2019 End-of Session Report

Prepared for OAFP July 2019 2019 SESSION SCORECARD

Key: ⇑ = Good for OAFP; ⇔ = Mixed result for OAFP; ⇓ = Poor for OAFP

Result Issue Bill # Details ⇓ PRIMARY CARE SB 765 OAFP’s proposal to increase the use of PAYMENT REFORM value-based spending and fix the methodology for how the OHA calculates primary care spending did not pass after meeting stark opposition from insurers in the second chamber. ⇑ HEALTHCARE COST SB 889 Sets up an implementation committee GROWTH BENCHMARK to develop a health care cost growth benchmark for all health care sectors. The concept is similar to the 3.4% annual growth target for CCOs, OEBB and PEBB. It’s based on a Massachusetts model. ⇑ HEALTHCARE FOR ALL SB 770 Creates a task force to look at AND MEDICAID BUY IN implementation of universal access in Oregon. ⇔ PRIMARY CARE TRUST HB 3253 The bill to create a primary care trust task force did not pass, but Rep. Rachel Prusak is working to set up an interim workgroup. ⇓ ENDS NON-MEDICAL HB 3063 Was poised to pass the legislature EXEMPTIONS TO midway through the session when VACCINES Senate Republicans walked out in protest over the corporate activities tax (HB 3427). To get them back in the building, Gov. Brown traded away the vaccination bill (HB 3063) and gun control legislation (SB 978).

BIG ISSUES DOMINATE SESSION Super majorities in both chambers meant Democrats had the votes needed to enact sweeping legislation on education funding, climate change, affordable housing and workers rights. Senate Republicans fought back by walking out, twice. Republicans’ first walkout was in protest over the new $2 billion corporate activity tax (HB 3427) to fund pre-K and K-12 education. The second walkout, in the closing week

2 of the session, stopped the cap and trade legislation (HB 2020) designed to address climate change. The Governor traded away gun control (SB 978) and a bill to limit vaccination exemptions (HB 3063) to get Senate Republicans back the first time. The second time, the Governor sent state police to bring back missing Senators. Sen. Brian Boquist (R-Yamhill) responded, “If you send the state police to get me, hell is coming to visit you personally.” He doubled-down on his threat saying, “Send bachelors and come heavily armed.” Democrats did push through major workplace changes including a new system for up to 12 weeks of paid family and maternity leave (HB 2005), and protections against sexual harassment and job discrimination (SB 726). Oregon became the first state to pass statewide rent control and banned no cause evictions for renters (SB 608).

KEY ISSUES

SB 765 – PRIMARY CARE PAYMENT REFORM FAILED For the past four years, insurers and CCOs have reported how much they spend on primary care as a percentage of their total medical spend. In 2017, Oregon passed a law that required insurers to increase spending on primary care to 12% of total medical expenditures. SB 765 built on this work by requiring insurers to meet value-based spending targets for primary care. The bill also sought to make the formula used to calculate that spending align with the national standard, so Oregon’s primary care spending can be compared with other states. “People around the country are asking how did Oregon increase primary care spending from 6% to 12% in one year.” Glenn Rodriguez, MD, said we didn’t. We just changed the formula. “The methodology change in 2017 changed the percentage of primary care spending without actually increasing the amount spent on primary care.” “We now have an inaccurate report,” Jennifer DeVoe, MD, Chair of the Dept. of Family Medicine at OHSU, said. DeVoe continued, “The more money you spend on primary care, the more money you save.” A report from Portland State found that increased primary care spending through patient-centered primary care homes (PCPCH) saved $240 million in the first three years through lower emergency room use, fewer hospitalizations and reduced specialty care costs. While the bill passed out of the Senate unanimously, it met stark opposition from the insurance industry in the House and was ultimately sent to the Rules Committee where it remained at Sine Die (the end of session). The insurance carriers that testified— Cambia, Providence, Samaritan and Care Oregon—said they support primary care spending but were united in their opposition to the bill. “A lot of the math doesn’t work for us,” Bill Bouska, Samaritan Health, said. “This is not a collaborative bill.”

SB 889 – HEALTHCARE COST GROWTH BENCHMARK PASSED The Oregon Health Authority will staff a 20-member implementation committee to develop a health care cost growth benchmark for all health care sectors. The concept is similar to the 3.4% annual growth target for CCOs, OEBB and PEBB. It’s based on a Massachusetts model.

3 When Massachusetts instituted this in 2013, they had the fastest rate of growth in the country. In the first four years of implementation, Mass has been consistently lower than national rates. The bill: • Creates a framework and key functions of the benchmark program, • Establishes an Implementation Committee under the Health Policy Board to develop program details, and • Requires a report back to the legislature in November 2020. OHA was given $1 million for the study and report.

SB 770 – HEALTH CARE FOR ALL COMBINED WITH MEDICAID BUY-IN PASSED First, OHA will be responsible for developing a Medicaid buy-in program targeting residents with incomes up to 600% FPL. The Medicaid buy-in plan will have benefits comparable to commercial plans sold on the Marketplace with minimal cost sharing, deductibles or co-pays. The bill directs OHA to utilize the CCO delivery model and CCO provider networks. That work is to be completed by May 1, 2020. Then OHA will shift its focus to a new 20-member Task Force on Universal Health Care appointed by the Governor and confirmed by the Senate. The task force will recommend the design of a single payer system covering everyone including those who use Medicare, Medicaid, commercial insurance and the VA. The plan is to cover to health care, rehabilitation, long-term care and respite care.

HB 2447 – HEALTH CARE DELIVERY FOR OREGON’S FUTURE PASSED The Oregon Health Authority will lead an effort to “envision the future of health care delivery in this state.” The bill gives nonprofit health care systems immunity from federal antitrust laws to participate in the discussion. OHA Director Pat Allen says he welcomes the idea because he sees misaligned financial incentives in the current system, problems dealing with upstream investments, and difficulty working with big health care cost drivers.

HB 3253 – PRIMARY CARE TRUST INFO HEARING ONLY The House Health Committee held an informational hearing on the concept of a primary care trust, teeing up the issue for possible consideration in a future session. The essential idea of a trust is that all payers pay a portion of their total medical expenditures into a fund, which in turn reimburses primary care clinics in a singular way. Dr. Michael Fine, a family physician and former Director of the Rhode Island Department of Health, said, “It’s a fool’s errand to think that we are going to compete for better primary care services when everybody is using the same clinics. All we are doing is wasting money by making practitioners’ lives more difficult.” Not only would a simplified and better-funded primary care system prevent unnecessary utilizations, reduce the length of hospital stays, and help patients with chronic conditions stay healthy, it would also save significant dollars due to reduced administrative burden, Dr. Fine told the House Health Committee. “20-40% of what primary care practices earn is spent on a billing and collections process that serves no one,” he said. Fine also pointed out that primary care makes up 65% of claims, despite accounting for only ~6% of costs nationally. Relieving insurers of that claims processing would significantly reduce their overhead as well.

4

SB 698 – RX TRANSLATIONS PASSED People who have limited English proficiency are twice as likely to misuse a medication. Emergency room visits and hospitalizations due to avoidable medication errors are expensive. Sen. Laurie Monnes Anderson (D-Gresham) said, “I feel like this is an equity issue and a justice issue, and I want to do it.” SB 698 seeks to address this by requiring pharmacies to provide translated instructions in the top 14 languages spoken in Oregon on the prescription label or informational insert. It allows the board to require other languages in the future based on demographic changes.

SB 872 – OMNIBUS RX PRICE TRANSPARENCY FAILED A controversial bill that did not make it over the finish line, SB 872 was championed by Sen. Elizabeth Steiner Hayward (D-Portland) but opposed by OMA, the insurance carriers and Pharma. Opponents said the last drug transparency bill, HB 4005, passed in 2017, hadn’t been fully implemented yet and it was too early to be making changes. Plus, they believed some of the changes proposed in SB 872 were too onerous or wouldn’t work. Among its many provisions, the bill would have required: • Insurers to annually report the 50 most frequently prescribed drugs, 50 most costly drugs and 50 drugs that caused the greatest increase in plan spending, • Hospital outpatient programs, ambulatory surgery centers, dialysis centers and physicians, not including primary care providers, who receive 15% of their annual revenue from the sale of Rx to report their markup for the 50 most prescribed and 50 most expensive drugs, total amount spent on each drug and total amount billed to insurers, • Drug manufacturers to disclose the value of their patient assistance programs, • Insurers to disclose their drug formularies, and • OEBB, PEBB and CCOs to contract with only fee-only PBMs. Ways and Means appropriated $390,000 to the OHA to implement the program but it was not voted on in the Senate in the closing days of the session.

SB 526 – UNIVERSAL HOME VISITING PASSED OHA is charged with establishing a voluntary, statewide universal nurse home visitation program for families with newborns, based on Family Connects, an evidence- based model. The plan requires health insurers to pay for the service with no cost sharing, coinsurance or deductibles. About half of the 40,000 babies born in the state are born onto Medicaid, says Sen. Steiner Hayward (D-Beaverton). Because the bill requires health insurers to cover the $600 price tag for these visits, the state is able to receive the federal Medicaid match for those children.

SB 579 – DEATH WITH DIGNITY WAITING PERIOD PASSED Oregon’s Death with Dignity law requires a 15-day waiting period between the time someone requests a prescription to end their life and receiving that prescription. SB 579 eliminates that waiting period for patients with less than 15 days to live. Geoff Sugarman ran the campaign that passed the original law in 1994. He said, “This bill does not allow someone to ask for and receive their prescription on the very same day. The process that is outlined in the law still must be followed. There still has to be an oral and a written request. There still has to be a second opinion. There still

5 has to be a counseling referral. There still has to be informed consent. None of those things go away.”

HB 3427 – BUSINESS ACTIVITY TAX TO SUPPORT EDUCATION PASSED The new business activity tax is designed to raise $2 billion per biennium for education (Pre-K through grade 12). The tax on businesses with receipts of more than $1 million would be $250 plus 0.57% of the total taxable business receipts in excess of $1 million. Businesses with receipts of less than $1 million are exempt, as are nonprofits, hospitals, long-term care, gasoline and groceries. The taxable receipts calculation also allows a 35% subtraction for either: • Purchases from other businesses, or • Labor costs. An individual or business with more than $500,000 in receipts must register with the Department of Revenue, but only those over $1 million pay the tax. Sen. Mark Hass (D-Beaverton) said the $1 million threshold means only about 40,000 of Oregon’s 460,000 businesses will pay the tax. The plan also includes minor reductions to the personal income tax rates and a comprehensive education-spending plan for the new funds. Business opponents of the new tax are collecting signatures to refer it to a statewide vote. If that happens, the ballot will be on January 21, 2020.

SB 649 – VACCINE INFORMATION FAILED Oregonians for Medical Freedom, an anti-vaccination group, introduced SB 649 to require providers to give patients a packet of information before administering the vaccine. The bill would also have changed the age of consent for vaccinations from 15 to 18. OMA opposed the bill saying it was redundant and unnecessary. “Federal law currently requires that physicians and other healthcare providers give patients vaccine information when a vaccine is administered.” The CDC Vaccination Information sheet is written in easy-to-understand language, geared for consumers. The bill did not move out of the Senate Health Committee.

HB 3063 – ENDS NON-MEDICAL VACCINATION EXEMPTIONS FAILED A small but very vocal minority descended on the Capitol, pleading with the House Health Committee to preserve their right to keep their children unvaccinated. “We are not a state to force medical procedures on people against their will,” one said. HB 3063 was a response to the recent measles outbreak in Vancouver, WA, and Portland. More than 70 people, most of whom are children under 10, contracted the disease that was considered eradicated in the United States in 2000. The bill would have continued to allow medical exemptions for vaccinations, but eliminate religious and philosophical exemptions. Children who did not keep up with required vaccinations would not have been allowed to attend public schools. Rep. Cedric Hayden (R-Roseburg) pointed out that none of the 10 measles cases in Oregon were contracted in school settings, and emphasized the negative impact this bill would have on the 31,000 non-immunized children in public school, 4,200 in private school, and 16,000 in daycare in Oregon. The bill passed the House and was expected to win passage in the Senate when Senate Republicans walked out in protest over the corporate activities tax (HB 3427). To get them back in the building, Gov. Brown traded away the vaccination bill (HB 3063) and gun control legislation (SB 978).

6

HB 2005 – PAID FAMILY & MEDICAL LEAVE PASSED Businesses thought they could get a better Family Leave bill working with legislators than fighting off a more onerous family leave ballot measure threatened for the 2020 election. HB 2005 is the result. The bill is modeled on Washington’s legislation and provides up to 12 weeks of paid leave per year (plus four unpaid weeks) to care for a new child, sick family member, or a death in the family. People experiencing domestic violence would also be eligible. Employers and employees split the cost of the paid leave insurance pool, with employers covering 40% and employees covering 60%. Employers with fewer than 25 employees are not required to pay the employer contribution but if they choose to, will be eligible for grants to hire temporary workers or cover overtime in the event an employee takes paid leave. People earning up to 65 percent of Oregon’s average weekly wage (~$1000) will receive 100 percent of their weekly earnings. For people making more, the percentage declines. Employees are eligible once they have worked 90 days or earned $1000. Democrats describe it as the most generous family leave law in the nation. The Employment Department will begin collecting contributions to the program on January 1, 2022, with benefits beginning on January 1, 2023.

HB 2220 – ALLOW DENTISTS TO GIVE VACCINATIONS PASSED Dentists routinely give patients shots, so why not allow them to give flu shots and other vaccinations as well? Phil Marucha, Dean of OHSU Dental School, said, “This is an excellent opportunity to provide this important preventive service.” Jim Smith, DDS, Kaiser Permanente, said, “Last year, we provided 2,500 vaccinations to vulnerable seniors by nurses and LPNs. Patients appreciate the one- stop shopping… Sometimes an entire family can be vaccinated in one visit.” Rep. Cedric Hayden (R-Cottage Grove), supports the rights of parents to not have their children vaccinated, but was a chief sponsor of this bill. “Dentists have the training and ability to do this,” he said. Illinois and Minnesota dentists have been able to provide immunizations since 2014. The Oregon law became effective May 6, 2019.

HB 2020 – CARBON CAP AND TRADE FAILED One of the most controversial bills of the session, HB 2020 led to the Senate Republican’s eight-day walkout at the end of the session. The bill would have made Oregon the second state, after California, to cap carbon emissions to combat global warming. The bill would have set a cap for greenhouse gases, established pollution allowances and created a market for industries to trade or purchase pollution credits. The target was to lower emissions to 45% below 1990 levels by 2035, and 80% below by 2050. Republicans feared it would severely damage rural Oregon by driving up the price of gasoline, and negatively impacting agriculture and forestry.

HB 2848 – MAIL ORDER VAPING PRODUCTS FAILED This would have required online retailers to confirm that the purchaser of vaping products is at least 21.

7 Rep. Pam Marsh (D-Ashland) said the number of high school students vaping nationally has doubled since 2017, reaching nearly 25% of all high school seniors. Joule, a vaping industry leader, was supportive of the bill.

SB 978 – FIREARM SAFETY OMNIBUS FAILED One of the top priorities for Gov. Kate Brown this session was firearm safety legislation. “As the governor of this state I cannot, and will not, stand by while firearms take the lives of our citizens and officers. It is simply unacceptable.” Ultimately, this bill and others were scrapped as part of the deal to bring back Senate Republicans after their first walkout of the session. The Senate bill would have included a swath of regulations including: • Allowing a retailer to set the age a customer must be to purchase a firearm. Under current Oregon law, a retailer who requires a customer to be older than 18 is discriminating. • Requiring firearms to be stored with a trigger lock, gun safe and cable-lock with certain exceptions. If your gun is stolen and it is unlocked, you could be held personally liable for damages.

HB 2013 – FIREARM SAFETY PASSED HB 2013 was the sole firearm legislation to pass this session. It strengthens law enforcements’ ability to enforce the relinquishment of firearms in the case of a restraining order or domestic abuse conviction. The bill requires an affidavit showing how and where the guns are stored.

HB 2014 – REMOVE NONECONOMIC DAMAGE CAP FAILED In 2016, an Oregon Supreme Court case limited non-economic damages to $500,000. This bill would have remove that cap. Sen. Floyd Prozanski (D-Eugene) explained, “What we’re trying to do is get back to the days when the jury decided whether someone was wronged, and that they decide how much is due in damages.” Opponents of the bill were aligned in their willingness to remove the cap in cases where the perpetrator was charged with a criminal act. But they distinguished between cases where the perpetrator acted with malice, and cases where the harm was unintentional. The bill failed 14-15 on the Senate floor. Three Democrats—Laurie Monnes Anderson, Elizabeth Steiner Hayward and Betsy Johnson—joined all the Republican Senators in voting “no”. Sen. Laurie Monnes Anderson (D-Gresham) explained her vote saying, “A non cap on noneconomic damages goes too far.”

HB 2011 – CULTURAL COMPETENCY CE PASSED “The impetus for this bill is simple: certain communities in Oregon face disparities in access to health care, the quality of care received and health outcomes,” said Speaker Tina Kotek (D-N Portland). The bill requires licensed health professionals to complete cultural competency continuing education once every four years. Licensing boards may accept continuing education not approved by the OHA if it addresses a list of skills identified by the OHA in rule.

8

HEALTH CARE PROVIDERS & BOARDS

SB 136 – NURSE ANESTHETIST RX PASSED Since 2013, certified registered nurse anesthetists (CRNAs) have had the ability to prescribe medications within their scope of practice. There is no limit on the types of medications they can prescribe, but there is a 10-day limit to their prescriptions. SB 136 removes that 10-day limit. CRNAs say that increasingly, patients are being referred to them for pain management services that include the use of prescription medications while they are being weaned from opioids, which isn’t a 10-day process. Anesthesiologists opposed the bill saying they would like to see the bill narrowed so CRNAs prescriptive authority did not include opioids.

SB 138 – MENTAL HEALTH RX ADVISORY GROUP PASSED This reestablishes the Mental Health Clinical Advisory Group, which sunset last December. The group makes recommendations to OHA about mental health medications on the preferred drug list and practice guidelines for treating mental health disorders, including advice dispensed through Oregon Psychiatric Access Line (OPAL), which provides real-time consultation for primary care physicians around the state.

SB 734 – NATUROPATH PAY PARITY FAILED The bill would require commercial insurance to reimburse naturopathic physicians at the same rate as licensed physicians. The Oregon Association of Naturopathic Physicians says that payments are on average 40% less than what physicians, physician’s assistants (PAs) and nurse practitioners (NPs) receive. One naturopath testified that her salary at an hourly level works out to be $13, which was the same amount she made as a “sandwich artist” at Quiznos. Commercial insurers say the bill would result in increased premiums for consumers. They are also concerned that the bill requires pay parity for any service performed by a naturopath; similar pay parity laws already on the books for NPs and PAs only require parity for primary care services. The bill died in Ways and Means because it would have increased costs to the state’s public employee plans by $8 million.

SB 742 – ATHLETIC TRAINER LICENSE PASSED This bill had two goals: 1. Replace the current registration requirement for athletic trainers with a new athletic trainer license. This provision passed. 2. Remove “athletes” as the only target population athletic trainers can treat. This provision did not pass. Legislators said they feared this would expand athletic trainers’ scope of practice.

SB 61 – ADDS PUBLIC MEMBER TO OREGON MEDICAL BOARD PASSED The Oregon Medical Board supported a bill to expand the board to include a third consumer representative. There was no opposition.

SB 62 – UNLICENSED MEDICAL IMAGING PASSED Current law prohibits employing a person that the employer knows is not licensed to practice medical imaging, as well as lying about one’s licensure to practice medical

9 imaging. The Board of Imaging was advised that someone could avoid being penalized by simply claiming, “they did not know the law.” This bill strengthens the law by prohibiting employment of someone an employer knows, or should know, is not licensed or permitted to practice medical imaging.

SB 64 – NURSING APPLICANTS AND LICENSEES PASSED This bill clarifies language in the Board of Nursing’s authorizing statute that refers to both “approval” and “accreditation”. The Board of Nursing approves a school’s nursing education program but is not an accrediting organization. The bill also tries to clarify use of the term “certification” as it applies to advance practice nurses. The bill distinguishes national certifications for APRNs from licenses issued by the Oregon Board of Nursing.

SB 65 – CERTIFIED NURSE MIDWIFE LICENSING FAILED The Board of Nursing wanted to create a new stand-alone license for Certified Nurse Midwives. This would have separated certified nurse midwives from nurse practitioners. The Board of Nursing said, “They will practice nursing as they do now, just under a different license type.” ONA opposed the idea saying the current statute is not that confusing and does not warrant separating Nurse Midwife Nurse Practitioners (NMNP) from the statutes that apply to other nurse practitioners. Ultimately portions of SB 65 were amended into SB 127 (see below) and passed.

SB 66 – AIR FORCE EDUCATION COUNTS TOWARD LPN LICENSE PASSED The Board of Nursing wants graduates of the US Air Force training program to be able to sit for the national licensed practical nurse licensure exam. The Air Force training program is not accredited, so those graduates are currently not allowed to sit for the national exam. The Army’s training program is accredited. The Oregon Board of Nursing said the Army and Air Force provide the exact same training. The bill also allows LPN applicants who are licensed in other states, based on their military education, to be licensed in Oregon.

SB 127 – NURSE PRACTITIONERS WHO SPECIALIZE IN NURSE MIDWIFERY PASSED This bill was “gut and stuffed” with elements of SB 65 (see above). It changes the term “nurse midwife nurse practitioner” to “nurse practitioners who specialize in nurse midwifery”.

HB 2945 – SEIU’S NURSE STAFFING CHANGES FAILED SEIU’s political director Felicia Hagins told the House Health Committee, “Short staffing is a critical issue,” and “nurse staffing committees are not working the way we would like them to.” The Service Employees International Union (SEIU) wanted to replace a registered nurse on hospitals’ nurse staffing committees with a certified nursing assistant (CNA). The bill also opened up the nurse staffing committee to issues raised by other hospital workers and increased funding for OHA enforcement and audits. The Hospital Association opposed the bill, calling it a “siloed approach.” The bill died in committee.

10

RURAL HEALTH

HB 2847 – RURAL MEDICAL PROVIDER TAX CREDIT EXPANSION PASSED Rep. Werner E. Reschke (R-Klamath Falls) and Sen. Dennis Linthicum (R-Klamath Falls) successfully expanded the list of hospitals whose medical staff may qualify for the rural health tax credit. Sky Lakes Hospital is currently excluded from that list, despite the fact that other physicians practicing in Klamath Falls qualify for the largest credit amount. Bob Duehmig, Deputy Director of the Office of Rural Health, testified that with this addition physicians would only qualify for the credit if they met the other eligibility criteria such as the $300k income cap. The expansion will cost the state ~$200k and allow about 40 additional providers to receive the credit. “Sky Lakes is at a disadvantage to all other rural hospitals at recruiting talent. This is meant to level the playing field,” said Reschke.

SB 5525 – HEALTH CARE PROVIDER INCENTIVE; PUBLIC HEALTH MODERNIZATION PASSED The Healthcare Provider Incentive Fund will be funded at current service level this biennium as part of the OHA budget. The Healthcare Workforce Committee, with OHA’s help, oversees these dollars and the programs they support such as loan forgiveness, loan repayment, Scholars for a Healthy Oregon and the rural malpractice subsidy. The Rural Health Association requested a budget note that would have directed OHA, in collaboration with the Healthcare Workforce Committee, to assess the underlying need for, cost-efficiency of, and potential effect of healthcare provider incentives and workforce development programs not currently funded in Oregon. Despite having agreement from OHA and Ways and Means Co-Chairs, it was not included in the budget. Another highlight of the budget is that public health will see a significant boost in funding as part of public health modernization. The additional investment of $10 million will increase communicable disease prevention, health equity support, increased emergency response planning and more.

SB 293 – INDIAN HEALTH SCHOLARSHIP PROGRAM FAILED The bill would have created incentives for American Indians in medical professions to return to their communities to practice. It would have provided scholarships that prioritized members of federally recognized tribes, and required recipients to practice in clinics that serve majority members of Oregon’s tribal communities. The program did not receive funding.

SB 754 – NURSE EDUCATOR TAX CREDIT FAILED Sen. Arnie Roblan (D-Coos Bay) introduced a bill that would have created a $10,000 tax credit for nurse faculty members at licensed nurse education programs in rural communities. Roblan says his community has had a nursing shortage due to a lack of eligible teachers at Community Colleges. “There are hundreds of students who would like these jobs, and hundreds of job openings, but what we have right now is a choke point,” Kyle Stevens, Southwest Oregon Workforce Investment Board told the Senate Health Committee. The bill passed out of policy committees but did not receive a hearing in the Joint Tax Expenditures Committee.

11

HB 2164 – TAX EXPENDITURES OMNIBUS BILL AND CAT FIX PASSED The legislature renewed the Volunteer Rural Emergency Medical Service Provider tax credit, which was set to expire in 2020. The credit makes up just $200k out of the $70 million that was allotted for credits this session. The legislature also extended and increased the Earned Income Tax Credit, which proponents say is one of the most effective anti-poverty measures we have. Other credits, including the political contribution credit, were reduced. Rep. Pam Marsh (D-Ashland) said, “We expect more and more about giving away tax credits. We want data to be sure we are getting something of public value.” The Joint Tax Expenditures Committee also included technical fixes to the commercial activities tax passed earlier this session as the funding mechanism for the Student Success Act.

SB 204, HB 2138 – EMT TAX CREDIT PASSED IN HB 2164 The Legislature extended the Volunteer EMS Provider Tax Credit until 2026. It provides $250 for volunteer EMS providers working at least 25 miles from a population center of 30,000. These providers must spend at least 20% of their practice time as volunteers, and work 25 miles from a population center of 30,000. “I am not sure most Oregonians are aware that once they venture beyond the Willamette Valley, they are dependent in great measure upon volunteers to respond if an emergency should occur,” says Robert Duehmig, Deputy Director of the Office of Rural Health. Wayne Eldersby, an EMT intermediate located in Halfway, told the House Revenue Committee that it costs him approximately $300 a year just for gas to get to and from calls. That is on top of the cost he incurs travelling to Baker, and staying in a hotel, just to receive his certification. Legislative support for the credit was broad and bipartisan. “This is a good one… It is probably one of the most targeted [credits] we have,” said Sen. Lee Beyer (D- Springfield).

MENTAL & BEHAVIORAL HEALTH

SB 22 – BEHAVIORAL HEALTH HOMES PASSED This bill modifies Oregon’s Patient-Centered Primary Care Home (PCPCH) statute to include standards for Behavioral Health Homes. It also changes the OHA’s responsibility for “certifying” school-based health centers as PCPCHs to “identifying” them as such. $560,000 is included in the OHA budget to implement the bill.

SB 141 – MENTAL HEALTH CRISIS LINE FAILED The hospital association proposed $4 million in state funding for hospitals to create or contract out a system to follow up with suicidal patients. HB 3090, passed in 2017, required hospitals to provide a “caring contact” with all behavioral health patients after they leave the emergency department. Suicidal patients are to receive that “caring contact” within 48 hours. Oregon hospital emergency departments see about 75,000 patients each year who are in a behavioral health crisis. Of those, approximately 10 percent are suicidal.

12 Funding in SB 141 would have helped hospitals create a system to provide the follow up care called for in HB 3090. It failed to move out of Ways and Means.

SB 707 – YOUTH SUICIDE ADVISORY BOARD PASSED SB 707 enshrines the Youth Suicide Alliance, which was set up in 2014, into statute as an advisory board to OHA. The bill passed with unanimous support in both chambers.

SB 808 – SUICIDE CONTINUING EDUCATION FAILED Sen. Lew Frederick (D-Portland) wanted to require 3-6 hours of suicide risk assessment continuing education for health care professionals, teachers, and administrators every 6 years. Multiple health care professionals testified in support. There was no opposition. Committee members were not content with an amendment to the bill that would require suicide continuing education for medical providers, so the Senate Health Committee sent the bill to the Senate Rules Committee to keep the bill alive. It died there.

SB 976 – BEHAVIORAL HEALTH JUSTICE REINVESTMENT PROGRAM FAILED The bill allocated $10 million to the Criminal Justice Commission (CJC) for a new grant program for community programs to keep people with mental illness out of the corrections system and hospital emergency departments. Supporters of these community-based behavioral health programs predict the investment would result in a “20% reduction in the number of jail bookings and emergency department visits by this population, as well as a similar reduction in the number of aid and assist referrals to the Oregon State Hospital.” The bill failed to move out of the Senate.

HB 2257 – OPIOID PACKAGE PASSED The Governor’s Opioid Task Force brought a comprehensive package of services in HB 2257. Among other provisions, the bill declares substance abuse disorder a chronic illness. Gov. Kate Brown told the House Health Committee, “It’s medical problem that needs a medical solution.” An Oregon Health Authority advisory group will study and implement training standards for substance use disorder (SUD) treatment. The bill also provides: • Data to health care providers on opioid prescribing patterns, • More access to a variety of treatment options, including Medication Assisted Treatment in communities and in the corrections system, • Support for families, especially new mothers, struggling with addiction issues, • A prohibition on CCOs, PEBB and OEBB from requiring prior authorization for the payment of medication-assisted treatment, • Better access to the Prescription Drug Monitoring Program (PDMP) for Dental Care Organization (DCO) dental directors, pharmacy directors and CCO medical directors, and • A SUD treatment pilot project in up to four counties for pregnant women using the Project Nurture model, which works with peer mentors and doulas to support new mothers. The legislature approved $2.5 million to begin this project.

13

HB 2510 – PANDAS/PANS AWARENESS DAY PASSED Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) cause symptoms such as rapid onset obsessive-compulsive disorders and tic disorders. Numerous parents testified with stories about their children who experienced symptoms and went undiagnosed, until they found a physician who was familiar with PANDAS/PANS, and were provided azithromycin. Children who received the antibiotic recovered quickly. Advocates of the bill say there is a lack of awareness of the illness in the medical community. HB 2510 designates October 9th as PANDAS/PANS Awareness Day. The bill passed unanimously in both chambers.

HB 2339 – OPERATING FUNDS FOR SOBERING CENTERS FAILED Rep. Duane Stark (R-Grants Pass) led the effort to secure state funding for sober centers. “These sobering centers are doing a fantastic job,” Rep. Stark said. The director of the Grants Pass Sobering Center said they had 150 patients in January 2019. “We see all kinds,” he said, “Including the 23-year-old power drinker and the 63- year-old chronic alcoholic. Last week we also had a family with three children after the father got a DUI.” In recent state budgets, the Oregon Health Authority has awarded matching grants to local sobering centers averaging $332,500 per facility. There are currently five sobering centers in Oregon with two more expected to open this biennium. So OHA requested $2.3 million for 2019-21. The House Health Committee approved the bill, sending it to Ways and Means, where it died.

HB 2627 – PEER-MANAGED RECOVERY CENTERS FAILED This bill required OHA to incubate and fund four new Recovery Community Organizations that are led and governed by people in recovery. Eric Eisler, MD, medical director at Serenity Lane in Eugene, said, “Long-term peer support is the key to recovery.” It would have invested $5 million, possibly from cannabis tax funds. The bill died in Ways and Means.

HB 2667 – SUICIDE INTERVENTION AND PREVENTION COORDINATOR FAILED Oregon’s suicide rate is 35% higher than the national average. In 2017, 825 people died by suicide in the state—87% were adults over the age of 25. Older adults are at particularly high risk of suicide and it is the leading cause of death for people ages 25- 44 in Oregon. Currently OHA has a Youth Suicide Intervention and Prevention Coordinator and a strategic plan to address the burden of youth suicide. This bill would have created a corresponding position and plan for adults. It failed to move out of the House Health Committee.

HB 2691 – MAKES OPAL PERMANENT PASSED The Oregon Psychiatric Access Line operated by Oregon Health and Science University, provides real-time psychiatric consultation to primary care providers. Since 2014, OPAL has provided 2,700 consultations to 1,600 primary care providers. The 2018 Legislature provided funding for clinicians serving the adult population for the first time. “In its first three months, the program received 132 calls from 20 counties in

14 Oregon, dealing with issues like how to approach a patient with paranoia, or how to treat anorexia in a first-time mother,” says OHSU Psychiatrist John Betlinski. HB 2691 makes OPAL permanent by putting it in statute. OPAL was funded with $900,000 in 2018 and is part of the OHA budget. It passed both chambers unanimously.

HB 2831 – PEER-RUN RESPITE FOR MENTAL ILLNESS FAILED Advocates say peer-support services can help those struggling with mental illness recover without hospitalization. Sharon Keene told the House Health Committee, “It’s an opportunity to be in a respectful place that gives us dignity and choice while we can actually work on our own healing.” The bill would have created a pilot program with three peer-run respite centers, one each in the Portland metro area, southern and eastern Oregon, at a cost of $2.25 million. OHA director Pat Allen said the centers would “fill a gap in the continuum of care by creating lower cost services.” The bill died in Ways and Means.

HB 3095 AND 3279 – SUD & MENTAL HEALTH REIMBURSEMENT FAILED Two bills sought to increase payments for substance use treatment and mental health treatment. HB 3279 would have required OHA to set the base reimbursement rate for substance use disorder (SUD) treatment at the same rate as mental health services, while HB 3095 would have required OHA to increase their base fee-for-service rates for behavioral health providers by 35 percent. HB 3095 included a $10 million appropriation to the healthcare provider incentive fund for mental health loan repayment. Both bills were sent to Ways and Means, where they died.

HEALTH INSURANCE

SB 139 – OMA PRIOR AUTHORIZATION FAILED The Oregon Medical Association (OMA) says a recent survey of its members found that 45% say prior authorizations often delay care; another 33% said prior authorizations sometimes delay care; and, according to the OMA, the problem is getting worse. Clinics and physicians gave examples including: • A prior authorization request to surgically repair a deviated septum was made September 27; denied two weeks later; appealed; denied again in December; finally approved on January 10 only to learn the policyholder changed insurers January 1 and had to start over again with a different carrier. • A nasal spray prescription for a 2-year-old with tonsillitis was denied. Instead, the insurer required step therapy using drugs not approved for children under 4. Appeals and denials delayed treatment for a month. An orthopedic surgeon from Portland said, “Oregonians are having to pay more and more for insurance they can’t use.” Insurers opposed the bill saying prior authorization is an important tool for implementing evidence-based care and that OMA’s bill would add significant costs. OMA tried to salvage the bill by removing CCOs from the utilization management provisions but the bill did not move out of Ways and Means.

15

SB 249 – DCBS PRIOR AUTHORIZATION PASSED Oregon’s Insurance Division said it received 90 consumer complaints last year about prior authorization. The complaints include delay and denial of health care treatments. SB 249 requires insurance carriers to make a determination within two days of receiving a request for prior authorization or within 15 days of requesting additional information. Jesse O’Brien with DCBS said, “This is not intended to change the prior authorization process but to make it more fair, open and transparent.” Insurers supported the bill but reminded the committee that it only applies to the regulated market, not to self-insured plans. The changes that take effect January 1, 2020.

SB 236 AND SB 587 – PRIOR AUTHORIZATIONS FOR PHYSICAL THERAPY FAILED Physical therapists said requiring prior authorizations for physical therapy creates administrative barriers and delays in patient care. These identical bills would have required payers to cover services provided during the initial visit, rather than requiring the patient to come back for their care. Courtney Johnson, HealthNet, told the Senate Health Committee this bill would make it difficult for insurers to track patients’ utilization of benefits. The bill had one hearing but did not move.

SB 250 – PUTS ACA PROVISIONS IN STATE LAW PASSED Because of uncertainty at the federal level, the Insurance Division wants to add key provisions of the Affordable Care Act (ACA) to Oregon law to protect consumers in case the ACA, or key components, go away. Among other provisions, SB 250: • Maintains protections for people with pre-existing conditions, • Clarifies that mental health parity requirements apply to individual and group plans, • Aligns Oregon’s small-employer plan requirements with proposed changes to HRAs (health reimbursement arrangements). • Enables DCBS to run a state-based risk adjustment program, if necessary. Mark Griffith, OSPIRG, said, “Preserving the guaranteed issue market and protecting individuals with preexisting health conditions is an important step” in protecting Oregon consumers. The bill takes effect January 1, 2020.

SB 537 – DUAL INSURANCE POLICIES FAILED Sen. Chuck Riley (D-Hillsboro) proposed a bill that would have required DCBS to create rules protecting people from out-of-pocket expenses when they have multiple coverages, and the sum of those coverages exceeds the cost of services. The bill had a quick hearing but did not move.

SB 728 – UNFAIR TRADE PRACTICES FAILED OAHU opposed efforts to add insurance to the Unfair Trade Practices Act. Consumers already have opportunities through DCBS to resolve insurance problems. The Senate Judiciary Committee held a hearing on the bill but it did not come up for a vote.

SB 735 – HOSPITAL & INSURANCE METRICS FAILED

16 The Health Plan Quality Metrics Committee’s establishing legislation (SB 440, 2015) has been interpreted to apply only to CCOs, OEBB and PEBB. SB 735 was designed to: • Expand the committee’s scope to include all commercial health plans, • Add an oral health representative to the metrics committee, • Establish a structure for hospital measures that will work across all payers, and • Allow the committee to create a core metrics set that all insurers would have to use, along with a menu of other measures that they could use. Carriers objected to the idea of core metrics. They wanted just a menu. The bill did not move out of committee.

SB 900 – DIALYSIS PAYMENT FAILED SEIU tried to stop the two large for-profit dialysis providers from paying the commercial health insurance premiums for dialysis patients so they can collect the high fees, which can run $12,000 to $15,000 per month. “We have to end this scheme,” Felisa Hagins, SEIU, told the Senate Health Committee. The bill would prohibit the American Kidney Foundation from canceling dialysis patient’s insurance plans mid-year if they get a kidney transplant and prevent them from steering patients to their affiliated clinics. Fresenius operates 48 dialysis clinics in Oregon. Their lobbyist said two-thirds of their patients receiving premium assistance are on Medicare that pays the clinic below cost. “If it was really a scheme, all of the money we gave to the American Kidney Foundation would be used for commercial insurance,” he said. Insurance carriers including Providence, Cambia and AHIP said they support the bill to stop “the abuse of third party payments by those who stand to benefit from higher payments.” The bill did not move.

HB 2703 – SHORT-TERM HEALTH PLANS FAILED OAHU proposed expanding short-term health plans to 12 months to provide an option for those who lose their insurance during the year but don’t have a qualifying event to purchase a new health plan. The House Health Committee understood the problem but did not support the solution. The Insurance commissioner, carriers and the Governor’s health care advisor expressed concerns about expanding access to plans that did not cover the essential health benefits. As a result of the bill, insurance commissioner Andrew Stolfi convened an informal work group including agents, carriers and consumer advocates to work on expanding access to plans on the individual market. The group focused on extending grace periods and agreed to work during the interim on redefining micro employers and hardship exemptions for late payment.

HB 3074 – RATE REVIEW UPDATE PASSED Insurance Commissioner Andrew Stolfi says that the intent of this bill is simply to streamline the rate review process. HB 3074 makes three changes: • Reduce the administrative burden in carrying out rate review, while still allowing for public input, • Remove the process for modified rates, and • Include technical clean up language. These changes will take effect during the 2020 rate review process.

17

PEBB & OEBB

The Public Employees Benefits Board (PEBB) and Oregon Educators Benefits Board (OEBB) now provide health insurance to about 300,000 Oregonians, 7% of the population, and more than the individual market. PEBB has 139,000 covered lives; OEBB 153,000. In 2018, for the first time, PEBB and OEBB’s coordinated care model plans are more popular than its PPO plans.

SB 780 – PEBB AND OEBB IN CCOS PILOT PROGRAM FAILED Sen. Elizabeth Steiner Hayward (D-Beaverton) and Sen. Lee Beyer’s (D-Springfield) bill would have created a pilot project to test the impact of allowing public employees and educators to purchase health insurance from the state’s Medicaid CCOs. Four counties—Josephine, Jackson, Curry, and southern Douglas—would pilot the concept. It was unclear what the reimbursement rate would be for providers under this plan. Would it be Medicaid, commercial or a blending of the two? A lobbyist for the public employees union, SEIU, said, “We are not sure that SB 780 is the right vehicle for this. We already know that our members in rural Oregon have trouble with access and worry that changes to reimbursement rates could worsen that.” The bill did not move out of Ways and Means.

HB 2266 – REINSTATES DOUBLE COVERAGE FOR OEBB & PEBB PASSED Double coverage for public employees in OEBB & PEBB was eliminated as part of a cost cutting bill passed in 2017. HB 2266 undoes that restriction. Small, rural school districts say the double-coverage prohibition makes it more difficult for them to recruit teachers and public employees to their communities. House Speaker Tina Kotek (D-Portland) said the savings from this prohibition were not as great as anticipated and she described it as an issue of fairness, “Where just because a couple both work as teachers or public employees they could not double insure, though they could if one of them worked for a private employer.” The bill also requires the OEBB and PEBB boards to enact a reasonable surcharge on public workers who choose double coverage for their families.

HEALTH INSURANCE MANDATES

SB 9 – EMERGENCY INSULIN PASSED Beginning January 1, 2020, pharmacists will be able to prescribe and dispense emergency insulin and supplies for diabetics. Sen. Peter Courtney (D-Salem) told stories about diabetics sharing insulin to get through the month, buying test strips on the black market and borrowing equipment. Jessica Adamson, Providence, said they don’t normally support mandates but, “This is one that will save costs by avoiding unnecessary visits to the emergency department.” Rep. Mitch Greenlick (D-Portland) asked why not allow pharmacists to prescribe insulin in non-emergency situations? Sen. Dennis Linthicum (R-Klamath Falls) said insulin was sold over-the-counter 45 years ago when he became an insulin-dependent diabetic. Carriers said the relationship between primary care providers and diabetics is important, so that change would require more conversation.

18

SB 242 – SURROGATE INSURANCE MANDATE FAILED A gay couple in Portland wants to have a baby but discovered that one of the biggest costs was health care for the surrogate mother. Under current law, Providence says health plans “provide comprehensive maternity coverage to surrogates that include care necessary to support a healthy pregnancy and care related to labor and delivery.” The carriers then recover those costs from the intended parents. SB 242 would have prohibited insurers from billing parents for those costs. The bill passed Senate Health but died in Ways and Means.

SB 740 – PROTON BEAM THERAPY MANDATE PASSED Insurers that cover radiation therapy for cancer treatment now have to cover proton beam therapy. The bill ensures that proton beam therapy, which is much more expensive than radiation therapy, can be subject to prior authorization. Jessica Adamson, Providence, said, “This will make sure this service is accessible to policyholders in those cases where it is medically necessary.”

SB 749 – FERTILITY SERVICES MANDATE FAILED This bill would have required health insurers to cover the cost of infertility and reproductive endocrinology services. “People are precluded from becoming parents because of the high cost of treatment,” attorney Robin Pope told the Senate Health Committee. The committee chair asked how much this new mandate would cost but none of the proponents had an answer. The bill died in committee.

SB 887 – ALTERNATIVE HEALTH CARE MANDATE FAILED Insurers including OEBB and PEBB would have been required to cover chiropractic, acupuncture and massage therapy without prior authorization under SB 887. The mandate included coverage for an initial evaluation and six follow-up visits. Mary Jean Brinkman, acupuncturist, told the Senate Health Committee, “Utilization management creates a barrier to care and a delay in treatment.” She said, “It is common with most pain-related complaints to take 8 to 25 visits with acupuncture to help address an issue.” Those multiple visits could lead to high costs. The bill did not move out of committee.

SB 911 – FERTILITY PRESERVATION FAILED Ten percent of cancer cases affect patients of childbearing age. In many of those cases, cancer treatment could result in infertility or sterilization. SB 911 would have required commercial insurance plans, Medicaid, PEBB and OEBB to cover fertility preservation of eggs or sperm, which can cost $30,000 to $50,000, for “iatrogenic infertility” caused by surgery, radiation or chemotherapy. Supporters predict this would apply to 150 patients per year but state agencies estimate a much bigger impact. OHA projected a Medicaid General Fund increase of $8.7M this biennium plus an additional $42M Federal funds. PEBB projected a .5%, $6.6M rate increase, and OEBB estimated a .2%, $1.02M rate increase. OHSU worked to lower the fiscal impact of the bill but it never made it out of Ways and Means.

19

HB 2845 – MIDWIFE MANDATE FAILED This bill would have required insurers to cover midwifery care in the hospital, birth center or home setting performed by all three midwife types: certified nurse midwife, certified naturopathic physician midwife and direct entry midwife. “Women and not insurance companies should be deciding where they will deliver babies,” a naturopathic physician from Portland told the House Health Committee. Proponents say insurers would save money because home and center-based births are much less expensive than hospital deliveries. Insurers oppose the bill citing patient safety. Jennifer Baker, Cambia, said, “This would force us to credential other providers including direct entry midwives.” The bill had one hearing but did not move.

MEDICAID FUNDING

The Governor proposed three bills to fill the $950 million Medicaid funding hole. The hospital and premium tax (HB 2010) passed early in the session. The tobacco tax (HB 2270) passed late and goes to voters in November 2020. The new, employer- responsibility tax (HB 2269) needs more work.

HB 2010 – HOSPITAL & PREMIUM TAX FOR MEDICAID PASSED Before the session, the Governor convened a stakeholder workgroup to develop a plan for secure, long-term Medicaid funding. This portion of the package: • Renews the hospital assessment for large hospitals at 6% of net patient revenue, and a lesser tax for small and rural hospitals • Increases the health insurance premium tax, including PEBB, OEBB and CCOs, to 2%, and ads a tax on stop loss premiums paid by self-insured entities, and • Sunsets in 2025. This package is expected to raise $335M this biennium and $1.8B in 2021-23. Republicans were clearly irritated by the speed at which it moved through the legislature. HB 2010 passed in February.

HB 2270 – TOBACCO TAX FOR MEDICAID PASSED Gov. Kate Brown championed a $2 per pack tobacco tax increase to support the Oregon Heath Plan saying, “By increasing the cost of tobacco products and e- cigarettes, HB 2270 not only provides the funding we need to provide health care coverage for Oregonians, it invests in prevention and cessation to improve the health of our communities.” The bill includes a new tax on vaping products and increases the cigar tax up to $1 per cigar. Oregon’s current cigarette tax of $1.33 per pack would increase to $3.33, putting it in line with California ($2.87 per pack) and Washington ($3.025 per pack). The proposed tax goes to voters in November 2020, so tax collection won’t begin until January 2021. Because of the late start, the tax would only raise $115M this biennium, but tax receipts are expected to increase to $350M in 2021-23.

HB 2269 – EMPLOYER RESPONSIBILITY ASSESSMENT FAILED Employers would have been required to pay at least 50-cents per hour for health care expenses (insurance or services) for each employee who works 8-hours or more.

20 This $500 million program was a late addition to the Governor’s Medicaid funding package. $120 million would have helped pay the state’s Medicaid cost; the other $380 million would have provided premium support through a new, and undefined state program. The bill died as part of business support for a $2 billion corporate activity tax to support education. According to the Oregon Health Authority, 25% of the million workers of large employers in Oregon are either ineligible for or not offered health care coverage by their employer. Another 150,000 are eligible but not enrolled in the employer’s insurance plan. In 2017, about 90,000 Oregonians working more than 8 hours per week for large employers were enrolled in the Oregon Health Plan. Legislators say large employers that use Medicaid as their default insurer should pay the state’s cost for that program.

MEDICAID/CCOS

SB 134 – STANDARDIZED SYSTEM OF CARE FOR CCOS PASSED This bill aims to address the lack of transparency in how Coordinated Care Organizations (CCOs) treat patients with mental illness and substance abuse disorders. It requires CCOs to publish behavioral health treatment options and resources online, making treatment systems more transparent and navigable. The bill makes it clear “tribal-based practices” for mental health and substance abuse prevention are recognized and paid for by Medicaid. The new provisions take effect in October 2019.

SB 137 – CCOS & BEHAVIORAL HEALTH FAILED NAMI (National Alliance on Mental Illness) wants to prohibit CCOs from contracting out all of their behavioral health services including utilization management, care coordination, denials and appeals. Tabitha Jensen, New Avenues for Youth, said they are trying to improve access to care and network adequacy for foster kids and others who need behavioral health services. “The wait lists for substance use disorder treatment, psychological evaluation, medication management and counseling services are often in excess of 12 weeks,” she said, “and available beds in treatment levels of residential care (Psychiatric Residential Treatment Services) are nearly non-existent. “ Senate Health Committee chair Sen. Laurie Monnes Anderson (D-Gresham) said this really should be done through contracts with the CCOs. The bill did not move out of committee.

SB 721 – CCO PAYMENTS TO SCHOOL-BASED HEALTH CENTERS FAILED This bill would have required CCOs to pay school-based health centers as in-network providers. Sen. Lew Frederick (D-Portland) said he introduced this bill to provide more mental health counseling in schools. But the bill would have applied to all services. Mary Williams, representing the CCOs in the Coalition for a Healthy Oregon, said their CCOs work closely with the school-based health centers and treat them the same as any other clinic. The bill did not move out of committee.

21

SB 1041 – CCO AUDITING AUTHORITY PASSED CCOs are multi-billion dollar businesses. SB 1041 will give the Oregon Health Authority new financial regulatory tools, including auditing for financial solvency, like DCBS has for the commercial insurance industry. FamilyCare, a CCO in the Portland area until 2018, and Rep. Alissa Keny-Guyer (D- Portland) raised concerns that the new transparency provisions are only a “baby step”, when what we really need is a “quantum leap”. The bill takes effect in October.

HB 2009 – MEDICAID BUY-IN (NOW IN SB 770) AND INDIVIDUAL MANDATE FAILED About 245,000 Oregonians, or 6% of the population, is still uninsured. Others are underinsured or can’t afford to use their insurance because of copays and deductibles. So legislators want to know if allowing Oregonians to buy a Medicaid health package through the CCOs would help. “This may be a more affordable option,” Rep. Andrea Salinas (D-Lake Oswego) told the House Health Committee. The idea was to use the Medicaid benefits package and pay Medicaid rates to providers. Salinas said she thinks that would cost individuals between $400 and $600 per month, but with no copays, deductibles or coinsurance, it might be a better deal for some people. Jeremy Vandehey, OHA, said a number of states are looking at options like this but there are a number of unanswered questions including the benefits package, cost share, provider rates and risk of the population. Insurance carriers say a Medicaid buy-in option “has the potential to adversely disrupt current markets and programs.” Ultimately, Medicaid buy-in was added to Healthcare For All in SB 770. HB 2009 also proposed a new individual health insurance mandate, which the carriers support. “The federal penalty for not having insurance was zeroed out while guaranteed issue remains,” Amy Fauver, Kaiser, said. As a result, “We fear the healthier population may avoid coverage, causing premiums to spike and destabilizing the market.” OSPIRG and other consumer groups also support the individual mandate. But the individual mandate portion of the bill did not move forward.

HB 2267 – CCO 2.0 POLICY CHANGES PASSED The Oregon Health Authority and Oregon Health Policy Board worked over the last 2 years to assess and address the Oregon Health Plan and how it should be altered in the next round of contracts. Known as CCO 2.0, the policy shift includes various changes that required a statutory change; HB 2267 reflects those changes. The bill: • Adds a second member from Community Advisory Board to CCO governing boards, • Creates a formal process for engaging tribes, • Creates more alignment between CCOs, local public health and hospitals to address social determinants of health, • Provides OHA the authority to create a reinsurance program to combat the rise of very expensive specialty pharmaceuticals, • Allows for adjustment of rates after initial six months of coverage, and • Clarifies that CCOs are large businesses.

HB 2678 – PREFERRED RX LIST FOR MEDICAID FAILED It’s rare for a bill to be defeated on the floor but that’s what happened to HB 2678.

22 The bill required the Oregon Health Authority to maintain a preferred drug list for the 100,000 fee-for-service Medicaid patients and a partially aligned drug list for CCOs. Rep. Rob Nosse (D-Portland) said, “By designating drugs as preferred, the state can increase the use of lower-cost medications when they have the same effectiveness as higher-cost alternatives.” The cost of Medicaid prescription drugs has grown from $591M in 2014, to $871M in 2018, a 32% increase. The OMA, ophthalmologists, orthopedic physicians and others opposed the bill. Rep. Marty Wilde (D-Eugene) said, “If we pass this bill we will reduce access for the most vulnerable people.” The bill failed on the House floor and was sent back to the Rules Committee.

HB 2986 – CCOS PARTNER WITH EQUITY COALITIONS FAILED The House Health Committee approved a plan requiring the Oregon Health Authority and CCOs to partner with regional health equity organizations when practical. Rep. Cedric Hayden (R-Cottage Grove) said, “I believe our CCOs are already doing this.”

HB 3397 – OREGON MEDICAID PURCHASING FAILED Rep. Cedric Hayden (R-Cottage Grove) believes that Oregon is overpaying for pharmaceuticals for the Oregon Health Plan. This bill would have created a Oregon Medicaid Purchasing Cooperative to advise the Oregon Health Authority (OHA) on best practices and to leverage purchasing power. Democrats say this bill was linked with HB 2678, a Medicaid preferred drug list, that failed on the floor and was sent back to the Rules Committee, so they sent this bill back to Rules as well.

RXS/MEDICATIONS

SB 9 – PHARMACISTS PRESCRIBE INSULIN PASSED In emergency situations, trained pharmacists can prescribe and dispense insulin and supplies for diabetics. Sen. Peter Courtney (D-Salem) talked about diabetics sharing insulin to get through the month, buying test strips on the black market and borrowing equipment. “I’m not okay with these stories. I don’t think anyone here is okay with these stories,” he said. Jessica Adamson, Providence, said they don’t normally support mandates but, “This is one that will save costs by avoiding unnecessary visits to the emergency department.”

SB 910 – NALOXONE NOTICE AT PHARMACIES PASSED Naloxone can quickly revive someone experiencing an opioid overdose. SB 910 requires hospital and retail pharmacies to post a notice that the drug is available there. The bill also allows pharmacists to distribute naloxone kits to agencies that work with individuals who might experience opioid overdoses and allows pharmacists to prescribe naloxone when dispensing opioids.

SB 409 – WHOLESALE IMPORTATION OF PRESCRIPTION DRUGS FAILED The bill, introduced by Sen. Dennis Linthicum (R-Klamath Falls), Sen. Elizabeth Steiner Hayward (D-Beaverton) and Rep. Rob Nosse (D-Portland), directed the Board

23 of Pharmacy to import lower cost prescription drugs of equal efficacy from Canadian wholesalers. Representatives from the pharmaceutical industry argued that though this bill has good intentions, there was no way for it to be fully implemented. The bill passed the Senate Health Committee and died in Ways & Means.

HB 2185 – PHARMACY BENEFIT MANAGER REQUIREMENTS PASSED The bill restricts how pharmacy benefit managers (PBMs) operate. The Oregon Pharmacy Coalition argued, “PBMs have gotten so strong, we can no longer negotiate contracts with the PBMs that are fair to pharmacists, pharmacies and patients.” HB 2185: • Allows patients to use a local pharmacy rather than mandating a mail order pharmacy, • Permits local pharmacies to mail prescription drugs to patients, • Defines specialty drugs, • Prevents PBMs from paying 340B pharmacies, including FQHCs and some hospital pharmacies, differently than other pharmacies, and • Bans gag clauses that prohibit pharmacists from telling consumers about lower- cost options. The PBMs still hope to clean up some of the definitions in the bill before it is implemented in 2021.

HB 2303 – PSEUDOEPHEDRINE PASSED In 2005, Oregon made pseudoephedrine a prescription-only drug because Sudafed can be used as a precursor drug to make meth. The law was very successful and meth lab incidents dropped from 600 in 2001 to near zero today. HB 2303 allows consumers to buy pseudoephedrine without a prescription but limits and tracks sales using a system called NPLEx, used in 35 other states. The bill passed despite opposition from a coalition of cities, counties and law enforcement agencies. The Association of Oregon Counties said that Oregon’s response to meth production so far has been a “phenomenal success,” and that with this bill, “we’re setting ourselves up for a resurgence of meth labs.” The ACLU opposed the bill on privacy concerns.

HB 2658 – 60-DAY NOTICE OF RX RATE HIKES PASSED This requires pharmaceutical manufacturers give the Department of Consumer and Business Services (DCBS) 60-days notice of any planned price increases of 10% or more for brand-name drugs, or 25% or more for generics. The bill includes a 12-month “look back” at drug increases on or before July 1, 2019, and exempts generic drugs that are produced by four or more companies.

HB 2679, HB 2680 & HB 2690 – BULK PURCHASING & WHOLESALE IMPORTATION FAILED The House Health Committee desperately searched for a way to lower prescription drug costs. It approved three bills, each with a different twist on the same basic idea: • HB 2679 allowed bulk purchasing with California, • HB 2680 allowed bulk purchasing with Canada, and • HB 2689 allowed wholesale importation of drugs from Canada. All three bills failed to move out of Ways and Means.

24

HB 2690 – PAYING CASH FOR RX INSTEAD OF INSURANCE FAILED This would have allowed pharmacists to let consumers know their Rx may be less expensive if they don’t use their insurance and just pay cash. Under the bill, those cash payments would count toward the person’s insurance deductible. The bill failed to move out of the House Health Committee.

HB 2696 – RX DRUG COST REVIEW COMMISSION INFO HEARING ONLY Rep. Rachel Prusak (D-Tualatin) hoped to “truly address the high price tag pharmaceutical companies place on medications for more profit.” Although the bill failed to move out of the House Health Committee, she hopes it can pass in 2021. HB 2696 would have: • Established a 7-member Drug Cost Review Commission that would track changes in prescription drug costs and, if deemed necessary, cap prices, • Created an 11-member advisory committee to assist with the board’s functions, • Mandated that pharmaceutical manufacturers provide written 30-day notice of specific prices increases within a 12-month period, • Allowed the commission to establish a maximum payment rate for a drug if its price is determined to be “unjustified or unduly burdensome to Oregonians”, and • Allowed the Attorney General to investigate manufacturers that exceed set rates and pursue legal action against them under the Unlawful Trade Practices Act. The concept is one of “affordability, not value”, meaning that it looks at giving everyone who needs it access to the drug, rather than trying to determine a drug’s monetary “value”. It presumes more people will take more medication, with “no intent to cause manufacturers to lose money.” The optimal system for it is a statewide all-payer, all-purchaser one. Maryland just became the first state to enact such a system into law.

HB 2753 – PHARMACISTS COULD SUBSTITUTE GENERIC RX FAILED Current Oregon law allows pharmacists to substitute generic drugs. This bill would have required pharmacists to fill prescriptions with the less-expensive generics. Pharmacist Kevin Russell said, “I don’t think [this bill] is necessary, we already substitute generics in every case we can. It seems an awkward, convoluted solution… I see this as a barrier rather than helping.” The bill failed to make it out of the House Health Committee.

HB 2799 – FLAT DOLLAR COPAYMENTS AND FORMULARY TRANSPARENCY FAILED Based on recommendations of an interim work group, HB 2799 would have required carriers to offer, in at least 25% of their benefit plans, flat dollar copayments for prescription drug coverage. In addition, it required carriers to report specified information about changes to the formulary, cost sharing, and utilization controls for prescription drugs annually to the Department of Consumer and Business Services (DCBS). Colorado and Montana have adopted these policies without seeing premium increases or other adverse outcomes. But Oregon carriers estimated that this would raise premiums between 1-3%. The bill failed to pass out of the House Health Committee.

HB 2840 – PHARMACY BENEFIT MANAGER REQUIREMENTS FAILED With similar provisions to HB 2185, HB 2840 died in Ways and Means. It had a $10 million price tag because of its impact on OEBB and PEBB.

25

HB 2935 – RX LABEL READERS FOR VISUALLY IMPAIRED PASSED Pharmacies are now required to provide prescription label reading devices to consumers who are blind or vision impaired. The devices read a microchip, embedded in the prescription label, out loud, giving instructions and warnings about that drug to the consumer. Institutional pharmacies, such as the state hospital, corrections and long-term care pharmacies, are exempt.

HB 2961 – RX ADS MUST DISCLOSE PRICE FAILED This bill would have required manufacturers to disclose the wholesale price of a drug in any advertisement, with penalties of up to $5,000 for each violation. Pharma testified, “When people complain, they are complaining about their co-pays or co-insurance. Typically these approaches focus on list price. The wholesale price is not a price we set, so it would be hard to include in an ad.” HB 2961 did not move out of the House Health Committee.

HB 3273 – RX “TAKE BACK” PROGRAM PASSED This bill requires manufacturers to create a statewide drug take-back program that would be run by a nonprofit contractor. There was broad agreement on the concept. Its aim is to help curb opioid addiction and keep pharmaceuticals out of our wastewater. Washington, California and New York already have similar programs. Amendments shifted most of the cost of the program away from Pharma and onto generic drug and over-the-counter drug companies. The Department of Environmental Quality will oversee the program, which is projected to cost $258,000 this biennium and will be covered by fees. It will become operational in February 2021.

HOSPITALS

HB 3076 – CHARITY CARE AND COMMUNITY BENEFITS PASSED House Health Committee chair Rep. Andrea Salinas (D-Lake Oswego) and the Service Employees International Union (SEIU) pushed to standardize non-profit hospital charity care and community benefits. 58 of Oregon’s 60 acute care hospitals are non- profit. The bill: • Requires charity care cover 100% of non-profit hospital bills up to 200% FPL, with a sliding scale of charity care up to 400% FPL, • Limits the interest rate on debt collections for non-profit and for-profit hospitals, and • Sets an individualized spending floor for each hospital’s community benefit beginning in 2021. The Oregon Health Authority will work with each hospital to set a community-benefit spending floor. As part of the formula, for-profit hospitals will be given credit for the taxes they pay. A report from OHA’s Office of Analytics shows that Oregon hospitals provided $2.2 billion in community benefits in FY 2016, 73% of which came from below-cost reimbursements from Medicare and Medicaid.

26 Rep. Rachel Prusak (D-Tualatin) said, “Despite all the work you do and your charity care policies, the number one cause of bankruptcy is still medical debt.” Rep. Salinas said, “Crushing medical debt does not have to be something that we accept. This legislation is about setting clear standards for every hospital, so that they are fulfilling their missions and meeting their obligations…”

HB 3342 – PLANT-BASED MEALS FAILED Osteopathic physicians introduced legislation to require hospitals, in-patient acute psychiatric care facilities and prisons to serve plant-based (vegan) meals any time a meal is served in their facilities. Rep. Tiffiny Mitchell (D-Astoria) said her father “was a walking heart attack waiting to happen,” but after going plant-based lost 150 pounds and was able to stop taking his two blood pressure medications and one statin medication. Hospitals amended the bill to clarify that they had to offer vegan options to patients and in their cafeteria but not if they rented a conference room to a community organization. The bill passed the House but did not move out of the Senate committee.

SB 23 – HOSPITAL ED DISCHARGE DATA TO OHA PASSED The Hospital Association supported SB 23, saying it codifies existing inpatient data collection practices and requires hospitals to submit emergency department discharge data to the Oregon Health Authority in the same manner. Jeremy Vandehey, OHA, testified, “This will tell us who shows up in the ED and for what issues. We will have a much better idea of what’s going on in ED with this.”

SB 140 – ED BOARDING PREVENTION FAILED The goal was to create an Emergency Department Boarding Pilot Project so patients with mental health issues aren’t stuck in EDs, sometimes for days or weeks, waiting for a community placement. The bill proposed pilots in six hospitals, one of which is a rural/frontier hospital, with $250,000 for each pilot. Alesha Beamer, PeaceHealth, said they need additional services for youth and adolescents. “Last year our emergency departments served 579 youth in crisis, 20% of who remained in the ED for more than 24 hours,” she said. The bill did not move out of Ways and Means.

SB 141 – CARING CONTACTS AFTER HOSPITAL DISCHARGE FAILED People who are discharged from the hospital for a behavioral health condition are at increased risk for suicide. David Westbrook with Lines for Life says that “Caring Contacts” provide in-depth follow up phone calls, which help to reduce the risk of suicide by 30-50%. Westbrook says it costs just $65 per patient to provide multiple calls. The hospital association introduced the bill asking for $4M to provide grants to hospitals to enhance their follow-up care. The program was not funded by Ways and Means.

SB 823 – WORKPLACE VIOLENCE PREVENTION PASSED Healthcare workers are four times more likely to be injured and require time away from work as the result of workplace violence than workers in private industry. Between 2013-2018, 10% of the nation’s disability claims for non-fatal assaults came from hospital workers.

27 SB 823 requires hospitals to conduct a comprehensive security and safety evaluation by June 30, 2021, based on the Workplace Violence Prevention Toolkit, developed by a coalition of hospitals, SEIU Local 49 and the Oregon Nurses Association. A provision requiring hospitals to hire 24-hr security personnel for emergency departments was stripped out of the final bill.

SB 941 – FUNDING FOR CURRY COUNTY EMERGENCY ROOM FAILED While SB 941 did not pass, the legislature allocated ~$2 million in funding for a new emergency department in Brookings, Oregon, which was included in SB 5050.

SB 1027 – NEEDLESTICK SAFETY PASSED Health care workers that suffer a needlestick injury while treating an unconscious patient can draw a blood sample to determine if the patient is HIV positive. The bill prohibits billing the patient’s health insurance for the cost of the test. The new law takes effect on October 1, 2019.

HB 2901 – SURGICAL SMOKE INFO HEARING ONLY Operating room nurses complain that surgical smoke resulting from cauterization or lasers is sickening. One nurse said, “Breathing in surgical smoke makes you immediately choke. You can taste the burning [human] flesh.” The bill would have required hospitals and ambulatory surgery centers to use smoke evacuation equipment during surgery. Many nurses testified that their hospitals already own smoke evacuation equipment, but it is up to surgeons whether to use it. OMA objected to legislation that dictates how a surgeon practices.

SB 5050 – FUNDING FOR CURRY COUNTY ED PASSED Included in the so-called “Xmas tree bill” is $2,042,000 for a new emergency room in Brookings, Oregon. Local officials say that various natural disasters over the course of the last decade have highlighted the need for expanded emergency health service infrastructure beyond the hospital in Gold Beach and urgent care clinic at Curry Medical Center in Brookings.

TELEHEALTH

SB 129 – OPTOMETRIST TELEMEDICINE PASSED This bill puts criteria in place to ensure patient safety and the appropriate use of optometrist telemedicine. It sets up a regulatory platform for the Board of Optometry to contemplate telehealth and telemedicine. “I never use my iPhone to diagnose eye problems,” Dr. McBride, a Beaverton optometrist, testified in to the House Health Committee. “At the end of the day, that’s what’s happening.”

SB 130 – TELEHEALTH FOR SCHOOL-BASED HEALTH CENTERS FAILED SB 130 would have created grants for school-based health center pilot projects that seek to increase access to behavioral and physical health using telehealth. With a $950,000 fiscal to implement the grant program, the bill died in Ways and Means.

HB 2190 – OPTOMETRIST TELEMEDICINE FAILED

28 Optometrists introduced similar bills in both chambers. With similar provisions to SB 129, which passed, HB 2190 failed to move out of the House Health Committee.

HB 2693 – TELEHEALTH REIMBURSEMENT FOR TEXTING AND EMAIL SERVICES FAILED ZoomCare wanted to require private insurers to reimburse chat, texting and email services. They said they currently offer services via online chat but that only about half of insurers reimburse for those services. Stakeholders took issue with the broad expansion of services, and particularly with the set amounts of reimbursement prescribed in the bill—80% of the in-person reimbursement for a physical health service, 90% for a behavioral health service. Providence and the hospital association were opposed to the bill. It died in committee.

STATE BUDGET

STATE REVENUES HIGH, TRIGGERS BIGGEST KICKER ON RECORD State economists were astounded by the increase in tax revenue this year. They said corporate and personal tax collections were $500 million higher than a typical year. This means the state has to return $1.4 billion in tax revenue to Oregonians, marking the largest kicker on record.

SJR 23 – PERSONAL KICKER REFORM FAILED The kicker “kicks” when revenues to the state exceed economists’ projection by more than 2%. When that happens, all of the additional revenue, including the 2%, must be returned to taxpayers. Since it was passed in 1979, the kicker has kicked 10 times and returned $3.4 billion to taxpayers. Rep. Christine Drazen (R-Canby) said, “The kicker is one of the only programs that keeps the growth of government in check.” In 2012, voters passed Ballot Measure 84, diverting the corporate kicker to K-12 spending. Legislators talked about a constitutional amendment to redirect personal kicker funds to K-12. The referral did not move to a vote.

SB 1049 – PERS REFORM PASSED The main piece of the bill is a refinancing mechanism, extending the payback period for the pension system’s $27 billion deficit. The bill also reduces employee retirement benefits in their side 401(k)-like accounts, by putting 2.5% of pay for employees hired before August 28, 2003, and 0.75% for those hired later, into an account to support pension benefits. Oregon is currently one of two states that does not require employee contributions to its pension plan. The bill reduces employee’s overall retirement benefits by 1-2% of pay. Public employees argue that they are already underpaid, and worry that this bill sets a precedent for future legislatures to further reduce their benefits. Public employee unions were outraged. The President of the Oregon Education Association said, “These unfair and illegal reductions are a betrayal of Oregon values.” The bill was effective June 11, 2019.

29

POLITICAL CAMPAIGNS

SJR 18 – REFERRAL TO VOTERS ALLOWING CAMPAIGN CONTRIBUTION LIMITS PASSED Oregon is one of only five states with no limits on campaign contributions. This bill doesn’t set a limit; it just makes them constitutional. The referral will be on the November 2020 ballot. Legislation actually setting campaign contribution limits did not make it through the process this session. There was significant debate on how high, or low, those limits should be. Expect to see competing bills on this issue in the 2020 and/or 2021 sessions.

HB 2714 – SETS CAMPAIGN CONTRIBUTION LIMITS FAILED Rep. Dan Rayfield (D-Corvallis) said, “The last time the Oregon legislature did anything on campaign finance limits was 1975, before I was born, and that action was to repeal campaign finance limits.” Rayfield led the effort to cap contributions per election to: • $1,000 for House candidates, • $1,500 for Senate candidates, and • $2,800 for statewide candidates. These proposed limits would also wipe out the standards approved by voters in 2006, which set limits of $100 for legislative candidates and $500 for statewide candidates. Those limits never went into effect because of a state Supreme Court ruling that Oregon’s constitution does not allow limits on campaign contributions. Critics of the proposal said the proposed limits were too high and would still tip the scales in favor of the wealthy. The bill did not pass.

###