The politics around health care in Oregon are about to change in unpredictable ways.
A big-spending governor’s race that’s leaving many questions unanswered. A huge new crop of rookie lawmakers and freshly-appointed agency heads. Adjustments needed for recently adopted laws. And a systemwide fiscal crisis in health care that, by one account, will break in the middle of the legislative session.
Such was the discussion during the Oct. 25 State of Reform Health Policy Conference in downtown Portland, which featured officials, lobbyists and experts.
A morning keynote panel of Oregon hospital officials presented a dire picture of staff shortages, red ink and overloaded emergency rooms, trends in which Oregon joins Washington and California. They said partnerships and creativity are going to be key. "I’m telling folks 'Hey, look at what’s going on in the West. because we may be the canary in the coal mine," said Becky Hultberg, president and CEO of the Oregon Association of Hospitals and Health Systems.
A panel of Salem lobbyists later that morning highlighted political uncertainties around the gubernatorial and legislative elections. The 2023 legislative session promises to feature “a whole bunch of new people who haven't been in the building before … trying to figure out where the restrooms are and how to get coffee,” said Fawn Barrie, a partner in the firm Legislative Advocates Government Affairs. She described the upcoming year as “a very unique situation.”
The next governor will drive changes in health care policy, “there are going to be new agency heads across the board, regardless of who becomes governor,” Barrie added.
In the Legislature, Barrie described “a mass exodus” of experienced lawmakers. She said there will be close to 30 House members who are new, and “typically, we have maybe 10, 15.”
There’s also uncertainty about the balance of votes in the 60-member House given the campaign money pouring into Oregon on the Republican side.
“Republicans really have an uphill battle to ever get to a majority in the House,” Barrie said. “But they are definitely making a run at it this cycle.”
The House Health Care Committee will be dominated by new faces, with seats possibly changing hands in its Senate counterpart. That goes for legislative leadership as well, Barrie said, calling it the “first time since I've been involved in Oregon politics where we have someone new in basically every leadership office.”
There’s also a possibility that Republicans take the state Senate. “Everything's up in the air,” she said. “which is a unique situation for a lot of us who are used to a little bit more consistency.”
Ryan Fisher, a senior associate with NW Public Affairs, focused on the state's finances. He said a budget situation that looked decent in September now appears to be moving “toward that crash landing and not the soft landing." Oregon will "very likely" enter a recession, "and in the past, recessions have always hit Oregon harder than other places. We're one of the first (states) to go in (to recession) and the last to come out.”
He expects the rosy state budget outlook that prevailed in September to change soon. “While there will always be some opportunities for some new investments (in state programs), they will be at the expense of other programs,” he said.
Courtni Dresser, vice president of government relations for the Oregon Medical Association, said workforce shortages will be the major issue of the session.
She said she’s seen surveys where 50 percent of nurses and 20 percent of physicians say they are leaving their jobs in the next year. “And not just leave their job, but leave health care,” she said.
She said the state needs short and a long term strategies to retain employees and cultivate new ones.
“That's starting all the way in middle schools and high schools. How do we get people excited about the healthcare industry? “
Tom Holt of The Holt Company said that looking ahead to the coming year, “there is kind of a reckoning happening.”
He said Oregon state government's history of taking on big, ambitious health care projects may now be reaching its limits, considering projects that include the universal health care task force, the bridge health plan task force, the paid leave program that has special significance in health care, the state’s health care cost-growth initiative, and a state merger oversight program that Holt said still likely needs tweaks.
“My point here is that we can’t do all of these big initiatives at once,” he said. “There’s going to have to be some sorting out for budget reasons, for just practical implementation reasons.”
Lawmakers Weigh In
Later in the morning Republican members of the House Interim Committee on Health Care, Rep. Christine Goodwin of Roseburg, and Rep. Raquel Moore-Green of Salem, spoke about their interests as the next session nears. Goodwin said “scope of practice issues (for health care workers) are forefront of my mind … looking at how to expand scope so that you can really serve more people and not restrict services. As we have talked about this meeting, it is very critical that we continue to allow access to services in our smaller rural communities everywhere.”
Reimbursement from insurers is also a concern, particularly for rural Oregon, she said, noting that her husband’s optometry practice is frequently taking deep discounts to provide care. “You're just not going to sustain practices and doctors, you're not going to attract doctors into those communities, if that reimbursement is so low,” she added.
She is concerned about the growth of the Oregon Health Authority’s mission and size. “I'm concerned about moving more decisions in the direction of the Oregon Health Authority. They already to me are like a huge freightliner that's just loaded with cargo, and they just can hardly move. And we just keep adding to them. And I'm wondering at what point this just sinks. I mean, this is obviously a system that has to be evaluated.”
Moore-Greene said she’s particularly focusd on behavioral health as “extremely rewarding … There's so many intersectionalities of life that hit mental and behavioral health, that folks need that second chance, they need that reset.”
She said discussion in legislative leadership to do away with the House Behavioral Health Committee is misguided. “I think it's a wrong decision. I believe that we have a system that everybody has acknowledged needs help and needs design; it needs leadership." Given the massive behavioral health spending approved by lawmakers last year, she said there's a risk of handing the troubled system back to the healthe care committee. “Well, that's where it's sat for how many years and didn't get the attention that it needed.”
During a lunch keynote, Oregon Health Authority Director Patrick Allen cited some of the agency's successes in recent years but framed the state's challenges starkly as well. “Our health care workforce is worn down, tired out and overwhelmed. Too many people in Oregon still lack health coverage. The cost of health care is rising faster than inflation. Our historically underfunded behavioral health system can’t retool fast enough to meet the needs of an escalating number of people in crisis, despite new funds.The toxic impact of disinformation and polarization has led to threats against health care and public health workers.And underlying all these issues is the stark and unacceptable reality of health inequity.”
In the afternoon, three Democratic legislative leaders — one who is leaving the Legislature — echoed others in saying health care workforce challenges and hospital capacity will be major issues at the Legislature this year. They reported on a number of initiatives under way, including the recent federal approval of Oregon Health Plan program changes and the Bridge Health Plan task force that's crafting a new coverage program for people who earn too much to qualify for OHP.
Sen. Kate Lieber of Portland said the Legislature needs to help hospitals on “the back end” to free up hospital space.
Rep. Maxine Dexter of Portland, a hospital physican, agreed, saying her work day of “seeing people lined up in the hallways” reinforces the gravity of the situation. “’The pandemic is over’ is what we keep hearing. And yet there’s no beds. And staff is exhausted.”
She said the state’s fentanyl crisis will be a focus for her this year.
They praised the recent Medicaid waiver from the federal government allowing the Oregon Health Plan to shift spending to health-related social factors, known as social determinants of health, such as housing.
“I don't know if any healthcare organization has billed Medicaid for housing before,” said Dexter, who has served on the House Health Care Committee and has been chairing the Housing Committee in the interim.
Rep. Rachel Prusak meanwhile, noted that earlier this year she’d decided to leave the Legislature in part due to the burnout that’s affected workers across the system. Since then, she’s gone to work at Oregon Health & Science University and feels rejuvenated. And she will continue working on state health policy issues — including the bridge health plan task force — while expanding her own experiences.
“I joined a team at OHSU of nurses and social workers who care for our community members who are houseless, that wind up as high utilizers of the hospital.”
Kitzhaber Closes With Hope, Urgency
In the closing afternoon keynote, former Gov. John Kitzhaber, a former emergency room physician whose work on health care reforms drew national acclaim, echoed a speech he gave recently to the group CCO Oregon, but with more detail — saying the state needs a “safe forum” where major health care players can negotiate their differences and tackle the big problems facing Oregon health care, including hospitals, pay rates and staffing ratios.
“This convergence of factors is becoming increasingly lethal. Oregonians are dying,” he said, referring to the situation in hospitals. “Oregonians will continue to die and suffer avoidable harm.”
He added, “If we don't act very soon to create a framework to resolve the long term cost structure problems in the healthcare system, this issue is going to explode in the middle of the 2023 session.”
Among other things, he said lawmakers need to take action to address the state's cost-growth target program, which limits providers to 3.4% cost-growth, despite inflation rates that are close to triple that number.
Kitzhaber noted that lawmakers of both parties, and health care leaders, came together more than a decade ago to forge bipartisan reforms that remade care under the Oregon Health Plan.
“It's imperative that we put aside our past animosities and come together as we did a decade ago to address not only the immediate crisis, but also the connected need to develop a path forward that restructures and stabilizes the delivery system,” he said.
You can reach Nick Budnick at [email protected] or at @NickBudnick on Twitter.