On April 5, 2022, TCF director of health care reform and senior fellow Jamila Taylor submitted the following public comment to the U.S. Department of Health and Human Services (HHS) in response to Oregon’s Section 1115 demonstration application. In her comment, Dr. Taylor explores how the waiver would reduce barriers to care for Oregon Medicaid beneficiaries and use Medicaid funds to address social determinants of health to improve health equity.
I am pleased to provide comments to the U.S. Department of Health and Human Services’ (HHS) request for public input on Oregon’s 1115 demonstration waiver request.
My name is Dr. Jamila K. Taylor and I serve as the director of health care reform and senior fellow at The Century Foundation (a progressive independent think tank), where I lead the organization’s work to build on the Affordable Care Act and develop the next generation of health reform to achieve high-quality, affordable, and universal coverage in America. I also work on issues related to reproductive rights and justice, focusing on the structural barriers to access to health care, racial and gender disparities in health outcomes, and the intersections between health care and economic justice. Throughout my twenty-plus-year career, I have also championed the health and rights of women of color and other marginalized communities both in the United States and around the world, promoting policies that ensure access to reproductive and maternal health care. I support Oregon’s efforts to remove barriers to care for patients covered by the Oregon Health Plan enrollees by expanding continuous coverage and expanding important sources of care such as doula services and the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. I also support the waiver provisions seeking to address social determinants of health using Medicaid funds.
Removing Barriers to Care for Medicaid Enrollees
Ensuring Medicaid enrollees have access to needed services is essential to improving health equity in the program. Oregon’s proposal would make significant progress toward minimizing churn in the Medicaid program and improving access to valuable services. Churn—when a patient transitions between different sources of coverage or between having coverage and being uninsured—has serious impacts for patients. Patients switching between sources of coverage may have to change providers, delaying their access to needed care. Beyond the direct impact to patients, churn has a fiscal impact as well. Studies have found that Medicaid churn in particular results in higher administrative costs for states, as well as less predictable and higher average spending within the Medicaid program.
Continuous Enrollment for Children
Oregon’s proposed expansion of continuous enrollment for eligible children through the end of the month in which their sixth birthday falls is a fantastic opportunity to improve children’s health. The first five years of a child’s life are crucial to laying the groundwork for their health and wellbeing. Ensuring that a child who became Medicaid-eligible during this period will remain so until they turn age 6 is crucial to ensuring that they maintain access to needed health care providers, regardless of changes to their parents income.
Similarly, Oregon’s proposal to establish two-year continuous enrollment for beneficiaries age 6 and up would stabilize other patients’ access to care beyond this crucial early period of life. As Oregon noted in their application, nearly a quarter of Medicaid enrollees in the state in 2018 and 2019 had been enrolled in the program within the previous six months. This suggests that minor fluctuations in income making them ineligible for the program are often temporary and should not be used to disenroll these households.
Research from the Pew Trusts supports this conclusion: according to an issue brief published in 2017, more than one-third of U.S. households had changes in income of 25 percent or more from year to year. These changes were generally equally split between increases and decreases, making a two-year period of continuous enrollment especially appropriate, as gains in one year may be offset in the following year. This would also help improve health equity, as the study found that Black and Hispanic households were more than 18 percent and 40 percent more likely than white households to experience volatile incomes, respectively.
Expanding Coverage for Incarcerated People
In addition to the continuous coverage provisions, the portions of Oregon’s waiver application expanding coverage to incarcerated persons will help improve health equity. As is the case nationwide, people of color, especially Black people, are overrepresented in Oregon’s criminal justice system. Maintaining Medicaid eligibility for incarcerated minors will help ensure that their incarceration does not interfere with their ability to access care, adding another issue to their ability to thrive.
Enrolling incarcerated adults in Medicaid in the leadup to their release will also help improve health equity. Up to 65 percent of the incarcerated population has some sort of substance use disorder, and the lapse in coverage after release can reduce a person’s access to treatment during the already turbulent period of their life after being released from prison. Treatment for substance use disorders also significantly reduces recidivism, making this provision doubly helpful for advancing equity.
Maintaining Eligibility for Disabled and Chronically Ill Youth
Expanding the eligibility for the Youth with Special Health Care Needs program from age 17 to age 26 will ensure that disabled and chronically ill Oregonians will maintain their coverage into the start of their adulthood in a similar manner as the Affordable Care Act did for many young adults. As Oregon noted in its application, more than two-thirds of enrollees in this program did not receive transition preparation services, and nearly half of enrollees were not prepared for the changes that would happen at age 18. Allowing a longer transition from the youth program into adult health care would help ensure that these patients are better equipped for this transition, improving health outcomes and lowering overall spending by the program by avoiding lengthy hospital stays.
Improving Access to Doula Care
Another way that Oregon’s waiver application would improve health equity and remove barriers to care is by improving access to doula care. Under the state’s current Medicaid plan, access to traditional health workers such as doulas is locked behind a treatment plan developed by a physician or other health care provider. This requirement represents a potential barrier to care for pregnant people whose health providers do not understand the impact that birth workers like doulas can have on maternal health outcomes.
Doulas have been shown to significantly improve maternal health outcomes. The United States has a maternal mortality rate of nearly three times higher than the next highest country. The fact that the U.S. maternal health crisis is pervaded by racial disparities proves that this high maternal mortality rate is driven by systemic racism and unequal treatment in the health care system. Expanding access to these essential providers by removing the barriers currently in place is essential to lowering the United States’ high levels of maternal mortality and reducing disparities.
Fully Realizing the Benefit of EPSDT
While most of Oregon’s waiver application is laudable, its approach toward the Early and Periodic Screening, Diagnostic, and Testing (EPSDT) aspect of the Medicaid program is less straightforward. It is certainly a good thing for Oregon’s children that the state is no longer seeking to waive the EPSDT provision in its entirety, but its request to maintain use of the Prioritized List of services represents a potential barrier to care, especially for the most marginalized children in Oregon.
The goal of the EPSDT requirement is to ensure that low-income children are diagnosed with and treated for any health conditions they may have before those conditions can develop into a more serious version. Developing a list of presumptively eligible services is a good start for implementing this goal, but the potential for services not on this list to be denied is a cause for concern. The Centers for Medicare and Medicaid Services (CMS) should work with the state to ensure that the processes to request and appeal medical necessity are robust, expeditious, and take into account the health care needs of medically complex children in the state.
CMS should also work with the state to promote this change in the EPSDT requirement. Federal law requires states to inform Medicaid-eligible families about the benefit, and CMS should work with Oregon as it creates these promotional materials in response to expanding the EPSDT benefit under this waiver. In particular, CMS should ensure the promotional materials to families clearly highlights the right to a medical necessity review in easily understood language.
Addressing Social Determinants of Health
In addition to reducing the barriers to care that Medicaid beneficiaries face, Oregon’s proposed waiver would address the social determinants of health (SDOH) that are the root causes of needing care. SDOH can account for up to 40 percent of the factors impacting a person’s health, and Medicaid is one important tool to address these determinants. The provisions of Oregon’s waiver build on the state’s extensive use of coordinated care organizations (CCOs). Under this approach, most Medicaid enrollees receive care through CCOs, which coordinate care between a patient’s physical, mental, and dental care providers.
Including Health-Related Services in Managed Care Rates
Allowing CCOs to include spending on “health-related services” as part of their medical spending under CMS regulations would promote CCO actions to address social determinants of health. Because of the other requirements in place by the Oregon legislature, this would also help improve health equity. HB 3353, passed in 2021, would require CCOs to spend at least 3 percent of their annual budgets on health equity investments. This spending would be a form of preventive spending, acknowledging that addressing the root causes of health needs will improve the population’s health in the future, as well as reduce costs to the Medicaid program in the long run. Because of the equity requirements put in place by the Oregon legislature, this would also further the Biden administration’s goal of promoting health equity among Medicaid enrollees.
Including SDOH Screenings and Referral in Quality Measures
In addition to including spending to address SDOH as medical spending, Oregon’s waiver seeks to include the level of SDOH screenings and referrals in its Quality Incentive Program beginning in 2023. Specifically, the state would measure the “rate of social needs screenings in the total member population using any qualifying data source.” This broad approach would allow CCOs to target their screening and referrals toward the needs of the populations they serve, which would not be uniform across the state.
In its final report in 2021 on how to address SDOH in Medicaid, the Oregon Health Authority discussed its plan to implement this measure. In the first year, CCOs would be required to submit plans for both what SDOH data they intend to collect and how they intend to collect it from providers. This level of state oversight would ensure that CCOs are not merely going through the motions of addressing SDOH, but have a meaningful plan in place to collect this data in a robust way that addresses the needs of their enrollees.
The state’s request to use some Medicaid funds to help build capacity in community based organizations (CBOs) will also help ensure that these screenings and referrals actually connect Medicaid enrollees with the services they need. Organizations that provide housing support or food security should not be expected to meet the increased demand from higher rates of screening and referrals without additional funding. This spending would be a strong investment, addressing the factors that impact people’s health in an equitable, long-term and focused way.
Directly Addressing SDOH Needs for Life Transitions
One of the most impactful aspects of this waiver is its proposal to use Medicaid funds to reimburse CCOs for SDOH spending for Medicaid enrollees going through specified life transitions. For example, the state has proposed to offer SDOH services to homeless enrollees (as well as enrollees at risk of becoming homeless), enrollees transitioning into dual eligibility, and enrollees transitioning into and out of foster care. The waiver proposes five broad categories of services, including housing supports, food assistance, and nonmedical transportation. Each of these has the potential to improve health among Oregon’s Medicaid enrollees, as well as narrow health disparities in the state.
The negative impact of homelessness on health is well-documented, and connecting homeless individuals with stable housing both improves health outcomes and reduces Medicaid spending. More than 45 percent of homeless people in 2021 across the country were Black, and while Oregon has made significant progress in recent years, more than 1,000 people were considered chronically homeless in the same report. Using Medicaid dollars to connect homeless people with housing will significantly improve their health.
Similarly, food insecurity is associated with worse health outcomes. Food insecurity is more common among single parent households and both Black and Hispanic households were more likely to be food insecure than white households in 2020. These trends hold in Oregon, as well: communities of color and single mothers were around two to three times more likely to be food insecure than the general population in 2020.
Connecting Medicaid enrollees with nonmedical transportation is a necessary component of ensuring these other SDOH programs work as effectively as possible. If Medicaid enrollees are unable to access the services they need and have been referred to, the referral would functionally be useless. Portland, Oregon was flagged in 2017 by researchers at the University of Texas at Austin as one of several cities with multiple transportation deserts, and this issue likely becomes worse in rural communities with less public transit. Medicaid spending on this transportation will help advance the positive impacts of various interventions aimed at addressing the SDOHs.
Oregon’s Waiver Would Improve Health Equity
Oregon’s 1115 waiver application demonstrates an important opportunity for CMS to further its goal of improving health equity in the Medicaid program. Promoting access to care among beneficiaries by promoting continuous coverage and expanding what services are covered is an important first step in ensuring that people’s health needs are being met. Similarly, Oregon’s proposed methods to use Medicaid funds to address the social determinants of health is a meaningful opportunity to transform the Medicaid program in Oregon from one that reacts to disease into one that promotes health among its enrollees. I appreciate the opportunity to comment on Oregon’s 1115 waiver application.