by Consuelo Echeverria
The Universal Health Care Commission’s (UHCC) October meeting focused on the mandated report due Nov 1st to the Washington State Legislature. At the same time our neighbor to the south, Oregon released its Joint Task Force on Universal Health Care report to its legislature.
The Oregon report is in the form of 13 recommendations to the legislature. Below are its highlights. Please note not all 13 recommendations are summarized. The full Report and all supporting documents are available on the Oregon Health Authority website.
The UHCC has been unable to formulate a vision of what a universal health care model should look like in Washington. This is despite the recommendations of the UHC Working Group 2021 Report which overwhelmingly recommended the single payer model which is projected to reduce aggregate system-wide expenditures by approximately $2.5 billion in the first year of implementation.
In contrast the Oregon Legislature set the vision for their Task Force with the requirement of a unified publicly funded health care system.
The Oregon Plan envisioned 2 taxes; income and payroll. Income is not relevant as a source of revenue in WA. The payroll tax is estimated to generate $12 billion, which is similar to the current Oregon tax structure for small businesses who do not offer Employment Based Insurance.
The Report recommends 6% for state administration (p. 57) and standard reimbursements at 124% of Medicare (Appendix B). This is between the current 85-170%.
The breakdown of costs in the Report may be useful. The source data for WA health care cost expenditures included Medicare, Medicaid and commercial insurance plans such as Aetna. However missing from the Washington data is the cost of administering our opaque insurance and billing system which is the result of Value Based Payments contracts and consolidation.
The Oregon actuary Report Universal Health Care Financial Modeling September 21, 2022 broke these administrative costs down, (p. 26) and found that the administrative efficacy of a global budget would save $2.1 billion in provider rate changes. Furthermore removal of insurance margin ($758 million), insurance carriers ($20 million) and commissions and marketings ($65 million) would save the state close to a billion dollars.
Optumas noted that “One benefit of a standardized fee schedule is a reduction in the amount of resources required by health care providers to manage multiple insurance payers related to reimbursement, practices, requirements (e.g., prior authorization), collection of patient cost sharing, and the submission of claims.” ( 24 pg.)
We can advocate that the Washington UHCC use this actuary Report to gain a better understanding of the drivers of healthcare costs in Washington and as further evidence of the true cost of privatization and risk shifting.
Value Based Payments / Purchasing
The Oregon Plan is trying to redefine “Value Based Purchasing (VBP)” which historically has been used to shift risk on to providers, to prioritize patient and community input to define what is of value. For example, regional communities will have influence over what outcomes are most important and thus incentivized in payment arrangements.
This concept of value via patient and community perspectives, may be useful for us in Washington as we try to redirect the impact of the VBP roadmap that the HCA is pursuing.
All members of the Washington UHCC are required to vote. In this penultimate meeting of 2022, The November Report to the Washington Legislature was approved with only Rep. Schmick voting no.
The Oregon Joint Task Force consisted of 20 members, with Legislative Assembly members being unable to vote.
Meetings & Staff
With the support of five staff, the Oregon Joint Task Force met for more than 250 hours, created:
Four Technical Advisory Groups (TAG)
Eligibility, Benefits and Affordability Technical Advisory Group
Provider Reimbursement Technical Advisory Group
Finance & Revenue Technical Advisory Group
Governance Technical Advisory Group
sponsored a Consumer Advisory Committee. This is in contrast to the Washington UHCC staff of 1 FTE split across 2 people. We need to advocare for comparable support and staff to help the Washington UHCC to move much more quickly in designing our universal healthcare system.
The Consumer Advisory Committee held 13 community listening sessions and business forums across Oregon. The community listening sessions targeted diverse (BIPOC) communities, while the business forums were held with farmers and small business owners. They met before the Technical Advisory Groups and after for feedback on the recommendations. A summary of their findings can be found here.
Eligibility and Enrollment
There will be a “no wrong door” policy, emphasizing that all Oregonian residents, including those who lack documentation, will be eligible for the Plan regardless of whether their employers offer health benefits. Out of state employees who work in Oregon will not be covered. (p.17)
The Oregon Plan used the Public Employees Benefit Board (PEBB) as their benefits model; the WA Report has no mention of coverage. We would support that PEBB be used, as it covers more benefit categories than the ACA’s essential benefits (e.g. complementary care, adult dental, adult vision). (p. 18)
The Report provides a good summary of 4 ways to deal with Medicare.
The Oregon Joint Task Force noted:
While Maryland and Vermont have coupled federal Medicare payments, implementation has had mixed results.
Even without full authority over Medicare funds, a demonstration of improved outcomes (1115 Innovation Waiver) could provide the state with evidence to seek an expanded role in administering Medicare benefits.
If unable to get federal permissions to integrate Medicare into the Oregon Plan, an alternative is to offer the Oregon Plan as additional wraparound services, such as behavioral health or dental care.
Oregonians with Medicare could also be exempt from certain taxes, eligible for tax credits, and/or reimbursed for medical expenses. (p. 21)
The Oregon Plan offers that their employers payroll tax will be keyed to wages to avoid an ERISA preemption. (McCuskey & Brown, Appendix A)
Long-Term Services and Supports
Long-term care will continue under Medicaid. The Plan will also cover some skilled nursing and home health care. It provides an option to purchase LTSS insurance from private carriers.
Payment for Health Care
No payment required at point of service. (p. 24)
The Oregon Plan will pay providers directly, no capitation, it highlights parity between rural and urban providers.
As HCFA-WA member Cris Currie noted, the report recommends allowing providers to serve those covered by self-funded plans in addition to serving those covered by the state plan (p. 24) and makes no mention of participation agreements. This appears to be straying from the McCuskey & Brown recommendation to require providers to exclusively serve the state plan (p. 65).
The Report considers single-payer systems that integrate private insurance. The Report recommends Complementary coverage to cover gaps in the public plan, for example Long-Term Care, with no duplicate insurance (p. 27).
Employers and Employees
There is no employment based insurance as all Oregon residents will be covered. All employers will pay a progressive payroll tax. The suggested rate is 7.25% for wages below $160,000 and 10.5% for wages above (p. 43). They admit that the total tax could be more or less than existing health insurance payments (Appendix C).
The Report did not resolve either Taft-Hartley, union-represented employees who are eligible for health benefits negotiated with multi-state employers, or Workman's Compensation; and it suggests further study for both.
As mentioned above, this brief does not cover all 13 recommendations. Please read the Report pgs. 13 - 36 for the full recommendations.
Dr. Weinberg, HCFA-WA Board member and a long time universal health care activist, shares Lessons for Washington State:
Our Universal Health Care Commission should be encouraged to think big and bold, as Oregon’s Task Force was charged to do.
Figuring out how to raise the necessary state funds in an equitable fashion will be a major challenge given our state’s rejection (at least so far) of any income tax.
Specific structures need to be included to include diverse segments of our population in the governance and operation of a plan.
Speed up the work of our UHCC, especially by adding funding for sufficient staff and meetings, because many people are being harmed now by the poor functioning of the present system.
Start negotiations early with the federal government regarding the needed cooperation and legislative/regulatory changes.
Include mechanisms for broad public outreach for input as the new system is designed.
Please feel free to use these lessons as guidelines for public commentary.