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Policy Points: We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage on mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression. Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications and reduced the share of respondents reporting unmet mental health care needs by almost 40%. There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations. Context: Expanding Medicaid to previously uninsured adults has been shown to increase detection and reduce the prevalence of depression, but the ways that Medicaid affects mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression remain unclear. Methods: We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage using a randomized‐controlled design, drawing on both primary and administrative data sources. Findings: Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications frequently prescribed to treat depression and related mental health conditions and reduced the share of respondents reporting unmet mental health care needs by almost 40%. The share of respondents screening positive for depression dropped by 9.2 percentage points overall, and by 13.1 for those with preexisting depression diagnoses, with greatest relief in symptoms seen primarily in feeling down or hopeless, feeling tired, and trouble sleeping—consistent with the increase observed not just in medications targeting depression but also in those targeting sleep. Conclusions: Medicaid coverage had significant effects on the diagnosis, treatment, and outcomes of a population with substantial unmet mental health needs. Coverage increased access to care, reduced the prevalence of untreated and undiagnosed depression, and substantially improved the symptoms of depression. There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations. [ABSTRACT FROM AUTHOR]

Section 1332 of the Affordable Care Act (ACA) provides states unprecedented flexibility to alter federal health policy. The authors analyze state waiver activity from 2019 to 2023, applying a comparative approach to understand waivers proposed by Georgia, Colorado, Washington, Oregon, and Nevada. Much of the waiver activity during this period focused on reinsurance programs. During the Trump administration, the most innovative waiver application was from Georgia, which sought to restructure and decentralize its individual market, moving away from the framework established by the ACA. While the Biden administration suspended Georgia's efforts, Democratic-led states have focused implementing waiver programs supporting and expanding on the ACA. This has included adopting public-option insurance plans offered by private insurers and expanding eligibility for qualified health plans for previously ineligible groups. The authors' analysis offers insights into contemporary health politics, policy durability, and the role of the administrative presidency., (Copyright © 2024 by Duke University Press.)

Research on behavioral health integration (BHI) often explores outcomes for quality and cost, but less is known about impacts of integration work on key patient experience outcomes. A mixed-methods longitudinal study of BHI was conducted in 12 primary care clinics in Oregon to assess how adoption of key integration practices including integrated staffing models, integrated care trainings for providers, and integrated data sharing impacted a set of patient experience outcomes selected and prioritized by an advisory panel of active patients. Results showed that adopting key aspects of integration was not associated with improved patient experience outcomes over time. Patient interviews highlighted several potential reasons why, including an overemphasis by health systems on the structural aspects of integration versus the experiential components and potential concerns among patients about stigma and discrimination in the primary care settings where integration is focused.

Following the Patient Protection and Affordable Care Act, Medicaid eligibility in the United States expanded to include low-income adults. One key challenge for organizations and providers serving the Medicaid population was predicting if and how this change would alter the composition of enrollees. This study characterized demographics, socioeconomic challenges, and health of the expansion and non-expansion Medicaid populations in a metropolitan area in Oregon using a survey and Medicaid claims. Results showed that the expansion population has more men and non-English speakers than the non-expansion population. They also have greater education and employment, but face similar socioeconomic challenges including struggling to meet basic needs and housing instability. This study also found comparable self-reported physical and mental health, but lower prevalence of physical or mental health diagnoses and several ambulatory care reactive conditions including hypertension, obesity, and type 2 diabetes. The authors concluded that expansion and non-expansion populations differ in sex, language, education, employment, and health, but they face similar socioeconomic challenges. This information is useful for organizations coordinating and providing care to Medicaid members so they can understand the needs of the population and set appropriate population health management strategies.

Background: Efforts to improve outcomes for the 10% of patients using two thirds of health care expenditures increasingly include addressing social determinants. Empiric evidence is needed to identify the highest impact nonmedical drivers of medical complexity and cost., Objectives: This study examines whether complex, highest cost patients have different patterns of critical life adversity than those with better health and lower utilization., Research Design: Using a validated algorithm we constructed a complexity/cost risk patient profile. We developed and fielded a life experience survey (Supplemental Digital Content 1, http://links.lww.com/MLR/B920) to a representative sample, then examined how the prevalence of specific adversities varied between complex, high-cost individuals, and others., Subjects: Surveys were sent to 9176 adult Medicaid members in Portland, Oregon., Measures: Our primary variable was high medical complexity health cost risk; an alternative specification combined health cost risk and actual utilization/cost. Our survey instrument measured exposure to early and later-life adversities., Results: Compared with healthy individuals in our population, medically complex individuals had significantly higher rates of adversity. The greatest risk of medical complexity and cost was associated with substance use [odds ratio (OR), 4.1], homelessness (OR, 3.0), childhood maltreatment (OR, 2.8), and incarceration (OR 2.4). Those with the highest prior year acute care utilization and cost had the highest rates of these same factors: substance use (62.5%), homelessness (61.7%), childhood maltreatment (55.5%), and incarceration (52.1%)., Conclusion: Clinical and policy strategies that mitigate high-impact social drivers of poor outcomes are likely critical for improving both health and costs for complex, high-needs patients.

Medicaid expansions through the Affordable Care Act began in January 2014, but we have little information about what is happening in rural areas where provider access and patient resources might be more limited. In 2008, Oregon held a lottery for restricted access to its Medicaid program for uninsured low-income adults not otherwise eligible for public coverage. The Oregon Health Insurance Experiment used this opportunity to conduct the first randomized controlled study of a public insurance expansion. This analysis builds off of previous work by comparing rural and urban survey outcomes and adds qualitative interviews with 86 rural study participants for context. We examine health care access and use, personal finances, and self-reported health. While urban and rural populations have unique demographic profiles, rural populations appear to have benefited from Medicaid as much as urban. Qualitative interviews revealed the distinctive challenges still facing low-income uninsured and newly insured rural populations.

In 2008 Oregon allocated access to its Medicaid expansion program, Oregon Health Plan Standard, by drawing names from a waiting list by lottery. The lottery was chosen by policy makers and stakeholders as the preferred way to allocate limited resources. At the same time, it also gave rise to the Oregon Health Insurance Experiment: an unprecedented opportunity to do a randomized evaluation - the gold standard in medical and scientific research - of the impact of expanding Medicaid. In this article we provide historical context for Oregon's decision to conduct a lottery, discuss the importance of randomized controlled designs for policy evaluation, and describe some of the practical challenges in successfully capitalizing on the research opportunity presented by the Oregon lottery through public-academic partnerships. Since policy makers will always face tough choices about how to distribute scarce resources, we urge thoughtful consideration of the opportunities to incorporate randomization that can substantially improve the evidence available to inform policy decisions without compromising policy goals.