Public meeting notice:

Tri-County Health Care Safety Net Board Meeting
Date: Wednesday, April 27, 2005
Time: 7:00AM to 9:00 AM
Location: Oregon Community Health Information Network, Inc.
707 SW Washington 9th Floor, Oregon Room
Portland, OR

See www.tcsne.org for more information.

Download agenda (PDF - Adobe Acrobat required)

Background
Though the Oregon Health Plan (OHP) has been a successful tool in assuring access to medical care to some of our region residents, the span between OHP eligibility and the ability to purchase medical coverage is great. In the Clackamas, Multnomah, and Washington Tri-County Regionthere are over 240,000 residents (about 17% of the population) that are without health insurance at some point during the year. (See demo in PowerPoint or in HTML) The Robert Wood Johnson Foundation has provided an opportunity for the leaders of the tri-county area to address this problem creatively. We are one of 13communities across the country selected to develop a strategy to make access to health care for all, a reality.

The implications of being uninsured are significant. The medically uninsured have greater difficulty obtaining access to needed medical care, The uninsured are generally less healthy than those that have medical coverage; they miss more days of work and/or school, they have increased occurrence of treatable disease, and they place greater demands on the health care system. Despite our favorable economy, the number of uninsured is still substantial, and, more importantly, many of our most vulnerable residents (low-wage earners, young families, and the elderly) are without access to medical care.

The uninsured population depends heavily on the compassionate services of the local health care safety net providers, (non-profit clinics and county health services) for their immediate medical concerns. This population also depends upon the charity of local hospitals for catastrophic care. The capacity of our safety net system has been saturated with demands for care, forcing some medical providers to limit access to care by closing their practices to new patients.

Implications of Inaction
Inaction is not a choice on the issue of assuring access to health care. Our workforce must be kept strong, a lack of health care makes it vulnerable. Our children need to be successful in their education years, a lack of health care prohibits this assurance. Our elderly population needs to be assured comfort in later years of life, a system that fails to assure the elderly access to health care will create a life of emotional and financial instability for our senior citizens.

Common Ground
Current statistics indicate that gaps in coverage exist in the health insurance programs provided through the State of Oregon and through employers. Our residents should have basic health care access. As a collaboration, we agree that (1) every citizen in our communities has the right to access quality, affordable health care, (2) it is the role of local government to convene a process to develop mechanisms to assure that citizens have access to care, and (3) It is necessary to include representation from all stakeholder groups to address the problem of access effectively.

The Tri-County Communities in Charge initiative will create the forum within which health care access for all within our region can be achieved. Our first year planning process revealed a strong community consensus around two themes which will serve as the foundation for our community's approach to care for the uninsured. The two themes are:

  1. Refine and restructure the safety net system to utilize existing resources with greater efficiency and effectiveness; and
  2. Increase access for defined populations and sub-populations through well-planned investment of resources for system expansion.
The Tri-County Communities in Charge initiative emphasizes processes that will transform the existing safety net into a well functioning, integrated system of care for the uninsured. The three major components necessary to accomplish this integration include the following:

What is a Safety Net Authority?

A Safety Net Authority is a concept that was birthed by the Core steering committee for the TCCIC project. The general concept of a Safety Net Authority is a defined body that is charged with assuring access to health care services. Support for this idea comes from other organizational examples that were developed to meet a community need. These examples locally include Tri-Met, The Housing Authority of Portland, The Port of Portland, and METRO. The functions of a Health Care Safety Authority were identified by the Core Steering Committee and graphically depicted in the functional diagram below.

Health Care Safety Net Authority

The conceptual outcomes of the Health Care Safety Net Authority are:

How will the Safety Net Authority be developed?

Creating a new, regional authoritative entity is a grand task. Though the Core Steering Committee generated the concept and functions for the Safety Net Authority, a higher level of community leadership was necessary in order to test and later implement such an entity. The three county boards convened a Blue Ribbon Panel on Health Care Access to further shape the strategy. The panel, comprised of 38 leaders, advocates, and consumers from Multnomah, Clackamas, and Washington Counties, spent the past five months learning about the difficulties of being uninsured. These meetings culminated in the decision to recommend a structure that maintained government as the convener and creates a partner relationship with local health systems, health plans, advocates, and providers.

The Tri-County Communities in Charge Blue Ribbon Panel completed its final deliberations on a recommended approach to improve health care access in the Portland metropolitan region. The unanimous decision of the panel at their April 3, 2002 meeting initiated a recommendation for the three counties to consider a Tri-County Health Care Safety Net Authority, developed by intergovernmental agreement and charged with improving access to care for our community's most vulnerable. The group hopes to have a draft of the regional approach available for comment by June, 2002.

Further, the panel's recommendation included the following Vision, Mission, and goals.

-Vision-

Low-income and uninsured residents of the tri-county area get the basic health care they need when they need it.

-Mission-

To assure access to primary and preventive health care services for the low-income and uninsured of Clackamas, Multnomah, and Washington counties in an appropriate and cost-effective manner.
-Goals-

1. Data- Assure that the health care safety net is able to collect demographic and utilization data, so that this data can ultimately be used for system planning.

2. Finance- Assure that adequate financial support is available to provide care for the low-income and uninsured.

3. Capacity- Assure that the local health care safety net has adequate clinical capacity - e.g., providers, other staff, facilities, equipment and supplies, etc.

4. Quality- Assure that the health care safety net provides care that meets quality standards as defined by Medicaid

Guiding Principles-

1. Inadequate access negatively affects all aspects of a person's life, that of their family, and the general community.

2. Absent a national or state solution to the access crisis, it is an appropriate role for local communities to take on the problem.

3. Because the poor and vulnerable have little or no resource, their access to care cannot be addressed by the market alone.

4. A local solution requires government leadership even if only local.

5. Addressing the problem of access to care locally requires the shared involvement of government, health systems, local providers and provider organizations, consumers and advocates.

6. Resources for care and care coordination are the responsibility of all convening partners, shared chiefly by government.

7. A long-term solution will require several short-term actions and the first is to create a structure to allow for centralized leadership for joint action.

8. The most appropriate structure for the development of an answer to the access problem is governmental in nature.

9. This structure must be able to respond to the needs of the community (broadly defined), the poor and the uninsured.

Blue Ribbon Panel meeting materials and Agendas are available here:

What is the Oregon Health Plan?

The Oregon Health Plan (OHP) offers health care to its members at little or no cost. OHP health care benefits include medical, dental, mental health and chemical dependency services.

Who is Eligible for Medicaid or OHP?

The following chart lists of the mandatory and optional categories under federal Medicaid law and coverage in Oregon's Medicaid programs.

To participate in Medicaid, states are required to cover all mandatory client groups and may elect to cover optional groups. However, states are not permitted to impose enrollment caps or waiting lists for any group of clients. In its waiver proposal, Oregon has requested that the federal government lift this protection for clients in optional groups.

Mandatory Client Groups under Federal Medicaid Law (covered under OHP)

Optional Client Groups covered in Oregon's Medicaid Programs

1 Federal law allows some variation form state to state of income levels.
2 In some other states, federal law may permit pregnant women and infants to be considered mandatory up to only 133% of the federal poverty level
3 Federal Medicaid law has three broad categories of client groups: mandatory categorically needy, optional categorically needy, and medically needy. States may elect to cover medically needy client groups just as they may elect to cover optional categorically needy groups, but some different rules apply to these two broad categories.

Despite the OHP, there are still many people without health insurance and therefore, without dependable health care access. Many of the folks in this predicament, a disproportionate number, are also members of minority communities. In an effort to further understand the issue of the uninsured, it is also necessary to understand why some are able to get on the plan and some are not. The research we have completed to date includes the following:

Oregon Health Plan logo  OMAP's home page.

What is Charity Care and what are Community Benefits?

In order to receive medical services, the uninsured in the Portland, Oregon Metropolitan area rely on community health clinics, county health departments, and non-profit hospitals.

Fifty-seven of the sixty-one acute care hospitals in Oregon are non-profit or publicly owned, while four are investor-owned. Non-profit hospitals are owned and operated for the benefit of local residents under the leadership of a volunteer board of directors. Non-profit hospitals in the United States have been exempt from taxation since 1751 when Benjamin Franklin established the Pennsylvania Hospital. They are exempt from federal and state income taxation as 501(c)(3) organizations, and from local property taxes under ORS 307.130. Tax law, as a tool of public policy, encourages non-profit hospitals to provide free and discounted services to the uninsured. It implies that the benefits that non-profit hospitals return to their communities need to reflect the value of their tax exemptions. In response, non-profit hospitals provide health-related services that would otherwise be left to the government, community agencies or, not provided.

Charity care is an ideal illustration of a "community benefit" provided by a non-profit hospital. Charity care is free or discounted services provided by a hospital for people who demonstrate they cannot afford to pay for care. Hospitals do not expect to receive payment for charity care services. Despite the critical role charity care plays, the uninsured are seldom aware of such assistance. Nationally, medical bills accounted for forty-five percent of personal bankruptcy filings in 1999. A recent study shows that of the estimated 64,000 uninsured living in Multnomah County (in which Portland resides), 20% have filed for bankruptcy because of medical bills; 25% are currently paying off medical bills; and 20% are in collections as a result of medical bill. Evidently, the uninsured, both nationally and in Portland, are not receiving adequate information and instructions to access financial assistance for hospital services. Many whom experienced financial hardship because of medical bills locally, would have qualified for free or reduced-cost care under Portland hospitals' charity care policies.

Tragically, hospital staff and the uninsured, are rarely aware of charity care policies or misunderstand the procedures. Paradoxically, providing free or reduced cost care to the uninsured is an unequivocal way to fulfill a hospital's community benefit obligation. To better understand non-profit hospitals and the vital community benefit - charity care - Oregon Health Action Campaign's (OHAC) Community Benefits Task Force monitored the accessibility of hospital charity care policies. Data was gathered via telephone and on-site surveys from six Portland non-profit hospitals. The result of the work completed through this campaign includes the following:

For further information about this program, contact Tom Fronk, Strategic Partnerships Director, at
503-988-3674 ext. 24272.

Links
Robert Wood Johnson Foundation
Communities in Charge
Multnomah County Health Department
Washington County Department of Health and Human Services
Clackamas County Public Health Division

The Access Project:

Health Care Policy - The Basics (PDF)
Resource Guide (PDF)

Health Department | Multnomah County
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