Talk Health Reform

How Low Can You Go?

The state of Florida recently passed a health reform bill that would reduce the number of uninsured in the state by offering a "no frills" state health insurance product for as low as $150 a month.  Insurers participating in the program would be required to provide coverage for annual physician visits, inpatient hospital stays, mammograms, prostate screenings, immunizations, emergency department visits, and prescription drugs. Specialist care and long-term hospitalizations would not have to be covered. The product would also be exempt from the mandatory benefits of other health insurance products sold in Florida. 

Oregon has experimented with the idea of limiting benefits in its Medicaid program, yet faced opposition from the federal government. The state currently has a Prioritized List of Health Services developed by a public commission for the Oregon Health Plan. Florida's plan is not administered through Medicaid; it does not get federal funding and does not require federal approval. 

The Oregon Health Fund Board Benefits Committee is currently considering recommendations to the Board to create an "Essential Benefits Package" that instead of covering all health services would prioritize evidence-based medicine that keeps people heathy.  Health services identified as higher priority would be provided at little or no cost to the patient, while lower priority services would have higher co-payments or not be covered.

Is limiting services the answer for expanding health coverage?  How can the maximum number of people be covered without breaking the state's bank?

Guest Post: Reforming Primary Health Care

This post was written by the Oregon Primary Care Association, a non-profit membership organization founded in 1984. OPCA represents Community Health Centers (also called Federally Qualified Health Centers or FQHCs).  The OPCA believes that every person has a right to accessible quality comprehensive health care.

The following post represents the views of the OPCA.

There is growing consensus among patients, providers, and policy makers that the delivery of primary health care is not working well in this country.  Providers are frustrated with the inability to prepare and review patient information before a visit and the financial pressures that limit their visit with each patient to 15 minutes or less.  Patients are dissatisfied with the relationships they have with their providers, and a majority of patients with chronic conditions report that they do not comply with treatment protocols in part because half of them did not understand their doctor’s advice (Bodenheimer, 2006).  Policy makers and health care purchasers are frustrated by a system that provides financial disincentives to support primary health care, despite strong evidence that investment in primary care will enhance outcomes and minimize expenditures over time.   

As Oregon looks to reform its health care system to enhance access, improve quality and reduce costs, how can we create a more efficient and higher quality delivery system for primary health care?

The Oregon Health Fund Board has been learning about national and local models to reform primary health care called the primary care medical home.  These models, supported nationally and locally by many health care organizations, aim to reform the delivery of primary health care by creating a patient-centered experience.  Important components/principles shared by these models include:

• The primary care visit is a Patient-Centered Experience, allowing adequate time for the visit, a sustained relationship with a culturally competent provider team, and patient-driven goals.
• Team Based Care is provided that is proactive, planned, and maximizes services during each visit.  Evidence-based medicine guides decision making, and team members each practice at the top of their ability/license.
• Behavioral health is fully integrated into primary health care.
• Provider Accessibility is enhanced through more timely visits, electronic (phone, email) contact with provider teams, and removal of transportation and cultural barriers.
• Care is coordinated and/or integrated throughout the entire health care process.  Community services are also coordinated, as needed, for the patient. 
• The Primary Care Medical Home is nested in a community structure that collaboratively leverages and maximizes resources.
• Payment Reform that provides appropriate compensation and incentives for these components is essential.

It is important to note that the Oregon Health Fund Board is also considering reform for the broader system termed the Integrated Health Home.  This discussion is focused on primary health care reform specifically – one of the key components of overall system reform.

Questions: 

How can providers optimize communication with patients?  What is the most effective way to manage care (where does the care manager “live”)?  What financial incentives are necessary to support such an enhanced model of primary health care?  Is a primary care home necessary for everyone, or just patients with the most complex health and social needs?  What does it mean to provide culturally competent primary health care?  How does reforming the primary care system impact reform for the broader health care system? 

Your Oregon, Your Health (Your Meetings)

Starting on Thursday, May 1, a series of community meetings will be held across the state to discuss health reform.  The meetings, sponsored by Oregon Health Forum, the Northwest Health Foundation and Oregon Health Decisions, are being held on behalf of the Oregon Health Fund Board. 

The meetings are open to everyone.  Your participation in small and large group conversations will help shape the future of health care in our state. You can come to the meetings without preparing formal testimony.  Everyone’s voice matters, and the organizers want to hear from:

• people with or without health care
• employers
• seniors
• people with disabilities
• anyone else interested in helping Oregon tackle access, cost and service issues

Meetings will be  held in Gresham, Newport, Astoria, Klamath Falls, Medford, Washington County, La Grande, Ontario, Coos bay, Eugene, Bend, Portland and Salem.  Click here for the times and dates of each meeting.   

Interpreters and child care are available upon request. Please contact Oregon Health Forum by email or phone, 503-226-7870 or 800-501-4220, to arrange these services.

Oregon Health Plan in the News

When the prioritized list that is used for the Oregon Health Plan was first unveiled, Oregon’s health care system made world news. Now, with the announcement that the state will be using a “health care lottery” to determine who gets covered when OHP reopens, Oregon is again on the national - and international - radar. And not all of the press is positive.

A segment called "Pick Sicks" that recently aired on Comedy Central's Colbert Report lampooned the OHP lottery. Even though his description of the situation is delivered in a humorous, "tongue-in-cheek" manner, the topic is a serious one. 

Understanding that there are limited funds in the current system and that the federal government does not allow sicker or higher risk people to be moved to the front of the line, is a lottery the best way to get eligible people covered?  What do you think about Oregon being the first state to try using a lottery for health care? 

Guest Post: CareOregon

This Guest Post is from CareOregon, a Medicaid managed care plan serving over 95,000 Oregon Health Plan members in 16 counties across the state.

The Oregon Health Plan (OHP), as initially envisioned in 1987, was supposed to provide access to care for all Oregonians with all segments of society sharing in the cost. However, twenty years after the development of OHP, we do not have enough state general funds allocated to either cover the intended OHP population or maximize our federal match. That means that for every dollar the state is not spending on OHP, we give up $1.57 from the federal government. Not fully funding the OHP “Standard” population means there are more uninsured Oregonians. When the uninsured get care, providers, payors and health care consumers pay for this care.

In order to get the federal dollars we are entitled to, we need to allocate additional state general fund dollars to OHP. But let’s not just keep putting money into a system without thinking about whether the system is designed to give us what we want for our population. The primary care system is a good place to start since it will improve patient care and reduce costs. Another way to improve our “bang for the buck” is to think about how we deliver and pay for care.

We know that coordination of care at a primary care level can result in better health for people and save significant money in the whole system. Paying for nurses to provide some of these services, rather than doctors, would save dollars in the system and improve outcomes. If health plans and insurers had more flexibility in how clinicians are paid, the delivery system could be transformed to provide the care people need for less cost. In addition, information that compared outcomes across programs would allow us to see if the money we are spending is well used.

Hopefully, the Health Fund Board and its committees will look for as many opportunities as possible to provide that flexibility and to maximize the state’s federal matching dollars. It’s a shame to leave that money on the table.

New Feature: Guest Posts

As part of its effort to engage interested people and groups in discussions about health reform topics, the editors of Talk Health Reform have asked groups engaged in reform to participate in the blog through guest posts.  Guests are asked to write about topics of interest to their organizations, which may be as narrowly or broadly focused as they would like. 

Tomorrow we'll debut this feature with our first guest post, from CareOregon.  CareOregon is a Medicaid managed care plan serving 95,649 Oregon Health Plan members in 16 counties across the state. 

Over the coming weeks and months we will feature guest posts by other organizations around the state. If you work with an organization engaged in health reform work in Oregon and would like to write a guest post, please email the Talk Health Reform editors. 

What Can We Learn From: California

As the Oregon Health Fund Board develops a comprehensive reform plan, many other states are moving in the same direction.  Some are ahead of us, others behind.  Are there lessons from other states’ experiences that could influence the success or failure of our own plan? At Talk Health Reform, we'll be looking at other states' experience planning and implementing reform and asking if these examples hold lessons for Oregon's reform efforts.

This week: California

Looking at the rise and fall of health care reform in California, what can we take away from our neighbor's experience?  Were there elements of California's proposal that you think we should either incorporate or avoid?  Like California, Oregon is trying to significantly expand coverage, enact comprehensive market reforms, and address failures in the delivery system.  The scale of the problem is similar in California and Oregon, too – 19% of California’s population is uninsured, compared to 17% in Oregon.

California’s plan included:

• The concept of “shared responsibility”, where individuals, employers, and the State all contribute to the health care system. 

• Both an individual mandate and a requirement that employers provide coverage or help pay into the system to help pay for insurance for lower income Californians.

• State contributions to help lower-income individuals and families pay for coverage.

• Tax credits for others so that the cost of health care does not exceed 5% of a family’s income.

• A health insurance pool, or “exchange”, where people with subsidies or tax credits could purchase individual coverage.

• An increase in the cigarette tax and new hospital fees to help finance the program.

More details on California’s plan can be found on the California Healthcare Foundation’s health reform website.  Health Affairs is also hosting on blog on California’s “shelved health care reform”.

The plan had support from businesses, labor, consumers, providers, and health plans, and yet it did not pass the Senate.  As our state considers a similar approach to covering our uninsured, how can we succeed where California failed?  Are there other states that you think have lessons for Oregon?  How can we be a leader for other states as well?

Undocumented Immigrants: Include, Exclude, Ignore?

According to the Oregon Center on Public Policy, an estimated 128,000 to 150,000 undocumented immigrants resided in Oregon in 2006.* Two years later that number has likely increased, yet would still possibly represent around 4 percent of the total population in Oregon.** While this group is a small segment of the entire population, it could play a divisive role in a push for universal health care coverage.

Two committees of the Oregon Health Fund Board (the Health Equities Committee and the Eligibility and Enrollment Committee) have held discussions on the topic and are in the process of issuing recommendations to the Board. Both Committees focused on humanitarian, public health, and cost-shift issues related to either ignoring undocumented Oregonians or creating a bureaucracy to actively exclude this group. The Committee members see their primary charge as advancing the goals of the Healthy Oregon Act by covering Oregon’s uninsured population. They do not want to enter into enforcement of federal citizenship requirements.

The Health Equities Committee recommends:

It is a long held Oregon value that all Oregon residents have equal opportunity to support their families, pay taxes, and contribute to the State’s economy. To maintain the health of that workforce, it is fair, wise and in the State’s economic interest that the Oregon Health Fund program shall be available to all Oregon residents.

As consistent with current practices in the private marketplace, no citizenship documentation requirements will be in place to participate in the Oregon Health Fund program.

To implement these recommendations, the Committee believes that the Oregon Health Fund Board should consider various policy implementation options. The Committee’s preferred option is:

Establish an ‘Oregon Primary Care Benefit Plan’, or alternatively a health care pool, within the Oregon Health Fund Program for non-qualified [legal immigrants who have been in the U.S. under 5 years, and individuals without documentation] Oregon residents who are unable to afford purchasing health care without a subsidy. Financing for this portion of the program could be structured so that industries employing non-qualified Oregon residents are directed to contribute through the “play or pay” requirement of the employer mandate.

What do you think the Oregon Health Fund Board should include in its consideration of this potentially hot button issue? How should undocumented immigrants be treated within a plan for universal health coverage in Oregon?

*Data based on reports from the Pew Hispanic Center and the former Immigration and Naturalization Service (now the U.S. Citizenship and Immigration Services Bureau).

**Additional information on immigrants and health care is available from a recent report by the Kaiser Commission on Medicaid and the Uninsured.

To Require or Not Require

Health insurance reform is topping the agenda of the major Presidential candidates.  The following links offer the health care proposals from:

• John McCain
• Barack Obama
• Hillary Clinton

While Obama and Clinton are offering proposals that look similar in many ways, they differ about whether to require people to get health insurance coverage (an insurance "mandate").  Both plans would ensure that insurance carriers could not turn people down for coverage due to a medical condition. Clinton's plan would require Americans to "get and keep insurance in a system where insurance is affordable and accessible."  The Obama plan has mandates only for children, requiring that "all children have health care coverage."

The rationale for a mandate is that it gets everyone (or almost everyone) into coverage.  Near universal coverage greatly reduces the costs associated with paying for care for the uninsured.  The premiums paid by insured people now pay for care for the uninsured, which is called a "cost shift."  The argument against a mandate is that if affordable, accessible, consumer-valued products are available, most Americans will get coverage.  The bureaucracy needed to enforce a mandate costs money, and universal coverage can be attained without it.

What do you think: are mandates necessary?  Can reform happen without them?  How can people - especially young, healthy, and lower income people - be encouraged to get coverage in a voluntary system?  If mandates are necessary, how can they be applied to encourage insurance purchase without overly penalizing lower income people?

Health Care: A Right?

One of the bills discussed during the Oregon Legislature's February session was House Joint Resolution 100. HJR 100 proposed to amend the Oregon Constitution to say that health care is a right.  To protect that right, HJR 100 would require the Legislature to ensure access to health care.  The resolution reads:

The people of Oregon find that health care is an essential safeguard to human life and dignity and that access to health care is a fundamental right. In order to implement that right, the Legislative Assembly shall establish by law a plan for a system designed to provide to every legal resident of the state access to effective and affordable health care on a regular basis.

The resolution passed in the House, but did not get a vote in the Senate.  If it had passed both houses, the resolution would have gone on the Oregon ballot. To go into effect it would have needed approval by the voters of Oregon. 

Oregonians have been willing to amend the constitution for many reasons.  However, this fall voters rejected the Healthy Kids initiative, which would have put a cigarette tax in the state constitution. 

Should health care be considered a right?  Should we change the state constitution to make such a right explicit?  Are there other was to ensure that everyone has access to health care?