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 and grown over 10% in the last decade. Growth has increased not only in urban, metropolitan areas but also in some rural areas. 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 Indian 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.

 

Oregon’s population has been increasing at a faster pace than the U.S. population as a whole over previous decades. Higher population growth is associated with a healthy economy characterized by higher employment and overall economic prosperity. Additionally, faster population growth also exerts long-term effects on traffic congestion, expanding urban areas at the cost of diminishing agricultural land, greater demand for affordable housing, childcare services, and increased demand for public services, among others. Oregon’s population change is greatly influenced by net migration. Currently, nearly 87 percent of population growth in Oregon is attributed to net in-migration. The contribution of migration in Oregon’s population growth will play an enormous role once the natural increase (births minus deaths) is expected to turn negative in 2027. When that happens, then the entire increase in population will have to come from the migration component (Oregon Demographic Trends, 2019).

 

With increasing population mainly due to in-migration, Oregon’s population is getting increasingly diverse in terms of race and ethnicity. Still, it remains one of the least diverse states in the country. In the 2020 Census, 75.1% reported as non-Hispanic White only, which has continued to decrease 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 birth rate is declining, following national patterns, with 47.8 live births per 1,000 women ages 15-44 compared to the national average of 55.8 for 2020 (Oregon Vital Statistics Annual Trends ; CDC provisional data ;). In 2020, Oregon had 39,817 resident births, of which 66.2% were non-Hispanic White, followed by 19.9% Hispanic, 5.3% Asian, 4.0% mixed race, 2.5% African American,  1% American Indian/Alaskan Native and 0.7% Native Hawaiian/Pacific Islander (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 weather barriers (including recent climate disasters like wildfires, extreme heat, and ice storms), to delivering and accessing health services, and issues related to workforce capacity and training needs varying vastly 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. 62.1 for urban service area). In rural and frontier services areas, ten have zero primary care provider FTE, 24 have zero dentist FTE and 21 have zero mental health provider FTE. While Oregon’s five-year (2014-2018) average inadequate prenatal care rate is 59.6 per 1,000 births per year, the average rate in frontier service areas is 97.1. Of note the Warm Springs service area which serves tribal members has a rate of 196.5, which is triple the state rate ( Oregon Areas of Unmet Health Care Need Report, 2020). 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 teaching hospital, Oregon Health & Science University (OHSU), is 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, in order for telehealth services to be equitable, families need access to broadband internet, digital literacy education, and skilled translation services.  Additionally, providers need payment parity between in-person and virtual visits—available during COVID—to continue to offer telehealth as a care option. Steps to codify that parity were taken with HB2508 in the 2021 Oregon Legislative session.

 

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 (Oregon Blue Book ).  62.3% of the population  aged 16 years and older is in the civilian workforce, and females comprise 57.9%; these are both similar to the national averages (US Census).

 

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 3.8%, placing it 30th 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 Division ). Oregon, like other states, has experienced unprecedented unemployment during the COVID-19 outbreak. In April 2020 every major industry in Oregon lost jobs as the economy suffered the largest one-month contraction in history, losing roughly 13% of jobs. Payroll employment in the leisure and hospitality industry fell an astounding 54.6% in April 2020. While private education and health care are large sectors that have historically added jobs during recessions and expansions, these sectors shed the second-largest number of jobs in April 2020 when COVID-19 measures directly prohibited elective and non-urgent medical procedures and closed schools. Private-sector employers cut 30,300 jobs in April 2020 () (Oregon Employment Division).

 

Oregon’s median household income was $62,818 in 2020 which is similar to the national average. The overall poverty rate is 11.4%, which is slightly higher than the national average (US Census). Oregon has a new three-tier minimum wage rate  that vary by geography  As of July 1, 2022  the highest rate of $14.75 per hour is within the Portland urban growth boundary, a standard rate of $13.50 per hour in other areas of the state, and a rate of $12.50 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. One-third of Oregon’s jobs paid an average wage of less than $15 per hour in 2019 (Oregon Blue Book). Wealth inequality across racial/ethnic groups persists with the median income of Black ($48,000), Hispanic ($56,900) and American Indian ($60,500) families with children being significantly less than the median income of white families with children ($89,100) (The State of America’s Children 2021).

 

 Almost all racial/ethnic minority populations have higher poverty rates than non-Hispanic Whites. In 2018, the unemployment rate for Latino Oregonians was 5.6%, compared to the 4.1% unemployment rate for White Oregonians. In 2014, the last year data was available for Black Oregonians, they faced an unemployment rate twice as high as Whites (Oregon Center for Public Policy, 2019). The 2019 poverty rate for children under 18 years is 13.1% 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 (10.2%) in Oregon: 20.2% for Hispanic children, 33.8% for Black children and 25.2% for Alaskan Native/American Indian children (The State of America’s Children 2021).   Nineteen percent of CYSHCN ≤17 years live in households with incomes below 100% of the Federal poverty level (NSCH, 2019-20).

 

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 47.6% of Medicaid and CHIP populations as of November 2020 (Centers for Medicare and Medicaid Services). 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 around what is required of CCOs have contributed to uneven care. Primary care practices with PCPCH 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, 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. Pandemic conditions led to a drop in enrollment with a total decrease of 18,030 students (-3.1%) over five years. Among K-12 public school students in Oregon, 39.6% are students of color which has increased from previous years; 17,693 students experienced houselessness; 14.2% receive special education services, and almost 10% are English Language Learners. Oregon’s 4-year high school graduation rate for all students is 82.6%, a significant increase over the past several years. The opportunity gap between students of historically underserved races/ethnicities and other students (White, Asian, Multi-racial) has continued to decrease by 3.1% in five years  (Oregon Department of Education, 2021 ). ). Data also indicate gaps in providing school health-related services. In 2020-2021, “30% (n=60) school districts did not report any school nurse FTE [full-time equivalent hours]. Out of the 137 districts who did report school nurse FTE, 44 were hired for less than half time, meaning that a nurse was available less than 20 hours a week for the entire district…[and] only 15 school districts (7.6%) meet the recommended ratio of 1 nurse to every 750 students.” [source ODE Annual Report.

 

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 2021, 79,782 Oregon children (age 3 – 21 years) were in special education, 3,330 children (age 0 – 3 years), received EI services, and 8,273 children (age 3-5 years) received Early Childhood Special Education services (Oregon Department of Education). 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.

 

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, 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.” Oregon’s higher education 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.

 

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 the programming for children with special health care needs.   They ensure that systems are addressing the needs of families, as well. 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 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 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. Phase one funding of $5 million was spent to enhance communicable disease capacity in select communities; phase two 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. In 2021, the Oregon Legislature allocated an additional $45 million in funding, an important and notable investment in Oregon’s public health system. The additional investment brought the total investment in public health modernization to $60.6 million. 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 Portland Housing Bureau 2018 report on housing costs and income, the rent growth has slowed in the past two 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.

 

Oregon has experienced an increased number of unhoused people, a crisis worsened by the pandemic. As of January 2020, an estimated 14,655 Oregonians experienced homelessness on any given day. Of that total, 825 were family households, 1,329 were Veterans, 1,314 were unaccompanied young adults (aged 18-24), and 4,339 were individuals experiencing chronic homelessness. The total number of homeless students for the 2018-2019 school year was 23,141, as reported to the Department of Education (United States Interagency Council on Homelessness, January 2020).

 

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 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 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 three 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 perform research, advocacy, and education. IDD provides health care to people of all ages who experience disabling conditions. They embrace 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 are also being measured and receive enhanced payment 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 6% of Oregon’s population is under five years of age, and 21% is under age 18 (USCB, 2019). Overall, 18.7 percent of Oregonians under age 18 live below the federal poverty level (The State of America’s Children 2021).

 

The 2019-2020 National Survey for Children’s Health (NSCH) estimated that 21% of Oregon children 0 to 18 years have special health care needs. These CYSHCN were mostly White, non-Hispanic, with 19.6% having Hispanic ethnicity, and 8.4% identifying as other, non-Hispanic.

Nearly 81.5% of Oregon CYSHCN have a condition that affects their daily activities, and 35.5% experience two or more functional difficulties (NSCH, 2019-2020).

 

According to the most recent state prevalence rates, 3.1% of Oregon children, ages 3 through 17 years, have autism spectrum disorder (ASD), compared to 2.9% nationally (NSCH, 2019-2020). In 2020-21, about 10,570 Oregon youth (age 5–21) receiving special education had ASD (Oregon Department of Education, 2021).

 

Of children and youth under age 21 insured, wholly or partially, through Oregon Medicaid in 2018-2020, 9.7% met the criteria for having complex chronic disease (OPIP, OHA & DHS 2021). 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). With 19.2% Black/African American, 17.8% multiracial, and 17.6% American Indian/Alaska Native (OPIP, OHA, & DHS, 2021).

 

Oregon’s Birth Anomalies (birth defects) 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 most prevalent conditions reported for CaCoon recipients in FY2021 were developmental delay, autism spectrum disorder, and other chronic conditions. In FY2021, 39% of children served in the CaCoon program had multiple conditions. The BASS program within PHD’s MCH Section is Title V supported, and works closely with the MCH Title V Women, Perinatal and Infants Team as well as OCCYSHN.

 

NSCH (2019-2020) estimates suggest that only 39.6% of YSHCN had worked in the previous 12 months, likely due to challenges in 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 270sites
• 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:  78 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 has 149 designated primary care Health Professional Shortage Areas (HPSA), 124 mental health HPSAs and 134 dental HPSAs. More than 300 sites have been approved as part of the National Health Service Corps (NHSC) to provide medical, dental, and mental and behavioral health services to all Oregonians, regardless of their ability to pay. In 2020, Oregon’s Community Health Centers provided 1,617,104 visits for 355,353 clients, including 82,697children. Of these patients, 18% were uninsured and 57% were covered by Medicaid (NAHC, 2020).

 

Oregon’s safety net includes a robust network of school-based health centers (SBHCs) which are statutorily defined, certified and funded. During the 2020-21school year, there were 78 SBHCs in 47 high schools, 6 middle schools, 11 elementary schools and 14 combined-grade campuses. During the 2020-21 service year, SBHCs provided 91,058visits for 28,610clients. 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 15 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. Most recently, 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. This work will be closely aligned with similar state level efforts, including the State Health Improvement Plan, the Oregon Alcohol and Drug Policy Commission Strategic Plan, and the Oregon Tribal Behavioral Health Strategic Plan. Membership in these groups reflects the diversity of sectors that support Oregon’s children and families in various settings, including schools, early learning, transportation, housing, criminal justice, and health.

 

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.

 

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: The top three reasons Oregonians cited for not being covered by OHP were: concern 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% with Medicaid and CHIP. OHP 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 1.3 million Oregonians . 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 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 (36.8%) of Oregon CYSHCN < 18 years were insured through Medicaid (NSCH 2019-2020).

 

In July 2017, the Oregon Legislature passed Senate Bill 558, known as the Cover All Kids Act, expanded the Oregon Health Plan to include all children and teens under 19, regardless of immigration status, up to a household income of 300% of poverty. The estimated impact is that 17,000 undocumented children and teens were newly 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 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 will 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 continues to 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 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).

 

• SB 526 (2019), passed universally offered home visiting 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. Previously, emergency coverage was based on the final diagnosis. Unfortunately, this could result in considerable expense for individuals if they go to an emergency room in good faith, but the diagnosis determines there was no serious cause for alarm. The policy could also discourage people with an actual emergency from seeking care, for fear of unexpected charges. 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. https://www.oregon.gov/oha/ERD/SiteAssets/Pages/Government-Relations/OHA%20End%20of%20Legislative%20Session%20Report%202022.pdf

 

• State Budget (biennium): Extended Postpartum Eligibility. There are severe racial disparities in maternal mortality among Oregonians, with studies showing American Indian/Alaska Native and Black people at a significantly higher risk of dying from a pregnancy related cause. The state Maternal Mortality and Morbidity Review Committee identified “inadequate access and missed opportunities to health care and medical services” and “inadequate access to wrap-around services” as contributing factors to maternal mortality. 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.
  https://www.oregon.gov/oha/ERD/SiteAssets/Pages/Government-Relations/OHA%20End%20of%20Legislative%20Session%20Report%202022.pdf 

 

• HB 4150: Community Information Exchanges. Systemic inequities and regional variations in the availability and delivery of social and medical services have long plagued many people and communities in Oregon. 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. 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.