The Child Health Insurance Program: Early Implemenation in Six States. Chapter VII: Chip in Oregon

07/01/1999

History and Implementation
The history of health insurance (especially Medicaid) for low-income children in Oregon established a context for implementation of CHIP in Oregon. The state has the only Medicaid program in the country that openly rations medical treatments for its recipients (i.e., the legislature annually sets priorities on allowable treatments) yet allows more categories of individuals to be eligible for Medicaid than do other states. The numbers and proportions of uninsured residents has declined in Oregon, contrary to national trends, so crowd-out is less of a worry there. The legislature meets every other year, and was not in session when Title XXI money became available to states, so the legislature has not yet played a role in policy decisions around CHIP. Moreover, Oregon had established precedence for publicly-funded insurance programs to cover the uninsured, beyond Medicaid — precedence that made it easier to embrace CHIP.

Pre-Title XXI

  • The origins and history of CHIP evolved in the context of a landmark Section 1115 demonstration, approved by HCFA(now known as CMS) in 1993, and called the Oregon Health Plan (OHP). Under the Plan, a panel of six consumers and five physicians meets to prioritize health services. The legislature then "draws the line" on the priority list to determine, based on available funding, those treatments that will be covered and those that fall below the line and will not be covered by Medicaid.
  • The concept was intended to "ration care, not people," so the demonstration also authorizes expanding Medicaid eligibility to persons who are not otherwise categorically eligible, such as childless single adults, and makes eligibility contingent only on income.
  • According to legislative staff, the eligibility expansions have added 120,000 people to OHP/Medicaid rolls, and resulted in costs of $285 million. The caseload and cost increases set the stage for legislators’ distress about Medicaid.
  • In November 1996, the voters passed an increase in the tobacco tax to support and expand the Oregon Health Plan.
  • When the legislature met the next year, it faced additional revenues available from projected tobacco tax proceeds. At that time OHP/Medicaid covered most children and adults up to 100 percent FPL, except children age six and under and pregnant women were covered up to 133 percent FPL. The legislature authorized expansion of coverage for children under age 12 in families earning up to 170 FPL. This would have added 25,000 children to OHP/Medicaid.

Title XXI

  • After the legislature adjourned, Title XXI money became available. The Emergency Board, which takes required actions when the legislature is out of session, refinanced funds from Title XIX to create matching funds for Title XXI, and approved the addition of children ages 12 — 18 under OHP. The combined expansions of eligibility to children ages 6 — 12 and 12 — 18 were projected to add 15,000 — 17,000 children to OHP. The legislative session during the winter and spring of 1999 will be the first opportunity for legislators to consider and examine CHIP.

At the time of the CHIP appropriation and its addition to OHP/Medicaid, Oregon had three other health insurance programs.

  • The Family Health Insurance Assistance Program (FHIAP) provides state-only funds to subsidize Oregonians who are unable to afford health insurance and have been uninsured for at least six months. The subsidies pay between 70 — 95 percent of the family share of premiums for health insurance plans offered by employers. Members must pay the unsubsidized portion of their share of the premium cost, as well as the usual co-payments and deductibles of the private insurance market. [A brochure and chart depicting monthly income eligibility levels by premium subsidy level are available at http://www.ipgb.state.or.us.]
  • The Oregon Medical Insurance Pool (OMIP), provides coverage to individuals denied individual health insurance because of a pre-existing medical condition. OMIP is not a low-cost insurance program1 but FHIAP subsidies can be applied to any of the four insurance plans offered through OMIP. Pricing varies by age and geographic location.
  • The Insurance Pool Governing Board (IPGB), offers a variety of group insurance plans at affordable prices to the self-employed and small businesses with no more than 25 employees.

Oregon is implementing CHIP in phases:

  • Phase I: An OHP/Medicaid "Look-Alike" was implemented in July 1998, which allows income eligibility up to 170 percent FPL for children through age 18. Children under 100 percent FPL are eligible for Medicaid, except for children under age 6, who are eligible up to 133 percent FPL. The asset test in CHIP and Medicaid is $5,000 regardless of family income2.
  • Phase II - A: FHIAP, also implemented in July, 1998, will be linked as much as possible to CHIP. The state intends to submit a Plan Amendment to HCFA(now known as CMS) for this phase and target implementation for May 1999. The Amendment will seek HCFA(now known as CMS) approval of FHIAP benefit plans to be qualified under Title XXI.
    • In his FY99/01 budget, the Governor has included assumptions about covering certain children in FHIAP with CHIP funds. These children would only be eligible for CHIP funding where the FHIAP plans meet benchmark coverage, either Kaiser or the state employees’ package.
    • Oregon will request permission (where cost effective) to allow any children and their families enrolled in a qualified HMO with a 50 percent employer contribution to enroll in FHIAP, if the cost would not exceed what it would have cost to cover the children only with Medicaid. The state projects that this scenario will add 7,000 individuals to FHIAP, of which 1,000 will be CHIP children.
  • Phase II — B: The state may also submit an amendment to conduct a pilot test with the state’s only Health Insurance Purchasing Cooperative (HIPC), called Associated Oregon Industries. The pilot would market CHIP coverage through the HIPC, offering to small employers the opportunity for subsidies to enroll uninsured employees in a health insurance plan. In effect, they would say to employers, "If you’ve got employees with children who are uninsured, it’s probably because the insurance is not affordable. We’ll make it affordable by offering them subsidies." The state would run the pilot test for two years, and evaluate the results. Associated Oregon Industries would use a third party to administer the plan.
  • Phase III: After implementing Phases I and II, the state would seek a waiver from HCFA(now known as CMS) to allow reimbursement of direct services by safety net clinics (school-based, hospital-based, community-based) to supplement Oregon’s insurance programs. State officials estimate that, even with their variety of publicly-funded insurance programs, they may never enroll more than 80 percent of eligible children. They believe there is a cadre of children who are very difficult to reach and enroll, or may never enroll, for reasons that include:
    • Parents think CHIP is stigmatizing because it is a government program;
    • Families live in rural areas and either have a healthy suspicion about government programs or are simply "anti-government";
    • Families are immigrants who arrived after August 1996.3 Many of these families already use Federally Qualified Health Centers, migrant clinics, and other community and hospital clinics.
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      State officials would like to use CHIP funds to reimburse clinics for this care. In particular, state staff pointed to a robust cadre of school-based clinics funded by the Robert Wood Johnson Foundation. The goal is to get uninsured, low-income children into this clinic care until they are enrolled in an insurance program. The Title XXI statute permits states to use only their 10 percent administrative funds for direct services. But Oregon officials said that their waiver request to HCFA(now known as CMS) will make the point that they have followed the statutory recipe, and still have uninsured, non-Medicaid eligible children, demonstrating the need to move beyond the insurance model.

Federal/State Financing

  • Oregon’s Title XXI allocation of Federal funds in the first year was up to $39 million. The state matching rate is 27 percent. State officials estimate they are spending $6 million in state matching funds.4
  • Oregon has a statutory cap on revenue expenditure increases. If revenue collections exceed the end of session forecast by more than two percent, the excess must be returned to the taxpayers. The forecasts are done in May of the odd years. Thus, Oregon never accumulates General Fund revenue surpluses, although the Legislature does set aside $25-35 million as an emergency fund for all of state government for the two-year period. As a result, large programs like the Oregon Health Plan have no "safety net" in the event of a budget overrun. To gain maximum legislative support for CHIP, the Medicaid agency guaranteed that the program would not run a budget deficit. Thus, the state chose to implement CHIP as a "stand-alone" Title XXI program so that enrollment could be capped. One official noted that to keep faith with the legislature, they have sized CHIP to stay within the Medicaid expansion dollars originally authorized by the 1997 legislature.

Current Enrollment
Oregon officials point proudly to a decade-long decline in the proportions of uninsured Oregonians. They estimate that in 1989 there were 450,000 of 2.7 million residents uninsured (about 18 percent); 22 percent of all children were uninsured. In 1998, they estimate that 345,000 of 3.2 million residents (about 11 percent) were uninsured; nine percent of all children were uninsured. CHIP has helped continue that trend.

  • For the Phase I Medicaid look-alike, Oregon had enrolled 10,200 children by January, 1999, and is targeting to enroll 17,000 — 18,000 children by spring of 1999. They enroll 300-400 children each week. Staff closely monitor applications in the pipeline to ensure they will not exceed the target enrollment. When the number of enrolled plus applications in the pipeline estimated to be eligible exceed the target, OMAP will be forced to close the pipeline for a few months until sufficient attrition occurs. People who apply when the program is closed and who appear to be eligible will be given priority notification when it reopens.
  • For Phase II, where CHIP/Oregon Health Plan and FHIAP become linked, the state expects to add another 7,000 individuals of which 1,000 will be CHIP children.
  • For Phase III, under a prospective waiver that would permit use of CHIP dollars for the provision of direct services, the state expects to pay for health care for an unknown additional number of children whose families did not enroll in the publicly funded insurance market (OHP/Medicaid, FHIAP or CHIP).

Key Factors for Oregon’s Implementation
Several circumstances and factors were critical to implementation of CHIP.

  • Timing was critical. Since the legislature was not meeting when Title XXI money became available, the Emergency Board approved, quickly, reprogramming of some tobacco tax funds as matching funds for CHIP. One legislative staff observed that was literally a one-line item in a two-inch-thick budget book.
  • Finding the state matching funds was relatively easy. The Department of Human Resources had already earmarked projected tobacco tax revenues to expand Medicaid to add children ages 6 — 12 under 170 percent FPL. These funds were designated as state matching funds for CHIP and children age 13-18 were added.
  • Data helped seal the case. The Oregon Health Council, a policy advisory body to the Governor and legislature, presented survey data documenting the large proportions of uninsured adolescents in the prospective CHIP population. These data bolstered the case for expanding eligibility through age 18.
  • Precedence was helpful. The state has a history of "breaking the mold" with government programs, in particular its Medicaid waiver demonstration that established the Oregon Health Plan. And they already had three other programs aimed at helping disadvantaged, uninsured individuals obtain health insurance.
  • Crowd-out was not evident. Unlike national trends in the opposite direction, Oregon was experiencing growth in employer-provided health insurance coverage.

Outreach

State Approach
Oregon’s Office of Medical Assistance Programs (OMAP), administering agency for CHIP, must balance its interest in outreach with fiscal constraints limiting the numbers of eligible children they are targeting to enroll this year. A second agency, the Insurance Pool Governing Board, has assumed a large part of the responsibility for outreach on CHIP while it simultaneously conducts outreach for the Family Health Insurance Assistance Program (FHIAP). FHIAP was designed prior to CHIP, but implemented at the same time. Outreach efforts both for FHIAP and CHIP are very proactive.

Key Players and Administration
Two agencies administer outreach for CHIP, with a third agency establishing CHIP policy and conducting research.

  • The Oregon Department of Human Resources houses OMAP, which administers CHIP and Medicaid. DHR characterizes their CHIP program as a Medicaid look-alike program. Both programs operate under the moniker of the Oregon Health Plan. Outreach activities undertaken on behalf of Medicaid over the past several years now also double as outreach activities under CHIP.
  • The Insurance Pool Governing Board, which administers several other health insurance subsidy programs for disadvantaged individuals, has taken responsibility for marketing, education, and outreach to children in families likely to be eligible for CHIP. Outreach activities for CHIP are most closely linked to similar activities for FHIAP. FHIAP offers state funds for three levels of income-conditioned subsidies to individuals unable to afford health insurance (usually available from their employers) who have been uninsured for six months.
  • The Office for Oregon Health Plan Policy and Research was established by and reports to the legislature. They are responsible for policy oversight, research, furthering the goals of the OHP, collecting health data, and being staff support to the:
    • Oregon Health Council, which recommends policy for OHP/Medicaid and CHIP;
    • Health Resources Commission, which oversees a process for deciding on the allocation of medical technologies in Oregon;
    • Health Services Commission, which prioritizes medical services for OHP/Medicaid.

Collaboration with Other Agencies and Organizations on Outreach
State officials strive for a seamless system of health care between CHIP and FHIAP so the Medicaid agency and Insurance Pool Governing Board strive simultaneously to locate children eligible for either program.

State Medicaid Agency

  • OMAP’s outreach methods include a simplified, integrated application form both for OHP/Medicaid and for CHIP. The form itself is four pages, on a double-sided fold-over with large print and ample white space for families to record the information. It is accompanied by an equally clear set of information and instructions that includes:
    • How to apply for OHP;
    • Why Social Security Numbers are needed5;
    • Your Health Insurance Rights and responsibilities;
    • The significance of the date-stamped application and the 30-day limit on returning the form;
    • Income guidelines and family size for eligibility;
    • Other health resources for you and your family;
    • Who to call about each of the other programs;
    • A one-page explanation of managed care;
    • Who might have to pay premiums and how much;
    • Special rules for victims of domestic violence; and
    • When insurance coverage will begin.
  • All applicants are screened first for Medicaid and then CHIP. Agency staff estimate there are 50,000 — 60,000 eligibles of all ages not enrolled in Medicaid. The joint application for these two programs does not cover FHIAP because officials did not want to ask FHIAP applicants about non-custodial parents’ availability of health insurance for their children — a Federal requirement under OHP/Medicaid. However, anyone applying for Medicaid and CHIP who is found ineligible for those programs is referred to FHIAP; and FHIAP applicants are informed about OHP/Medicaid and CHIP.
  • The agency offers a 1-800 phone number to call to receive date-stamped applications and an information packet.
  • The agency has established a variety of sites where people can pick up date-stamped applications, including:
    • Hospitals;
    • Clinics;
    • WIC Centers;
    • FHQCs;
    • Rural Clinics;
    • Tribal Clinics;
    • All county public health centers; and
    • Welfare offices.

In January 1999, OMAP staff completed the training of workers in these centers to help applicants fill out the form and to answer questions about Medicaid and CHIP.
  • The OMAP provides date-stamped applications with a 30-day return deadline to ensure that providers will be paid. While insurance plans may not distribute date-stamped applications, providers may do so. A substance abuse treatment center, for example, can hand out an application to an adolescent and begin treatment right away. Center staff encourage families to send it in within 30 days, which provides some assurance that the center will be reimbursed for treatment provided during the retroactive eligibility period.

The retroactive eligibility period lasts about two weeks, since that is how long it takes the agency to process an application and enroll a child.

Other State Agencies
Insurance Pool Governing Board staff are conducting the largest outreach effort on behalf of the FHIAP and CHIP programs. These efforts involve other state and local agencies, called community partners, as well as non-profit organizations.

  • Staff conducted more than 100 training seminars since April 1998 at a variety of locations where uninsured families are most likely to visit or live. Seminars last a half a day, and are aimed at a variety of participants who come in contact with the uninsured. Seminars have been held in 28 cities in all parts of the state. Among participants were 953 insurance agents.
  • 924 "community partners" have participated. Community partners include:
    • Adult and Family Services;
    • Disabled Services agencies;
    • Employment Department;
    • Vocational Rehabilitation Division;
    • Education Department;
    • WIC programs;
    • Department of Consumer and Business Services;
    • County and Public Health Departments;
    • Head Start and Healthy Start programs;
    • Mental Health agencies and clinics;
    • Community Action Agencies;
    • Jefferson and Beaverton School Districts;
    • Legal Aid staff;
    • Information and Referral agencies;
    • Providers, hospitals, and health centers;
    • Homeless and youth shelters and service agencies.
  • Board staff mailed 45,000 notices to food stamps recipients and placed inserts in Medicaid denial notices;
  • They put up posters at various locations in the seminar communities. Posters have removable stickers with the FHIAP 1-800 phone number, so families could pull them off and take them home.
  • Staff at all of the seminars distributed a tri-fold brochure on FHIAP and CHIP that includes answers to simple questions:
    • What is FHIAP?
    • Do I Qualify?
    • How Does FHIAP Work?
    • How Do I Figure My Income Level?
    • What Are My Other Options?
    • What’s My Next Step?

Under "What Are My Other Options", the reader learns about CHIP. The brochure includes an eligibility chart of family income ranges for OHP/Medicaid, CHIP, and FHIAP. The brochure contains a tear-off reservation card to mail in. By design, the reservation card is not an application or pre-application, because the program wants to convey the message that they have a reservation list, to ensure that they enroll only the number of people they can serve. This message applies to FHIAP as well as CHIP.

Board staff noted that approximately 37 percent of FHIAP enrollees are eligible for CHIP but are remaining in FHIAP because the parents are willing to pay something to stay in what they perceive as a private program. FHIAP staff have surveyed families of children in FHIAP and asked why they did not enroll their children in CHIP. The most frequent response is that CHIP is a free government program while FHIAP is not perceived as a government program.

Media Activities
A radio news release, NewsNet, was aired for stations to use in late September. News releases were distributed to local newspapers in June and September, one month before and after the program began.

Creating a Seamless Health Care System for Eligible Children

Presumptive Eligibility

  • Oregon does not offer presumptive eligibility to children applying for CHIP because state Medicaid officials assumed they would have to fund it with their capped administrative funds.
  • Retroactive eligibility is provided through date-stamped applications at a variety of locations. The application has clear instructions alerting the family to return it within 30 days to ensure eligibility back to the date of application.

Continuing Eligibility
CHIP children, once certified and enrolled, enjoy a six month continuing eligibility period before re-certification must occur.

Simplified Application and Eligibility Decisions

  • OMAP believes the simplified, integrated, four-page application form for Medicaid and CHIP makes the application process very easy for both programs. They have tried to make the accompanying instructions to families equally clear.
  • They offer one-to-two-week turnaround time on eligibility and enrollment decisions to those applicants who return the date-stamped applications within 30 days of acquiring them.
  • The entire application process can be completed by mail, with no need for the family to come to an office.

Funding for Outreach

  • OMAP reports spending only a small amount of its administrative funds on outreach. Officials feel they must conserve most of their administrative funds for management and operational activities. The fiscal constraints on the number of children they are targeting to enroll this year makes them cautious about too aggressive an outreach campaign. They do not wish to create unrealistic expectations among uninsured families about the capacity of CHIP to enroll children.
  • Most of the outreach funds were spent on printing and distribution of the date-stamped application forms, and training of the workers in the various hospitals, clinics and other sites where CHIP information and applications are available.
  • The Insurance Pool Governing Board has a $1 million appropriation for the biennium to conduct outreach for FHIAP. Since outreach targets both FHIAP and CHIP eligible families combined, staff cannot estimate a separate portion that is spent on CHIP.

Marketing to Hard-to-Reach Populations

  • FHIAP staff participated in five Rural Health Forums held across the state, and made presentations at 21 other conferences. These included:
    • Oregon Health Action Campaign Annual Conference;
    • Small Business Fair;
    • Commission on Children and Families;
    • Chinook Winds Casino and Confederated Tribes;
    • Chambers of Commerce.
  • They held meetings with Oregon Fishing Families in eight coastal communities to promote CHIP and FHIAP.
  • Staff designed and disseminated information about CHIP and FHIAP that included a special barbers and hairdressers board brochure (22,000); they mailed marketing materials in English and Spanish to Head Start Centers, the Oregon Association of Hospitals and Health Systems, Disproportionate Share teaching hospitals, school nurses and school-based clinics, industry associations, county commissioners, and Rotaries.

Woodwork Effect
Several officials in Oregon noted the tension that may result if the state does so much outreach that they create more demand for CHIP than they can respond to, and have to form waiting lists. More budget-related concern was expressed, however, that CHIP outreach will cause Medicaid eligibles to "come out of the woodwork" and drive up OHP/Medicaid costs. Since the CHIP program was implemented, in July 1998, the number of children covered by OHP/Medicaid has increased by 3,000.

Potential Future Outreach

  • A potential source of outreach funds for CHIP is the $300,000 annual grant for the next three years from the Robert Wood Johnson Foundation for their Covering Kids initiative. OMAP staff hope to use the funds to target outreach on homeless youth in Portland, a high uninsured area in Eastern Oregon, and two areas in southern Oregon with high proportions of Hispanics.

Advice for Other States

  • Capitalize on other state health insurance programs’ outreach efforts for CHIP outreach. This can conserve CHIP administrative funds for real administrative expenses such as application processing and enrollment and computer systems enhancements.
  • Monitor the number of applications in the pipeline, awaiting eligibility decisions, if enrollment targets are limited by budgetary constraints to avoid exceeding the targets and claims budget.
  • Customize outreach efforts for the hard-to-reach populations in your particular state. In Oregon, these include fishing families and Native American tribes.
  • Outreach should focus on populations with disproportionately high numbers of uninsured. In Oregon, those are Hispanics and rural residents.
  • Reach out to private insurance agents and a broad group of community partners to publicize CHIP.

Crowd-Out Prevention

State’s Response
Some historical information is helpful to understanding state decisions about crowd-out prevention strategies.

  • The State Legislature enacted an employer mandate statute in 1989, requiring all employers in the state to provide health insurance for their employees, or pay into an insurance fund. The statute was intended to take effect in January of 1994, was subsequently deferred by the legislature — first to July of 1995 for all affected employers, and then to March, 1997 for businesses with 26 or more employees and to January, 1998 for businesses with 25 or fewer employees.
  • The mandate expired without ever being implemented.
  • Simultaneous with enactment of the employer mandate, legislation passed to expand Medicaid to all below 100 FPL, and develop a benefit package based on a prioritized list of services. The expansion was based on the assumption that the impending employer-provided insurance mandate would cover most of those above poverty. Although the employer mandate expired, employer-based coverage is on the rise in Oregon. The Governor has cautioned that the state move deliberately with CHIP expansions, so as not to reverse the trend of rising employer coverage.

Waiting Period

  • As an explicit employee crowd-out measure, The Oregon Health Council recommended and OMAP adopted a six month waiting period for children in families who dropped insurance or are currently insured. This was a contentious issue between staff of the Council, OMAP, the Insurance Pool Governing Board, and advocates. Since the Legislature was not in session, they have not yet expressed opinions on the topic. Council staff want at least six months of solid data on impacts, before considering a recommendation to shorten or eliminate this waiting period.
  • The waiting period was contentious and resulted in a split vote. The contention arose around the "equity issue" — whether the waiting period would apply only to those insured or also to those with access to employer-provided insurance who have not enrolled. A small majority voted to limit the waiting period only to those who are already insured.
  • Some Council members and staff felt that one of CHIP’s big challenges would be the inequity between families who made the sacrifice and paid premiums for employer-provided insurance, thus rendering them ineligible for CHIP for six months, and those who did not and were immediately eligible.
  • Others believed that crowd-out would be extremely unlikely to occur so long as there was a six month waiting period, because the projected eligible population for CHIP will be so small among the number of families covered by private insurance. There are 1.9 million Oregonians with private insurance coverage, so those officials think that a small program like CHIP that may serve 15,000-20,000 children is unlikely to contribute to crowd-out.

Council staff looked at other states’ experiences and studies on crowd-out, but found no conclusive evidence. They believed that Minnesota denies subsidies even to those with access to insurance, which is not deemed relevant to Oregon’s plans.
  • Under Phase II, Oregon is requesting HCFA(now known as CMS) approval to use CHIP funds in the private sector group market to subsidize employer coverage for the whole family. Officials are looking beyond the notion of using a "shoebox" approach to calculating when a family reaches the five percent limit on out-of-pocket expenses. They are searching for actuarial alternatives for estimating at what points different types of families are likely to hit the limit.

Employer Crowd-Out

  • State officials are more concerned about employer crowd-out than employee crowd-out. They fear the propensity is high for employers to drop dependent coverage in the face of CHIP and FHIAP’s availability, calling this "push out."
  • With CHIP’s free coverage for children, and employers’ far larger share of FHIAP premiums than a family’s share of premiums, officials worry that employers will stop contributing to dependent coverage.
  • Health Council staff have not determined how to measure "push out" but are giving it considerable thought.

Premiums

  • There are no premiums charged for children in CHIP. However, families in FHIAP pay 5, 10, or 30 percent of their premium costs in the FHIAP program. Under the state’s proposal for Phase II, enrolling families in FHIAP but funding eligible children in those families with Title XXI funds (where cost-effective), it is not clear whether the state will continue exempting the children’s portion of the premium costs.

Lock-out Periods

  • Since there are no CHIP premiums, there are no disenrollment penalties for failure to pay.
  • Under the Phase II plan, the state will establish policies about whether children funded with Title XXI in FHIAP face a lock-out period, if their families fail to pay a premium.

Co-payments

  • CHIP children currently do not make co-payments for health services.

Employer Buy-In

  • Under Phase IIB, the state may request permission from HCFA(now known as CMS) to conduct a pilot test of employer buy-in, subsidizing employee premiums for employer coverage. They would work with the state’s only health insurance purchasing cooperative — Associated Oregon Industries — to market CHIP coverage to employers for eligible families not enrolled in their employer’s plan. The state is committed to conducting an evaluation.

Data Collection and Evaluation

The State Legislature created the Oregon Health Plan Policy and Research office to conduct planning research and evaluation on the Oregon Health Plan, including Medicaid and, now, CHIP. The legislature requests specific studies and OHPPR reports during the interim or two years later, when the legislature reconvenes. OHPPR has a staff of 20 and an annual budget between $700,000 and $800,000.

Staff usually design and conduct their own surveys of providers, plans, and families, although they occasionally contract out to a local survey specialist. Staff also can initiate studies if they obtain a foundation grant (e.g., from the Robert Wood Johnson Foundation).

OHPPR plans to analyze data from a variety of sources to assess CHIP. There is speculation that the Legislature will be most interested in research on crowd-out, while the advocates are most interested in research on the impact of the six month waiting period.

Data for Program Design

  • In 1993, the RAND Corporation and Mathematica Policy Research conducted a study of health insurance in 13 states, of which Oregon was one, which included a household survey and employer survey. In 1997, they conducted a follow-up. The data (available in a report to be published in late 1999) helped Oregon officials study the potential for crowd-out and led the Council staff to recommend the six month waiting period for those insured.

Data for Evaluation

  • Staff in OHPPR and FHIAP worked with the Urban Institute and the RAND Corporation on the best approaches to analyze CHIP. The combined staff have developed an evaluation plan that will be part of the Phase II Plan Amendment they will send to HCFA(now known as CMS).
  • The Oregon Population Survey, the most significant effort underway, is a data collection and research response to the Oregon Healthy People initiative. The survey includes questions about employer-sponsored insurance, and about the coverage families have in place. [To view data from the ’94 and ’96 OPS, see www.govinfo.kerr. orst.edu.] Since the CPS sample size for Oregon is too small to accurately estimate the numbers of uninsured at anything other than the statewide level, their own Oregon Population Survey has been a more useful source of statewide data.
  • OPS surveys include 5,000 households of approximately 14,000 individuals, every other year. "The Uninsured in Oregon 1997" reports on the 1996 results. The next report is available in March 1999 on 1998 results, at www.govinfo.kerr.orst.edu.
  • Staff will analyze the penetration rates in OHP/Medicaid and CHIP from OPS. However, they recognize these data can mask the distinction between insurance coverage and access to care. Oregon officials believe that the state has one of the highest rates of alternative medicine usage in the country, with very little of it covered by traditional health insurance plans. While officials estimate that the penetration rate in Medicaid and CHIP could climb into the high seventy percent range, the coverage of alternative treatments and services used by enrollees could remain low. On the other hand, chiropracty has recently been added to coverage by many insurers in the state, and other alternative medical treatments are being considered for coverage.
  • Staff also plan to analyze the effect of the six month waiting period on potential CHIP eligibles. They cannot use OPS for this analysis, as it was last fielded only a month or two following implementation of CHIP. Instead, they will analyze special items on the combined Medicaid/CHIP application form, and an accompanying, one-page Medical Resource Report. The items include:
    • List anyone who can get health insurance through an employer or absent parent.
    • List anyone who has health insurance now. Do not include anyone covered by OHP only.
    • List anyone who had health insurance any time in the last six months. Do not include any time that you were covered by OHP only. Include the month and year your coverage ended.
    • Researchers will merge data on how many children were turned down for CHIP due to the waiting period with data from the 1998 Population Survey, and calculate the average period of uninsurance. This should provide guidance on whether they can roll back the waiting period.
  • Other data is available from a monthly Wage Survey conducted by the Department of Employment. Each month they routinely survey a different occupation code among Standard Industrial Classification(SIC) codes, so that after three years they have covered all occupation codes in the state, and begin the cycle again. Questions asked of employers and employees include those relating to the availability of health insurance coverage, and how much the employer and employee pay of the premiums. The sample size is 150 businesses per occupation. Data from the Wage Survey will be merged with data from OPS and from the Medicaid/CHIP application form to analyze employee crowd-out.
  • Council staff also plan analysis of employer crowd-out, but have left a "place-saver" in the evaluation plan until they determine precisely how they will measure this. They may survey a sample of families with children enrolling in CHIP and enrolling in FHIAP to assess what insurance coverage they lost before enrolling in CHIP or FHIAP. Both programs require six months without insurance prior to enrollment.
  • FHIAP staff will analyze reservation cards and applications for FHIAP and CHIP to assess the success of discrete outreach activities. The objective is to gauge why they are not succeeding with certain groups and modify their outreach efforts, accordingly. They will continue to survey FHIAP families about why they do not enroll their eligible children in CHIP, to share this information with OMAP and the Council. Reports and other resources about FHIAP and CHIP are available at http://www.ipgb.state.or.us.

Challenges to Implementation

Ten Percent Cap on Administrative Expenses

  • Staff on the Oregon Health Council believe the cap on Federal match for administrative expenses will impede OMAP’s outreach activities during Phase I and II. Those funds must be conserved for real administrative functions, like processing applications and enrolling CHIP children. Council staff expressed concern that OMAP will need to hire more people for those functions and to re-determine eligibility and upgrade their computer systems. They appreciate, therefore, the funding available to IPGB for simultaneous outreach for FHIAP and CHIP.
  • Council staff believe the cap will cause a more serious impediment during Phase III, when they hope to gain HCFA(now known as CMS)’s permission to fund direct services with CHIP money. They acknowledge that HCFA(now known as CMS) has indicated it may grant waivers permitting more than ten percent spending on administrative costs for outreach and payment for direct services.

Web Sites for More Information

For additional information, visit a web site at:

http://www.omap.hr.state.or.us

1 - Though not an insurance program, OMIP is funded in part through pro rata assessments on health insurance carriers.
2 - Assets are non-income resources available to an applicant family, such as a car.  A family with a car worth more than $5,000.00 is ineligible for CHIP or Medicaid.
3 - Federal law makes immigrants arriving after August 1996 ineligible for most public assistance benefits.
4 - This is not state General Fund revenue, but revenue from state tobacco taxes.
5 - Social security numbers and copies of social security cards are required "for you and anyone you are applying for."