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Survey paints a troublesome picture of the Oregon Health Plan and Medicaid cuts nationwide.
Patricia Stuart, 48, mother of three, has always worked. She’s been a nanny, switchboard operator, jewelry salesperson, community organizer, pizza delivery driver, and more. She’s never been without work for more than three months at a time, she says, but with 20 jobs in the last 10 years, she’s never held a job very long.
Things began to get bad for her a dozen years ago. When winter came, she often was unable to function. She might put on one shoe, then search 20 minutes for the other shoe—only to find it where she’d been in the first place. She thought she might have seasonal affective disorder (SAD).
Eventually, she was diagnosed with a mental condition similar to a bipolar disorder, she says. That’s when her Catch 22 began.
Without medication she couldn’t hold a job. When she went on the Oregon Health Plan, the state’s public health insurance for low-income and disabled people, she got medicines and could work. But when she took a job, she earned too much to qualify for the plan, and employers required 90 days’ employment before health coverage kicked in, she says. With no medication, Stuart usually found herself unable to hang on to the job.
Things got worse for Stuart and thousands of other Oregonians in 2003, when the state implemented cost-cutting measures to the Oregon Health Plan. Required to pay more for her prescriptions, Stuart found herself cutting her dosage by two-thirds to stretch the medicine through the month.
Stuart’s experience is no surprise to Matthew Carlson ’91, assistant professor of sociology, who is studying results of the Oregon Health Plan changes. After all, he says, it doesn’t take a rocket scientist to predict what happens when you ask people with no income to pay for health insurance. Still, Carlson’s come across a few bombshells.
“The biggest surprise was the degree to which there were negative impacts,” says Carlson. “The numbers we were seeing were horrifying.”
In 2003, Carlson and other researchers launched a study of 2,783 people enrolled in the Oregon Health Plan when the state began cost-cutting measures. The group was to be surveyed three times through 2005.
Results for the first two surveys are in, and as Congress begins to grapple with Medicaid funding for the entire nation, Carlson’s study is catching the eye of governments and agencies across the country.
What the researchers found is not pretty.
I’m currently getting $66 a week unemployment. I’d like to pay my premiums due, but I’m broke. I’m staying in a [borrowed] motor home in front of a friend’s house. –Study participant
Even modest cost increases can knock people off public coverage, especially the poorest of the poor. In 2003, the state began requiring some Oregon Health Plan members to pay monthly premiums of $6 to $20 and to make co-payments when they saw a doctor or filled a prescription. Anyone who missed a premium payment was automatically kicked out of the program for six months.
Even members earning $187 or less per month (25 percent or less of the federal poverty level) were required to pay. Thousands of poor people couldn’t make the payments and left the plan. Some 40,000 Oregonians who made less than 10 percent of the federal poverty level, $75 a month, dropped out of the plan, including 4,000 single parents with children.
Without coverage, many could no longer afford to see a doctor. Of the people who had been without coverage for a year or more, 69 percent said they had not seen a doctor in the previous year even though they had a medical condition that required a doctor’s care. Asked why, 89 percent cited lack of money.
I get paid on the 5th and 20th of each month. I lost my benefits because I could not pay for myself and my son before the 20th (always after). They cut me off for six months now . . . I need pills and yearly check ups, which I need now but can’t get them until April or March. My son is the same way. –Study participant
And, they racked up debt. By the time people surveyed had been without health insurance for a year, 40 percent owed $500 or more in medical bills. A third of the people who owed money cut back on food or paying other bills to make payments on medical bills. Others simply defaulted.
On a positive note, the study also found that if coverage is restored within three to six months, the human suffering is lessened. In the first three months without coverage, the percentage of respondents who needed health care but were not able to get it was 38 percent, about the same as that of people who continued coverage. After three months, the numbers for those without coverage who could not get needed medical care shot up to 72 percent.
Tina Edlund ’79, of the Office of Oregon Policy and Research and a co-researcher on the study, says such results may help the state redesign the program in anticipation of the time when money is available for reinstituting some of the cuts. However, right now the state is trying to hold down costs even more by cutting 75,000 from the Oregon Health Plan. They’re more than halfway to their goal.
As a result, researchers say, Oregon has created a skyrocketing number of people with no health insurance—ordinary people who must turn to safety nets and charity care. Which, says Bill Wright, analyst for the Center for Outcomes Research and Education at Providence Health System, can raise the cost of health care for everyone.
The researchers call it a “cascading effect,” says Wright, a co-researcher on Carlson’s study. When people have no health care—especially those with chronic conditions such as diabetes—they are not able to see a doctor and are more likely to get sicker and sicker. Finally, in desperation they turn to emergency rooms.
Half of the people who left the Oregon Health Plan because of cost, the study found, had an emergency room visit within six months. Hospitals must shift the cost of these charity cases to the larger group of people who can afford to pay for services—or their insurance companies. That, in turn, raises health care costs for everyone. This cost shift is already responsible for an extra $922 a year in the cost of an average family’s premium, according to the consumer group Families USA.
It’s true, says Wright, that at first glance, the state’s cost-cutting measures appear to save money. Total dollars spent on the Oregon Health Plan are down. But instead of preventative care through the Oregon Health Plan, the uninsured are finding care in the much more expensive form of emergency room care and hospital stays—as charity cases. “Somebody,” says Wright, “absorbs that cost.”
I receive $655 a month for SSI (supplemental security income)—over the limit for Oregon Health Plan Plus. How can anyone live on $655 a month and pay for health care? –Study participant
The Oregon study is apparently the first research into such changes to public health insurance programs. And policymakers around the county are looking to it for insight.
Nearly half of all states have implemented cost-cutting measures similar to Oregon’s—cutting vision, dental, and mental health coverage (19 states); toughening eligibility requirements or raising costs (21 states); and expanding or adding co-payments (20 states). As those measures are beginning to be felt, many of these states are contacting Oregon for the study’s findings.
Highly respected national organizations such as the Kaiser Family Foundation, which publishes papers closely read in Washington, D.C., have requested information. A widely read journal in the industry, Health Affairs, recently published results of the first survey. And the Commonwealth Fund, which helped fund the study, has published results of the two surveys taken to date.
Those reports and other findings of the study will be available to Capitol Hill this fall when Congress begins deliberating the future of Medicaid. Carlson is glad.
Medicaid reform, says Carlson, should be a national conversation. “I hope in some small way, our study can contribute to that conversation,” he says. “The question is, What makes sense for society as a whole? People shouldn’t have to get that sick. Not in a country with as much money as we have.”
And the study is also an omen for the rest of us, Carlson believes.
I’m one of those people working part-time without medical insurance because the company doesn’t offer it. I’m not sickly. I am 58 years old. My thyroid stopped working about 12 years ago, and I’ve been taking synthroid since. Yes, I skip days because a month’s supply cost me $20 to $25, and if I’m getting a short check, I skimp on everything. –Study participant
Last year in Oregon, 600,000 people did not have health insurance, Carlson says. One million more people across the U.S. lost coverage. And people are paying more for health insurance every year. “As this trend continues,” predicts Carlson, “we’re going to see increasing difficulty in getting health care services.
“What happens when people in the Oregon Health Plan have to pay more or lose benefits is what we’re likely to see across the nation. This study is the proverbial canary.”
Melissa Steineger, a Portland freelance writer, wrote the articles “Edit to Fit,” “Party Down,” and “Chasing the Multnomah Myth” in the spring 2005 PSU Magazine.
Read more about the PSU connection to this innovative collaborative research effort.
Oregon Health Plan Timeline
Pre-1994: Medicaid provides matching funds to states to provide health care to qualifying individuals earning less than the federal poverty level and disabled people.
1994: Oregon Health Plan launched in part to provide health care to the working poor. State uses Medicaid money and HMO-style cost-management to expand coverage to Oregonians earning up to the federal poverty level or less. An additional 120,000 Oregonians qualify for health coverage. Oregon's uninsured rate drops from 18 percent to 10 percent.
January through March 2003: Dwindling dollars force state to cut back on Oregon Health Plan. Two plans created: Oregon Health Plan Plus for Medicaid-eligible people and Oregon Health Plan Standard for remaining low-income people. Premiums increase to between $6 and $20. Co-payments of $5 to $250 required for medical care and prescriptions. State cuts coverage for mental health, substance abuse, dental care, vision, and durable medical equipment.
September 2003: Oregon Health Research and Evaluation Collaborative conducts first survey of Oregon Health Plan Standard members. The plan loses 40,000 members because they can no longer afford the premiums.
Summer 2004: Based in part on study findings, Oregon reinstates coverage for mental health and substance abuse treatment. Co-payments are cut for some.
November 2004: Second survey conducted. Twenty-eight percent of former plan members have had no health insurance coverage in the past year.
Summer 2005: Legislature eliminates premium payments for individuals makig 25 percent or less of the federal poverty level.
October 2005: Final survey scheduled to begin.