Uncertainty about the fate of the Affordable Care Act spells confusion for Oregon Health Plan patients and providers and leaves the state facing tough budget decisions
The Oregon Health Plan is reputed to be one of the most innovative and ambitious Medicaid programs in the nation.
The program provides health care for 1 million people, or nearly 25 percent of Oregon’s population – anyone who makes below roughly $16,000 a year or is disabled or elderly.
Oregon Health Plan patients receive their care through coordinated care organizations, or CCOs, which were created in 2012 to coordinate the physical, mental and dental health care of Oregon Health Plan patients. If a patient goes to the doctor and shows signs of anxiety, the doctor can connect the patient with mental health care in the same building. Electronic health records ensure that a doctor or a dentist or an emergency room nurse can see which medications a patient is on. Through emphasis on preventive and primary health care, medical staff helps patients stay healthy and out of the emergency room.
Oregon has received billions of dollars from the federal government to help fund the state’s 16 CCOs, partially because the coordinated-care model is expected to cut health care costs while improving people’s health.
According to the state, that is already happening: Since 2012, Oregon’s CCOs have already saved $1.4 billion in health care costs. Emergency room use has been cut by a third, and preventive health care – such as doctor’s visits, immunizations and teeth cleanings – have all increased dramatically.
That progress now hangs in the balance with the likely repeal of the Affordable Care Act.
Repealing the ACA became the biggest campaign promise made by President Donald Trump and the Republican caucus, and a vote is expected fairly quickly. The ramifications of a repeal are still unknown.
The structure of Oregon’s CCOs is not threatened. A new federal waiver allowing them to continue operating was approved in mid-January and is in effect until January 2022.
What is at stake is how much federal funding will be available to fund the Oregon Health Plan, whether the plan will continue to provide health care for its one million members – including 350,000 Oregonians now on the plan due to the expansion of Medicaid – and how destabilizing any change to the Affordable Care Act will be for provider networks and health care programs.
With the Affordable Care Act’s fate unknown, Oregon is preparing to take on more of the responsibility of providing health care for the state’s most vulnerable residents through legislation and tax proposals.
One of the biggest challenges state government – including the Oregon Health Authority, which oversees the Oregon Health Plan – and health care providers face is uncertainty.
The providers
What it means to repeal the ACA is unclear, said Janet Meyer, the chief executive officer of Health Share of Oregon, a CCO that serves the Portland metropolitan area. “It’s a very complicated set of policies and regulations and programs. There’s a lot of confusion.”
It’s not clear if the entire health care law will be repealed or if popular parts of it – including allowing children to remain on their parents’ plan to age 26 and the prohibition on denying health insurance to people who have a pre-existing health condition – will be kept in place.
It’s also not clear what will replace the law. Despite the fact that the Republican-controlled House of Representatives has voted dozens of times in recent years to repeal or change the ACA, leaders in the Republican Party have not released draft legislation to replace it.
The uncertainty prompted Oregon Health & Science University President Joe Robertson to announce in mid-January that OHSU would significantly reduce hiring, almost tantamount to a hiring freeze, until it became clearer what the state’s budget and federal funding for Medicaid and other health programs would be.
Rob Soans is a physician assistant who has practiced primary care for 20 years at Manzanita Urgent, Primary and Specialty Care, a clinic in Nehalem, Oregon.
One can tell from the clinic’s name that Soans, on any given day, sees the gamut of health conditions in the rural, impoverished community.
On a recent Saturday, Soans performed 11 house calls in 14 hours. One elderly woman had lost her glasses, so she could not see the numbers on the syringes she uses to give herself insulin. Soans gave her a pair of reading glasses he had bought at Costco.
He told another woman, a 29-year-old who brought her 2-year-old child with her to the clinic, that she has cancer. He got phone calls and texts throughout the day from patients.
In addition to children immunizations, routine checkups, and helping people manage chronic conditions, people suffering from heart problems, burns, broken limbs, the flu and other urgent ailments walk through the door.
“I serve everybody who walks in the door,” Soans said.
Like other medical providers, he is frustrated by the Affordable Care Act’s nebulous future. He predicts that, if people are dropped from insurance, they will return to the emergency room for care and medical costs will skyrocket.
Regardless of whether his patient will be able to pay in the future, he says he will continue to provide them with care. “I’ll show up everyday and take care of my patients,” Soans said. “I really think that, unfortunately, the downstream effects of this are going to be negative.”
“Unless they truly don’t care about taking health care from millions of people, some version of Obamacare will remain,” Scott Ekblad, the director of OHSU’s Office of Rural Health, said.
Ekblad said that is a sentiment shared among many rural healthcare providers. People who received health insurance due to the Affordable Care Act and “who had a lot of delayed medical needs and are finally seeing a provider…aren’t going to stop seeing their providers,” he said. “In those small, close-knit communities, providers see people regardless of their ability to pay.”
Ekblad said rural communities—which often have high unemployment rates, lower average income and, therefore, higher rates of people eligible for Medicaid—will be deeply affected by marked changes, or wholesale repeal, of the Affordable Care Act.
“We stand a real risk of losing some of our smaller, low-volume rural hospitals,” Ekblad said.
Many of those hospitals, especially along the coast and in eastern Oregon, remain open twenty-four hours a day, with medical staff available, even if there isn’t the patient volume to necessitate remaining open all hours of the day. Ekblad said the Affordable Care Act benefitted rural hospitals greatly due to the increase of the insured population, which ensured that hospitals could be reimbursed for services they provided.
“There were many hospitals in the state that were operating in the red and it was simply the increase in the insured level of their patients that made them show a little bit of black again,” he said.
The patients
Ed Blackburn, the executive director of Central City Concern, a social service agency that serves homeless and low-income Portlanders, said patients who go to the Old Town Clinic have already assumed that they no longer have health insurance.
“We’ve had doctors say, ‘Why are you canceling your appointments?’ and patients are saying, ‘Because I won’t be covered anymore.’ They’re coming in the door and saying, ‘Will you still see me?’” Blackburn said. “It’s very stressful for those people. It’s stressful for all the providers.”
Blackburn said Old Town providers already struggle to make sure the patients most in need remain enrolled in health insurance. Now they find themselves explaining that patients will have insurance at least for a year, if not longer, depending on how quickly Congress acts.
“It’s a lot of work,” Blackburn said.
The main reason, Blackburn and others said, that Oregon Health Plan patients have reacted so strongly is because of the enormous role becoming insured has had on their lives – something they describe as life-changing.
“We have mentally ill people who would not have health insurance because they have a disability,” Blackburn said. “We have people in the middle of cancer treatment. There are people with diabetes, wondering where they will get their insulin. Their care is integral to them. Their lives are so much better because they’ve managed their addictions or their pain or their illnesses.”
Lisa Greenfield, 25, became covered by the Oregon Health Plan about a year and a half ago. She applied to join the plan three times in the past. Each time, she was denied because she did not meet Oregon Health Plan’s restrictive eligibility criteria, put in place during the recession.
Greenfield, who grew up in Portland, began using drugs when she was 19 and living with her mother. Her mother “got tired of me using” and kicked her out.
Homeless, she continued to use drugs. She tried to quit heroin cold turkey but said she couldn’t make it “past day two of being sick.”
She compared heroin withdrawal to the flu, but 100 times worse. “You’re vomiting, you’re sweating, you have diarrhea,” she said. “It’s excruciating.”
So she kept using, until she entered drug treatment at Central City Concern. While there, she was enrolled in the Oregon Health Plan, which had since added 350,000 Oregonians onto coverage with the ACA’s expansion of Medicaid.
Greenfield now regularly takes Suboxone, which reduces her cravings and keeps her off heroin. She also takes medication for bipolar disorder and participates in group therapy. She doesn’t pay any out-of-pocket costs. She goes to the doctor if she gets sick.
She credits becoming insured for allowing her to get her life back together.
“I work. I’m going to go back to school. I pay my own rent. I pay my own phone bill,” she said. A year ago, she said, she could not have done any of those tasks, which many people take for granted.
The possible repeal of the Affordable Care Act frightens Greenfield, who worries that she will start using drugs again. There’s no way that she could afford to pay for her Suboxone prescription, which costs thousands of dollars each month.
“There’s no way I could afford that,” she said. “I will get sick. I will go through withdrawals. I’d be in a lot of pain.
“Obamacare has helped me tremendously,” she said. “If that goes away, the whole foundation that I’ve built my life upon in the last year is turned upside-down.”
The belief expressed by Greenfield – that her life is in order because of health insurance – is one shared by many Oregon Health Plan patients, Meyer said.
Becoming healthy “makes you feel like you have a bit of control in your life,” Meyer said. “By empowering people to seek preventive and primary care, you give them the hope that they can work their way out of poverty, and work toward whatever their goal is in their life.”
Health Share provides health care to approximately 80,000 of the 350,000 Oregonians who make up the “expansion population,” the people now covered by the Oregon Health Plan because of the Affordable Care Act’s provision to expand Medicaid in states that accepted additional federal funding.
The majority of that population, Meyer said, is under age 45. On average, she said, 300 people have a prescription filled each day. Half of the population have had their teeth cleaned since receiving coverage.
“We think of teeth cleaning as this little luxury,” Meyer said. “Not really. It’s part of being employed. We know that people with better oral health have a better chance of retaining their employment.”
If the federal government chose to cut the parts of the Affordable Care Act that extend health insurance to the Medicaid expansion population and other populations now insured because of the law, it would be inhumane, she said.
“To have been given access to health insurance and then so quickly have it taken away, it would be devastating,” she said. “It’s a horrible thing to contemplate. That is just a travesty.”
The state
As the Oregon Legislature convenes for a six-month session this month, the state faces a $1.7 billion deficit, approximately $1 billion of which is due to the federal government no longer paying for the costs of insuring Oregon’s Medicaid expansion population.
Gov. Kate Brown’s budget proposal, released in December, calls for continuing to cover the Medicaid expansion population. The budget plan also does not change the eligibility requirements to be covered by the Oregon Health Plan, nor does it change the services the plan provides.
Whether Brown’s intentions come to pass is dependent upon the Legislature’s enacting new taxes to close the budget deficit without affecting the Oregon Health Plan. Brown wants to raise the state’s cigarette tax by 85 cents a pack, double the liquor tax, increase alcohol licensing fees, and allow some tax credits to expire.
Brown’s budget also calls for increasing the hospital provider tax, which is sure to become the most controversial of the governor’s tax proposals.
Oregon’s hospitals are exempt from paying property taxes because hospitals provide charity care – essentially providing health care to people regardless of whether they can pay. That was important in a pre-ACA Oregon when the rate of people who were uninsured was higher than it is today.
Because more people have insurance, hospitals provide less charity care but are reimbursed, through insurance, for care hospitals provide. So hospitals have made money. Providence Health & Services, the state’s largest hospital system, has $6 billion in cash reserves.
The governor’s budget is an optimistic one; the budget developed by the co-chairs of the Legislature’s budget-writing Ways and Means committee is not. That budget assumes a state budget with no new revenue, including no new taxes. The Oregon Health Authority’s budget would be cut by 27.5 percent. The co-chair’s budget makes it clear that every part of the state’s health system would be affected, including reducing dental services and addiction services provided by the Oregon Health Plan, with the exception of pregnant women.
That budget also calls for cutting health insurance coverage to the 350,000 people now insured through Medicaid expansion.
The other gaping question is how Medicaid will be funded at the federal level. The idea that has gotten the most attention is funding Medicaid through block grants, which Republican House Speaker Paul Ryan advocates.
Block grants are lump sums of money provided to states or programs. It’s still unclear if states would be given a concrete amount of money for Medicaid, leaving it up to the states to decide how to fund their Medicaid programs. It’s also unclear if the amount of the block grant would be based on enrollment numbers—as funding is currently calculated—or other demographic information.
“I haven’t gotten my head wrapped around a CCO model works under block grant funding,” Meyer said. “I find it hard to believe that block grant funding can sustain the (Oregon Health Plan) as it is today in Oregon. The devil is in the details. That’s a whole new world, if that is in fact where we go as a nation.”
Blackburn, like many others, believes the Affordable Care Act will not be entirely repealed; the political consequences of 30 million people becoming dropped from health care coverage are too great.
“People can die,” he said. “They’ll suffer needlessly. We would have a lot of sick people in the emergency room. We’ll have a lot more uncompensated care in community health clinics.”
* This story has been updated to correct Janet Meyer's title with Health Share.
