Nearly two years ago state health officials began quietly phasing out a decades-old initiative to promote the best care for the most people under the Oregon Health Plan, and now observers are wondering what exactly the plan is to replace it.
So far, few details have been shared about what the state intends to set up in place of the decades-old OHP program known as the “prioritized list” of covered services. State officials say that's because many of those details have not been worked out yet.
But longtime observers of the program, like consultant and former Oregon Health Authority employee Charles Gallia, are worried.
At stake in the state’s efforts is the level of services covered for more than 1.4 million low-income Oregonians enrolled in the state version of Medicaid. At issue as well is how roughly $7 billion is spent every year on the program, since it remains to be seen how state officials intend to screen out wasteful care while ensuring the services provided are supported by research.
In June, after perusing documents describing the state’s efforts, Gallia said they seemed to lack detail and said he thinks the move to replace the list calls for a robust engagement process similar to the one that established the list in the first place. The prioritized list, he said, has saved the state billions.
“It’s a fundamental component of the Oregon Health Plan,” he said. “And it was the fairest and most objective way of addressing a limited amount of resources in a non-political way ... It's one of the biggest advances in health care in the country.”
Former Gov. John Kitzhaber, a longtime champion of the list, told The Lund Report in an email that “In general, I would prefer that it be ‘updated’ rather than ‘replaced.’ It is a unique tool that no other state has, and it has been largely underutilized over the past decade.”
Landmark, lighting rod
First issued in 1990, the Oregon Health Plan list of covered services tried to emphasize coverage of basic health care while declining to cover costly services such as organ transplants. Critics called it rationing and said it was discriminatory against groups with rare diseases. A system covering conditions afflicting the largest group of people while using research based on the dominant white majority was inherently discriminatory, critics say.
Defenders said rationing happens throught the U.S. health care system already, it's just not done publicly — and argued an evidence-based, public process to ensure equity could stretch scarce resources .
Federal officials at times have balked at the Oregon program. In 2022, when the state was proposing to renew federal approval of the program, advocates said that when applying the list to children in the Oregon Health Plan, it violated a federal law guaranteeing coverage of medically necessary services for low-income children — with some saying it amounted to racial discrimination as well.
Public records obtained by The Lund Report indicated that some state and federal officials agreed. Weeks after an in-depth article was published, Gov. Kate Brown's administration announced that it would stop applying the list to children, causing some advocates to celebrate.
Later that year, buried in a press release about new health care spending initiatives, the state announced that legal authority for the prioritized list of services covered for adults would be “moved” to a different legal document by 2027. Asked in a press conference about rumors the agency planned to shut down or “sunset” the list, then-Director of the Oregon Health Authority, Pat Allen, said the program would be relocated in terms of its legal basis, but it “will continue to exist.”
Last week, asked about the mixed messages circulating as to whether the state’s 30-year-old approach to coverage is going away, Deputy Director Dave Baden of the Oregon Health Authority, which oversees the program, told The Lund Report that “the core concept of evidence-based choices for what is covered in Medicaid and what is not covered in Medicaid is going to continue.”
How that would happen is unclear.
Baden and other state officials said planning is ongoing and many details have not been worked out. In general, the plan is to handle benefits the way other states do, with some categories of services — such as physician services — listed as mandatory for coverage, and others listed as “optional” — the latter meaning the state or an Oregon Health Plan insurer can deny coverage subject to appeal.
Baden said the intent is that Oregon will still continue to add a level of review over and above what Medicaid does. But it's unclear how the state could screen out procedures that are thought to be investigational, lack evidence or constitute bad care while balancing concerns about equity and fairness.
Meanwhile, state health officials are declining to release an Oregon Health Authority report that assessed how other states operate their Medicaid benefits programs. Asked for the report, a spokesperson declined and cited a clause of the Oregon Public Records Law that gives public officials some discretion to decide whether to withhold a document related to legal advice.
What prompted the decision to scrap the prioritized list is unclear. A state spokesperson wrote in an email that “Lately, CMS has expressed concern that the (list) excludes some mandatory services.”
Baden, for his part, said the state asked the federal government to renew its approval of Oregon's prioritized list of covered services, and in discussions it became clear “that was not going to be accepted” by the federal Centers for Medicare and Medicaid Services. That's why the federal program renewal nearly two years ago called for the prioritized list to be reformulated in a more standard format used with other states, and that it be removed from the federal approval document by 2027.
Asked for documentation of the CMS concerns related by the state spokesperson, they wrote in an email that “these sentiments were shared informally through verbal negotiations with CMS.”
Public involvement plan hazy
A document presented to a state advisory committee in June stated that “Oregon leadership” — referring to the Oregon Health Authority, Gov, Tina Kotek and key lawmakers — is expected to sign off on the state’s plan this summer. By next year, the changes are to go to the Oregon Legislature for approval before developing an amendment to Oregon’s Medicaid plan to submit to the federal health authorities.
Previously, official public statements and an internal state document obtained in June described a limited engagement process to discuss their plan to replace the list, featuring a virtual meeting for “member proxies” this summer but no mention of public meetings to gather input from the general public before issuing a plan. The document suggested the public would not be able to comment on the proposal until after it's formulated and shared with the Legislature later this year, and again when it is submitted to the federal government.
Baden and other officials, however, indicated the state does intend to hold public meetings on the proposal – including a webinar some time in the fall. It just hasn’t scheduled them yet. “We do have plans for CCO member proxy sessions, virtual sessions with members and the public for public input and comment,” he said.
The state intends to work closely with insurer-like entities that contract with the state to oversee Medicaid spending regionally, known as coordinated care organizations, while formulating the plans, documents show.
Gallia, for his part, said that the planning process could explore ways to emulate the best parts of the program that's going away. he said the list amounted to “rationing healthcare to those services that are cost-effective, and that is not a heavy lift.” He said the new approach bears its own risks for OHP members and needs to be thought through: “It's a big deal.”
Impact of change unclear
Several people familiar with the list said that it has lost some of its significance over the years. That's because federal officials years ago told the state it could only increase the Medicaid benefits it covered; it could not decrease them further.
Paul Terdal, an advocate for people with autism who has lobbied the state to increase its coverage of some services, said he is not sure how big a change the new plan will turn out to be.
“The way I read what they’re doing is more about just bending to reality,” Terdal said of the changes. “I don't think it's actually going to change much.”
As for public involvement, he said that the health authority should encourage and seek out comment from people affected. But he said that it can be difficult to get good comment from members of the public who may be focused on their individual health problems.
“I think the government has a role in sort of reaching out (to) consumer groups, so I would certainly encourage them to do more to reach out to us,” he said. Engaging with the public can be hard, but state officials should "really try."
Baden said that once launched, the program will have a public process around deciding whether categories of services are covered, much as it does now with specific services.
So the state's Health Evidence Review Commission, populated by experts who weigh the evidence backing certain procedures, would remain in existence, though its function would change.
Baden expressed confidence that it would be able to protect state spending while also ensuring the state is providing equitable coverage.
“Making sure that we keep that going is what we want to do,” he said.
(Jake Thomas contributed reporting for this article.)
"Physician services — listed as mandatory for coverage, and others listed as “optional” — the latter meaning the state or an Oregon Health Plan insurer can deny coverage subject to appeal" Is a scary statement. If a CCO can start denying coverage for any reason they can come up with, what happens to the money they save? They already have billions of dollars in their huge bank accounts and have no requirements to share surpluses with providers who actually care for patients assigned to the CCO. They continue to hold back a large percentage of what they do pay for claims as a 'risk withhold'.....but none of that money is ever returned to providers because there is no requirement for them to do so. Before coverage requirements are dumped down the drain, more accountability for state dollars must be put in place so it doesn't just end up in some shareholder's pocket.