Geography and environment

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 weather barriers to delivering and accessing health services, and issues related to workforce capacity and training needs varying vastly in different regions of the state. 

Demographics

Oregon’s population of 4 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. Approximately 84 % of Oregonians live in urban areas, while 16 % live in rural and frontier areas. 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. Portland is the largest metropolitan area, with about 2.4 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 Indian people from over 100 tribes make up the approximately 72,000 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 participate in the Northwest Portland Area Indian Health Board.

 

Oregon’s minority population has increased in recent years. In the 2010 Census, 83.6% reported as White only, a drop from 90.1% in 2008. Hispanics make up the largest minority population at 11.7%, a 64% increase since the 2000 Census. Other races have remained about the same, with Asians at 3.7%, African Americans at 1.8%, and American Indian/Alaska Natives at 1.4%.

 

Oregon averages 45,000 births per year and 69% of births are White, followed by 20% Hispanic, 5.3% Asian, 2.3% African American, and less than 2% Native American. Birth rates in Oregon are lower than national average, with 66 births per 1,000 women ages 15-44 compared to the national average of 69.2. In 2017, about 6% of the population was under 5 years of age, and 15% was 5-17. Overall the median age of Oregonians is 38.4 years, and the median age of mothers for all births is 27.

 

Children and Youth with Special Health Care Needs (CYSHCN)

The 2017 National Survey for Children’s Health (NSCH) estimated that 18.8% (162, 853) of Oregon children 0 to 18 years have special health care needs. These CYSHCN were mostly White, non-Hispanic. About 24% were of Hispanic ethnicity and 11% identified as other, non-Hispanic.

 

Nearly 44% of Oregon CYSHCN have a condition that affects their daily activities and over 36% experience 2 or more difficulties related to functionality (NSCH, 2016). According to the most recent state-level prevalence rates, 2.7% of Oregon children age 3 – 17; currently have Autism Spectrum Disorder (ASD) compared to 3.1% nationally (NSCH, 2017). In 2017, about 10,500 Oregon youth age 3 – 21 who receive special education were identified as having ASD (Oregon Department of Education [ODE], 2017).

 

Significant advances in science and technology have reduced the risk of mortality for CYSHCN, resulting in an increase in morbidity due to chronic illness and disability. Of children under age 18 insured through Oregon Medicaid in 2015-2016, 6.1% of children met criteria to identify as having complex chronic disease. Of those, 6.7% were Black/African American, 5.6% were Native American, and 5.6% were multiracial (OPIP, OHA, DHS, 2018). Eighteen percent were categorized as having non-complex chronic disease. Of those, 19.2% were Black/African American, 17.8% were multiracial, and 17.6% were Native American (OPIP, OHA, DHS, 2018). Youth and young adults with special health care needs (YSHCN) are living longer and assuming productive lives. However, only 51% of Oregon YSHCN graduated from high school in 2014 (NCES, 2013-14). NSCH (2017) estimates suggest that less than 29% of YSHCN have worked in the previous 12 months, likely due to challenges in managing their own health, difficulty accessing available resources to support their health needs, and other social factors.

 

Oregon’s Birth Anomalies (birth defects) Surveillance System (BASS) tracks prevalence of select birth anomalies using birth certificate, hospital discharge, and Medicaid data. Children with risk factors or conditions that receive services through our intensive home-based public health nursing care coordination program, CaCoon, are tracked through a statewide database. The most frequent risk factors and conditions cited for CaCoon recipients during FY2017 were developmental delay (DD), other chronic conditions, Autism Spectrum Disorder (ASD), and heart disease. Children can have more than one risk factor recorded. During FY2017, approximately 70% of children in the CaCoon program had multiple risk factors.

 

Economy and poverty

Economy

Oregon’s economy impacts maternal and child health, as well as population growth and state revenues. The top employers are in food services, administrative and support services, trade contractors and construction, health care and hospitals, computer and electronic manufacturing, and retail. In 2017, Oregon’s population grew by 64,700 people, 56,800 of those due to in-migration.

 

Unemployment

Oregon’s seasonally adjusted unemployment rate peaked in May 2009 at 11.6%. Since then, unemployment rates have improved, with rates falling to 9.3% in 2011, 8.8% in 2012, 7.8% in 2013, 6.9% in 2014, and 5.5% in 2015. Oregon’s unemployment rate for April 2019 is at 4.3%, placing it 40th among states. However, rates around the state range from 3.4% to 8.4%, with southern and central Oregon counties experiencing greater unemployment.

 

Income and poverty

Oregon’s median household income was $64,610 in 2017, placing it 27th among US states. The Small Area Income and Poverty estimates (SAIPE) report for 2014 estimated poverty at 16.4%, with 21.3% under age 18 and 25% under age 5 living below poverty. Almost all racial/ethnic minority populations have higher poverty rates than non-Hispanic Whites (African American 41%, Hawaiian/PI 36%, Native American 34%, Latino 30%, non-Hispanic whites 15%, Asian 12%). Nearly one-third of CYSHCN ≤18 years live in households with incomes less than 100% of the Federal poverty level, although this estimate should be interpreted with caution (CAHMI, 2018).

 

State revenues and budgets

Over 90% of the state’s general fund support 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, the state continues to face budget shortfalls.

 

Housing and education

Housing

Oregon has 1.7 million housing units estimated by the American Community Survey (U.S. Census Bureau). Of households that spend 30% or more of income on housing, 54.4% rent, 38.2% had mortgages, and 15.4% own without mortgages. The median monthly housing cost for each group was $894 for renters, $1,591 for mortgaged owners, and $464 for other owners. 2.5% of households did not have a telephone service and 8% were without a car or vehicle for transportation. According to the Portland Housing Bureau 2018 report on housing costs and income, the rent growth has slowed in the past 2 years to just over 2%, and the average rental unit now costs $1,430 per month. Rising rental and home sale prices in recent years have displaced many Portlanders, disproportionately affecting people of color and lower incomes.

 

Education

Over their lifespan, children in Oregon have access to private and public preschools, Head Start, public schools, community colleges, universities, and graduate education.

 

Oregon’s Early Learning Division (ELD) supports all of Oregon’s young children and families to learn and thrive. The Division is focused on: Child Care, 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 580,690 students enrolled from kindergarten through grade 12. Among k-12 public school students in Oregon, 37% are students of color; 52% qualify for free or reduced lunches; 13% are in special education, and 9% are English Language Learners. Oregon’s 4-year high school graduation rate is 79%, up slightly in past two years.

 

Every child in Oregon identified as needing special education has at least one of the disabilities defined in the IDEA. In Oregon, children must have an established diagnosis of developmental delay to receive EI services; EI or Early Childhood Special Education does not serve children who are at risk of DD. In 2017, 87,156 Oregon children age 3 – 21 years, were in special education and 4,114 children age 0 – 3 years, received EI services (ODE, 2017). Students in special education made up 13.6% of the K-12 population.

 

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.

 

Insurance coverage

According to the most recent Oregon Health Insurance Survey, more than 3.7 million Oregonians - nearly 94% - are covered by health insurance. However, 11% were uninsured at some point in time in the past year.   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 for insurance.  Disparities in uninsurance by race and ethnicity are evident, with Asian Oregonians having the lowest uninsurance rates, and Hispanic Oregonians having the highest. About 21% of Hispanics were uninsured at some time in the past year.

 

Despite Oregon’s high rate of health coverage, more people could be covered. Most people who were uninsured when the study was conducted were eligible for the Oregon Health Plan or a subsidy to reduce the cost of commercial health coverage.

• Children: 9 out of 10 children who lack health coverage are eligible under OHP or a premium-reduction subsidy through the health insurance marketplace.
• Adults: Similarly, nearly 9 in 10 young adults and 8 in 10 older adults (ages 35-64) qualify for OHP or a subsidy for commercial health coverage.
• Reasons for lack of OHP coverage: A large portion of the uninsured were eligible for OHP. The top three reasons Oregonians cited for not being covered by OHP were: concerned about high costs of coverage (44 percent); not eligible, make too much money (36 percent); and concerned about quality of care (21 percent).

Oregon has expanded Medicaid coverage (Oregon Health Plan – or OHP), to cover adults whose income is 133% of the Federal Poverty Level (FPL). Pregnant women are covered to 185% FPL, and children to 300%. OHP pays for medical, dental and mental health services for low-income Oregonians. Since ACA implementation, OHP enrollment has grown by 557,000 people, and OHP now covers nearly 1 million Oregonians. OHP pays for 53% of Oregon births, including prenatal and delivery coverage for approximately 3100 undocumented women covered through the state-funded prenatal expansion program and Citizen Alien Waived Emergent Medical (CAWEM) program. 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 (36%) of Oregon CYSHCN < 18 years were insured through Medicaid (NSCH 2016-2017).

 

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. 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. Oregon is currently reviewing applicants for the second round of CCO contracts which will be awarded in January 2020 for 2020-2024.

 

In July 2017, the Oregon Legislature passed Senate Bill 558, which expanded the Oregon Health Plan to include all children and teens under 19, regardless of immigration status, up to a household income of 305 percent of poverty. The estimated impact is that 17,000 undocumented children and teens are eligible for healthcare as of January 1, 2018.

 

Also passed into law in July, 2017, was House Bill 3391, known as the Reproductive Health Equity Act (RHEA). This bill provides for expanded coverage for Oregonians to access reproductive health services, especially those who, in the past, may have not been eligible for coverage of these services. 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 people with Oregon private health insurance plans, 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 will also be covered.

 

Safety net and health system

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. 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 each of 36 county jurisdictions is the designated local health authority (LPHA). Currently, there are 33 county health departments (LPHAs) and 1 health district serving 3 small rural county populations. Local health departments are legislatively mandated to provide 10 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.

 

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

• Total Health Care Facilities:  263 Clinics and 62 Hospitals
• Federally Qualified Health Centers: 154 Clinics in 63 Cities and 26 Counties
• Rural Health Clinics:  63 Clinics in 44 Cities and 26 Counties
• Migrant Health Centers: 15 centers in 12 cities in 10 Counties
• Tribal and Indian Health Service:  21 Clinics among 9 Tribes and 11 Counties
• School-Based Health Centers:  76 Clinics in 25 Counties
• Oregon Community Sponsored/Other Clinics: 33 Clinics in 12 Cities and 10 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 has 102 designations for primary care Health Professional Shortage Areas (HPSA), and 76 dental HPSAs. More than 300 sites have been approved as part of the National Health Service Corps (NHSC) to provide health care to all, regardless of ability to pay. Safety net clinics cared for nearly 360,000 patients in 2013, providing 950,000 medical visits, over 261,000 mental/behavioral health visits, and 202,000 oral health visits. Nearly 30,000 migrant/seasonal farm workers and 32,000 homeless clients were served.

 

Oregon’s safety net includes a robust network of school-based health centers (SBHCs) which are statutorily defined, certified and funded. During the 2017-18 service year, there were 76 school-based health centers in 45 high schools, 7 middle schools, 11 elementary schools and 13 combined-grade campuses. During the 2017-18 services year, SBHCs provided services to 35,815 clients.

Geography presents a significant barrier to obtaining care for CYSHCN. Twenty-three percent of CYSHCN live in rural areas of Oregon (NSCH, 2011/12). Families living in rural and frontier counties of central and eastern Oregon, experience challenges obtaining 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 teaching hospital, Oregon Health & Science University (OHSU), is located. Mental and behavioral health services are one of the most difficult services to access geographically for CYSHCN and their families, due to a lack of providers in rural and frontier communities.

 

Current and emerging state issues impacting maternal, child, and adolescent health

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 (described in II.A.1-5) are also key drivers of Maternal, Child, and Adolescent Health across the lifespan.

 

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 over half of Oregon’s Medicaid population. CCOs are responsible for providing care for people covered by Medicaid. Despite Oregon’s healthcare transformation rollout with its commitment to the Triple Aim, families and partners across the state still report significant unmet needs for the CYSHCN population. Families also experience confusion about which entities are responsible for coordinating care for CYSHCN across multiple systems. CCO incentive metrics do not incentivize primary care providers (PCPs) to prioritize CYSHCN within their practices, due to insufficient payment for care coordination. Also, there are no consistent policies across CCOs regarding the type and amount of services covered, except for the Applied Behavioral Analysis (ABA) mandate for children with Autism Spectrum Disorder.

 

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, which includes representation from Oregon’s Title V director, 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 child care licensing and monitoring throughout the state.
• Implementation of a tiered quality rating improvement system for child care known as Spark.
• Coordination with Early Intervention/Early Childhood Special Education services.
• The P-3 Alignment initiative which collaborations with the K-12 system to align curricula and activities across preschool/Pre-K programs and grades K through 3.

 

In 2018, The Early Learning Council (ELC) completed a strategic planning and engagement process, which resulted in the Raise up Oregon plan. Title V was a key partner in its development, and now in its implementation.

 

Changes resulting from early learning system transformation have the potential to be particularly relevant to CYSHCN, as they will incorporate systems for universal screening. The ELC's plan to achieve these goals includes: building a system for targeting and identifying Oregon's children with high needs through a system of early and universal screening and risk assessment; ensuring that there is a range of high-quality programs that can effectively meet the needs of different families and populations of children with high needs; and supporting families to make choices about programs that will best ensure the school readiness of their children.

 

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 applying for PCPCH recognition. Initially the program consisted of 3 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 5 tier levels, with the 5th tier being the highest. One of the CCO incentive metrics is the percentage of CCO members who are enrolled in a recognized PCPCH. In turn, CCOs may offer practices incentive payments for achieving recognition status within the program.

 

Modernization of Public Health

Governmental public health in Oregon is currently undergoing 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 system. 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 Phase one funding of $5 million was spent to enhance CD capacity in select communities; phase 2 funding, approved by the 2019 Legislature provides an additional $10 million to modernize the public health approach to communicable disease, emergency preparedness and impacts of climate change on health. 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.

 

Alignment with Oregon Health Authority, Public Health Division, and Institute on Development & Disability’s priorities and initiatives

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

 

Oregon Health Authority (OHA) Triple Aim

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. Title V’s prevention and health promotion work supports the triple aim through interventions with vulnerable populations at critical stages of the life course. Section II.F.4 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 & Disability (IDD) improves the lives of individuals with disabilities or special health needs through leadership and effective partnership with individuals, families, communities, and public and private agencies. IDD honors individual and family perspectives, provides clinical services, communicates complete and unbiased information, and partners with and encourages individuals and families to participate in care and decision-making. In addition, IDD is committed to excellence in interdisciplinary clinical practice, research, education, policy development, and community service. 

 

State Public Health Improvement Plan

As part of Public Health Accreditation, Oregon created a state health profile and developed a State Health Improvement Plan, which was updated this year with new 2020-24 priorities. The new SHIP priorities include: Institutional bias; Adversity, trauma and toxic stress; Economic drivers of health; Access to equitable preventive health care, and Behavioral health. Title V is a critical partner whose work is threaded across all the new 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, and is required report on those plans annually.  The CCOs are also being measured on their health outcomes in key MCAH areas such as adolescent well care, preventive oral health, depression screening, and family planning. Title V works with the CCOs as a provider of: technical assistance, data, and contracted public health and prevention services. Currently, Oregon is in midst of generating a new round of CCO contracts, so the landscape and assessments conducted by the CCOs may change as new CCOs come on board.

 

State statutes with relevance to Title V

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 being considered in the current session.
• ORS 326.425 Establishes the Early Learning Council, which oversees the Oregon Early Learning System.
• 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).

 

 

Title V Administration priority setting process

As the availability of flexible state funding streams has become more limited in recent years, it has become necessary to focus Title V work more narrowly. Budgetary constraints, and alignment with State as well as Federal Agency priorities, impact priority-setting. Both the MCAH and CYSHCN Title V Directors have multiple ongoing mechanisms for determining the importance, magnitude, value, and priority of competing factors which impact maternal, child, and adolescent health in the state. These include the 5-year needs assessment, ongoing assessment of health status data, and participation (either directly or through their staff) in many state and local level policy groups. The MCH Section’s new strategic plan is also a key tool for priority setting, particularly for the MCH portions of the Title V program.