurance costs. One way is to hire temporary workers without benefits.

  • The public safety net has more holes in it, as Medicaid participation has been limited and funding cut for public health care clinics.

  • Heath care technology continues its steady march ahead, opening new diagnostic and treatment options and adding more costs.

Retired Law School Dean Reflects on Ruling

Symeon Symeonides pondered a moment, then said he had no idea how the U.S. Supreme Court would rule on the constitutionality of the Obama health care law, especially the individual mandate requiring every citizen to have health insurance. The high court will hear arguments in the case next week.

An internationally renowned constitutional law scholar, as well as one of Salem's best-kept secrets, Symeonides said it might be easier for states like Oregon to impose a health insurance buying mandate than for the federal government to do so. After all, he said, Massachusetts passed a mandate a few years ago and it appears to be working — though Republican presidential candidate and former Massachusetts governor Mitt Romney would rather kick the issue to the background. 

Symeonides and I, along with Willamette Law School's development director, Mike Bennett, sat down for a drink last week to reflect on the Supreme Court case, which stands to be one of the most significant in years, perhaps even rivaling the abortion or desegregation decisions. It was only about a week before Symeonides headed off to Brussels, where he will be working for several months to advise the European Union on how to draft a new constitution.

If states found the political wherewithal to impose an individual mandate — and Symeonides, ever an astute observer of political winds, thinks that could be a tall order — it might be easier legally because it wouldn't run up against the U.S. Constitution's commerce clause. Under Article 1, the clause gives Congress "the power to regulate commerce with foreign nations and among the several states, as well as Indian tribes."  The outcome of the court case rests, at least in part, on how current justices interpret the commerce clause and whether regulating commerce "among the several states" allows for an individual health insurance mandate.

The New York Times published an article last week, with the headline,  "At Heart of Health Law Clash, a 1942 Case of a Farmer's Wheat."

"If the Obama Administration persuades the Supreme Court to uphold its health care overhaul law, it will be in large part thanks to a 70-year-old precedent involving an Ohio farmer named Roscoe C. Filburn."

Seems that Mr. Filburn sued to overturn a 1938 law that told him how much wheat he could grow on his property and imposed a penalty on him if he grew too much. The Court ruled against Mr. Filburn, and that ruling serves as the pivot for what the justices will begin considering next week. The Times says interpretations of the Filburn case may form the basis for decisions by the two current-day justices who are considered the swing votes in this case, Anthony Kennedy and Antonin Scalia.

Promise of Cash Makes Reform Vote Likely

Governor Kitzhaber and one of his health care gurus — Dr. Bruce Goldberg, head of the Oregon Health Authority — returned from Washington, D.C. a couple weeks ago with a load of cash. They reported the Obama Administration promised to help Oregon continue reforming its health care system with $2.5 billion over five years.

As always with such pledges, some observers will say "show me the money."  But the Kitzhaber/Goldberg report made headlines just as legislative committees met at the Capitol to prepare in earnest for the February legislative session, at which health care reform will be one of the big topics.

Embodied in Legislative Counsel bill draft #97, the details of a key reform — Coordinated Care Organizations (CCOs) — made its debut. The idea is to focus care, especially for low-income Medicaid recipients, closer to where they live around the state.

News of the prospective $2.5 billion to finance reform probably came close to assuring that the legislature will pass reform legislation in February. It will be almost impossible to say no.

Here are other developments from last week's legislative committee meeting days:

       *  Three officials — Goldberg; Eric Parsons, chair of the Oregon Health Policy Board; and Mike Bonetto, the governor's health care policy assistant — gave House and Senate committees a report on reform progress and received a respectful reception.

       *  A group of health care policy leaders from the Portland metropolitan area, led by Greg Van Pelt, CEO of Providence Health & Services, and George Brown, CEO of Legacy Health System, updated lawmakers on progress to form a CCO that would organize care for citizens in the tri-county area.  The group, which has been meeting for three weeks and intends to keep working, calls itself the "Tri-County Medicaid Collaborative." It was viewed as a significant development because so many organizations – about 30, including health systems, insurers, counties and MCOs – have taken the initiative to follow-up on the governor's health care transformation vision. Similar, though smaller efforts are under way in other parts of the state.