Oregon Health Plan

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.

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.

Saxton Exit Adds Drama to Medicaid Funding, CCOs

With funding for the Oregon Health Plan facing a referral to voters, the resignation of Lynne Saxton as head of the Oregon Health Authority creates more anxiety for health care stakeholders, including the fate of Coordinated Care Organizations.

With funding for the Oregon Health Plan facing a referral to voters, the resignation of Lynne Saxton as head of the Oregon Health Authority creates more anxiety for health care stakeholders, including the fate of Coordinated Care Organizations.

The departure of Lynne Saxton as head of the Oregon Health Authority adds more drama to the fate of the Oregon Health Plan, the state’s Medicaid program.

Legislatively approved funding for the Oregon Health Plan faces a potential referral by three GOP Oregon House members who claim the funding plan contained in House Bill 2391 amounts to a sales tax on health care. If the referral makes it to the ballot and voters approve it, Oregon lawmakers could face a budget hole greater than $300 million over the next two years.

Saxton’s departure could have implications for the coordinated care organizations created in conjunction with Oregon Health Plan funding to act as transformational models for bending the health care cost curve and integrating physical, mental and dental health services.

“With the most prominent visionaries of the CCO development process long removed from office (including Governor Kitzhaber), Saxton was a tether to the old guard at OHA that built the CCO model,” writes DJ Wilson, organizer of the State of Reform effort, in a blog post this week.

Wilson, who advises on health care policy, says Oregon health care leaders are already antsy because of congressional actions that threatened to slash Medicaid funding and the looming Oregon Health Plan funding referral. “Saxton’s removal exacerbates to their anxiety.”

He links the anxiety to what Wilson says is a widespread view that Governor Brown doesn’t consider health care policy one of her top priorities. He quoted one unnamed stakeholder as wondering “who the advocate will be at the state to take the transformation model into the procurement next year, into the legislative session, and make sure the CCO model continues. We may just be heading back to managed care.”

That could be ironic because Saxton resigned in connection with a running battle with FamilyCare, one of 16 CCOs operating throughout Oregon. Jeff Heatherington, CEO of FamilyCare, once accused OHA of acting like a “bully.”

An even more fundamental problem is OHA, according to Wilson. “Since 2013, OHA has had four leaders, two interim and two permanent. Pat Allen is now the fifth.” Allen was named acting OHA director after serving since 2011 as director of the Department of Consumer & Business Services. Wilson says Allen is respected as an effective agency manager, but some health care stakeholders are unsure of his knowledge about CCOs and Medicaid.

Brown told Allen his “highest priority from day one should be restoring trust with the public, legislators, stakeholders and, most important, the clients OHA serves.” In a statement, Brown said, “I have asked Pat to bring his expertise to the Oregon Health Authority and lead the agency into a forward looking and responsible steward of taxpayer dollars.”

Allen responded to Wilson’s questioning by saying, “I’m committed, as is the governor, to the CCO model as the only realistic way to deliver Oregonians improved health through quality care we can afford.”

Straightening out OHA could take time and energy. Dating back to the Cover Oregon fiasco, OHA’s bureaucracy and culture have been criticized. Rep. Mitch Greenlick, in a recent interview, questioned the agency’s dedication “to making sure the most eligible people have access to care” as opposed to “dotting all their I’s and crossing all their t’s.” In the previous session, Rep. Greenlick was the leading legislative voice on the future of CCOs and will continue that conversation in next year's short February session.

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.

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. 

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.

Words Matter as Much as Policies

Will Oregon Governor John Kitzhaber convince the federal government to give money back to the state because of progress here on health care reform?As a person who likes and uses words, I have noticed that the health care debate — both heading toward the U.S. Supreme Court and the 2012 Oregon Legislative session — has been marked by words apparently designed to get the attention of those involved.

Consider these examples:

  • Regarding the "you-have-to-buy-health-insurance mandate" that is heading to the U.S. Supreme Court, a health economist at the Massachusetts Institute of Technology, put it this way:  "Health reform without an individual requirement is the spinach you need to get the chocolate you want."
  • On the same issue, a former health care policy advisor to President Bill Clinton was quoted last week as saying that "health reform without an individual mandate is like driving a train without tracks; you can still move, but you can't get to your destination and it will be a tougher and far more costly trip."
  • Or, consider this quote used last week in an update for Oregon legislators on the Health Insurance Exchange: "Our assumption is that the exchange is being born in a political battlefield. Half of Oregon never wanted you to exist and other half wanted much more than what you are. It seems your biggest challenge will be to gain the trust from both sides that you are an honest broker of information and opportunity — not the purveyor of a political agenda."