Congress is considering cuts to Medicaid that would affect millions of Americans. Under a current proposal, nearly half of the Oregonians enrolled in the Oregon Health Plan would be required to prove they’re working or volunteering 80 hours a month to keep their coverage. In Oregon, some fear changes to Medicaid could hit health care in rural communities especially hard.
Evan Saulino is a family physician providing clinical care in the Columbia River Gorge. His commentary on possible cuts to Medicaid was recently featured in the Oregon Capital Chronicle. He joins us with details of his concerns and how federal changes to Medicaid would affect rural healthcare.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. We turn now to the potential cuts to Medicaid that Republican lawmakers are moving forward with right now. Among other provisions, the current Republican bill would require that beneficiaries prove they are working or volunteering at least 80 hours a month. It would introduce copays for many beneficiaries. It would also greatly reduce the amount of federal money sent to Oregon under the Affordable Care Act’s Medicaid expansion.
Evan Saulino is a family physician in the Columbia River Gorge. He wrote about these potential cuts for the Oregon Capital Chronicle recently, and he joins us now. It’s good to have you on Think Out Loud.
Dr. Evan Saulino: Hi, thanks for having me.
Miller: I want to start with the real basics. What role does Medicaid play right now in Oregon?
Dr. Saulino: Medicaid is really a lifeline for a huge number of Oregonians – almost 1.5 million Oregonians, almost 500,000 children, 75,000 seniors. And in rural areas of the state, the Eastern, Central, Southern Oregon counties, almost half – 40%-50% of the population – depends on Medicaid. So that has funded a lot of really great work in Oregon, innovative work to give better care for larger numbers of people over the last decade or so.
Unfortunately, the cuts we’re looking at are just gonna be catastrophic, especially for those rural areas where the coverage rates are now higher. Thousands of folks are going to lose coverage and essential health benefits access. Rural community health centers access, critical access hospitals are gonna be likely forced to either cut services like women’s health or obstetrical care. Some are going to face the real threat of closure. Family wage jobs, these jobs in health care, are going to disappear.
So overall, I’m worried about the economics as well as the health care effects of these cuts across Oregon, again more in areas of rural Oregon.
Miller: Are you talking about your own patients as well?
Dr. Saulino: Absolutely. I take care of patients across Hood River, The Dalles, across the Gorge and actually on the Washington side as well. And I am working with bringing together a loose group of folks who are really all concerned about this from all corners of the state. Again, doctors, other health organizations like community health centers, rural hospital leaders, folks who are really worried about the effects that these cuts are gonna have on their communities, on the people in those communities and often the most vulnerable folks.
Miller: A lot is still up in the air, but can you give us a sense for the kinds of cuts to Medicaid that Republicans are considering most seriously right now?
Dr. Saulino: Are you talking about the work requirements and the requirements for copays and stuff like that?
Miller: Exactly … yeah.
Dr. Saulino: I mean, to be honest, neither of those make any sense for different reasons. I’ll start with the work requirements. The work requirements are modeled on programs in Georgia and Arkansas, specifically Georgia, that failed. The state spent millions of dollars on programs that had to be stopped because they didn’t work. So why would we spread a program like that that actually didn’t work on a state level, and now we’re gonna make all the states do that, when that just puts administrative barriers in front of people and actually doesn’t solve any problems?
The outcomes from that we know are actually not gonna save the government money, it’s just gonna create a bunch of paperwork. Work requirements need to be tried and actually function on a state level first. And then if that works, we can have a national conversation about maybe spreading something, but we don’t spread things that don’t work, it doesn’t make sense ...
Miller: Let me stick with that just for a second, because I do want to run a succinct justification for the work requirement that I saw. This came from the Republican chair of the House committee that was tasked with finding nearly $1 trillion in federal spending cuts over the next decade, Representative Brett Guthrie from Kentucky. He said, “Medicaid was created to provide health care for Americans who otherwise could not support themselves. But Democrats expanded the program far beyond this core mission.”
I’ve seen other justifications or explanations that are pretty similar, saying basically, a work requirement is valid and necessary because the population that now gets Medicaid is larger and more able to work than was originally envisioned. What’s your response?
Dr. Saulino: That is not attached to reality on the ground, especially in rural communities. Folks in rural communities receiving these benefits are not in the middle class. They are working most of the time, or they’re providing care, or they’re children – the vast majority are children – or they’re pregnant. They’re folks who are disabled, they might be elderly folks in long-term care. These are not generally folks who can work. What we know about that whole population is that 8% of them could be working.
And in rural communities, if we had a jobs program that was effective, that actually gave people access to jobs and a family wage, that would be excellent. What we’re talking about is cutting benefits from folks that are low income, that are poor, essentially, in communities where they don’t have good access to economics. And again, thereby taking away the family wage jobs in the health care industry, because those are gonna go away, and making things worse. That’s gonna make people leave these communities, so it’s counterproductive.
It doesn’t make sense. And actually, tying the idea of health care overall to employment is one of the things that is holding our country back, holding innovation back in our country. Overall, these folks who receive these benefits – even in Oregon, it’s 185% of the poverty level – housing is very difficult to afford, groceries are difficult to afford, health care is very difficult to afford. So the idea that this is not helping the poorest or most vulnerable people, even in an expansion state, is absurd.
Miller: I should note that according to a 2023 survey by the Kaiser Family Foundation, 64% of Medicaid recipients between the ages of 19 and 64 were already working; 31% were not working because of disability, caregiving or attending school; and 8% were not working due to retirement, inability to find work or another reason.
What about another of the provisions in the bill which would allow states who have recipients … I think it would simply be at the upper end of income eligibility, but I’m actually not sure about the specifics of this provision. It would allow states to have them pay copays for services. What do you think of that idea?
Dr. Saulino: It’s a horrible idea. It’s not aligned with good health care outcomes and it’s not aligned with cost savings. And we know this because we’ve tried this in Oregon before. Other states have tried this, and what the results reliably show is that people have poor health care outcomes. People, especially on the low level of income, 185% of poverty … I don’t know the number, if you could pull the number, it’s something like $29,000 for a family of four. Maybe it’s $35,000 for a family of four. In this economy, that is not very much money.
So those folks, what they do is they have a barrier to go see the doctor. They avoid going to see the doctor for things that are small initially but could become life-threatening emergencies. What we did in Oregon is, we tried this and what we found is that costs overall, there was no money saved. People avoided care. Costs were higher overall. So, there is no cost savings. This will just put unnecessary barriers in front of folks to receive basic care, preventive care, primary care, necessary care in the emergency room if they need to.
We don’t want to put barriers in front of people, especially in the low income spectrum where they’re trying to figure out, can I afford food, housing or transportation? Or, do I go to the doctor for this thing that I’m worried about, but I don’t know if I can pay the copay. So, that primary care access without a copay is absolutely critical and we can’t have that go away by charging people barriers.
With your insurance now, you hate those copays and deductibles. You curse them, you don’t understand them. So why would we expand that idea to folks with Medicaid, especially when we know it doesn’t work, and they’ve tried it in this state and it didn’t work.
Miller: Who would end up paying for care if significant numbers of Oregonians, who currently get health care paid through Medicaid, lost their coverage? When they went to the emergency room, who would pay?
Dr. Saulino: We would. We would pay. All the people who have private health insurance, that’s who would pay. Because folks in the emergency room, if you go to the emergency room, by federal health care law, you have to be seen. They don’t do a wallet biopsy. They see you, take care of you and take care of your situation, and then figure out payment later. A lot of those folks who can’t pay, unfortunately we’re one of the few countries where health concerns that go untreated turn into health crises that bankrupt families. So you’re piling tragedy on tragedy for families.
If people can’t pay when they go to the emergency room, because they don’t have coverage, then that cost is passed on to people who have insurance. So your premium, my premium, your employers are gonna have to all pay more. So overall, what we’re gonna find here with this law is not cost savings for taxpayers. We will not see any cost savings for taxpayers.
What we’ll instead see is higher health care prices as a result, fewer people with coverage, and more people desperate and crowding emergency rooms which are already overcrowded, rather than having access locally to address their health care issues early. So it’s a spiral effect. It’s really a horrible policy strategy overall, especially when we’re not gonna save money as individuals, taxpayers or as a nation by doing these things.
Now, there are things we could do to save money, provide really good care and improve. Don’t get me wrong, there are a lot of things we could do to improve and we’ve done some of those things. We still have lots of room for improvement still in Oregon, but the idea that cutting services or benefits to poor people is going to save money overall is not true. Health care is like a balloon. If you squeeze in one place, it bulges out another place. So, folks with private insurance, your employers, your own health care, if you have private insurance, that will get more expensive.
Miller: Just briefly, you said there are things you could do to reduce costs nationally. What are they?
Dr. Saulino: Absolutely. Oregon really leads the country in innovative approaches to improving care delivery, improving how we care for people. And there’s a variety of things, harmful bureaucracy and administrative burden, barriers in front of providing people good care. There’s also structural things, some of which we’ve done in Oregon – our Medicaid innovations, coordinated care organizations and improving primary care. Improving primary care in this state saved over a billion dollars over 10 years. If we spread that idea to the whole country, we’re talking about hundreds of billion dollars in potential savings. We’ve done great things to improve comprehensive maternity care in this state.
So there are things that we’ve done to improve, like health care quality and the outcomes of what we do while we’re caring for more folks. All of that has generated billions of dollars in federal and state savings, actually, compared to if we didn’t do those things. What I’d like to see, and what we would like to see – the folks that I’m working with – is to try and engage folks in community discussions around rural Oregon, specifically around these issues, to spread what does work, what we’ve shown does work, what can result in cost savings …
Miller: If I may just interrupt briefly, because I feel like there just has been something I’ve been misunderstanding about this. We heard something similar from John Kitzhaber, former governor, former emergency room doctor, about two months ago when we talked to him. And the stat that I can’t get past is that, when you look at per capita Medicaid spending by state, only six states spent more per person in 2022 than Oregon did. That’s the most recent year that I could find data for. It just makes me wonder, if the rest of the country followed our lead, how would that not lead to higher overall per capita costs?
Dr. Saulino: Right, right. This is really a point of investment. What is unique about Oregon’s model is it has predictable, measurable costs that will rise. And it also has innovation and federal dollars going towards trying to create better care for more people. So that does lead to higher costs. You don’t renovate a factory by stripping all the resources out of it. You do it by actually investing some resources and then measure how you are doing. That’s what Oregon has done, and again, it’s not perfect. We have things to do, but what we do know is compared to doing nothing, we’re saving money.
And I also do think, to your point, in terms of some of the investment dollars actually helps offset what’s called a “cost shift” between the different payers for Medicare, Medicaid and private insurance. They all pay different things for the same services. Oregon’s investments in things like quality and primary care – things that actually do make a difference – those do cost money up front, but they can lead to a lot of good return on investment on the back end. That takes some time.
Looking at that isolated data that you just mentioned, again, costs are a little higher than some states. What you need to look at is the trend of cost and the relative cost versus complexity and the kinds of services that you’re getting. That’s why long-term evaluations of policy are really important. Like I mentioned, the primary care model evaluation, which was the evaluation of eight years of data, of all payer data, not just Medicaid. You really do need to look at the population.
People shift from one payer to another. They’re on Medicaid today, and then they get a job and then they’ve got private insurance, then they lose their job because those guys downsize and now they’re back on Medicaid. People switch around and that’s very difficult to track unless you got access to that whole data set.
My point is that state analysis, some of these other analyses that look at all costs, not just Medicaid, are really important. It’s actually that siloing of believing we’re dealing with health care costs by trying to change what Medicaid costs alone and not dealing with the whole system, that actually causes us problems, again, because people shift around. What we need to do is design health care around people instead of individual payment systems. If we do that, we’re gonna have better outcomes.
Miller: Evan Saulino, thanks very much.
Dr. Saulino: Thank you for having me.
Miller: Evan Saulino is a family physician in the Columbia River Gorge.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
“Think Out Loud®” broadcasts live at noon every day and rebroadcasts at 8 p.m.
If you’d like to comment on any of the topics in this show or suggest a topic of your own, please get in touch with us on Facebook, send an email to thinkoutloud@opb.org, or you can leave a voicemail for us at 503-293-1983.
