Talk Health Reform

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?