March 2015 Cover Oregon Consumer Advisory Committee Report

Cover Oregon and the current Oregon Healthcare Exchange under the Affordable Care Act

by CAC member Roberta Hall

On Friday, Feb. 27, Cover Oregon’s Consumer Advisory Committee (CAC) met for the last time. The place was the Durham headquarters of Cover Oregon, soon to be dissolved, though the space will be used for several more months. The exchange is not by any means abolished, however, as its activities will continue under the Department of Consumer and Business Services, the state’s largest regulatory agency. (This transfer occurred about a week later.) The important points that the public should know appear to be these:
1. Cover Oregon costs have been reduced significantly. In 2014 the budget was 90 million dollars, of which 80 million were spent, whereas this year the budget is 15 million. Last year, the average cost per enrollee was $48, and this year it is $10. Last year, enrollment was done with both paper and online techniques developed under contract to the state of Oregon, whereas 2015 enrollees used technology developed by the federal government (HealthCare.gov).
2. The King v. Burwell case, heard in the Supreme Court on Wed., March 4, is a legal challenge to federal tax credits offered in the 2010 Affordable Care Act (ACA). It applies to states that did not set up their own exchange; however, Oregon is one of 16 that did. Oregon continues to run its own exchange, albeit using technology developed by the federal government. Still, if the plaintiffs win, and tax credits are not provided in the other states, it would change the ACA’s impacts dramatically.  Regardless of the outcome (expected in June of this year), the extension of Medicaid to persons with incomes less than 138% of the federal poverty level is not affected by the suit. Oregon’s Medicaid system, OHP, is now administered by the Oregon Health Authority (OHA).
3. Once again, at the 11th hour, the OHA extended the deadline for OHP fast-track enrollees to renew their coverage; “fast-track” refers to automatic enrollment because of prior income-certification through the food-stamp program. The previous deadline was 2/28, but that has been extended to March 31. It was estimated that the remaining fast-track population who need to act before the 3/31 deadline is about 32,000. There has been a backlog, but the OHA has announced that it is hiring more call center staff to address that serious problem.
4. One of the obligations Cover Oregon staff are working on, in addition to clearing up problems that the technology collapse caused earlier, is getting the small business healthcare insurance program (SHOP) online. Right now, there is a manual process in place until a permanent solution is found.  You can find out more here. Employers with 1-50 employees face no penalty for not providing insurance, but it is my understanding that they can use the program if they wish, and some have been using it.  Starting in 2016, employers with 51-99 employees will be required to provide insurance.  Employers with 100+ employees are supposed to offer coverage to 70% of their employees this year, 2015.
Ten members of Cover Oregon’s CAC attended the Feb. 27 meeting, seven in person, and three online. Much of the meeting was given to a report and Q and A with Director Aaron Patnode.  Alicia Blevins discussed income tax forms pertaining to the individual insurance obligation and Qualified Health Plans (1095-A); next year a tax form (1095-B) will also be sent to people enrolled in a government-sponsored plan like OHP.  Joel Melton and D’Anne Gilmore from the Department of Consumer and Business Services, together with Director Patnode gave an update on the apparently amicable transition process. Cover Oregon staff members Rachael Oh, Kelly Harms, and Cherie Miller ran the meeting and performed recording and online activities. CAC members thanked them and Director Patnode for their work, and expressed regret that these employees had in effect been held accountable for problems that they had no control over.
Please note that Cover Oregon employees are not state employees, so they will not be transferred to other state jobs, nor do they have PERS. The director of the agency where the exchange is now housed did not keep director Patnode on staff after the take-over, and the agency is laying off about 50 more in March; several current Cover Oregon staff will continue, perhaps through June. I, for one, appreciate their service and believe that the successes the exchange has had in extending healthcare coverage to many more Oregonians – perhaps approaching half a million – are due to their efforts and dedication.
Advocacy groups such as Mid-Valley Health Care Advocates need to follow these changes as they unfold in order to advise people correctly as well as to learn more about the complexities of making changes in the structure of the state’s healthcare-related programs.


Roberta Hall, member, Cover Oregon CAC, March, 2015



Oregon Health Plan Terminations

This is a letter from Beth Englander, State Support Unit Attorney at the Oregon Law Center. Please read it and pass the information on to people who may get dropped from their coverage.

Dear community partner : Are you seeing clients who received a notice from the Oregon Health Plan saying their coverage will end soon?

67,000 low income Oregonians were just recently told by the state that they (or their citizen children) will lose their Oregon Health Plan coverage at the end of January or February.  Those people received a notice in the last 6 months telling them they need to go through a renewal or re-determination process in order to keep their OHP coverage.   Many of those people tried to renew or re-determine (some by going to the federal healthcare.gov website, some by trying to call OHP, some by trying to get help from their local self-sufficiency office/case worker) but are still getting a letter from OHP saying something like:

“Your Oregon Health Plan benefits are ending.  We have not received your renewal information.  Your benefits will end on  (date)”. 

Some people are getting notices from OHP in a language they don’t understand and are not sure how to respond to the notices.

The Oregon Law Center and Legal Aid Services of Oregon are trying to help people who tried to renew or didn’t understand that they needed to renew keep their Oregon Health Plan coverage.  If you are providing services to (or assisting) a client/patient who is going to lose their OHP (or their citizen children will lose their OHP coverage) and who tried to “re-determine” or couldn’t understand what to do due to language barriers, please contact Beth Englander at the Oregon Law Center, at 503-473-8321.  

We would like to help people keep their OHP coverage.   If you or others in your organizations talk to people who received an OHP termination notice, would you please have your staff person call me at 503-473-8321?  Or direct the clients themselves to our public benefits hotline at 1-800-520-5292.   Below and attached is a letter on this topic that you could distribute to anyone who might have contact with clients who are being told their OHP coverage is ending. 

Thank you for your time. 

Beth Englander


Elizabeth Hayes: The Uncovered

From Portland Business Journal:

In 2019, five years after the Affordable Care Act has kicked in and, presumably, Cover Oregon’s woes are a distant memory, many more Oregonians will have insurance than do today.

But not everyone.

An estimated 120,000 Oregonians who are subject to the “individual mandate” will still lack insurance, according to a new fact sheet by the Oregon Center for Public Policy. Here’s a breakdown:

• An estimated 71 percent — or 84,000 people — will be low income, earning below 200 percent of the federal poverty line.

• At least two thirds of them — or 56,000 people — will earn too much to qualify for the Oregon Health Plan.

• Another 11,000 would make too much for a tax subsidy through Cover Oregon to help offset the cost of their premium.

The subsidy is available for those earning under 400 percent of the federal poverty level. But even a subsidy wouldn’t place insurance within reach for many of these people, hence the tens of thousands of future uninsureds.

“The primary issue is affordability and the options available on Cover Oregon,” said Janet Bauer, health care policy analyst for the Center for Public Policy.

When other states offered coverage to those who made too much for Medicaid, here’s what happened: If the premium was at 1 percent of their income, 57 percent took the plans. When the premium rose to 4 percent, the “take up rate” dropped to 25 percent.

“Low income individuals are very price sensitive,” Bauer said.

In addition to the 120,000 estimated uninsured, another 99,000 undocumented immigrants will also lack insurance, as will another 69,000 who are deemed exempt from the mandate, including those who aren’t required to file federal taxes, tribal members and those experiencing hardship circumstances, the Center for Public Policy estimates.

Despite all this, the picture would look much bleaker without health reform. Under that scenario, there would be 680,000 uninsured in 2019, up from 600,000 in 2013.

“That, to our minds, is major progress,” Bauer said, “but we’re not there yet.”

One possible way to fill the gap in affordable coverage is for the state to offer what’s called a Basic Health Plan for people who make between 139 percent and 200 percent of the federal poverty level, too much for Medicaid. A bill to study the cost of such a program in Oregon will be considered by the Legislature in February.

More next week on how exactly it would work.

Low income, lower coverage

By 2019, a vast majority of the estimated 120,000 Oregonians still uninsured will be low income, defined as earning below 200 percent of the federal poverty line, according to research from the Oregon Center for Public Policy. All are subject to the “individual mandate” that requires individuals to obtain health insurance or pay a penalty.

71% - BELOW 200% OF FEDERAL POVERTY LINE

20% - BETWEEN 200% - 400% OF FEDERAL POVERTY LINE

9% - OVER 400% OF FEDERAL POVERTY LINE

Elizabeth Hayes covers health care for the Portland Business Journal.

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Glimpses of the CCO Summit- Achieving Health Systems Transformation?

December 4, 2014

Report by Lee Mercer, President Health Care for All-Oregon
December 4, 2014

Speaking to 1300 plus attendees at the Coordinated Care Organization Summit in Portland, Susan Johnson, Regional Director, US Department of Health and Human Services (Region 10) said Oregon is “leading the nation like a North Star” towards creating a sustainable model of health care for the future. Nichole Maher, President of the North West Health Foundation sees the key to health in our communities and health outcomes being now defined by zip code, race, income and other social determinants. She thanked Governor Kitzhaber for a budget reflecting dedication to health equity.

Kitzhaber outlined some of the successes of Oregon’s recent initiatives— 95% of Oregonians have health insurance and a million have enrolled in a new health care model. As the CCO’s start covering public employees we are moving towards savings that culminate in a structural budget surplus in 2123.

Building on this theme, keynote speaker Don Berwick, MD, former administrator, Centers for Medicare and Medicaid Services, and Founding CEO, Institute for Healthcare Improvement, praised Oregon and the attendees of the conference. “Bravo! You’re doing something amazing—there is a bright light here.”

But, he noted, there is “a burden of leadership for Oregonians as pioneers.” Pioneers are bound to experience uncertainties. He said Oregon should sense the importance of what we are doing and maintain cooperation—unprecedented levels of cooperation. Everyone must be willing to give up something as we stay focused on the triple aim of better care, better health and lower cost. The cost of health care is inhibiting us from being what we want to be as a nation.

His thesis, illustrated by graphs showing escalating costs, is that health care is “confiscating” opportunity in terms of eating up public finance. As premiums rise faster or through taxes), it is all, sooner or later, coming out of the pockets of the workers. And it means that health care is stealing from all the other programs that government might be providing.

He sees the health care system metaphorically like the Choluteca Bridge, in Honduras. Built well by US engineers, it has weathered every storm for generation, but, over the years, the river has moved and the bridge is no longer relevant.

To make health care relevant and effective, Berwick noted, we must begin treating it as a human right and build a system which is cost effective and sustainable. He sees a need for developing a cooperation index in our work. A focus on transformation and not the finances. He concluded by congratulating Oregon again on its successes, adding “the country needs you!”

Numerous Health Care for All Oregon advocates, proudly wearing their red t-shirts proclaiming health care as a human right, were disappointed that Berwick, an outspoken supporter of single payer as a candidate for Governor in Massachusetts, didn’t mention this needed systemic reform. He probably didn’t want to steal the thunder of the progress in reducing health care costs by Oregon’s CCO system.

Then a series of speakers outlined how they have organized their CCO’s in communities throughout Oregon. Much emphasis was on building the Community Advisory Councils that guide CCO’s. A number of moving personal stories illustrated the partnering of behavioral, physical and dental health specialties throughout the state. Also, stories emphasized partnership with early childhood education.

Kevin Campbell, a former business man and now CEO of Greater Oregon Behavioral Health, Inc. noted that, in Eastern Oregon, it was less about talking health care transformation and more emphasizing community strengths and local control. A big piece was doing Community Health Improvement Plans. In their vast region, 12 counties developed 12 independent plans and then found a unifying consensus. Not only did they serve Medicaid/OHP users, but philanthropic support was forthcoming which meant many of the facilities and services are available for all in the communities. One grant was given for each county, and the OHSU Center for Evidence Based Policy helped assess the grant projects.

CCO 101

Judy Mohr Peterson, Director of Division of Medical Assistance Programs (Medicaid) at OHA, spoke in a break out group providing an overview of the Coordinated Care Organization system. She started by outlining the reasons for the need for transformation:

  • Health care costs are unsustainable

  • Health outcomes are not what they should be

  • Lack of coordination between physical, behavior and dental health

Previously, during a budget crisis, there were three ways to deal with a shortfall of Medicaid dollars. One was to cut people, and thus began the lottery for OHP participation. Another was to cut benefits- this often meant cutting mental health, dental health or prescription drugs, all of which are optional under Medicaid. Finally, they could cut provider rates.

Under Kitzhaber’s vision of the triple aim, the goal was better health, better care and lower costs. Not just one or two, but all three. So Oregon set out to reduce waste, improve health and take steps to build a more sustainable model.

There are now 16 CCO’s, and 95% of 1,000,000 folks on Medicaid are enrolled. Mental, physical and dental health are all in one budget. Incentives are in place for quality and achieving growth limited to 3.4% (a cut of 2%).

Mimi Haley (Columbia Pacific CCO) and Coco Yackley, Operations Manager, Columbia Gorge Health Council, outlined more of the nuts and bolts of putting CCO’s together. In the Gorge the CCO was embedded in an existing organization (Pacific Source). The Community Advisory Council was formed, giving Pacific Source one vote, with 50% consumers and 50% “at risk” (financially) organizations. The Clinical Advisory Panel (optional) was also formed.

The Columbia Pacific CCO was formed in the coastal counties of Clatsop, Columbia, Tillamook and Douglas. It operates under a global budget as a wholly owned LLC of Care Oregon in partnership with Greater Oregon Behavioral Health. There are 15-20 directors. One seat each is held by Care Oregon and GOBH. There are 4 Community Advisory Councils, one for each county. They have grown from 7,000 to 25,000 members. Some of the health strategies include Health Home Assessments (discovered a woman who used oxygen has carbon monoxide leaking from her furnace—after repairing, she no longer required oxygen) and Health Resiliency (trauma informed support to “high utilization” patients).

Among challenges cited by the CCO’s include billing issues, different payment models and provider shortages. They couldn’t give metrics on provider shortages, but noted that most dentists in the area do not take Medicaid. Coco Yackley quipped that she could “see why single payer would help” due to the complexity of the various payment systems. Well child visits paid for by Medicaid, may, in a private insurance plan, be on a different annual calculation, so those patients may have to pay out of pocket.

Appreciating the opportunity to learn about the cost savings and system improvements being pioneered in Oregon’s Community CCO transformation, a nagging question remains. If this system is indeed more patient centered, why are all the metrics cited for its success, cost saving outcomes, not health outcomes?

In the Executive Summary of the 2013 Performance Report large improvements cited are:

Decreased emergency department visits. Emergency department visits by people served by CCOs have decreased 17% since 2011 baseline data. The corresponding cost of providing services in emergency departments decreased by 19% over the same time period.

Decreased hospitalization for chronic conditions. Hospital admissions for congestive heart failure have been reduced by 27%, chronic pulmonary disease by 32% and adult asthma by 18%.

Developmental screening during the first 36 months of life. The percentage of children who were screened for the risk of developmental, behavioral and social delays increased from a 2011 baseline of 21% to 33% in 2013, an increase of 58%.

Increased primary are. Outpatient primary care visits for CCO members increased by 11% and spending for primary care and preventive services are up over 20%. Enrollment in patient centered primary care homes has also increased by 52% since 2012, the baseline year for that program.

So cost savings are great and more screenings and primary and preventative services are wonderful.

But where are the patient health outcomes? How is the health of the folks not doing emergency room visits? Are they managing their congestive heart failure, chronic pulmonary disease and adult asthma? And how is the health of the kids being screened and patients getting primary care services?

At some point beyond cost savings and increased services, health outcomes need to be the final measure of a sustainable health system. When we have metrics which say that, in Oregon, we have achieved the lower infant mortality and higher life expectancy rates, the lowered rate of disease and the other health outcomes achieved by all industrialized countries which have in common universal, publicly funded health systems, we can say we are fully succeeding in transforming our health system.

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MVHCA's Bobbi Hall reporting on the Cover Oregon Consumers Advisory Committee meeting in Portland

June 6 --I attended the statewide Cover Oregon Consumers  Advisory Committee meetings in Portland. I'm a member, and about 12 or  so of us show up once a month and hear from administrators about changes that are going on, and get updates;  we also ask a lot of  questions and give advice to the Cover Oregon administrators based on  what people in our home areas tell us.Yesterday was special because Clyde Hamstreet (the interim CEO) and  Tina Edlund  (the transitions director) spent an hour and a half with  us. They gave us the report they had given to the Oregon Legislative committee on May 28, and we had lots of questions for them. They have  made many structural changes. Re-structuring means that Oregon will complete the year on a secure  financial base. Many of the working parts of the Cover Oregon website  will be kept. In the future, OHA will be responsible for OHP enrollment, rather than Cover Oregon. Though the Federal website will  be used in November for commercial insurance plans, Oregon will retain  control of how they both are managed, and Oregon's insurance rates  will remain lower than those of most other states. Also, commercial rates in November will NOT be the same as they are now so people interested in changing their commercial plans need to check the Cover Oregon site in the fall.


The Cover Oregon board will meet  Thursday and possibly make some more decisions. Everyone at the meeting spoke very highly about the Community Partners and Navigators,  and the agents, who have helped people to enroll successfully. We also observed that many new enrollees need help in understanding how to use the system. Overall, we on the committee felt good about the meeting and the attitudes of the new managers, who very much want the programs to succeed. My own feeling is that the public attitude toward Cover Oregon is improving and will continue to, once the public learns how many people have been enrolled (more than 400,000 now). 

Report by Bobbi Hall

Oregonians! Don't Be Afraid of the Oregon Health Plan (Medicaid)

Many Oregonians who qualify for free health coverage through Medicaid via the Oregon Health Plan (OHP) are refusiing to sign up because they fear that the State will come after their assets when they die.  There was a good deal of confusion early on because the rules had not been updated to reflect the expansion of Medicaid to a larger number of people based on income alone, not assets.  

Here is what the Oregon Health Authority published in November, 2013 when they updated their forms to correct the Medicaid Recovery issue:

Estate Recovery and the Oregon Health Plan

The Oregon Health Authority will no longer implement estate recovery for OHP clients

What is happening?
The Oregon Health Authority is changing the policy on estate recovery for the Oregon Health Plan benefit. The Oregon Health Plan (OHP) is Oregon’s public medical, dental and menta health care benefit.

For any coverage that starts October 1, 2013 or later, members of OHP who are not receiving long-term care services will not be subject to estate recovery. This policy change affects all current and future enrollees on OHP.

Why this is happening?
OHA is making this change because the estate recovery program was not designed for health benefit programs such as OHP Plus. It was designed for long -term care services for people who need them due to age or disability. It allows for reimbursement of public dollars for long-term care services. These are services that go beyond medical care or hospitalization. Long-term care services can include care in a nursing home care, community-based care, such as a Foster Home or Assisted Living Facility, or full-time assistance with daily living in an individual’s own home. Long-term care is not a covered service under OHP Plus.

 

Here is what FactCheck.Org has to say:

Q: Does the Affordable Care Act allow states to confiscate the estates of seniors on Medicaid when they die?

A: No, but a 1993 federal law requires states to recover Medicaid costs for long-term care from the estates of deceased Medicaid beneficiaries over the age of 55.

The interaction of the federal Affordable Care Act and existing state Medicaid estate recovery laws is a legitimate issue and something that Medicaid recipients need to understand before they sign up. They should know that the rules vary from state to state, with some states dunning the estates of deceased Medicaid beneficiaries for all Medicaid costs and others just for long-term care. And the rules keep changing. AARP’s Moorhead says so far two states (Washington and Oregon) have changed their rules to limit estate recovery to Medicaid costs related to long-term care, as required by the 1993 federal law.

So please do not hesitate to sign up for OHP because of the Estate Recovery Program. If you are worried about the fact that your income fluctuates and you may go in and out of OHP eligibility, you may want to attend an information session about Oregon's Basic Health program on May 8th in either Corvallis or Monroe.

 

Cover Oregon and Other Healthcare Expansions---Update, March, 2014

The March meeting of the Cover Oregon Consumer Advisory Committee (CAC) provided little new information except that enrollments by hand and, to some extent, using agents operating directly through the internet, are continuing, but still are behind schedule. Agents help clients with commercial products and community partners help clients who qualify for the Oregon Health Plan (OHP/Medicaid), and at least as I understand it, no agents have yet been compensated for the time taken out of their business to do this. The hope is there, but in this health care episode, there are many uncompensated players. Beneficiaries are those who have succeeded in getting signed up for Oregon Health Plan  or gotten lower cost and improved insurance coverage, many (about 79%) with federal tax credits covering part of their premium. Some who qualify, however, still lack coverage.

The relationship between Cover Oregon and Oracle continues to be difficult. The Oregonian reported on Mar. 13 that a federal report on Oracle and Cover Oregon is scathing. However, it did corroborate the statements of some Cover Oregon employees that Oracle had repeatedly denied requests for information--that is, Cover Oregon had attempted to manage the contract, but been rebuffed. Clearly, the contract itself had been deficient, based on non-existent trust.

At the April CAC, members will discuss what other things Cover Oregon can do to accomplish its mission of improving the health of the population.

One optional ACA expansion, Basic Health, is being studied. It is a program to extend health services to more low-income people (those under 200% of the poverty line), including legal immigrants with less than 5 years residence who heretofore have been excluded from Medicaid (OHP). A bill to establish this study, HB 4109, passed in March. A discussion I had with the Chair and Vice-chair of the House healthcare committee about what Basic Health is aired Mar. 10 on KBOO and can be heard here.

---Roberta Hall

InterCommunity Health Network Coordinated Care Organization Seeks Lincoln Co. Representatives for Community Advisory Council

The Community Advisory Council is looking to fill vacancies in Lincoln county with two IHN-CCO members (or a parent/guardian of a member) and one representative from the community at large.To be considered for the Council, complete this application and submit it by March 21. Click here to learn more about the duties of the Council.

The Council meets the second Monday of January, March, May, July, September and November (March 3 being the one exception) from 2 to 5 p.m. in alternating counties.

 



El Consejo Consultivo de la Comunidad está buscando representantes en el condado de Lincoln para cubrir las vacantes de dos miembros de IHN-CCO (o un padre / guardián de un miembro) y un representante de la comunidad en general. Para ser considerado para el Consejo, complete esta solicitud y enviarlo antes del 21 de marzo.

El Consejo se reúne el segundo lunes de enero, marzo, mayo, julio, septiembre y noviembre (el 3 de marzo siendo la única excepción)  de 2:00pm hasta las 5:00pm en los condados alterna.

Cover Oregon (CO) Consumers Advisory Committee meeting Feb. 7, 2014

Because of snow, this meeting was virtual and lasted only an hour and 15 minutes. Director Bruce Goldberg gave a 20-minute update on enrollment: in addition to 123,000 people enrolled fast-track, 67,517 applicants were enrolled in OHP and 35,247 in commercial plans; an additional 35,000 applicants have received information to enroll. Process is “hybrid” – a combination of internet and paper modes (no full internet yet). CO is working with agents and community partners and testing upgrades. CO is restructuring its customer service to improve flow. Also: The cost of hiring additional people is being covered within existing budgets of OHA and CO; it still is possible for CO to be self-funded at the required time; there is an improved online-fillable pdf application; they are looking at contingencies to put into place IF the site is not IT-ready at the end of the open-enrollment period (probably this is Mar. 15—not sure, and they are asking the feds to extend it, but doubt their request will be granted).
Following are answers to a few of the many questions he responded to: MODA has gotten most of the commercial business, and with Kaiser this amounts to more than ¾ of enrollees. After CO determines eligibility for OHP, the files go to OHA, which is supposed to send info to enrollees and OHA has backlogs (he hopes within the next 10 days this will be caught up). An applicant who is determined OHP eligible is covered retroactively to the date of the application, whereas someone enrolling in a commercial plan starts on the first of a month (depending on when the forms come in). Ads for CO have been pulled but a public service campaign will begin toward the end of Feb. to highlight the Mar. 15 enrollment deadline.  –Roberta Hall, CAC member from Corvallis