Advocate: Next goal is containing cost of health care

Oregon has done well to expand health care coverage over three decades, a former leader of the state health agency says.

But Dr. Bruce Goldberg also said that Oregon can do more to improve those services for low-income and older people — and to restrain their annual growth in cost. He said Oregon has done so with its network of coordinated-care organizations that serve one million recipients under the Oregon Health Plan — and the state needs to expand their approach.

Goldberg spoke at a May 9 meeting of Willamette Women Democrats at the Celebrate Conference Center in Lake Oswego. Since 2016, he has been a professor at the School of Public Health run jointly by Oregon Health & Science University and Portland State University. From 2003 to 2005, he led the Oregon Office of Health Policy and Research.

Goldberg was the director of the Oregon Department of Human Services between November 2005 and January 2011, when the Oregon Health Authority became a separate agency. He led it for three years until he resigned in 2014, after the state’s botched attempt to develop a computer system for both Oregon Health Plan recipients and people who relied on new federal tax credits to help purchase individual coverage in a statewide marketplace.

Oregon uses the federal online marketplace, which encountered its own problems, developed under the Affordable Care Act of 2010. It is known as “Obamacare,” after the president who advocated for it and signed it into law.

Employment-based health insurance in the United States began during World War II, and is still largely a tax-free employee benefit today. Although national health insurance never became a reality, Congress passed and President Lyndon B. Johnson signed legislation in 1965 to create federal health insurance programs for people 65 and older (Medicare) and for low-income people (Medicaid).

Medicare and health spending is now one of the leading categories of federal spending, along with Social Security, military and interest costs on the national debt.

Under the Affordable Care Act nearly a quarter century later, Oregon was among the first states to embrace the expansion of Medicaid (Oregon Health Plan) to people earning less than 138% of the federal poverty level. According to the Centers for Medicare and Medicaid Services, 40 of the 50 states and the District of Columbia have approved the expansion — although voters bypassed legislatures in some states to do so.

Different tiers

Though the official uninsured rate in Oregon has dropped to 6% — and a committee is scheduled to present recommendations to the Legislature in 2027 to bring that number to zero — Goldberg said there are still differences in how health care is provided.

“Think about this: We have a health care system that pays doctors and hospitals less to take care of poor people and old people like me, if you are over 65 — and more to take care of young, well-insured individuals,” he said.

“Our health care system likes to take care of people who are insured, who have jobs and who are healthy. Our health care system has a disincentive to take care of those of us who are over 65 and on Medicaid. That is so unjust — and yet we accept that every day.

“We really see dramatically different outcomes in care. So it’s a mess.”

Goldberg said Oregon has proven that need not be the case.

Regional networks

He referred to the development of coordinated-care organizations, 16 of them across Oregon, that were created in 2011 and 2012 to improve health services to the now one million recipients of the Oregon Health Plan, accounting for roughly 25% of Oregon’s population. Most already were receiving services through managed care, but Goldberg said the network of coordinated-care organizations is different.

Their boards consist of consumers, providers and those with financial interests. Goldberg said their decisions are based on a set amount of money, known as a “global budget,” at a fixed rate of growth “that we could afford.” They also integrate physical and mental health, dental care and substance abuse treatment.

Goldberg also said they got more flexibility in spending, recognizing that better outcomes might result from actions other than paying for medicines or medical procedures.

Then-Gov. John Kitzhaber, himself a physician and the chief author of the original Oregon Health Plan, negotiated with Obama administration officials for a multi-year federal commitment. In exchange, the new network of coordinated-care organizations pledged to limit the annual overall growth in costs by 2 percentage points under the rate of medical inflation.

“The best way to stay within your budget is not to deliver care, so they needed standards to live up to and ensure they were providing care,” Goldberg said.

“The amazing thing is that when you lowered the growth rate by 2 percentage points, we have saved more than $3 billion over 10 years. And we have improved health.”

His examples: Usage of emergency rooms, the most expensive form of care, dropped by 29%. Readmissions to hospitals were cut by 33%, admissions for asthma were down by 50% and for heart conditions by 32% — much of which is attributable to prevention and early intervention.

“The goal is to extend this into other parts of our health care system,” Goldberg said.

Experts argued about the after-effects of the Oregon experiment, but Goldberg said virtually everyone agrees there is still room for cost savings in health care — and not just from high administrative expenses.

Ex-legislator’s view

Rachel Prusak, a former Democratic state representative from West Linn and a nurse practitioner, also spoke to the gathering. She suggested another way to help — if Oregon can find enough instructors to train nurses. Instructors often are paid far less than if they were working as nurses.

Prusak also said that while doctors can practice telemedicine, nurses should be present in every community if Oregon can train enough nurses, particularly for mental health and substance abuse treatment.

“We have been talking about it,” said Prusak, who was appointed executive director of the Oregon Board of Nursing in July 2023. “But now, it is a crisis that has grown even worse.”

Prusak served two terms in House District 37 from 2019 until 2023. She sat on the House Health Care Committee in 2019, and became its chair in 2020. She led it during the 2021 session.

pwong@pamplinmedia.com