A Comprehensive Assessment of Four Options for Financing Health Care Delivery in Oregon.

This article describes four options for financing health care for residents of the state of Oregon and compares the projected impacts and feasibility of each option. The Single Payer option and the Health Care Ingenuity Plan would achieve universal coverage, while the Public Option would add a state-sponsored plan to the Affordable Care Act (ACA) Marketplace. Under the Status Quo option, Oregon would maintain its expansion of Medicaid and subsidies for nongroup coverage through the ACA Marketplace. The state could cover all residents under the Single Payer option with little change in overall health care costs, but doing so would require cuts to provider payment rates that could worsen access to care, and implementation hurdles may be insurmountable. The Health Care Ingenuity Plan, a state-managed plan featuring competition among private plans, would also achieve universal coverage and would sever the employer-health insurance link, but the provider payment rates would likely be set too high, so health care costs would increase. The Public Option would be the easiest of the three options to implement, but because it would not affect many people, it would be an incremental improvement to the Status Quo. Policymakers will need to weigh these options against their desire for change to balance the benefits with the trade-offs.

Benefit policy and disenrollment of adult Medicaid beneficiaries from the Oregon health plan.

Oregon's Medicaid program experienced a dramatic decrease in its non-categorically eligible adult members after implementing a new benefit policy in February 2003 for these beneficiaries. The policy included four main elements: premium increases for some enrollees; a more stringent premium payment policy; elimination of some benefits, including mental health and substance abuse treatment; and, the imposition of co-payments. The study compared monthly disenrollment rates eight months before and after the policy change. The new premium payment policy was found to be the main driver of disenrollment, followed by benefit elimination. Premium increases and co-payments had limited impact. Disenrollment was particularly high among vulnerable beneficiary groups, including people with no reported income, those previously obtaining premium waivers, methadone users, and other enrollees with substance abuse conditions. Better understanding of the relationship between benefit design and retention in public health insurance programs could help avoid the unintended policy effects experienced in Oregon.

Uninsurance among children whose parents are losing Medicaid coverage: Results from a statewide survey of Oregon families.

CONTEXT: Thousands of adults lost coverage after Oregon's Medicaid program implemented cost containment policies in March 2003. Despite the continuation of comprehensive public health coverage for children, the percentage of uninsured children in the state rose from 10.1 percent in 2002 to 12.3 percent in 2004 (over 110,000 uninsured children). Among the uninsured children, over half of them were likely eligible for public health insurance coverage. RESEARCH OBJECTIVE: To examine barriers low-income families face when attempting to access children's health insurance. To examine possible links between Medicaid cutbacks in adult coverage and children's loss of coverage. DATA SOURCE/STUDY SETTING: Statewide primary data from low-income households enrolled in Oregon's food stamp program. STUDY DESIGN: Cross-sectional analysis. The primary predictor variable was whether or not any adults in the household recently lost Medicaid coverage. The main outcome variables were children's current insurance status and children's insurance coverage gaps. DATA COLLECTION: A mail-return survey instrument was designed to collect information from a stratified, random sample of households with children presumed eligible for publicly funded health insurance programs. PRINCIPAL FINDINGS: Over 10 percent of children in the study population eligible for publicly funded health insurance programs were uninsured, and over 25 percent of these children had gaps in insurance coverage during a 12-month period. Low-income children who were most likely to be uninsured or have coverage gaps were Hispanic; were teenagers older than 14; were in families at the higher end of the income threshold; had an employed parent; or had a parent who was uninsured. Fifty percent of the uninsured children lived in a household with at least one adult who had recently lost Medicaid coverage, compared with only 40 percent of insured children (p=.040). Similarly, over 51 percent of children with a recent gap in insurance coverage had an adult in the household who lost Medicaid, compared with only 38 percent of children without coverage gaps (p<.0001). After adjusting for ethnicity, age, household income, and parental employment, children living in a household with an adult who lost Medicaid coverage after recent cutbacks had a higher likelihood of having no current health insurance (OR 1.44, 95 percent CI 1.02, 2.04), and/or having an insurance gap (OR 1.79, 95 percent CI 1.36, 2.36). CONCLUSIONS: Uninsured children and those with recent coverage gaps were more likely to have adults in their household who lost Medicaid coverage after recent cutbacks. Although current fiscal constraints prevent many states from expanding public health insurance coverage to more parents, states need to be aware of the impact on children when adults lose coverage. It is critical to develop strategies to keep parents informed regarding continued eligibility and benefits for their children and to reduce administrative barriers to children's enrollment and retention in public health insurance programs.

The demise of Oregon's Medically Needy program: effects of losing prescription drug coverage.

BACKGROUND: In January 2003, people covered by Oregon's Medically Needy program lost benefits owing to state budget shortfalls. The Medically Needy program is a federally matched optional Medicaid program. In Oregon, this program mainly provided prescription drug benefits. OBJECTIVE: To describe the Medically Needy population and determine how benefit loss affected this population's health and prescription use. DESIGN: A 49-question telephone survey instrument created by the research team and administered by a research contractor. PARTICIPANTS: A random sample of 1,269 eligible enrollees in Oregon's Medically Needy Program. Response rate was 35% with 439 individuals, ages 21-91 and 64% women, completing the survey. MEASUREMENTS: Demographics, health information, and medication use at the time of the survey obtained from the interview. Medication use during the program obtained from administrative data. RESULTS: In the 6 months after the Medically Needy program ended, 75% had skipped or stopped medications. Sixty percent of the respondents had cut back on their food budget, 47% had borrowed money, and 49% had skipped paying other bills to pay for medications. By self-report, there was no significant difference in emergency department visits, but a significant decrease in hospitalizations comparing 6 months before and after losing the program. Two-thirds of respondents rated their current health as poor or fair. CONCLUSIONS: The Medically Needy program provided coverage for a low-income, chronically ill population. Since its termination, enrollees have decreased prescription drug use and increased financial burden. As states make program changes and Medicare Part D evolves, effects on vulnerable populations must be considered.

The on-call crisis: a statewide assessment of the costs of providing on-call specialist coverage.

STUDY OBJECTIVE: A recent change in the delivery of emergency care is a growing reluctance of specialists to take call. The objective of this study is to survey Oregon hospitals about the prevalence and magnitude of stipends for taking emergency call and to assess the ways in which hospitals are limiting services. METHODS: This was a cross-sectional, standardized survey of chief executive officers from all hospitals with emergency departments in Oregon (N=56). This e-mail-based survey asked about payments made to specialists to take call and examined changes in hospitals' trauma designation and ability to provide continuous coverage for certain specialties. RESULTS: We received responses from 54 of 56 hospitals, representing a 96% response rate (100% of trauma centers). Twenty-three of 54 (43%) Oregon hospitals pay a stipend to at least 1 specialty, and 17 (31%) hospitals guarantee pay for uninsured patients treated on call. Stipends ranged from $300 per month to more than $3,000 per night, with a median stipend of $1,000 per night to take call. Trauma surgeons, neurosurgeons, and orthopedists were the specialists most likely to receive stipends. Seven of 54 (13%) hospitals have had their trauma designation affected by on-call issues. Twenty-six hospitals (48%) have lost the ability to provide continuous coverage for at least 1 specialty. CONCLUSION: Problems with on-call coverage are prevalent in Oregon and affect hospital financing and delivery of services. A continuation of the current situation could degrade the effectiveness of the trauma system and adversely affect the quality of emergency care.

The impact of increased cost sharing on Medicaid enrollees.

Many state Medicaid programs are implementing cost-saving mechanisms, but little is known about the impact of those strategies on low-income people. Recent increases in cost sharing for Oregon Health Plan (OHP, Oregon's Medicaid program) members have created a natural experiment that is ideal for examining such impacts. Early results from an ongoing cohort study suggest that cost-sharing increases led to a large reduction in OHP membership. Those who left OHP because of the cost-sharing increase reported inferior access to needed care, used primary care less often, and used hospital emergency rooms more often than those who left OHP for other reasons.

Medicaid programme changes and the chronically ill: early results from a prospective cohort study of the Oregon Health Plan.

OBJECTIVE: To describe the impacts of recent Oregon Health Plan (OHP) policy changes on individuals living with chronic illness in Oregon. METHODS: A mail survey was conducted of 1374 OHP beneficiaries who were directly affected by the new policies. The analyses reported in this article represent baseline findings from the first of three survey waves in an ongoing prospective cohort study. RESULTS: A significant association was found between Medicaid policy changes and high rates of disenrolment from the OHP. Compared to the non-chronically ill, the chronically ill were more likely to report inability to pay for medications, higher medical debt, more unmet health needs, and poorer health status. Among the chronically ill, those who lost insurance reported decreased access to and utilization of healthcare, more medical debt, and more restriction of medications. DISCUSSION: As policy-makers restructure public programmes to accommodate tight budgets and rising healthcare costs, people with chronic illness can easily be overlooked. Chronically ill individuals face disproportionate financial and health burdens. Small cost-saving policy changes can lead to widespread disenrolment that cascades into reduced access to healthcare services, altered utilization patterns, and financial strain.