By State Representative Rob Nosse
As this month’s column is published a few days before the election (brace for impact!), I will save my reactions regarding the results for the December issue. I will preview the 2025 Oregon Legislative Session in January or February. For this month, I am writing that classic “back to school” essay about how I spent my summer, which was all about Medicaid, which we also call the Oregon Health Plan (OHP).
Medicaid is four programs based on eligibility. Oregon is one of the few states that does all four. We even have a fifth program, referred to as Healthier Oregon, which is Oregon’s own program that covers immigrants who are poor who do not have a documented legal status. Authorized by Title XIX of the Social Security Act, Medicaid was signed into law in 1965 alongside Medicare to cover very low-income people. Although the federal government establishes certain parameters for all states to follow, each state administers their Medicaid program differently, resulting in lots of variations in Medicaid coverage across the US.
In 1997, the Children’s Health Insurance Program (CHIP) was signed into law. It provides federal matching funds to states to provide health coverage to children in families with incomes too high to qualify for Medicaid, but who also can’t afford private coverage. All states have expanded children’s coverage significantly through their CHIP programs, with nearly every state providing coverage for children up to 200 percent of the Federal Poverty Level (FPL). Oregon does this at 300 percent of the FPL—among the most generous in the US.
In 2014, the Affordable Care Act (ACA) gave states the option to expand Medicaid eligibility to individuals under age 65 in families with incomes below 133 percent of the FPL. We jumped on this and enrolled over 400,000 people. Each state makes a choice to do this. There are still 10 states that have not expanded Medicaid, mostly in the South, though Wisconsin has also held off.
The Basic Health Plan was also enacted by the ACA and provides states the option to offer Medicaid-style insurance to low-income residents who would otherwise be eligible to purchase coverage through the Health Insurance Marketplace, providing more affordable coverage and better continuity of care for people whose income fluctuates above and below Medicaid and CHIP levels. You have to be below 200 percent FPL to qualify but above 133 percent of the FPL. Oregon is one of three states that has chosen to do this, starting in July of this year.
One out of three Oregonians gets their health insurance via Medicaid—approximately 1.4 million Oregonians. Half of Oregon’s children are on Medicaid.
For the vast majority of Oregonians, their Medicaid benefit is provided by Coordinated Care Organizations (CCO), which are a type of managed care organization. We have 16 of them that operate in regions around the state. The two in the Metro area are Health Share and Trillium Community Health Plan. Most states have managed care in their Medicaid programs, though a few have none at all. When you are not part of a CCO, it is up to you to find providers. We sometimes refer to that as “open card.” Again, the vast majority of Oregonians on Medicaid are working with a CCO, and that is by design.
My summer of Medicaid meant lots of interactions with different stakeholders, including three six-hour meetings where CCOs, providers, the (OHA) and any other group who cared could pitch their ideas on how to make Medicaid work better in Oregon. I also went to conferences in Tennessee and Washington, DC and attended various speaking engagements across the state.
At these national conferences it was shocking to hear state leaders (mostly from states who have not expanded Medicaid under the ACA) that were proud that they cut their Medicaid rolls and got their enrollment down. Our state is proud we kept people covered! I also learned that we run a good program and have for decades. National health care leaders that care about Medicaid look to Oregon.
Back in Oregon, we talked about CCO contract length, increasing payment rates for all kinds of providers, especially for psychiatric care and maternity care in hospitals, what CCOs should do with excessive profits (CCOs are private entities), and the role CCOs ought to have in behavioral health, as in can we get them to do more. All of this will be vetted in the 2025 session.
Meanwhile, it was just reported that the OHA budget is overextended by $260 million, mostly due to state hospital expenses and Medicaid expenses because we maintained our enrollment. We were supposed to give the CCOs a 3.4 percent raise in their rates, but OHA recently announced that to save money we will only do a 3.1 percent raise, and the rumor is that we need additional revenue—taxes to the tune of $500 million above what we are already collecting to cover the costs of Medicaid for the next state budget.
As chair of the House Committee on Behavioral Health and Health Care, Medicaid is an incredibly important topic to me. I will end up spending a lot of time on it next year during the session. Now you know why.
