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New Medicaid Waiver Seeks to Relieve Housing, Behavioral Health Crises

The proposal for renewing Oregon’s Medicaid and Children’s Health Insurance Program waiver includes a significant emphasis on supportive housing for beneficiaries.
May 4, 2016

The proposal for renewing Oregon’s Medicaid and Children’s Health Insurance Program waiver includes a significant emphasis on supportive housing for beneficiaries, as the Oregon Health Authority leaders seek to drill down on a key social determinant of health that has reached crisis levels from Portland outward.

Some of Oregon’s coordinated care organizations have sought to help stabilize the living situation for vulnerable members, but the federal government has stymied state Medicaid programs that have desired to build more low-income housing.

The new waiver, which is the plan by which the state can deviate from the generic federal bylaws governing Medicaid programs, will seek to stay within the bounds of providing for the health of those on Oregon Health Plan, while doing what it can to stabilize housing for members.

The Health Authority is willing to wager that since Oregon has saved the federal government $29.7 billion since it first adopted the Oregon Health Plan in 1994, the Centers for Medicare and Medicaid Systems will allow Oregon to innovate on targeting more social determinants of health.

The waiver also continues the state’s 2012 innovation -- the coordinated care system, which has saved $1.7 billion compared to other states since its inception by reducing the growth in healthcare costs. Those savings have been driven by a 23 percent decline in emergency department utilization and a reduction in hospital stays for chronic conditions: short-term admissions for diabetes have dropped by a third and hospital stays for chronic obstructive pulmonary disorder and asthma have dropped by two-thirds since 2011.

The overall state Medicaid budget will continue to have a fixed ceiling which is 2 percentage points below the national standard for medical inflation, or about a 3.4 percent annual increase.

The Oregon Health Authority projects it will save federal taxpayers another $4.8 billion through 2022 -- with one big caveat: those savings do not include the cost of exorbitantly expensive biological drugs such as those to treat Hepatitis C.

Several activists attended the Oregon Health Policy Board meeting Tuesday to protest the state’s restrictions on Hep C medication, which they allege has been limited to a few hundred people despite the thousands of Oregon Health Plan members who carry the liver disease.

It’s also unclear whether the $1.7 billion in savings includes the $1.9 billion in extra cash the feds gave Oregon in 2012 to kickstart the transformation. The new waiver will also ask for additional federal help to assist with behavioral health coordination, an area that has been seriously lagging by most CCOs.

Lori Coyner, the state Medicaid director, told the Oregon Health Policy Board that the state and coordinated care organizations may be able to assist with deposits for rent, move-in costs and temporarily assist vulnerable members with their monthly rent. What it can’t do is fund capital construction or provide housing indefinitely.

As a draft copy of the waiver notes, families that are homeless are at a much greater risk of poor health outcomes that lead to large medical bills, with much higher rates of chronic illness, substance abuse and more severe mental health disorders.

The waiver calls for new “community health partnerships” that will coordinate housing providers, county officials, hospitals and behavioral health providers to streamline housing supports and save the system money by stepping down more people from costly institutional settings like the Oregon State Hospital, nursing homes and jails and enable more community-based care.

Housing programs will zero in on the costliest patients, those who repeatedly utilize emergency rooms or inpatient hospital services and who have been diagnosed with two or more medical conditions. Homeless people and those with serious behavioral health needs will also be singled out for support.