In Umatilla County, 39% of residents are on Medicaid. In Malheur County, that number jumps to almost 52%.
Both of these counties and more in Eastern Oregon have higher-than-average rates of Medicaid enrollment compared to the rest of the state. Changes to Medicaid made by the Trump administration will mean major cuts to the program that provides healthcare for many in Oregon.
Ann Ford is the CEO of GOBHI, a mental healthcare provider for this side of the state. She’s also the behavioral health head of the Eastern Oregon Coordinated Care Organization, the group that manages the Oregon Health Plan for much of the east side of the state.
Ford joins us to share the challenges of providing care and what Medicaid cuts could mean for patients.
Note: The following transcript was transcribed using AI and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. We end our week in Umatilla County with a conversation about health care, both physical and behavioral. Ann Ford is very well positioned to give us the lay of the land. She’s a CEO of Greater Oregon Behavioral Health Inc., or GOBHI, which provides a wide variety of mental health care options for residents in the entire eastern half of the state. She’s also the president of the Eastern Oregon CCO. That is the organization that manages care for all Oregon Health Plan enrollees in that same enormous geographic area.
With major cuts coming to Medicaid, we thought now was a particularly good time for this conversation. Ann Ford, welcome to Think Out Loud.
Ann Ford: Thank you for having me.
Miller: So as I just mentioned, you’ve got two big and overlapping but discrete leadership positions for people in this eastern half of the state. One specifically in behavioral health and the other more broadly, it’s all of Medicaid for half the state. I want to take them one by one. What does GOBHI, Greater Organ Behavioral Health Inc., do?
Ford: GOBHI is a nonprofit that was founded in the ‘90s, and our primary mission is to provide behavioral health and social services, primarily in the Eastern Oregon half of the state. However, we do also cover treatment foster care, which partners with the Oregon Department of Child Welfare, ODHS, and we provide treatment foster care homes all over the state of Oregon. So we do a variety of things. What happens in most rural communities when organizations are good and can step up, we do step up. And so over the years we’ve just stepped up and taken a lot of what needed to be covered in Eastern Oregon.
Miller: What are the biggest issues you’re facing right now as you try to provide this care in half the state?
Ford: Geography is always a concern for us, right? Sometimes the response time in which people want behavioral health folks to respond to crisis, you can’t even drive across some of our counties in that time. Like Harney County, you can’t possibly drive across in the amount of time we’re supposed to respond to a crisis. So geography and then the workforce; trying to get a workforce out here is really hard. It’s hard to recruit and retain professionals in rural areas.
Miller: Is housing playing into that? We’ve heard that in the past in other conversations, not even just for health care, but health care, it seems like it keeps coming up.
Ford: Yeah, housing is a big concern out here. In fact, we have some of our community mental health programs which have to provide crisis services for behavioral health needs 24 hours a day, 7 days a week, 365 days a year. They’re actually having to purchase homes and set up places for folks to live when they come in to work.
Miller: You mean they find people who accept a job, but then there’s no housing that they can find or afford?
Ford: Right. There’s no housing. So we’ve had people that have turned down job offers that they were really excited to take, but at the very end of it they just couldn’t find housing.
Miller: Before you became an executive, you were a community mental health program provider yourself. Does that inform the way you think about this work, now that you’ve assumed leadership roles?
Ford: Absolutely. I worked for Options for Southern Oregon, which was the community mental health provider in Southern Oregon, for 10 years, and I was their director of compliance. And with that, also, is a very large region we were covering down there. So my rural experience definitely informs what I’m doing out here.
Miller: Are there state-level policy changes that you think would make what you’re talking about easier for you to provide behavioral health care, whether it’s substance use disorder treatment, treatment for acute depression, crisis treatment? You provide a pretty broad array of services, but are there state-level policy changes that you’d like to see?
Ford: Yeah, reduction of administrative burden. The behavioral health system, in particular, it’s just layered with reports. We have to fill out this report and this form, and it’s a 12-page intake packet for someone just to enter services.
Miller: Is that because of state requirements or federal ones?
Ford: Both. It’s a mix of state and federal.
Miller: Does that paperwork serve a purpose, do you think, or is it just plain bad red tape?
Ford: It seems more data gathering than it does actually serve a purpose. What I would be looking for is, if I walked into my primary care physician’s office, it’s a one- or two-page intake packet, right? And then I get immediately taken back and seen for my issue.
Miller: Some of those pages have a lot of questions to answer.
Ford: They have a lot of questions.
Miller: Small print of what you’ve experienced in your life already, but you’re saying it’s still maybe one or two pages.
Ford: It’s still significantly less.
Miller: Why is it so much longer for behavioral health care?
Ford: There’s just a lot of red tape that’s been built into this system, and I think that’s the biggest help we need right now from the Oregon Health Authority. How do we reduce that administrative burden? How do we make care easier for the folks that need the care?
Miller: How do you think about … So that’s one end of it. The people who need care, are they seeking it to a high enough degree?
Ford: We always hope for more involvement in mental health, but honestly, in the since-COVID area, our level of services have only increased. We’re seeing more and more people now for mental health services, so we are seeing more people engage with the system.
Miller: And in your mind, it’s not just because needs have increased, but a willingness or desire to get help has increased?
Ford: Yeah, I think so. Mental health is becoming less taboo. People are starting to be more willing to get out in the community and be seen at mental health centers. I think it’s becoming more accepted, which is good.
Miller: [You are] the CEO of GOBHI, which stands for Greater Oregon Behavioral Health Inc. [You are] also the president of Eastern Oregon CCO Coordinated Care Organization. Those are the organizations that collectively manage all of Medicaid, all of Oregon Health Plan enrollees in the state. So let’s turn to that, starting with just some points about the scale of the reach of OHP, especially in rural Oregon. What do you see in terms of the numbers?
Ford: We have a greater percentage of folks that are covered by Medicaid in rural Oregon than we do in the metro regions. And we have certain counties in our region like Malheur County, where more than 50% of their population is on Medicaid. So we see a greater need out here. We see a greater need for coverage out here.
Miller: Just to put some other numbers there … So Malheur, the latest numbers I saw were 52%. In Umatilla County where we are now, 39% of residents are on the Oregon Health Plan. In Klamath County to our south, it’s 43%. And a bunch of other counties near us are in the 30s or the 40s. I mentioned that now is a good time to talk with you because major cuts are coming. Broadly, what did H.R.1, otherwise known as the One Big Beautiful Bill Act, do to Medicaid?
Ford: Well, it’s going to require people to either volunteer or have employment a certain number of hours per week. I think where my greatest fear comes in is for those that have chronic mental illness and are not able to do that, and how are we going to prove that they still need to remain on Medicaid? And also, how are we going to get them to engage in that process? Because it’s a large process to go through and reapply for Medicaid, and it’s a lot of steps. So I’m worried we’re going to lose folks that are really critically ill just based on the process.
Miller: When you say “lose folks,” play that out. So they lose their Oregon Health Plan eligibility … And here, are you talking about people who are currently accessing services, and those services are being given to them, and then the providers are getting reimbursed through the state but largely through the feds? When you say lose them, what happens to them?
Ford: Well, when you lose coverage, you can no longer afford to go to your doctor. You can’t afford to go to your mental health therapist. You can’t afford the medications that are currently keeping you safe and stable in the community. So, oftentimes what we’ve seen is people cycle through the emergency department, and that’s requiring the emergency departments to also provide uncompensated care, which is not sustainable. And then we see folks that if they can’t or don’t go to the emergency department, then they become involved with law enforcement at some point. And then they end up in the forensic system. And if folks stay on their insurance and are able to stay on their medication and stay in treatment, hopefully we can disrupt that cycle.
Miller: Do you have any clarity yet? So you talked about the employment verification piece of this. Changes to SNAP benefit eligibility, which are similar in terms of that kind of an increase in the frequency and rigor – for lack of a better word – of eligibility, those have already gone into effect. Has that given you some sense for what to expect in terms of Medicaid?
Ford: The numbers that I heard coming up from the state of those that lost their SNAP eligibility, I think were more than people expected. They were higher than people expected. So, that gives me concern that that’s also going to happen in the Medicaid space, that the numbers are going to be greater than we expected. There is the whole part of H.R.1 where we have to not only prove the person has a diagnosis, but that they’re functionally impaired and cannot meet that requirement. So what are the steps for that requirement? What do we have to prove that somebody’s functionally impaired?
Miller: To be exempted from the requirement.
Ford: To be exempted. So what are all the steps and hoops that somebody’s gonna have to jump through to get the documentation needed for that?
Miller: This change in eligibility is just one version of Medicaid reduction that Oregon and other states are going to be hit by. Oregon, in some ways, will be hit harder because we have a higher percentage of our residents on Oregon Health Plan, because of state efforts that have been successful over the last 10 years, or since the Affordable Care Act in particular. Do you have clarity yet on where those cuts are actually going to land, what the state is going to decide on?
Ford: I don’t think there is real clarity on where the state is going to decide. I know there’s been a couple groups talking about this and a couple reports that have been delivered to the state, but I’ve not heard of any firm “this is where we’re headed.”
Miller: The way I’ve come to understand this is that there are basically three really big levers that a state has if it’s going to lower its overall Medicaid costs. It can reduce the number of people on the plan. Some of that’s going to happen by eligibility changes. It can reduce the services that are covered. So in Oregon, say, moving the line up in terms of what is going to be reimbursed for. Or, it can reduce how much money providers get in reimbursement, how much they get for providing this service. Of these three policy levers, which one do you think the state should pull the hardest on?
Ford: Oh, I don’t know if there is a good one to pull. I think that’s the dilemma. If we cut the provider payments, then we’re gonna end up with hospital systems and health care systems that don’t survive this. And if a hospital closes in a region, it’s really hard to open the hospital again. So, people’s services are going to become further away. If you reduce the number of services, then you have to look at which services you reduce and what is the fallout from that reduction? I know one of the reports said reduction for behavioral health case management. Case management is what keeps folks out of the hospital.
Miller: What do you mean by that?
Ford: So case management is a particular service that a bachelor’s-level person typically provides, and it’s linking people to resources – Is it housing? Is it food? Is it medical care? It’s those things you need to stay safe as a person. That’s the intention of case management. Case management is a primary tool to keep people out of the hospital. If your basic needs are met, and you’re physically OK and mentally safe, you’re probably not likely to go to the hospital. That’s how we keep people out of the hospital. So if we cut that one lever, I’m afraid on the behavioral health side we’re gonna see an increase in the hospitals.
Miller: What’s the timeline for this? When are these cuts actually going to be made, and when are the effects that you’re fearing likely to be seen?
Ford: I think, as those re-enrollments start, we’re going to see some major changes happen throughout 2027. And reading the rest of H.R.1, it seems like the cuts just increase from there. I think 2027 is going to be the start.
Miller: We asked folks on Facebook how accessible medical and mental health providers are in their communities.
Alice Gilson Hepburn, who lives in Pendleton, according to her profile, wrote, “Specialists are hard to come by. You usually have to go to Walla Walla or Tri-Cities, maybe Hermiston, if you’re lucky. Mental health providers are actually easier.” She wrote,“Some are independent but accept Medicaid. They do have a waiting list. I can’t speak to inpatient mental health care, but it must be hard since our little town has so many living rough who could benefit.”
Mel Custalow wrote, “I have PacificSource Medicare. There are two providers that take it. Two, of over 100,000 people. One of the places had over a three-year waitlist. They weren’t taking additional names.”
And finally, Karin Creswell wrote, “It’s a 45-minute drive to the nearest hospital. There are only two clinics serving our area. That covers two cities.”
You’ve been nodding as I was reading this, so I guess you’re used to these numbers?
Ford: Yeah, I mean, unfortunately none of this is surprising. In rural areas, specialty care is very, very hard to come by. It’s really hard to get specialists to move out here, not only because of the ruralness, because of the patient volume they need to operate a specialty clinic.
Miller: To what extent can telehealth solve that? Linda Zahl wrote, “Video appointments are great. However, trying to get into Portland OHSU for an MRI or other procedure is almost impossible.” I’m curious where telehealth can help plug these holes and where it’s not viable or not appropriate?
Ford: In the behavioral health space we’ve seen a lot of good use for telehealth for therapy. Therapy is incredibly effective over telehealth. Where we’re not seeing it effective, of course, is in the crisis. If somebody’s in a crisis, telehealth is not a good way to reach somebody. We’re seeing it really effective for those lower level services for people that are stable.
Miller: I want to turn to the bigger picture because you’ve been working in these spaces for a while, and I think it’s especially helpful that you’ve been in behavioral health for a while. Because one of the big ideas of the coordinated care organization (CCO) transformation that now former Governor John Kitzhaber put forward was to get rid of those silos that had long existed, to break them down, to combine in a more coordinated way – mental health care, behavioral healthcare and physical healthcare – and then with the aim of improving care for people and keeping costs restrained.
It’s a big question, but let’s just start digging into the basics of it first. Is it working? Is a CCO model working in Oregon?
Ford: I think in general, yes, it is. I mean, I’m of an age where I was around before CCOs, and I was a provider and also worked at an MHO, a mental health organization. And what we found is, let’s say we had somebody with schizophrenia who had a diabetes diagnosis pop up. We didn’t know who to call on the physical health side to even get that managed. Now we’re all working together, and we’re all co-managing those patients. So, wherever they show up, there’s somebody that’s involved. And if we see a different issue pop up, then we reach out to the other side of the team and get them involved.
Miller: And people can reach out? They speak the same language. They can coordinate care. One of the main promises of CCOs, you say that is working.
Ford: I think that is working.
Miller: OK. But it seemed like there was a little bit of hesitation for the other part. So where do you see room for improvement?
Ford: What I think I’ve seen, not in my CCO but in other CCOs, is we’re seeing a reduction of the behavioral health benefit. And you’re hearing some of those community providers talk about they’re not able to continue if those reductions continue. I think ensuring that the behavioral health benefit is strong in every single CCO and well-funded in every CCO is critical.
Miller: What are the reasons for those reductions in benefits? Is it as simple as money, that when financial folks are looking at the numbers, they say this is somehow unsustainable, we’re spending too much money on mental health care, and it’s not working for our bottom line? Or is it more complicated than that?
Ford: It’s more complicated than that. We’re trying to manage an entire system and keep an entire system afloat. I mean, if you just look at the Eastern Oregon region, there’s hospitals, there’s primary care providers, and everybody has needs and everybody’s costs are increasing. And the unfortunate part of mental health care is always that the physical health person has always had more power than the mental health person. When we’re funding budgets, physical health care always gets a larger proportion of the budget. That’s just how it’s always been. I think there’s some need to shift that, because what’s happening with our mental health drives most of what’s happening with us physically.
Miller: Are other CCOs in Oregon run by people like you who come from the behavioral health side more so than the physical health side?
Ford: The GOBHI, and the EOCCO and Moda model is very different from the other CCOs, and I think that’s been one of our big strengths. We’re co-managing this benefit, so we’re each doing what we’re really, really good at. And I think that’s been a huge strength for our model. In some of the other systems, I’m seeing they may have a few people in behavioral health, but the system of that seems to have degraded over the years.
Miller: Ann, thanks very much.
Ford: Thank you.
Miller: Ann Ford is the president of the Eastern Oregon Coordinated Care Organization, CCO. She’s also the CEO of Greater Oregon Behavioral Health Inc., or GOBHI.
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