Impact of the Oregon Health Plan on Access and Satisfaction of Adults with Low-income (2024)

PMCID: PMC1430346

Janet B Mitchell, Susan G Haber, Galina Khatutsky, and Suzanne Donoghue

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Objective

To evaluate the effects of the Oregon Health Plan (OHP) on beneficiary access and satisfaction.

Data Sources

Telephone survey of nondisabled adults in 1998.

Study Design

Two groups of adults were surveyed: OHP enrollees and Food Stamp recipients not enrolled in OHP. The Food Stamp sample included both privately insured and uninsured recipients. This allowed us to disentangle the insurance effects of OHP from other effects such as its reliance on managed care and the priority list. OHP and Food Stamp adults were compared along the following measures: usual source of care, utilization of health care services, unmet need, and satisfaction with care.

Data Collection

The survey was conducted by telephone, using computer-assisted telephone interviewing techniques.

Principal Findings

Much of OHP's impact has been realized by its extension of health insurance coverage to Oregon's low-income residents. The availability of health insurance significantly increased the utilization of many health care services and reduced unmet need for care. OHP was associated within a higher percentage of enrollees having a usual source of care and higher rates of Pap test screening among women compared with Food Stamp recipients. OHP enrollees also reported significantly higher use of dental care and prescription drugs; use we attribute to the expanded benefit package under the priority list. At the same time, OHP enrollees reported a greater unmet need for prescription drugs. Drug treatment for below-the-line conditions was one reason for this unmet need, but often the specific drug simply was not in the plan's formulary. OHP enrollees were as satisfied with their health care as those Food Stamp recipients with private health insurance.

Conclusions

Despite the negative publicity prior to its implementation, there is no evidence that “rationing” under OHP's priority list has substantially restricted access to needed services. OHP adults appear to enjoy access equal to or better than that of low-income persons with private health insurance and have far greater access than the uninsured.

Sociodemographic Characteristics and Health Status

Table 1 compares sociodemographic characteristics and health status of OHP beneficiaries with insured and uninsured Food Stamp recipients. Oregon Health Plan beneficiaries were significantly more likely to be female and significantly less likely to be married compared with Food Stamp recipients. This is not surprising, given that one third of the OHP sample were eligible through the AFDC program (which is largely composed of single mothers). There were no differences in the average age of OHP and comparison group members.

A high proportion of both OHP and comparison group adults reported that they were “currently employed in a job for pay,” although the comparison group was significantly more likely to be employed (62 to 70 percent vs. 45 percent). Reflecting the population of the state as a whole, the vast majority of both OHP beneficiaries and Food Stamp recipients reported they were White and non-Hispanic. There was considerable difference in educational levels, however, with the insured Food Stamp sample significantly better educated compared with OHP adults and the uninsured sample somewhat less educated.

Finally, there was a marked difference in geographic location, with uninsured Food Stamp recipients more likely to be residing in rural parts of the state. This is consistent with state surveys that have documented higher rates of the uninsured in rural areas (Office for Oregon Health Plan Policy and Research 1999).

Oregon Health Plan beneficiaries were in significantly poorer health compared with Food Stamp recipients. They had lower SF-12 scores for physical health than both insured and uninsured Food Stamp recipients and lower mental health scores than the insured recipients. (Lower scores on the SF-12 indicate poorer health.) Similarly, OHP members were approximately three times more likely than those in the comparison groups to report that a disability or health problem kept them from working at a job.

Usual Source of Care and Utilization

OHP beneficiaries were significantly more likely than comparison group members to report that they had a usual source of care, that is, “a place they usually go to when they are sick or need advice about their health” (Table 2). Among those with a usual source of care, OHP beneficiaries also were significantly more likely to report that they had a usual health care provider, that is, “a particular doctor or other medical person that they usually see at this place.” These higher rates for OHP versus insured Food Stamp recipients may reflect their higher rate of enrollment in a managed care plan; almost all of the OHP sample were enrolled in a managed-care plan (97 percent) compared with approximately one half (54 percent) of the insured comparison group (data not shown). Managed-care enrollment for the insured Food Stamp sample was based on self-report, unlike for OHP where we could independently verify enrollment. Unfortunately, no other health insurance information was collected for insured Food Stamp recipients, for example, type of plan and benefits.

As a rule, utilization of health care services is significantly higher for OHP beneficiaries than for both insured and uninsured comparison group members. The majority of OHP beneficiaries (71 percent) had seen a physician in the past 3 months, compared with 58 percent of insured Food Stamp recipients and only 31 percent of uninsured recipients. Healthy, nonpregnant adults are unlikely to visit the physician more than once a year, however, and the percent with a physician visit in the past 12 months may be a more reasonable measure for comparison. Although the utilization gap is definitely narrowed, OHP beneficiaries were still significantly more likely to have seen a physician at least once during the past year, especially compared with the uninsured.

Compared with uninsured Food Stamp recipients, OHP members were significantly more likely to have received a routine physical exam during the past 12 months. Oregon Health Plan members were also significantly more likely to have had their blood pressure checked than those in either comparison group.

Two questions were asked of women respondents only: (1) whether they had had a Pap smear in the past 12 months and (2) for those 40 years or older only whether they had a mammogram in the past year. Women enrolled in OHP were more likely to have had these screening tests than comparison group women, but the differences were not statistically significant (except for Pap tests, where the OHP-uninsured difference was significant at the 0.10 level).

Oregon Health Plan adults were far more likely to have visited a specialist in the past year, compared with Food Stamp recipients, and were twice as likely to have been hospitalized. Specialist visits included visits to OB-GYNs and hospitalizations included maternity admissions; thus, these differences might be explained by the preponderance of females in the OHP population.

Unlike many private health insurance plans, the OHP covers many dental services for adults. This may explain the significantly higher number of OHP adults who have seen the dentist in the past year. The difference is particularly marked for the uninsured who are only half as likely to have visited the dentist compared with OHP members (25 vs. 57 percent).

Oregon Health Plan beneficiaries were significantly more likely to have received a prescription for medicine over the past year compared with Food Stamp recipients. The differences in use are quite high; 86 percent of OHP adults got a prescription compared with 62 percent of insured Food Stamp adults and only 46 percent of those without insurance. Many factors could contribute to these differences, including medical need, access to a physician to prescribe the drug in the first place, cost of the drug, and insurance coverage. (OHP covers most prescription drugs, but not all commercial policies include drug coverage). We can control for some, but not all, of these other factors in our regression analyses. Finally, OHP adults were also more likely to have received mental health care or drug or alcohol treatment compared with Food Stamp recipients, although the difference was statistically significant only with the insured comparison group. We know that OHP beneficiaries are in poorer mental health (based on their SF-12 scores) than insured Food Stamp recipients, and this may explain the utilization difference.

Unmet Need

Although OHP beneficiaries report receiving more health care services than comparison group members, they may still not receive as many as they need or they may encounter difficulties trying to obtain the services they do receive. As shown in Table 3, nearly three quarters of both OHP and insured Food Stamp adults reported it was somewhat or very easy to get the care they needed. In contrast, a significantly smaller number of uninsured adults (33 percent) found care was easy to get. Note, however, the substantial number of uninsured Food Stamp recipients reporting they did not need care over the past year: 31 vs. 12 percent and 19 percent for OHP and insured Food Stamp adults, respectively.

Approximately one eighth of OHP beneficiaries (12.8 percent) reported they had needed to see a specialist during the past 12 months but were not able to do so. This is significantly more than insured Food Stamp recipients (7.6 percent) but significantly fewer than uninsured Food Stamp recipients (29.1 percent). These uninsured adults overwhelmingly reported it “cost too much” as the reason they were unable to receive specialist care. In contrast, only one quarter of OHP adults not receiving specialist care cited costs as the reason. The most frequent reason given (40 percent of cases) was the plan or primary care provider would not approve the care.

OHP adults were significantly less likely to report an unmet need for dental care than either of the two comparison groups. The vast majority of both insured and uninsured Food Stamp recipients needing but not receiving dental care cited costs as the reason. OHP adults who did not receive needed care despite being covered reported that either they could not find any dentists willing to accept OHP patients or they were not able to get an appointment within a reasonable amount of time. (Historically, there has been a shortage of Oregon dentists willing to treat Medicaid patients, a problem that continues to exist under OHP).

Approximately one sixth of OHP beneficiaries (17 percent) said they were not able to obtain prescription medicine they needed, a significantly higher number than the insured comparison group (6 percent) but a significantly lower number than the uninsured group (26 percent). These uninsured adults cited costs as the reason for not getting the medicine. Among those OHP enrollees with an unmet need for prescription medicine, almost two thirds (61 percent) said they did not get the medicine because OHP would not pay for it. The second most frequent reason (20 percent) was their primary care physician would not approve the prescription.

Relatively few respondents reported they needed but did not receive mental health or drug or alcohol treatment. However, OHP beneficiaries were significantly more likely to report such an unmet need, compared with insured Food Stamp recipients. These OHP respondents cited a wide variety of reasons, including lack of OHP approval, lack of physician referral, facility waiting lists, etc. There was no difference in unmet need for mental health or substance abuse treatment between OHP and uninsured comparison group members.

Of course, one reason OHP beneficiaries may not receive a needed service may be because the service was “below the line” of the priority list. As part of a separate series of questions, OHP beneficiaries were asked whether OHP had refused to pay for care their doctor said they needed. One quarter (25.2 percent) reported OHP had denied payment in the past year. Prescription drugs were by far the most common uncovered service, either because the drug was “below the line” (typically allergy drugs) or because the drug was not in the plan's formulary (see Mitchell and Bentley 2000, for a description of the methodology used to identify below-the-line services.) Altogether, ten percent of the OHP sample reported OHP would not pay for care their doctor said they needed because the treatment fell below the line. In addition to allergy drugs, other frequently mentioned below-the-line services included TMJ splints and treatment of back problems, such as physical therapy and chiropractic care.

Satisfaction with Care

Oregon Health Plan beneficiaries were generally far more satisfied than Food Stamp recipients with both the quality of care they received and the depth of their insurance coverage. As shown in Table 4, OHP members were significantly more likely to rate their ability to see “the doctor or other medical person that [they] want to see” as very good or excellent compared with those in either comparison group. OHP beneficiaries were also significantly more satisfied with their “ability to see a specialist when needed” than the uninsured and were as satisfied as those with private health insurance.

Oregon Health Plan beneficiaries clearly perceived their insurance coverage for both wellness and illness care as being superior, with about two thirds rating it as very good or excellent. In contrast, significantly fewer Food Stamp recipients rated their coverage this highly; only one third reported their coverage for “preventive care and routine visits,” and 45 percent reported their coverage for “treatment when sick” as very good or excellent.

Finally, the majority of OHP beneficiaries stated that they were very satisfied with the overall quality of care they received, significantly more than those in the two comparison groups. Not surprisingly, the uninsured were particularly dissatisfied.

Empirical Specification and Estimation

The descriptive results shown earlier demonstrated marked differences in utilization, with OHP beneficiaries consistently using more health care services than uninsured Food Stamp recipients and often more than those with private health insurance as well. However, OHP adults were significantly more likely to be female and in poorer health compared with the two comparison groups, both factors that could explain their higher use rates. In order to test the impact of OHP on access and utilization, we used regression analysis to hold these and other covariates constant.

Two variables were used to capture the impact of OHP: (1) a health insurance dummy set equal to one for both OHP members and Food Stamp recipients with health insurance and (2) an OHP dummy variable set equal to one for OHP beneficiaries only. The health insurance dummy variable captures the effect of being insured on access and use. The OHP variable captures aspects of OHP above and beyond the program as a health insurance plan per se. These include, for example, OHP's benefit package (defined by the priority list) and its greater reliance on managed care. Ideally, we would have included a separate variable to capture managed care. The very high managed care enrollment among OHP beneficiaries (97 percent) did not allow us to separate out managed care from other OHP effects. Covariates included age, gender, race/ethnicity, health status, education, employment, marital status, and geographic residence.

Results

Table 5 displays odds ratios for all of the equations. The availability of health insurance has a powerful effect on the utilization of most medical care services. OHP beneficiaries and Food Stamp recipients with health insurance were both significantly more likely than the uninsured to have a usual source of care, have seen a physician, received a routine exam and blood pressure check, visited a specialist, seen a dentist, and received prescription medicine.

The absence of an insurance effect on ER use and hospital admission is not surprising. Persons with emergencies and with conditions serious enough to warrant hospitalization appear to get care, regardless of insurance status. Hospitals may also be less apt to turn people away because of liability concerns. The lack of an insurance effect on the remaining utilization measures (Pap test, mammography, and mental health/substance abuse treatment) on the other hand is surprising.

The OHP dummy variable is positive and significant in 4 of the 12 utilization equations. The odds of receiving Pap test screening in the past year was significantly higher among women enrolled in OHP. Oregon Health Plan beneficiaries were also significantly more likely to have made a visit to a specialist (albeit significant only at the 10 percent level), above and beyond the increased odds associated with health insurance per se. Enrollment in OHP also raises the odds of a dental visit and receiving prescription drugs, again above and beyond the increased odds associated with having health insurance.

Although the OHP variable is insignificant in the remaining eight regressions, it is important to keep in mind that OHP enrollment does raise the odds of making a physician visit and receiving a routine exam and blood pressure check relative to being uninsured. This effect is being captured by the health insurance variable.

Table 5 also presents odds ratios for the four unmet need equations. Insured respondents (whether insured by OHP or by private health insurance) were significantly less likely to report an unmet need for a specialist visit, prescription medicine, or mental health/substance abuse treatment compared with the uninsured. The access gap is considerable; adults with health insurance were only one fifth as likely as the uninsured to report that they needed but did not get a visit to a specialist or a prescription drug. Although the odds ratio associated with health insurance was not significant, unmet need for dental care was significantly lower for OHP enrollees, however.

Although the availability of health insurance reduced the odds of unmet need for prescription medicine among all insured respondents, there was a large off-setting effect for OHP beneficiaries. Compared with both insured and uninsured Food Stamp recipients, OHP enrollees were significantly more likely to report they needed a prescription drug but did not get it. We believe that this is due to two factors: (1) the priority list, which does not cover prescription drugs for certain conditions, such as allergies, and (2) the greater managed care enrollment of OHP beneficiaries, which makes them more subject to formularies.

Eligibility Expansion

Much of OHP's impact has been realized by the simple extension of health insurance coverage to Oregon's low-income residents. The availability of health insurance coverage significantly increased utilization of many health care services. Oregon Health Plan beneficiaries and Food Stamp recipients with insurance were significantly more likely than the uninsured to have a usual source of care, see a physician, receive routine exams, see a dentist, and receive prescription medicine. The size of this impact was often considerable; health insurance, whether OHP or private, raised the odds of a physician's visit more than threefold.

Even though OHP and privately insured respondents may receive more health care services than the uninsured, they still may not receive as many as they actually need. Measuring “unmet need” for care may provide a more rigorous test of access under the OHP. Again, health insurance availability played an important role in reducing unmet need for services. Insured adults (whether insured by OHP or by private health insurance) were less likely to report they had needed but not received a visit to a specialist or dental care compared with the uninsured.

Managed Care

Like many state Medicaid programs, Oregon has chosen to mandate managed care enrollment for its AFDC and expansion beneficiaries. As noted earlier, research to date comparing Medicaid managed care versus fee for service has been ambiguous, with some studies finding access to some services restricted under managed care, such as specialists, whereas others show improved access to a usual source of care. Although we could not explicitly test for managed-care effects (as virtually all OHP beneficiaries were enrolled in a managed care plan), we did attempt to capture the impact of OHP above and beyond the program's impact as a health insurance plan per se.

Oregon Health Plan beneficiaries were twice as likely to have a usual source of care, presumably because enrollment in a managed care plan ensures a primary care provider is designated for each enrollee. Women enrolled in OHP also were twice as likely as other women to receive a Pap test, a finding that can perhaps be attributed to the preventive care orientation of managed care. However, OHP enrollment had no impact on the odds that a woman would receive mammography screening. Although the small number of women aged 40 years or older in our sample may be partly responsible for this finding, it bears further investigation.

There was no evidence of barriers to access to specialist services under OHP. Oregon Health Plan enrollment actually increased the odds of visiting a specialist over the past year (albeit only at the 10 percent level) and had no effect on unmet need for specialist care. Perhaps most telling is the fact that the majority of OHP beneficiaries rated their ability to see a specialist when needed as good or excellent, levels equivalent to those of the privately insured.

Priority List

The use of a priority list to define the Medicaid package is the single most distinctive aspect of the OHP. We attempted to measure its impact in two ways: with our OHP dummy variable (which also captures managed care effects) and with a specific question on services denied by OHP. Oregon Health Plan beneficiaries were significantly more likely to have seen a dentist and to have received prescription medicine over the past year compared with Food Stamp recipients. We attribute this to the inclusion of adult dental services and prescription drugs in the OHP benefit package, benefits often excluded from private health insurance plans. At the same time, adults enrolled in OHP were twice as likely to report they had needed prescription medicine over the past year but had not been able to receive it. When asked directly if OHP had ever refused to pay for a treatment they and their doctor thought they needed, prescription medicine was the single most frequently mentioned treatment that OHP would not pay for, sometimes because the drug treatment was below the line and hence not covered, but more often because a specific brand-name drug was not authorized by the respondent's managed-care plan or included in the plan's formulary.