Stiff opposition from care organizations as well as concerns raised by providers have killed a bill pushed by the Oregon Health Authority in Salem that would have dismantled decades-old limits on state-funded health services.
Scheduled for a public hearing on March 27, House Bill 2917 was pulled from the House health care committee’s agenda at the request of the agency.
“There’s just too much controversy,” Rep. Rob Nosse, the committee’s chair who introduced the bill on behalf of the agency, told The Lund Report afterward. “And so we’re gonna see if we can figure it out on a task force.”
The issue is rooted in efforts to make sure the state stretches its limited Medicaid funding as far and fairly as it can under the Oregon Health Plan, which covers 1.4 million low-income Oregonians.
The agency’s retreat in Salem marks the most significant setback yet for the Oregon Health Authority officials’ year-old plans to close down the so-called “prioritized list” program.
Instead of endorsing the agency’s proposal, the legislative committee supported a bill backed by a coalition of dozens of care organizations and providers that support retaining a modified form of the program.
House Bill 2212 would set up a task force to study the potential impacts of eliminating the list and report back to the Legislature by February.
Program has 30-year history
Since the early 1990s the state has maintained a list of procedures and treatments that are covered for free for people with low incomes under the Oregon Health Plan.
An expert advisory committee sets the list aided by hearings. There, groups, companies, experts and members of the public can provide input on a treatment’s costs and benefits.
“With more potential Medicaid cuts coming from Washington DC, the state is going to need every tool it has to manage that.”
It’s a form of health care rationing, but supporters say the commercial health care system already rations care behind the scenes. The Oregon program, they say, operates with transparency based on medical evidence to provide the most good for the most people.
“The prioritized list provides a transparent, public, equitable, evidence-based, and accountable way of determining what is covered,” according to testimony submitted by the coalition that supports retaining the program. It includes the Oregon Medical Association, the Oregon Dental Association, the Oregon Council for Behavioral Health and the Association of Oregon Community Mental Health Programs, the Oregon chapter of the National Alliance on Mental Illness, as well as several regional care organizations that oversee coverage for the Oregon Health Plan.
Critics of the list, however, say the way the program limits access to care can be discriminatory. And over the years the list has become a target for advocates, federal officials and others. When it comes to kids, it is no longer used due to concerns over access and that it violated federal law.
Bridget Budbill, lobbyist for the Oregon Law Center, told lawmakers during a hearing last week that while the prioritized list has had positive results, “they require significant trade offs for some individuals.”
She said that in some cases there are people whose bodies “just do not respond the same way” to treatments on the prioritized list. Ending the prioritized list in its current form, she said, “opens the door for some modest reduction in the complexity of accessing healthcare” for the center’s clients who need treatments not prioritized by the list.
“These Oregonians have more hoops to jump through to get the health care they need via our Oregon Health Plan,” she said, adding that “many people will not appeal” denials of coverage.
State officials sent mixed messages
Oregon won federal approval for the system decades ago with help from its Congressional delegation and despite some resistance by federal Medicaid officials. Since then, no other state has followed its lead.
There had long been internal debate at OHA over the program. More than a year ago, after Dr. Sejal Hathi was named to head the agency, the agency launched plans to eliminate the list entirely.
Health agency officials sought to instead generally handle things as they’re done in other states, where officials approve groups of services or benefits to be covered under Medicaid. And the agency’s leadership persuaded Gov. Tina Kotek to approve the idea.
“These Oregonians have more hoops to jump through to get the health care they need via our Oregon Health Plan."
Asked why the change was necessary, Oregon Health Authority leaders said federal officials did not like the list and required the state to eliminate it when renewing the state's version of Medicaid.
Critics however, unearthed evidence indicating that federal officials only told Oregon to remove the regulations defining the program from one specific federally approved Medicaid agreement to another, not to kill it. Instead, it could be moved to a different federally approved agreement.
Based on that federal input, former Gov. Kate Brown’s administration had planned to retain a modified form of the system, as then-health authority Director Patrick Allen told reporters in a 2022 press conference. Only later did state officials decide to eliminate it entirely.
Task force will help settle the debate
Oregon Health Authority leaders say they will continue developing plans to eliminate Oregon’s alone-in-the nation system. According to a spokesperson, the agency pulled the bill merely to allow “additional time to address the legislature’s questions.”
But the coalition of nearly 30 provider groups and care organizations that support keeping the list predicted in testimony the task force would “ensure” the program continues in modified form.
Former Gov. John Kitzhaber, who helped launch the list as an Oregon state senator, has been fighting its elimination. He argued that it’s never been used as robustly as it could to fight waste and ensure evidence-based care.
Former Oregon Health Authority Director Bruce Goldberg agreed.
“With more potential Medicaid cuts coming from Washington DC, the state is going to need every tool it has to manage that,” he said. “Therefore the state needs to retain the prioritized list. The state will need to prioritize benefits.”
While the original prioritized list underwent public hearings around the state, the critics say, the agency’s effort to remove it has happened largely behind closed doors and with scant discussion with people outside the agency about whether it’s a good idea.
Considering the size of the Oregon Health Plan budget, changing the system shaping its coverage “needs significant visibility,” Rick Blackwell, a lobbyist, PacificSource Community Solutions, which serves more than 350,000 Oregon Health Plan members, said during a hearing.
Dental is imbedded in the prioritize list. It and a reduced benefit package saved adult dental from going to only take care of emergency procedures. The most expensive part of the dental benefit package are complete dentures. At first in this new benefit package they were covered once per lifetime, but then were covered once every 10 years. Partial dentures are covered for resin based partials and not for metal partials. This new benefit package that saved adult dental was based upon the priorities of the OHP, diagnosis, prevention and people not suffering from the disease of caries (infection that causes cavities) and periodontitis (the disease that causes infection of the supporting structures of the teeth). In all actuality it was designed by what Dr. Kitzhaber learned being an emergency department (ED) doctor in Douglas County namely:
1)keeping dental patients out of the ED, 2)not treating the recipients with dental disease with antibiotics and pain pills, 3)not doing dentistry especially on children in the hospital OR for it puts young children's brains at risk for learning disabilities, 4) having a program so children do not get cavities which can cause traumas which cause phobias, failure to thrive, miss time from school and all kinds of problems over life including ending upon with a denture and being dentally disabled, 5) making it so adults do not have dental problems that keep them from being unemployable such as missing front teeth. He said and I quote "You have the dental license to take care of people on including Medicaid, use it!"
The OHA is about to make a costly mistake, namely covering cast partial dentures. It is costly because unless it includes replacing a front tooth patients have a tendency not to wear them, if done in the presence of an out of control dental infection that causes cavities, the clasps that hold the partial in place will accelerate the cavity on that tooth and cause tooth loss and finally if not done correctly they act like an orthodontic appliance and cause the tooth to become loose and be lost. This is why only plastic partials are covered, mainly to be able to make it so someone does not have to go around with lost front teeth. We dentists know cast partial dentures are just a short step to a complete denture.
Because of the issue around complaints making it so the dentist has to say no to the patient because the dentist does not think the disease is under control for a partial denture, if the dentist says no, he is not supported and judged for it. The HERC recommended partial coverage as a political decision its seems for my understanding is all the dental members of the subcommittee suggested not including them in the benefit package for the reasons listed above.
Mike Shirtcliff DMD