Perspective from the 19^th Hole is the title I chose for my personal blog, which is meant to give me an outlet for one of my favorite crafts – writing – plus to use an image from my favorite sport, golf.  Out of college, my first job was as a reporter for the Daily Astorian in Astoria, Oregon, and I went on from there to practice writing in all my professional positions, including as press secretary in Washington, D.C. for a Democrat Congressman from Oregon (Les AuCoin), as an Oregon state government manager in Salem and Portland, as press secretary for Oregon’s last Republican governor (Vic Atiyeh), and as a private sector lobbyist.  This blog also allows me to link another favorite pastime – politics and the art of developing public policy – to what I write.  I could have called this blog “Middle Ground,” for that is what I long for in both politics and golf.  The middle ground is often where the best public policy decisions lie.  And it is where you want to be on a golf course.

At least two views have emerged on the controversy over how much money to put into Medicaid, the program that serves health care needs of the country’s low-income population. 

As always, perhaps more than two.

• One view came from Dr. John Kitzhaber, the former governor in Oregon, who, when he held public office, made health care policy his top priority.  He was very innovative then; and now he still deals with health care policy from that vantage.
• The other view came from U.S. House Republicans in a proposal that focused on cuts, not reform – and it appears to have a chance to pass the House, though as I write this, the fate in the House is unclear.

Kitzhaber’s proposals make sense.  The House R’s, not so much.

In an opinion piece posted in the Washington Post last week, Kitzhaber illustrated why, when he was a governor in Oregon, he focused on health care reform, not just cuts.

Frankly, he sullied his reputation near the end of his term when he came under review for ethical failings by the Oregon Government Ethics Commission.  [And, for the record, I am a member of that Commission, so I will not comment further on that Commission’s work.]

To illustrate Kitzhaber’s health care policy chops, I’ll post excerpts from what he wrote for the Post under this headline – “Democrats should push for change in the system.  Oregon offers a model.”

From Kitzhaber:

“As negotiations continue on the budget bill Trump wants Congress to pass, Medicaid is squarely in the crosshairs.  The Congressional Budget Office estimates Medicaid could lose up to $880 billion over the next 10 years, and that millions of low-income Americans would lose their health coverage.

“The Democrat Party has understandably reacted with outrage.  But its ‘no cuts or reforms to Medicaid, period’ mantra creates a false choice between cuts and defending the status quo.

“On one hand, any action that reduces funding for Medicaid, without also making structural changes to the program, will in fact cause millions to lose coverage.  That is unacceptable — and will increase costs in the long run for most Americans.  

“People without insurance tend to access care through hospital emergency rooms, where federal law requires they be seen and treated.  That uncompensated cost is reflected in higher premiums for those who have health insurance.”

Kitzhaber has maintained for years that just cutting Medicaid made no sense because it does nothing to ensure the long-term viability of a popular program that serves thousands of Americans.

More Kitzhaber:

“The party (the Ds) needs to come up with a better solution, which would both improve the program and save money.  We did it in Oregon.  Since 2012, my state has provided Medicaid through community-based coordinated care organizations (CCOs).  Faced with rising costs, inefficiencies in care delivery and inequities in outcomes, we looked for ways to focus on health rather than disease, and to reward techniques that worked.

“And, significantly, we changed the financial incentives.  CCOs operate on a budget indexed to a growth rate below medical inflation.  They are required to maintain enrollment and benefits, and also to meet metrics around quality, outcomes and patient satisfaction.  This realigns the incentives to focus on health rather than disease, by emphasizing prevention, primary care, and reducing waste and inefficiency.  We rebuilt our Medicaid system from the bottom up.”

Today, CCOs serve most of the Oregon’s 1.4 million Medicaid recipients, and between 2011 and 2021, operated within the per-member, per-year growth rate, met the required quality and outcome standards — and realized a net cumulative savings of approximately $3.7 billion.

Finally, Kitzhaber uses a metaphor to make his case for reforming Medicaid.

“Think of our medical system as a house, built decades ago,” he says, “and think of Americans as the family that has lived in that house for generations.  The way the house was designed made sense when it was built.  But over time, the family changed — and so did its needs.  The structure of the house, though, remained the same and it’s now too expensive for the family to maintain.  At some point, the house must be redesigned so that it meets the evolving needs of the family.”

So, Kitzhaber says, the basic structure of Medicaid — and the rest of our health-care system — was put in place some 60 years ago and hasn’t materially changed since then.

From his post in Oregon far away from the fray in Washington, D.C., he advocates useful reform ideas.

I hope they could gain traction, not as a magic answer, but as a notion that could change the “always cutting” characteristic of current Medicaid.

Meanwhile, the process in Congress turned raucous last week as folks came to protest against Medicaid cuts and some of them got hauled out of a House committee meeting for failing to be quiet. 

But the debate does indicate this salient point:  Individual lives will be affected under Medicaid, so this is more than just a debate over a budget.  It’s what behind the budget that counts. 

Just ask Dr. Kitzhaber.