Medicare Waiver Update: Inequities and Behavioral Health

By Daniel Perez-Crouse

Continuing discussion over the Oregon Health Authority’s (OHA) drafting of a Medicaid waiver application for 2022-2027, a forum hosted by the OHA focused on how issues of equity can be addressed, with a particular focus on behavioral health and community involvement.  

For a quick reminder, the 2022-2027 waiver, as stated on Oregon.gov, aims to improve the Oregon Health Plan (OHP) by creating a more equitable, culturally and linguistically responsive healthcare system, containing costs with quality healthcare, investing in equitable and culturally appropriate healthcare, and ensuring everyone can get the coverage they need. 

The initial focus of the talk was centered around OHA’s recommended concept of Health Equity Zones, which they describe as a, “model that shifts decision-making power and resources to regional community collaboratives designed to integrate care across health and social systems and reduce the rate of cost increases.”

Senator Elizabeth Steiner Hayward, who is also an Adjunct Associate Professor of Family Medicine at OHSU, discussed what she felt are necessary, technical alterations to the OHP (that are being proposed and have not been finalized) to address inequities, such as increasing eligibility from six months to 12 months. 

“The vast majority of people on the OHP are living complicated lives. They work one, two or three jobs to try and keep a roof over their families’ heads. Filling out paperwork every six months meant there was a lot of churn on the OHP,” she said. 

In addition to this, making it so kids under the age of six have five years of “continuous” eligibility, with two years of eligibility for those six and older. 

Lastly, she mentioned a desire to do away with users going through their own income verification. Instead, the OHA would get this information on the back end through the department of revenue, further limiting barriers to accessing the OHP. 

Speaking of barriers, the area of inequities many of the panelists addressed was around behavioral health. Director of SO Health-E (Southern Oregon Health Equity Coalition), Annie Valtierra-Sanchez, mentioned there was a stronger need than ever before for these services in her communities. 

For example, those among Latinx groups affected by wildfires, “were desperate in terms of the next steps and not even knowing what to do,” she said. 

Stick Crosby, Network and Health Equity Director for AllCare Health, Inc., elaborated on the necessity of diversity within the system to address inequities amongst behavioral health needs. 

“A therapist of color is going to fully understand how an individual may be dealing with racism in their lives and they’ll be able to address that and talk about it during a session. 

“That is something we should value and that is something we should stratify reimbursement for and make sure those providers are being reimbursed for those services.”

Valtierra-Sanchez clarified that three percent of the waiver budget is being invested in health equity and 20 percent is going towards enhancing provider payments and behavioral health. 

She noted the importance of language and making sure there are professionals who can speak the languages of in-need communities to properly facilitate communication. 

Moreover, Crosby noted, “If you are an individual that utilizes sign language, you are not going to have a good time in a therapy session through an interpreter.” 

Hayward elaborated on how behavioral health is linked to physical health (and the push-pull nature between the two). 

“High-stress levels and challenges that bring those on, while not having coping skills that mitigate the effects of that stress, makes diabetes and blood pressure worse. They also make it harder to focus on your own health. And when your body isn’t well, it’s much easier to become depressed.” 

While Hayward understands the prescient need for improved behavioral health services for the suffering inequities, among other things, she wanted to remind people this waiver won’t take effect until 2023 and that improving systemic issues like this take time. 

“If it doesn’t look dramatically different in 12 months, it doesn’t mean we’re not trying to fix it. We need grace and input from the community over what’s working and not working. And understanding that we can’t change things overnight.” 

Valtierra-Sanchez echoed the need for patience but stressed that this can be alleviated or mitigated if communities are properly consulted, updated and made a part of the process on a consistent, genuine basis so that two years don’t go by without communication and suddenly there are questions over why things went wrong. 

She said this, among other practices, is important to maintain “accountability from the community over what was requested.” 

This is just a sample of what was discussed. Other finer details of where funds should be allocated, voices that need to be elevated and more were covered and the entire discussion can be watched at bit.ly/MedicareInequities.

Medicare Waiver Update: Inequities and Behavioral Health

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