III.B. Overview of the State

 

Oregon’s Demographics, Geography, Economy, and Urbanization

 

Demographics and Urbanization

Oregon’s population of 4.2 million makes it 27th in population among US states. Oregon has large rural and frontier areas, resulting in an overall population density of 40 people per square mile. Oregon’s population has increased faster than the national average. Approximately 65% of Oregonians live in urban areas, 33% live in rural areas and 2% live in frontier areas (Oregon Office of Rural Health). Population density ranges from about 4,228 persons per square mile in Portland to 7 persons per square mile in frontier areas and 23 persons per square mile in areas with 50,000 or less population (US Department of Agriculture). Portland is the largest metropolitan area, with about 2.5 million people. Other urban centers include Salem, the state capital, Eugene, in the mid-Willamette Valley, Bend, in Central Oregon, and Medford, in Southern Oregon. There are 9 Federally recognized Native American tribes in Oregon and indigenous people from over 100 tribes make up the approximately 76,000 Native Americans and Alaska Natives living in Oregon. The Portland area has the 9th largest urban Native American population in the US, and 43-member tribes from Idaho, Oregon and Washington participate in the Northwest Portland Area Indian Health Board.

 

With increasing population mainly due to in-migration, Oregon’s population is becoming increasingly diverse in terms of race and ethnicity. However, it remains one of the least diverse states in the country. In the 2020 Census, 75.1% reported as non-Hispanic White only, a proportion that has decreased over time. Hispanics make up the largest minority population at 13.4%, more than doubling since the 2000 Census. Other races have slightly increased, with Asians at 4.9%, Native Hawaiian or Other Pacific Islander 0.5%, African Americans at 2.2%, American Indian/Alaska Natives at 1.8% and 2 or more races at 4%. Approximately 15% of Oregonians speak a language other than English at home and about 10% of the population is foreign-born. About 10% of the population under 65 years has a disability (US Census).

 

Oregon’s fertility rate has declined since 2010, following national patterns, with 48.9 live births per 1,000 women ages 15-44 compared to the national average of 56.3 for 2021(Oregon Vital Statistics Annual Trends ; CDC Birth Data). In 2021, Oregon had 40,931 resident births, of which 65.4% were non-Hispanic White, followed by 20.3% Hispanic, 5.2% Asian, 4.1% mixed race, 2.6% African American,  0.9% American Indian/Alaskan Native, 0.8% Native Hawaiian/Pacific Islander and not stated 0.7% (Oregon Vital Statistics Annual Report). In 2020, 5.5% of the population was under 5 years of age, and 20.5% was under the age of 18 (US Census). Overall, the median age of Oregonians is 39.7 years, and as of 2017 the median age of mothers is 29 for all births (OVS, 2017).

 

Geography

At 96,981 square miles, Oregon is the ninth largest state in the U.S. Oregon's landscape varies from rainforest in the Coast Range to barren desert in the southeast. Oregon’s large size and geographic diversity create challenges for the Maternal, Child, and Adolescent Health system, including the concentration of services in urban areas, geographic and meteorologic barriers (including  climate disasters like wildfires, extreme heat, and ice storms). These challenges can negatively impact delivery and access to health services, and compounds issues related to workforce capacity and training needs that  are vastly different in different regions of the state. Rural and frontier service areas have greater unmet need than urban areas (as determined by low score of 46.4 vs. 62.6 for urban service area). In rural and frontier services areas, ten have zero primary care provider FTE, 23 have zero dentist FTE and 24 have zero mental health provider FTE. While Oregon’s five-year (2015-2019) average inadequate prenatal care rate is 60.1 per 1,000 births per year, the average rate in frontier service areas is 101.6. Of note the Warm Springs service area which serves tribal members has a rate of 214.1, which is triple the state rate ( Oregon Areas of Unmet Health Care Need Report, 2021). Although the COVID-19 pandemic has resulted in a significant increase in telehealth services, broadband internet services may not be available in rural and frontier areas. Overall, about 86% Oregonians have broadband internet subscriptions (US Census).

 

Geography presents a considerable barrier to accessing care for CYSHCN. Families living in rural and frontier Oregon counties experience challenges getting the services they need, particularly specialty care. Specialty care services for children are concentrated in urban areas along the Interstate 5 corridor, especially in Portland, where the only children’s hospitals (Oregon Health & Science University’s Doernbecher Children’s Hospital, Emmanuel Legacy Randall Children’s Hospital, and Shriner’s Children’s Hospital), and the only teaching hospital (OHSU) are located. Mental and behavioral health services are especially difficult for CYSHCN and their families to access, due to a lack of providers throughout the state. The COVID-19 pandemic resulted in a sudden and substantial increase in telehealth services. It may be possible to leverage telehealth to improve or increase health care and services for rural Oregon CYSHCN with insufficient access to local providers. However, families with insufficient hardware, broadband, digital literacy, or translation services lack equitable access to telehealth services.

 

Economy

Oregon’s economy impacts maternal and child health, as well as population growth and state revenues. Prior to the COVID-19 outbreak, Oregon’s seasonally adjusted unemployment rate had peaked in May 2009 at 11.6%, and unemployment rates steadily improved over the decade. In March 2022, Oregon’s unemployment rate was 4.0%, placing it 42nd among states and is well below the 6.1% it reached in March 2021( Bureau of Labor Statistics). However, the recovery prior to the pandemic was unevenly experienced around the state with southern and central Oregon counties experiencing greater unemployment (Oregon Employment Department). Oregon, like other states, experienced unprecedented unemployment during the COVID-19 outbreak.

 

Oregon’s median household income is $62,818 in 2020 which is similar to the national average. The overall poverty rate was 1.4%, which is slightly higher than the national average (US Census). Oregon has a new three-tier minimum wage rate that varies by geography, from $15.45 per hour in the Portland Metro area to $13.20 per hour in designated nonurban counties. Although Oregon’s minimum wage is higher than most other states, private-sector workers in Oregon tend to work fewer hours per week and their average wage earnings are below the national level. Wealth inequality across racial/ethnic groups persists with the median income of Black ($61,000) and Hispanic ($56,500) families with children being significantly less than the median income of white families with children ($96,000) (The State of America’s Children 2023 Factsheet).

 

Almost all racial/ethnic minority populations have higher poverty rates than non-Hispanic Whites. In 2021, the unemployment rate for all Oregonians was 6.6%. Oregon population groups that have higher unemployment rates are Blacks at 10.1% and American Indian and Alaska Native at 7.4% (Oregon Center for Public Policy). The 2022 poverty rate for children under 18 years is 12.1% (Oregon Kids Count) and 12.7% for children under 6 years, the 10th highest in the US.  Additionally, 5.6 percent of children under 18 (6.4% of children under 6) are very poor.  Children of color have significantly higher rates of poverty than white children (11.2%) in Oregon: 19% for Hispanic children, 25% for Black children and 25.2% for Alaskan Native/American Indian children (The State of America’s Children 2023 Factsheet). Fifteen percent of CYSHCN ≤17 years live in households with incomes below 100% of the Federal poverty level (NSCH, 2020-21).

 

Oregon’s new  Paid Leave Oregon program began January 1, 2023, with employees and large employers with 25 or more employees paying into paid leave and employees able to begin accessing benefits September 3, 2023. Paid Leave provides job protection while employees take paid time off during qualifying events for family leave, medical leave, or safe leave. Examples of qualifying events include the birth or adoption of a child, a serious medical event for self or a family member or for someone experiencing domestic violence. Up to 12 weeks of paid leave can be taken in a 52-week period and up to 2 additional weeks (up to 14 total weeks) may be taken for pregnancy, birth or health needs because of childbirth. Paid Leave Oregon provides income for every week of Paid Leave, and some employees will get 100% of their wages.​

 

Oregon’s strengths and challenges that impact MCH populations

Key state issues impacting Maternal, Child, and Adolescent Health include: health systems transformation, Oregon’s Early Learning System transformation, medical home for CYSHCN including cross-systems care coordination and shared care planning, and the modernization of Oregon’s Public Health system. Upstream factors, including the state of Oregon’s economy, employment, equity, education, and the environment are also key drivers of Maternal, Child, and Adolescent Health across the lifespan. The impacts – both direct and indirect – of the COVID-19 pandemic on Oregon’s MCAH population will doubtless be unfolding for many years. This year’s report was written to account for those impacts that are known at this time. 

 

Oregon health systems transformation

Oregon’s health systems transformation efforts have been ongoing since before the Federal Affordable Care Act (ACA) implementation, and alignment of public health, including Maternal, Child, and Adolescent Health work with health system transformation is a key priority for the State. Oregon’s health system transformation, and the unique role Coordinated Care Organizations (CCOs) in serving the MCAH population is described in detail in section III.E.2.b.iv.

 

CYSHCN needs and health systems transformation 

Children make up 35.8% of Medicaid and CHIP populations as of December 2022 (Centers for Medicare and Medicaid Services), and 43.75% of Oregon CYSHCN ≤17 are insured wholly or partially by Medicaid or SCHIP (NSCH, 2020-21). Oregon’s CCOs are responsible for ensuring care for people covered by Medicaid. Despite the state’s commitment to the Triple Aim, families and providers still report considerable challenges for the CYSHCN population. Families experience confusion about who is responsible for coordinating care for CYSHCN across multiple systems. While CCOs are required to provide specific care coordination activities for CYSHCN, implementation has been both complex and uneven. Lack of CCO care coordination capacity and a lack of clarity about what is required of CCOs have contributed to uneven care. Primary care practices with Patient Centered Primary Care Home status attest to making progress toward standards that may or may not include CYSHCN. The inconsistency in types and amounts of coverage confuses families and exacerbates disparity and inadequate care for CYSHCN. While coverage for Applied Behavioral Analysis (ABA) for children with Autism Spectrum Disorder is mandated, the number of providers has decreased, and access remains uneven.

 

Education

Over their lifespan, children in Oregon have access to private and public preschools, Head Start, public schools, community colleges, universities, and graduate education. About 90% of persons in Oregon older than 25 years have graduated from high school (US Census).

 

Oregon’s Early Learning Division (ELD) supports all of Oregon’s young children and families to help them learn and thrive. The Division is focused on childcare, early learning programs and cross systems integration, policy and research, and equity. Programs provided through the ELD include Early Head Start, Head Start and Oregon Pre-K, Healthy Families Oregon, Preschool Promise, and Relief Nurseries.

 

Oregon has 197 public school districts, 1,246 public schools, and 560,917 students enrolled from kindergarten through grade 12. The Oregon Department of Education’s “North Star” Goal for the 2021-22 school year was to safely and reliably provide in-person instruction every day, including their Care and Connection efforts all year long post-pandemic. Additionally, the work of the Student Success Act (SSA) is firmly underway. Signed into law in 2019, the SSA invests $1 billion into Oregon schools each biennium, for example over half of the funds in the SSA encompass the Student Investment Account (SIA) which holds critical momentum for community engagement and deep investments in student well-being. Another portion is providing the youngest learners access to preschool programs across the state. Despite the pandemic, the SSA has hit key implementation milestones, and ODE remains committed to deepening community trust through equity-centered priorities that center collaboration and open communication. Additional efforts for the 2021-22 school year included:

• The Oregon State Board of Education and ODE have made guidance, educational resources, and toolkits available to support safe and inclusive schools.
• The Early Learning Division and ODE launched a plan to reimagine Oregon’s kindergarten assessment.
• Recognizing the unique strengths and assets of Oregon’s students through the implementation of House Bill 2845, Oregon’s Ethnic Studies Curriculum.
• Responding to Senate Bill 744, which gives Oregon a chance to update and innovate its outdated graduation requirements and rebuild an education system in a way that equitably serves Oregon’s Black, Latino, Latina, Latinx, Indigenous, Asian, Pacific Islander, and Indigenous students, as well as students who are LGBTQ2SIA+; emerging bilingual; and those navigating foster care, houselessness, and poverty

 

There were 553,012 students enrolled in Oregon public schools in 2021. Oregon’s K-12

public schools experienced a dramatic, unprecedented enrollment decline during the 2020-21 school year and again in the 2021-22 school year, attributed to the COVID-19 pandemic. Oregon’s schools serve 27,672 fewer students (-4.7 percent) than it did in 2017-18. Among K-12 public school students in Oregon, 40.3% are students of color which has increased from previous years; 18,358 students which is an increase over the previous year; 14.2% receive special education services, and almost 11% are English Language Learners. Oregon’s 4-year high school graduation rate for all students is 80.6%. While the opportunity gaps for historically underserved student groups have diminished in recent years, they still remain substantial. For cohort graduation rates, the gap between students of historically underserved races/ethnicities (Black/African American, Hispanic/Latino, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and other students (White, Asian, and Multiracial) has continued to decrease (by 1.2 percentage points in five years). Oregon Department of Education, Oregon Statewide Report Card 2021-2022).

 

Data also indicate gaps in providing school health-related services. In 2021-2022 only 17 school districts (8.6%) met the recommended ratio of 1 school nurse for every 750 students.  ODE’s yearly data collection on school nurses and students with medical needs continues to demonstrate a significant shortage of nursing services for all students in Oregon. Only 47% (n=92) of districts in Oregon reported staffing one or more full-time school nurse. Although Oregon schools did report an increase of 34 school nurse FTE statewide from the 2020-21 school year, 27% (n=54) of school districts did not report any school nurse FTE. Out of the 143 districts who did report school nurse FTE, 45 districts reported less than 0.5 school nurse FTE, meaning that a school nurse was available less than 20 hours per week for the entire district. Eleven out of 142 school districts reported no school nursing services are available for their medically fragile, medically complex, and/or nursing dependent students enrolled in their district  (Nursing Services in Oregon Public Schools 2021-22 Legislative Report).The National Association of School Psychologists’ analysis of 2020 data from the U.S. Department of Education showed that Oregon had 1,659 students per school psychologist, greatly exceeding the recommended ratio of 500:1, highlighting the shortage of mental health services in schools in the same timeframe when the American Academy of Pediatrics declared a “national emergency in child and adolescent mental health.”

 

Every child in Oregon identified as needing special education has at least one of the disabilities defined in the Individuals with Disabilities Education Act. In Oregon, children must have a diagnosed physical or mental condition that is likely to result in a developmental delay to receive Early Intervention/Early Childhood Special Education (EI/ECSE) services. In 2022, 78,714 Oregon children (age 3 – 21 years) were in special education, 3,718 children (age 0 – 3 years) received EI services, and 6,845 children (age 3-5 years) received Early Childhood Special Education services (Oregon Department of Education, 2021-22). The educational impacts of the pandemic on CYSHCN remain to be seen. Anecdotal reports indicate that many children in special education experienced particular difficulty with online education.

 

Oregon’s higher education system includes seven public universities and the Oregon Health & Science University, 17 public community colleges, over 50 private colleges and universities, and hundreds of private career and trade schools. About 33% of Oregonian’s have a Bachelor’s degree or higher (US Census).

 

Early learning system transformation

Oregon’s early learning system transformation, guided by the Early Learning Council (ELC), is a key partnership for Title V, and another effort that is shaping the changing context for maternal and child health in our state. The vision for early learning system transformation is to: 1) Ensure all Oregonian children arrive at kindergarten ready to learn and having received the early learning experiences they need to thrive; 2) Children are living in families that are healthy, stable and attached and 3) Oregon’s early learning system is aligned, coordinated and family centered. The ELC directs the Early Learning Division of the Oregon Department of Education, which is responsible for numerous activities and initiatives including but not limited to:

• 16 regional Early Learning Hubs which coordinate services for children 0 to kindergarten entry across five sectors: early learning, human services, health, K-12, and business.
• The Office of Child Care, which manages childcare licensing and monitoring throughout the state.
• Implementation of a tiered quality rating improvement system for childcare known as Spark.
• Coordination with Early Intervention/Early Childhood Special Education services.

 

In 2018, The Early Learning Council (ELC) completed a strategic planning and engagement process, which resulted in the Raise up Oregon Plan (RUO). Title V was a key partner in its development, and now in its implementation. The ELC established the Raise up Oregon Agency Implementation Coordinating Team (RUOAICT) to drive cross-sector implementation of the RUO plan. The Title V Director sits on this team.  The Early Learning Council is currently in the process of developing Raise Up Oregon, second edition in which Title V staff are engaged.

 

Early Learning Hubs ensure that systems are aligned so that children 0-5 and their families can access the services and resources they need to be ready for kindergarten.  The Hubs are particularly relevant to CYSHCN because they create referral pathways for screening and assessment. They guide programming for children with special health care needs and ensure that systems address the needs of families. Some Early Learning Hubs have expanded their workforce to include Family Navigators or Family Resource Specialists, positions designed to help families identify and access community resources.

 

Patient-Centered Primary Care Home (PCPCH) Program

The PCPCH Program is Oregon’s realization of the patient-centered medical home concept. The program’s goal is to accomplish the Triple Aim of health care. OHA established a set of recognition criteria, a technical assistance guide, and a self-assessment tool to aid practices in achieving PCPCH recognition. Initially the program consisted of three tiers of recognition, with the 3rd tier being the most advanced level of recognition. In 2017, the program revised the recognition criteria and expanded to five tier levels, with the 5th tier being the highest.

 

Modernization of Public Health

Governmental public health in Oregon continues to undergo a major restructuring and modernization based on the recommendations of a legislative task force and the core functions of public health. HB 3100, the Modernization of Public Health Bill is based on the Task Force Report and uses a framework of foundational capabilities and programs that are needed throughout the state and local public health systems. The changes focus on the need to achieve sustainable and measurable improvements in population health; continue to protect individuals from injury and disease; and be fully prepared to respond to public health threats. A Public Health Modernization manual has been developed, along with a Modernization Plan based on assessment of the capacity and gaps in the governmental public health structure across Oregon. The legislature has made increasing investments since 2019, most recently appropriating $112 million in the 2023 Legislative Session to continue and enhance public health modernization during this biennium. State Title V and local grantees are integrally involved in ensuring that maternal, child, and adolescent health programs are aligned with and central to public health modernization.

 

Housing

Oregon has nearly 1.8 million housing units with 62.4% being owner-occupied (Census Bureau). Of households that spend 30% or more of income on housing, 51.6% rent, 31.4% had mortgages, and 14.9% own without mortgages. The median monthly housing cost for each group was $1,110 for renters, $1,699 for mortgaged owners, and $538 for owners without a mortgage. 2.2% of households did not have a telephone service and 7.5% were without a car or vehicle for transportation. According to the State of Housing Portland 2022 report on housing costs and income, the average overall asking rent increased by 3.7 percent from the previous year and average rent was $1,614 per month. Rising rental and home sale prices in recent years have displaced many Portlanders, disproportionately affecting people of color and lower incomes.

 

Oregon experienced one of the nation’s largest increases in homelessness between 2020 and 2022. The number of people experiencing homelessness grew nearly 23% during the two-year span, increasing by 3,304 people to about 18,000, according to a federally mandated physical count of homeless individuals. Oregon had the highest rate of chronic homelessness in the nation with 44% of individuals experiencing homelessness showing patterns of chronic homelessness (someone that has a disability and been homeless for more than one year or has experienced homelessness multiple times over several years). Oregon also reported that nearly 2,000 (59%) of its 3,373 homeless individuals in families with children were living unsheltered in early 2022. No other state had nearly as high a percentage of people in homeless families living unsheltered (The 2022 Annual Homelessness Assessment Report to Congress).

 

Oregon Health Authority’s roles, responsibilities and interests impacting Title V service delivery

Oregon’s Title V work is interwoven with the priorities and initiatives of Oregon Health Authority (OHA) and the Public Health Division, the OHSU Institute on Development & Disability (IDD), and those of local health departments and tribes. At the state level, Title V aligns with the OHA Triple Aim, IDD priorities, the Oregon State Public Health Improvement Plan, and the Public Health Division Strategic Plan, as well as with the priorities of the Coordinated Care Organizations (CCOs).

 

The Oregon Health Authority (OHA) is responsible for most state-level health-related programs in Oregon, including Public Health, Medicaid, Addictions and Mental Health, the Public Employees, and Oregon Education Benefit Boards, and the Oregon State Hospital. The Oregon Health Policy Board oversees the OHA and is a nine-member, citizen-led board appointed by the Governor and confirmed by the Senate

 

Oregon’s public health statutes and programs are administered by the Public Health Division within OHA, and most of Oregon’s 36 county jurisdictions is the designated local public health authority (LPHA). Currently, there are 33 LPHAs and one health district serving two small rural county populations. Two counties have given back their local public health authority to the state, and in those counties, OHA is responsible for the mandated public health services. LPHAs are legislatively mandated to provide ten core public services. The Conference of Local Health Officials represents and advocates for local health departments in negotiations with the state and works to assure that they have the skills and resources necessary to carry out their work.

 

Oregon Health Authority (OHA) Triple Aim and Strategic Goal

OHA is the central agency that oversees health transformation in Oregon, guided by the Triple Aim of improving the lifelong health of Oregonians; increasing the quality, reliability, and availability of care for all Oregonians; and lowering or containing the cost of care so it's affordable to everyone.  OHA also has a strategic goal of eliminating health inequities in Oregon by 2030. Title V’s prevention and health promotion work supports the Triple Aim and the strategic goal through interventions with vulnerable populations at critical stages of the life course. Section III.E.2.b.iv describes Title V’s work in support of health system transformation and the partnership with CCOs in more detail.

 

Institute on Development & Disability

The Institute on Development and Disability (IDD) is part of the Department of Pediatrics at OHSU. The IDD works with patients, families, clinicians, researchers, and other professionals to improve the lives of people with disabilities. They engage in research, advocacy, and education. IDD clinicians also provide health care to people of all ages who experience disabling conditions from across Oregon. They support the right of people with disabilities to determine the course of their lives, and to live as fully integrated, contributing members of their communities.

 

State Public Health Improvement Plan

As part of Public Health Accreditation, Oregon created a state health profile and developed a State Health Improvement Plan (SHIP),which was updated in 2020 for the 2020-24 priorities. The SHIP priorities include: Institutional bias; Adversity, trauma and toxic stress; Economic drivers of health (including issues related to housing, living wage, food security and transportation); Access to equitable preventive health care; and Behavioral health (including mental health and substance use). Title V is a critical partner whose work is threaded across all the SHIP priorities.

 

CCO Community Health Improvement Plans and Outcome Metrics

Title V work also aligns with, and supports, the community health improvement plans of the CCO’s, as well as their performance metrics. Each of the 16 CCOs has developed a community health improvement plan (CHIP) which details their commitment to improving population health through a long-term, systemic effort, and is required to report on those plans annually. The CCOs also receive enhanced payments based upon their health indicators in key MCAH areas such as pre-K well child visits, child and adolescent immunizations, preventive oral health, depression screening, and postpartum care. OHA chose to drop the longstanding adolescent well care visit metric in the 2020 round of CCO incentive metrics. This change impacted the selection of Oregon’s MCHB priority areas for the new block grant cycle. In 2018 and 2019 a legislative requirement was enacted for CCOs to invest some of their profits back into their communities. After meeting minimum financial standards, CCOs must spend a portion of their net income or reserves on services to address health inequities and the social determinants of health and equity (SDOH-E), named the SHARE Initiative. CCOs may also use their global budgets to address members’ social needs and community SDOH-E through health-related services (HRS).  Title V works with the CCOs, providing technical assistance, data, and contracted public health and prevention services.

 

Oregon’s system of care for meeting the needs of underserved and vulnerable populations, including CYSHCN

 

Populations served

About 5% of Oregon’s population is under five years of age, and 21.3% is under age 18 (USCB, 2022). Overall, 18.7% of Oregonians under age 18 live below the federal poverty level (The State of America’s Children 2021).

 

The 2020-2021 National Survey for Children’s Health (NSCH) estimated that 20% of Oregon children 0 to 18 years have special health care needs. These CYSHCN are mostly White, non-Hispanic, with 22.4% having Latino ethnicity, and 12.1% identifying as other, non-Latino. Nearly 67% of Oregon CYSHCN have a condition that affects their daily activities, and 31.6% experience two or more functional difficulties (NSCH, 2020-2021).

 

According to the most recent state prevalence rates, 2.8% of Oregon children, ages 3 through 17 years, have autism spectrum disorder (ASD), compared to 2.9% nationally (NSCH, 2020-2021). In 2020-21, about 10,628 Oregon youth (age 5–21) receiving special education had ASD (Oregon Department of Education, 2021-22).

 

Of children and youth under age 21 insured through Oregon Medicaid in 2019-2021, 9.7% met the criteria for having complex chronic disease (OPIP, OHA & DHS 2023). These children are disproportionately from communities of color, with 6.7% Black/African American, 4.9% Native American, and 5.6% identifying as multiracial (OPIP, OHA, DHS, 2018). Eighteen percent of Medicaid enrollees were categorized as having non-complex chronic disease (OPIP, OHA & DHS, 2021), including 19.2% Black/African American, 17.8% multiracial, and 17.6% American Indian/Alaska Native (OPIP, OHA, & DHS, 2018).

 

Oregon’s Birth Anomalies Surveillance System (BASS) tracks the prevalence of select birth anomalies using birth certificate, hospital discharge, and Medicaid data. Data are collected on children who receive public health nurse home visiting services through the CaCoon program. The BASS program is supported by Title V, and works closely with the MCH Title V Women, Perinatal and Infants Team, as well as with OCCYSHN.

 

NSCH (2020-2021) estimates suggest that only 41.3% of YSHCN had worked in the previous 12 months, likely due to challenges managing their own health, difficulty accessing available resources to support their health and disability related needs, and other social factors.

 

Health services infrastructure

Primary care and safety net health services are available through independent medical providers and through the following facilities.

• Hospitals:  62 hospitals
• Federally Qualified Health Centers: 34 FQHCs operating more than 270 sites
• Rural Health Clinics: 107 clinics in 30 counties
• Tribal and Indian Health Service: 9 federally recognized tribes and the Urban Indian program have multi-county service areas and associated clinics
• School-Based Health Centers: 81 clinics in 25 counties

 

Oregon’s Primary Care Office (PCO) works closely with the non-profit Oregon Primary Care Association (OPCA) and the Office of Rural Health to support Oregon’s safety net services. Oregon’s Health Professional Shortage Areas (HPSA), have increased over past two years with lower percentage of need met in state - 167 (63.57% need met) for designated primary care HPSAs, 141 (29.08% need met) for mental health HPSAs and 157 (31.83% need met) for dental HPSAs. There are 283 service center sites for community health centers in Oregon providing medical, dental, and mental and behavioral health services to all Oregonians, regardless of their ability to pay. In 2021, Oregon’s Community Health Centers provided services for 376,515 clients, including 88,426 children. Of the total number of patients, 18% were uninsured and 54% were covered by Medicaid (National Association of Community Health Centers, Oregon Health Center Fact Sheet 2023).Oregon’s safety net includes a robust network of school-based health centers (SBHCs) which are statutorily defined, certified and funded. During the 2022-23 school year, there were 81 SBHCs in 52 high schools, 6 middle schools, 10 elementary schools and 13 combined-grade campuses. During the 2021-22 service year, SBHCs provided 126,673 visits for 40,069 clients. Oregon Health Plan (OHP), Oregon’s Medicaid program (medical, dental, and mental health care services), is provided primarily through Coordinated Care Organizations (CCOs) - Oregon’s version of Accountable Care Organizations. There are currently  16 CCOs serving Oregon’s 36 counties. CCOs currently serve nearly 90% of OHP clients. The innovative structure and function of CCOs is a central component of health reform in Oregon, as described in previous reports.

 

Integration of services

Integration of primary care, behavioral health and social services continues to be an area of opportunity in Oregon. Several cross-agency workgroups have been formed in the past several years to identify solutions to these issues. In 2019 a Governor’s Behavioral Health Advisory Council was created with the task of developing recommendations aimed at improving access to effective behavioral health services and supports for all Oregon adults and transitional-aged youth with serious mental illness or co-occurring mental illness and substance use disorders. A final report has been published containing prioritized recommendations and alignment with other state efforts; including the State Health Improvement Plan, the Oregon Alcohol and Drug Policy Commission Strategic Plan, and the Oregon Tribal Behavioral Health Strategic Plan.

 

Financing of services

Insurance coverage

According to the most recent Oregon data, about 4 million Oregonians - 95% - are covered by health insurance. Insurance coverage increased by 1.4% from 2019 to 2021, over the Covid-19 pandemic. Despite significant gains in health insurance coverage, disparities remain for some groups in Oregon. The percentage of the population that is below 400% of the Federal Poverty Level (FPL) has lower insurance coverage than those above 400%. People living in frontier areas have lower insurance coverage than rural or urban areas.  While insurance coverage is high in Oregon, low-income people are less likely to be covered. Young adults, between ages 19 – 34 were less likely to be covered than any other population. Among children 18 and under, 97% were covered by insurance.  Disparities in un-insurance by race and ethnicity are evident, with Asian Oregonians having the lowest un-insurance rates, and Native Hawaiian/Pacific Islander having the highest followed by Hispanic Oregonians (19%; 15.4% respectively) at any time over the past year.

 

Oregon has expanded Medicaid coverage (Oregon Health Plan – OHP) which pays for medical, dental, and mental health services for low-income Oregonians. Since ACA implementation, OHP enrollment has grown by 718,520 people, and OHP now covers over 1.5 million Oregonians. OHP covers adults whose income is 133% of the Federal Poverty Level (FPL), pregnant people and infants up to 185% FPL, and children under age 19 with household income up to 305% FPL with Medicaid and CHIP, regardless of immigration status. This was the result of Senate Bill 558 known as Cover All Kids Act which passed in 2017. Oregon received a Medicaid 1115 demonstration waiver, effective October 2022 through September 2027, which allows for longer continuous eligibility for Oregon Medicaid enrollees. Under the terms of the waiver:

• If a child under age six is determined eligible for Medicaid, they will stay eligible until they turn six, even if their circumstances (family income, etc.) change in a way that would otherwise make them ineligible.
• For people six and older who are determined eligible for Medicaid, they will stay eligible for at least 24 months, even if their circumstances change in a way that would otherwise make them ineligible.
• Young adults (19-26) with special health care needs are eligible for Medicaid with income up to 300% of the poverty level.

 

This waiver allows Oregon to go well beyond the minimum requirements, ensuring that people maintain continuous coverage and reduce the “churn” that happens when people transition in and out of the Medicaid system due to frequent eligibility changes. Additionally, as of January 1, 2023, Oregon Early and Periodic Screening, Diagnostic and Treatment (EPSDT) coverage was re-instituted, as Oregon did not renew the longstanding waiver around EPSDT for children.

The demonstration waiver also includes payment for  social supports for some members to help improve health outcomes \. These benefits will be provided to members experiencing defined transitions in their lives and may include housing supports, food assistance, and protection from climate events.

 

OHP pays for 43% of Oregon births, including prenatal and delivery coverage for approximately 3100 undocumented women covered through the state-funded prenatal expansion program and Citizenship Waived Medical (CWM) program (formerly known as Citizen-Alien Waived Emergent Medical, CAWEM). About 20% of all Medicaid enrollees are Hispanic, 3% African American, 1.5% American Indian/Alaskan Native, 3% Asian or Pacific Islander, 58.5% Caucasian, and 14% “Other” or “Unknown”. More than one-third of Oregon CYSHCN < 18 years were insured wholly (35%) or partially (6.7%) through Medicaid (NSCH 2020-2021).

 

Also passed into law in July 2017, was House Bill 3391, known as the Reproductive Health Equity Act (RHEA). This bill expanded coverage for Oregonians to access reproductive health services, especially those who, in the past, may have not been eligible. It also provides protections for the continuation of reproductive health services with no cost sharing and prohibits discrimination in the provision of reproductive health services. The Reproductive Health Equity Act ensures that Oregonians with private health insurance coverage, including employee-sponsored coverage, have access to reproductive health and related preventive services with no cost sharing regardless of what happens with the Affordable Care Act. Medical care for undocumented women up to 60-day postpartum is also be covered.

 

State revenues and budgets

Over 90% of the state’s general fund supports core functions in three areas: education, health and human services, and public safety. Oregon does not have a sales tax, and recent attempts to increase corporate taxes through ballot measures have failed to pass. Furthermore, state law mandates a “kicker” refund to taxpayers in any year in which state revenues exceed projected by more than 2%. Consequently, even with robust employment and income tax collections, the state may face budget shortfalls.

 

Oregon statutes and regulations with relevance for Title V Block Grant authority and state programs

The following are key state statutes for Oregon’s Title V program:

• ORS 413 defines to the Oregon Health Authority (OHA) and the Oregon Health Policy Board, which were created by the Oregon Legislature in 2009. Most health-related programs in the state are under the OHA, including Public Health, Medicaid, Addictions and Mental Health, the Public Employees and Oregon Education Benefit Boards. OHA is overseen by the Oregon Health Policy Board.

 

• ORS 431.375 governs the policy on local public health services, local public health authority, and the provision of maternal and child public health services by tribal governing council.

 

• HB 3650, passed in 2011, sets the framework for health system transformation and the CCOs which are a cornerstone of Oregon health system transformation and provide care to Oregon’s Medicaid (OHP).

 

• HB 3100, passed In July 2015, implements the recommendations made by the Task Force on the Future of Public Health Services and sets forth a path to modernize Oregon’s public health system so that it can more proactively meet the needs of Oregonians. Legislation to expand support for Public Health modernization is considered each current session.

 

• ORS 444.010, 444.020 and 444.030, the Oregon Health and Science University (OHSU) is designated to administer a program to extend and improve services for CYSHCN, including the administration of federal funds made available to Oregon for services for children with disabilities and CYSHCN.

 

• Oregon is one of 39 states that passed ASD mandates that require health insurers to provide the behavioral therapy Applied Behavior Analysis (ABA) to children with ASD and other developmental disorders under 18 years old who have health insurance.

 

• HB 4133, passed in 2018, created Oregon’s Maternal Mortality and Morbidity Review Committee (MMRC).

 

• SB 526 (2019) created universally offered home visiting program for Oregon newborns.

 

• HB 3391, the Reproductive Health Equity Act, provides expanded coverage for reproductive health services including preventive services with no cost sharing, and services for Oregonian who had previously been ineligible due to immigration status.

 

• HB 4035 makes a $120 million investment to maintain health care coverage gains achieved during the pandemic, even as many Oregonians will face a challenge in keeping their coverage when the federal Public Health Emergency related to COVID-19 ends. Through this legislation Oregon has an opportunity to reduce unnecessary coverage transitions while preserving existing coverage options for people who are best served through marketplace or employer-sponsored plans.

 

• HB 4052: Mobile Health Units - aims to improve access, starting with communities most affected by health inequities. The bill requires OHA to provide grants, funded with $1.6 million General Funds to operate two culturally and linguistically specific mobile health units as pilot programs to improve health outcomes of Oregonians impacted by racism.

 

• State Budget (biennium): Expanded Citizenship Waived Medical (CWM) program, formerly known as Citizen-Alien Waived Emergent Medical (CAWEM), covers emergency care for adults who would qualify for Medicaid if they met the U.S. citizenship or residency requirements. The budget includes $5.4 million General Funds ($14.2 million Total Funds) to cover admission to an emergency room when a person presents symptoms a prudent layperson would consider an emergency, even if the final diagnosis turns out to be not serious. (Legislative Session Report 2022)

 

• State Budget (biennium): Extended Postpartum Eligibility. The budget includes $2.4 million General Funds ($8.8 million Total Funds) to provide additional months of postpartum health care. This will help ensure the potentially complex health needs following pregnancy can be attended to, resulting in improved health outcomes for all Oregonians. (Legislative Session Report 2022)
  
• HB 4150: Community Information Exchanges. HB 4150 instructs OHA’s Health information Technology Council to convene the Community Information Exchange Workgroup to accelerate, support, and improve a secure and confidential statewide Community Information Exchange. A Community Information Exchange (CIE) helps address this by enabling community-based organizations, state agencies, health systems, county health departments, social service agencies, and technology partners to coordinate efforts to assess and address the social determinants of health.