Q&A: James Schroeder begins as head of Oregon Health Authority
Leaning back at his desk in a Portland office building, James Schroeder appeared relaxed and undaunted on only his second day as interim director of the Oregon Health Authority, overseeing more than 5,000 employees.
Schroeder, 51, takes over a job some consider one of the toughest in state government, in which making some people unhappy is essentially guaranteed.
His predecessor, Patrick Allen, lasted five years, using political and management skills developed as a longtime public servant. But he found himself criticized as overly bureaucratic and ineffectual on behavioral health reform, leading Gov. Tina Kotek to promise his ouster before her election in November.
Schroeder comes from a public service background as well. Born in Idaho, he worked as a physician assistant caring for diverse patients at low-income clinics before shifting into management and, eventually, heading the Medicaid program at Kaiser Permanente before shifting to Health Share of Oregon, the state’s largest insurer-contractor serving the low-income members of the Oregon Health Plan. He also served as a U.S. Army medic in Iraq.
He said he’ll use his life experiences to help him guide the agency in its next phase.
This article has been edited for clarity and brevity.
The Lund Report: Tell me your origin story: When did you first find yourself interested in health care?
James Schroeder: I’m adopted. That drove me to have an interest in health care. But the real moment that I decided to go into health care is I had been asked to do some work in Honduras as an interpreter for health care providers in Honduras.
There was a group from a university that was going down primarily to look at tuberculosis, and they needed someone that could hike and do the physical part. I happened to meet those unique needs, so I got to do that for like four months.
With that experience of working with them and helping patients to understand questions and things that they had, I came back and applied to school after that.
TLR: What was that Honduras experience like?
Schroeder: Life and career changing. We would have people that came for days to come receive health care — walking, horses, etc., just so that they could talk to someone and get medications and treatment and things like that. We were quite a way out in the rural area, about four hours outside Tegucigalpa. We’d always joke that you ride up there on the chicken bus, because it’s a bus with everybody and their farm animals and stuff. It was undeserved, not dissimilar from what you experienced in rural areas sometimes, here in the United States.
TLR: How did you go from being a clinician to a clinic manager, then CEO of Health Share?
Schroeder: It’s a good and bad news story. I was a full time clinical that had been helping the organization with some recruiting and other things. And the CEO of that community health center literally left in the middle of the night. I got a call at 6 a.m. to come help out and ended up being asked to serve as the interim CEO for that organization — and discovered that there was good reason that they left in the middle of the night. And so, I had to do a lot of setting things right. I learned very expeditiously what is required. They ended up asking me to stay as the full-time CEO.
Kaiser hired me to help them grow and expand and get better at Medicaid. I was national, so I was flying all over. I wanted to be home more, I have kids and wanted to be closer while they were in high school. And I was attracted to the collaborative nature of the culture at Health Share.
TLR: Did you apply for this job? Or were you pitched on it?
Schroeder: Gov.-elect Kotek and her team reached out, and we started having conversations about health in the state. We really started with other things besides the Oregon Health Authority before we got to OHA. She was just looking to learn my perspective to make sure that it aligned with her top priorities. She eventually asked if I would be willing to step in as the interim health authority director.
TLR: How is it going?
Schroeder: I mean, it’s day two. And mostly my approach to most everything is, I come in wanting to listen, learn, inquire. And start to understand the people, the organization, etc. So, I mean, I’m just barely into that at this point. I know, the programs well. I don’t know, the agency, the people, etc. Medicaid, I’ve been doing for a long time, but this is a new place for me.
TLR: Yesterday, in your open letter to the health care community, you talked about issues including equity, social determinants of health, access, outcomes, housing and behavioral health. How you would contrast where you intend to take OHA with the post-Kitzhaber direction that Pat Allen inherited and advanced with reforms to the Oregon Health Plan and coordinated care organizations, known as “CCO 2.0.”
Schroeder: So, the interesting thing is the goals of CCO 2.0 are those of my open letter. If you look at what the big priorities were in that, health equity was a huge one and social determinants were a big component of CCO 2.0. And now we have the tools (of the recently approved federal Medicaid waiver) that I highlighted in the open letter that will help us make more progress. So I actually think there’s a lot of alignment.
TLR: So you will take those reforms further along the direction that’s already been going.
Schroeder: Think about when CCO 2.0 started in 2020. What happened in the third month of 2020 was COVID. So COVID gave us an opportunity to act on social determinants and health equity, and to learn from that, but in a more focused way. Now we have the ability, hopefully, to continue that focus and help overall as opposed to just on COVID response.
TLR: Do you expect to bring a different leadership style?
Schroeder: I’m a clinician. So, I think that brings a unique vantage point. I’ve been a community health clinician with a focus on folks that preferred a language other than English. I think the other part that I really want to move on that is the collaborative piece. So, if we’re going to work on improving behavioral health, it has to be a collaborative approach between health system CCOs, OHA, etc. Collaboration is going to be a huge theme for me.
TLR: Speaking of behavioral health, Measure 110 funds have been spent largely on filling in things that Medicaid cannot pay for. But as you know, there’s a shortage of detox facilities, residential treatment and recovery, housing stabilization centers for patients. Providers say that even after the rate increases in Medicaid, the reimbursements don’t come close to covering the costs of addiction care. And there’s been no coordinated effort to fix these gaps and address the needs of patients that are on this supply of very available and harmful drugs. How are you going to address that, and fill the gaps in the system to provide access to care?
Schroeder: I go back to the comment that I said about collaboration. I have my own experiences in behavioral health, and (new Behavioral Health Director) Ebony Clarke does as well. But we’re not going to be able to solve this if we don’t sit down with those providers in communities, etc., and work on creating that system of care. So, I don’t have all of the answers. But I hope to pull together the people that, collectively, we can get to those answers so that we can make it better than what it is today. And Medicaid is one of the payer sources, but we have to make sure that we’re utilizing all the funds that we have available for the behavioral health system.
TLR: It’s been more than 10 years since former-Gov. John Kitzhaber’s vision led to Oregon Health Plan reforms. How do you view his vision? Is it still relevant, and how would you modify it today? It had a lot to do with cost control and spreading reforms, not just in the Oregon Health Plan, but into the private sector.
Schroeder: I think the vision is still relevant, and that we’ve made a lot of strides with the CCO model. But we still have further to go. expanding the role of social determinants in health hasn’t been fully realized the health equity component is one that we have to continue to work on. And I think the other one that I would highlight is more around that community centered approach. Not that we don’t do that, I think we still have room to improve on that vision in the CCO model.
TLR: As the CEO of Health Share, you saw the state add a lot of conditions or deliverables to CCO contracts. Do you think the administrative burden on CCOs is too much?
Schroeder: We need to be about achieving outcomes. How we show that we’re achieving those outcomes is where we can probably adjust. Lots of administrative reporting doesn’t necessarily demonstrate outcomes and does create an extra amount of work. I think we do have some work to do to look at what are the outcomes that we’re trying to achieve.
TLR: In your open letter, you didn’t mention the word transparency, which obviously was a big deal for Pat Allen. And here, I hear you talking about maybe less reporting, or different reporting. Where do you stand on transparency?
Schroeder: It’s not less transparency. I don’t know that more reporting gives you more transparency, it gives you more reports. If we drive towards outcomes, that actually is a higher level of transparency, then perhaps reports can be, depending on what we’re talking about. For me, transparency is implied if we’re going to bring these collaborative tables together. If we’re not being transparent and authentic. Transparency has to be part of that collaboration, for sure.
TLR: The biggest CCO that you oversee in your new position is your former employer. You were the leader of it. What potential conflicts of interest do you see and how will you approach that?
Schroeder: I’ll work with the state to make sure if there are any conflicts that we identify those and work through that. But as far as how I work with Health Share, I have positive relationships with people there. And we need Health Share to be successful for all of the stuff that we just talked about to be successful. So, I hope to continue to work collaboratively with them to achieve the goals that we talked about. At the same time, we need outcomes from them just like anybody else. So that same accountability will apply to Health Share as much as it will to any other CCO.
TLR: How do you see working to implement Measure 111, the state constitutional amendment establishing the right to affordable health care?
Schroeder: We have achieved a level of coverage that most states would be envious of. So, I think we still keep striving till we get to 100%. We have a lot in the works that’s going to help us get even closer. Part of the excitement and joy for me is even though it’s incremental percentages, it’s real people.
TLR: Is it realistic to think that the state of Oregon can bring down the cost curve? And if so, what do we need to be doing that we’re not doing now?
Schroeder: I think we’ve got to continue to work on that — we haven’t gotten it entirely right yet. But again, I think we should celebrate that we’ve actually made some good progress. I also think that it costs a lot when we have behavioral health systems that are not able to meet our communities’ needs. So, getting those things where we need them, spending those dollars — same with on housing and other social determinants of health — are investments into that long-term goal of cost containment.
Jan 12 2023