Janet Raines has walked in health care limbo on two bad knees for several years.
Raines, of Medford, badly needs knee replacement surgery. She cannot walk without assistance and has not been able to work since she left her job as a nurse because of her condition.
Like many Americans over the years who have been forced out of their jobs, Raines has had to fend for herself when it comes to medical care.
She applied several times to various insurance companies and was denied because her bone-on-bone knees are considered a pre-existing condition.
Attempts to get coverage through the Oregon Health Plan led nowhere, because Raines couldn't win a spot through the cash-strapped program's lottery, which was instituted because applicants far surpassed the number of open slots every year.
Now, finally, relief for Raines may be on the horizon.
On Jan. 1, Raines will be one of an estimated 16,000 Jackson County residents — and as many as 90,000 people statewide — who could be newly eligible to get coverage through the Oregon Health Plan in 2014.
At the same time, thousands of people already on the Oregon Health Plan will receive expanded coverage, a benefit spurred by the Affordable Care Act.
"It was really frustrating," Raines says. "I gave up and applied for disability and was denied."
Because her knees made it impossible to exercise, Raines gained a considerable amount of weight, which led to more medical issues, including depression.
Now, with the sweeping set of health care reforms set to hit on Oct. 1, Raines hopes she'll finally be able to stop the cascading effect and get the health care she needs.
Starting today, Jackson County residents can begin applying for OHP coverage with their local Department of Human Services office or they can visit the Cover Oregon website at www.coveroregon.com. OHP eligibility is based on income. A single person who earns about $15,800 per year, for example, or a family of four with an income of $32,500 will be eligible for OHP benefits.
Most of the expansion will be paid for by the federal government. The Patient Protection and Affordable Care Act, also known as Obamacare, calls for states to expand Medicaid to low-income adults and provides federal funds to cover 100 percent of the costs of these newly eligibles from 2014 through 2016, according to the Oregon Health Authority. The federal matching rate will then decrease over the next four years to 90 percent in 2020. Not only will more people get coverage through the Oregon Health Plan, for many people already on the plan, coverage will improve. In the past, OHP offered coverage under a "standard" plan and a "plus" plan. Everyone currently on OHP's standard plan will be converted to the plus plan, and the standard plan will be discontinued. That means recipients who don't currently get dental care or coverage for such services as physical therapy will receive more comprehensive coverage.
"Everyone in Oregon will have access to coverage, and I don't think people understand that," says Patty Wentz, spokeswoman for the Oregon Health Authority.
"In January 2014, everyone earning up to 130 percent of the federal poverty line can get on the Oregon Health Plan. Homeless people are going to be able to have health coverage. Adults on the edge of society will have insurance. That will have a big effect.
"And for social service agencies providing care to them, they won't have to scramble to get paid," Wentz says.
Under the emerging system, many OHP enrollees will be directed to coordinated care organizations that have been set up across the state, including AllCare, a CCO based in Grants Pass that serves Jackson, Josephine and Curry counties, plus a portion of southern Douglas County. The CCOs are networks of primary care physicians, dentists, mental health workers and other health care providers who will work together to ensure OHP patients are receiving care in a coordinated and effective fashion.
A large part of the focus will be on preventive medicine and the management of chronic illness.
One goal of the coordinated care organizations is to cut down on the number of people who use hospital emergency rooms for their medical care, says Jeanie Lunsford, spokeswoman for Care Oregon, a health plan that provides services to five coordinated care organizations that serve about 160,000 people in Oregon.
"You don't want to help people only when they're so sick that they have to go to the emergency room," Lunsford says. "That is the most expensive form of care."
The CCOs have been coming together over the past two years in preparation for the health care reform deadlines. And while the various health care providers are in the process of gelling, much work remains, Lunsford says.
"I don't think we're completely there yet," Lunsford says. "There is still a lot of work to do before we are fully coordinated."
Of concern are patients who live in rural areas who might have trouble accessing primary care physicians. Most physician groups and mental health providers are based in urban areas such as Medford, which presents a challenge to rural dwellers on fixed incomes who might have trouble making trips into town to receive care.
"The CCOs will do what they can to ensure patients can see health care providers on a timely basis," says Wentz. "Access is a concern in rural Oregon."
Most of the 90,000 people on the waiting list for the OHP will begin receiving letters in the coming week telling them they may qualify for the expanded coverage. Many of these people still won't qualify for OHP, Wentz says, but they will be eligible for subsidies when they purchase insurance through the state's online marketplace. In Jackson County, it's estimated that about 23,000 uninsured people earn between 139 and 400 percent of the federal poverty limit, making them ineligible for the Oregon Health Plan, but eligible for some sort of subsidy on their private health insurance premiums when they buy through Cover Oregon.
"We will refer them to Cover Oregon to find what they qualify for," Wentz says. "Most of them will qualify for financial assistance rather than the Oregon Health Plan."
People shopping for insurance through Cover Oregon will compare rates and plans offered by eight private insurance carriers to determine what coverage would best suit them. The financial assistance comes from federal subsidies that will help lower their premium costs.
Some residents who are already enrolled in the Supplemental Nutritional Assistance Program (SNAP, commonly referred to as "food stamps") will qualify for a fast-track enrollment process for the OHP. These people will receive information through the mail in the coming weeks on how to proceed into the OHP program. People on the Oregon Health Plan will pay between $9 and $20 per month in premiums, plus small co-pays for some medical services, including $1 to $3 per prescription.
Nola Rice, 54, of Medford, says the OHP expansion won't help people like her who do not qualify for the program but are too poor to afford private insurance. Rice says she applied for OHP a few weeks ago and was turned down.
"I haven't had health care in five years," she says. "I'm worried about this mandate to buy insurance. I'm at my wit's end.
"I don't have $100 to my name," Rice says. "I don't have anything good to say about this Obamacare crap."
Rice says she hasn't been able to find a job outside low-paying seasonal work at Harry & David. Even the federal subsidies will be of little help to her, she says.
"Yes, I will get a discount on insurance, but if I can't afford anything at all, what good will it do me?" Rice says. "I don't know where they think I'm going to get this money from."
Brenda Johnson, CEO of La Clinica, says many of the people who will become eligible for OHP have lived with chronic illnesses that have gone untreated for years.
"These are people who might have started out with one illness, but because they did not have insurance, they now suffer from numerous illnesses," Johnson says.
Raines is one of those people, and she's patiently waiting until she receives word that she has finally qualified for OHP.
She will learn more on Oct. 10, when she has a consultation with a specialist dedicated to helping patients navigate Cover Oregon.
"I'm cautiously optimistic," Raines says.
Reach Mail Tribune reporter Chris Conrad at 541-776-4471 or firstname.lastname@example.org.