2017 End-of Session Report
Prepared for ORHA
March 2016


2017 SESSION SCORECARD

Key: = Good for ORHA; = Mixed result for ORHA; = Poor for ORHA 


Result

Issue

Bill #

Details

HEALTH CARE WORKFORCE INCENTIVES & TRAINING

HB 3261

$21 million into Health Care Provider Incentive Fund to pay for workforce incentive programs and new health care training programs

RURAL HEALTH TAX CREDIT

SB 178 HB 2066

Extended for 4 more years with a new income cap on recipients at $300k, with an exception for OB providers and general surgeons, as well as a 10-year limit on the collection of the credit moving forward

MEDICAID PROVIDER TAX

HB 2391

Taxes hospitals, CCOs and insurers in order to maintain Medicaid expansion population coverage. Includes .7% real tax on DRG hospitals and 4% tax on A & B hospitals.

PRIMARY CARE SPENDING

SB 934

Insurers required to spend 12% of medical spend on primary care by 2023; Primary Care Payment Reform Collaborative extended

COVER ALL KIDS

SB 558

15,000 undocumented children will receive Medicaid coverage at a cost of $36M in 2017-19 and $55M in 2019-21. No federal matching funds can be used.

KEY ISSUES

SB 178 HB 2066 – Rural Provider Tax Credit Passed 

A significant grassroots effort by the Oregon Rural Health Association and its

member groups saved the Rural Provider Tax Credit after it was marked for “sunset” by the Tax Credits Committee.

House Speaker Tina Kotek (D-Portland) helped negotiate a revised tax credit package. The final version of the Rural Provider Tax Credit: 

  • Caps recipients’ income at $300,000 (single or joint) with exceptions for general surgeons and OB providers.

Establishes a new 10-year lifetime limit going forward for anyone receiving the credit.

Includes a 4-year sunset.
All other provisions in the Rural Provider Tax Credit remain the same. 

HB 3261 – Health Care Workforce Incentives and Training Passed

Ways and Means put $21 million into the new Health Care Provider Incentive Fund to pay for workforce incentive programs and new health care training programs. The funding includes:

$4 million for Loan Repayment
$1 million for Loan Forgiveness
$5 million for OHSU’s Scholars for a Healthy Oregon scholarship program
$1 million for new scholarship programs like Scholars for a Healthy Oregon at 
schools like Comp NW and Pacific U.

$4 million for the Rural Malpractice Subsidy Program
$1 million in discretionary funds for the OHPB to invest where it is most needed. $4 million to help develop health care professional training programs. This could 
include GME subsidies, preceptor incentives and/or loans or grants to help universities and community colleges create new training programs. $1 million for administration. Rep. Nancy Nathanson (D-Eugene) said these direct allocations are a transitional step. In 2019, the Oregon Health Policy Board’s Workforce Committee will report to the Legislature how it recommends spending the fund in the future. Rep. Knute Buehler (R-Bend) wanted assurances that the training funds would be spent in rural Oregon and not downtown Portland. Sen. Elizabeth Steiner Hayward (D-Portland) said the goal is to create training programs in communities like Bend, Medford, Roseburg and Eugene that while not rural are scattered around the state. 

HB 3085 – Funding for Healthcare Workforce Training Programs Failed

Sen. Elizabeth Steiner Hayward’s (D-Portland) proposal for an assessment of a penny per day per member for commercial insurers, third party administrators (for self- insured companies) and CCOs would have raises $22 million per biennium to fund health care workforce training programs. This revenue source was politically difficult due to the premium tax discussions taking place throughout the session. While the revenue source was problematic, there was broad support for the training programs it would have funded. Key portions of the bill were folded into HB 3261, the Healthcare Workforce Incentive bill, with funding coming from a different source. 

HB 2373 – Adds Pharmacists to Rural Provider Tax Credit Failed

Rep. Carl Wilson’s (R-Grants Pass) and Rep. Greg Smith (R-Heppner) want to add pharmacists to the Rural Provider Tax Credit to help attract more pharmacists to rural Oregon. Scott Ekblad, Office of Rural Health, submitted testimony showing there are currently 879 pharmacists in rural Oregon. Adding them to the tax credit would cost $7.2 million per biennium, almost a 50% increase in the cost of the tax credit. And that doesn’t add any pharmacists. It just pays those who are already there. Rep. Smith floated the idea of only adding pharmacists in frontier counties but that did not make it into the final Rural Provider Tax Credit package.

SB 485 – Medical Practice Ownership Passed

This bill expands the medical practice ownership statute to allow majority ownership of a practice by someone other than a physician if the business entity provides the entirety of its services in rural health clinics. “I’ve been on this committee when you’ve brought this bill before and I was dubious, but I am not dubious anymore. I think this is a great idea,” Sen. Elizabeth Steiner Hayward (D-Portland) told her colleagues. 

HB 3439 – Medical Clinic Ownership Passed

The Oregon Nurses Association proposed this bill to allow nurse practitioners and physician assistants in addition to physicians to own a clinic. Under current statute, only a physician may be the majority shareholder in a practice. This bill also allows NPs and PAs to establish new or purchase existing clinics in Oregon. The new law takes effect January 1, 2018.

HB 2751 – Add OTs to Loan Repayment Failed

Rep. Greg Barreto (R-Cove) requested this bill on behalf of the Occupational Therapy Association of Oregon. The bill would add occupational therapists to the list of providers who qualify for Oregon’s loan repayment program. There is an abundance of evidence supporting older adults staying at home independently lowers hospital admissions, says Katie Smith, an occupational therapy student. She says she is very interested in practicing in rural Oregon, but has over $100,000 in debt. A representative from the optometric physicians testified in support as well. She asked that they be included in any or all of the incentive programs. Doug Barber on behalf of the Oregon Rural Health Association testified in reluctant opposition to the bill. He said, “We have no doubt that occupational therapists provide a great service to their clients. However the loan repayment program is the most oversubscribed incentive program we have... There were 124 MDs, NPs, PAs, and dentists that needed this program but were not awarded last year.” Sen. Elizabeth Steiner Hayward (D-Portland) echoed this sentiment. 

HB – Medicaid Provider Tax Passed

Filling the Medicaid hole was one of the big budget challenges legislators faced during the 2017 session.

The tax package includes:
Agency savings and cost reductions $71m
CCO rate of growth reduction (from 3.4% to 2.8%) $36m
Revenue adjustments $100m
Discontinue hospital transformation program $68m
Increase DRG hospital tax to 6% $120m
New rural hospital tax at 4% $90m
New intergovernmental transfer with OHSU $105m
New managed care/insurer tax (incl. PEBB) at 1.5% $205m

General Fund increase $139m

TOTAL $934M

Hospitals agreed to the plan, even though it adds a .7% real tax on top of the existing 5.3% tax and adds a new tax on the rural hospitals. Commercial insurance carriers, with the exception of Cambia, also supported the plan. Cambia says the tax structure isn’t fair since self-insured plans are exempted. DCBS Director Pat Allen says the tax on insurers will be offset by a new reinsurance plan for the individual market. Allen says, “The reinsurance plan is expected to reduce rates in the individual market by 4.9%. There is also a psychological benefit to reinsurance. The reinsurance plan will increase carrier confidence in the individual market, which enhances their willingness to participate in the market.” Carriers are expected to pass through the 1.5% insurance tax to small and large groups. The Governor’s Health Care Advisor Jeremy Vandehey made the case for the provider tax package citing a number of key statistics:

23,000 health care jobs have been added in Oregon since 2014.
ACA Expansion will bring $5B in federal funds to Oregon in 2017-19. The uninsured rate has been reduced from 17% to 5%.

Democrats were ultimately able to pass the tax with the help of one Republican House member who is retiring, and a handful of Senate Republicans. Rep. Julie Parrish (R-West Linn) has proposed a referendum on the insurance tax portion of the package. If she succeeds in collecting enough signatures, the election would be on January 23, 2018. 

SB 1067 – Cost Containment Passed

The Legislature passed a cost containment bill they say will save at least $94M General Fund and $178M Total Funds in PEBB and OEBB. It also makes minor changes to PERS and eliminates vacant positions in state agencies.

The PEBB and OEBB changes:
Require PEBB and OEBB to develop a plan to merge the boards.
Eliminate double coverage for PEBB and OEBB employees who have family 
members also employed by PEBB and OEBB.

Requires PEBB and OEBB to limit growth to 3.4% per year.
Ties hospital rates for PEBB and OEBB to 200% of Medicare – exempts A & B 
hospitals, critical access hospital, as well as Coos and Klamath hospitals. This is expected to cost hospitals $190M this biennium in lost revenues. Sen. Fred Girod (R-Stayton) opposed the bill because, “it is a double-whammy for hospitals” coming on top of increases to the hospital tax to fund Medicaid. “I can’t vote that way.” Sen. Richard Devlin (D-Clackamas) said, “If our standard is always going to be cut somebody else but not me, we are never going to do much cost containment.” On the House floor, Rep. Julie Parrish (R-West Linn) said the hospitals are facing a half-billion dollars in reduced payments from state programs this biennium. “In other bills we have not given hospitals haircuts, we’ve given them big whacks. You can’t give them three haircuts. Then you go bald.” 

HOSPITALS

HB 2664 – ASCs and Extended Stay Recovery Center Pilot Failed 

Oregon Ambulatory Surgical Center Association worked hard to pass a bill that would extend how long a patient may remain in care at an Ambulatory Surgical Center (ASC) and Extended Stay Recovery Center (ESC) from 24 to 52 hours. The bill was amended to allow only 16 ESCs to be licensed in the first 5 years. It would have required 8 of those centers to be joint ventures with another health system, 5 to be non-affiliated, and 3 open licenses. Jessica Adamson, Providence, says that the OHA needs to submit a waiver request to enable the participation of Medicaid and Medicare. They will also need a waiver to allow an ASC and an ASC extended care center to operate under the same license. Most members of the Hospital Association opposed the bill saying there were still too many unanswered questions. The bill died in Ways and Means but is expected back in 2019.

SB 419 – Hospital Rate Setting Task Force Passed

This bill creates a task force to look at the Maryland model of hospital rate setting and report back to the legislature in the short session. During a hearing in the House Health Committee, Robert Murray, the former executive director for the Maryland Hospital Rate Setting Commission, said that Maryland has a federal waiver so Medicare, Medicaid and commercial payers all pay the same rate to hospitals. As a result, the federal government has paid an additional $50 billion to the state than it would have without the waiver. (The federal government has said it would not give another state the same waiver.) Murray also described hospital rate setting as “a very daunting undertaking.” He said he had a staff of 35 and a $13 million budget when he ran the commission. He also said a number of states have tried rate setting and failed. “Washington adopted the Maryland law word for word and they still failed.” Jared Mason Gere, lobbyist for the Oregon Education Association, testified during one hearing that hospital costs are rising at the same time executive compensation is skyrocketing. Felisa Higgins, SEIU, “We feel strongly that hospital costs are the largest part of our health care dollar and should be controlled.” Rep. Knute Buehler (R-Bend) commented, “My experience is when you price fix, you cost shift to other places. My concern is that you would see admissions go up.” That is, it would depart from Oregon’s trend toward value-based payments and incent hospitals to see as many patients as possible. 

HB 2552 – Short Term Mental Health Treatment at OSH Failed

The idea was that Oregon State Hospital would provide short-term mental health treatment and residential care, on each of its campuses, to take pressure off of hospital Emergency Departments. The idea came with a huge price tag and did not gain any traction.

SB 494 – Advance Directive Rules Adoption Committee Failed

SB 494 would have created a committee to look at advanced directive forms and given the group rulemaking power over the adoption of an advanced directive form. Efforts to update Oregon’s 23-year-old Advance Directives form stalled for the second legislative session in a row.

SB 816 – ED data collection Failed 

The Oregon Health Authority wants authority to require hospitals to submit data about Emergency Department visits. “The ED is the front door of the hospital, “ Jon Collins, OHA, told the Senate Health Committee. “In 2015, Oregonians had 1.4 million ED visits. Half of Oregon’s 340,000 inpatient stays started in the ED.” Hospitals oppose the bill saying they already report ED data voluntarily, at no charge, to Apprise Health Insights. The bill would allow OHA to impose fees on hospitals to collect the same data. Legislators were confused. They understood the value of ED data but couldn’t figure out why a bill is needed. OHA said, “To track ED Boarding, we need the time they enter and time they leave. Current data often leaves that blank. That is an example of what we are trying to enforce.” No action was taken on the bill.

SB 817 – Freestanding EDs Failed

The Oregon Health Authority does not allow non-hospitals to use the word “emergency” in communications or advertising. Zoom+Care wants to be able to advertise the Zoom Super clinic they currently operate as an emergency service provider. This bill would have allowed them to do so but did not move forward ultimately. Zoom+Care lobbyist Len Bergstein told the Senate Health Committee, “This is a modest reform that will ease the burden of overstuffed emergency rooms,” says Bergstein. Mark Zeitzer, an emergency physician who works for Zoom+Care, gave the committee some examples of services such as a dislocated thumb, an abscess, or diagnosing appendicitis, that a primary care doctor is unlikely to treat but doesn’t need to be treated in a traditional ER. Sen. Lee Beyer (D-Springfield) asked, “Is there anything that precludes you from providing these services currently?” The Zoom+Care panel answered “no.” Sen. Elizabeth Steiner Hayward (D-Portland) asked, “Are you taking Medicare and Medicaid patients?” They responded that they do not but are in conversations with FamilyCare and CareOregon about seeing Medicaid. Robert Barriatua from the American College of Emergency Physicians, testified in opposition to the bill. “Emergency Rooms are required by law to see any patient that walks through the door. A patient could be turned away from Zoom+Care because of their inability to pay,” he argued. The Hospital Association and Cambia Health opposed it as well. “There is not a lot of excitement from this committee to pass this bill,” says Chair Sen. Laurie Monnes Anderson (D-Gresham). “You will need to convince us if this bill is to move.” 

SB 964 – PA Practice in Hospital Facilities Passed

Hospitals and Physicians Assistants both support allowing hospitals to grant privileges to PAs. They say this is already common practice but PAs are not explicitly mentioned in Oregon administrative rule. The bill passed both chambers unanimously and was signed into law by the Governor.

HB 2620 – Hospital assault Failed 

Assault of a hospital worker would increase from a misdemeanor to a felony under HB 2620. Rep. Sheri Malstrom (D-Beaverton) told the House Judiciary Committee, “Hospitals lead all industries in non-fatal workplace assaults.” Witnesses said too often misdemeanors are not prosecuted because of the volume of these assaults. Dr. Mike Newcomb, Chief Operating Officer at Legacy Health said, “Hospital workers are required to evaluate and treat patients, no matter how belligerent they are.” He described one incident where an abusive family member told her, “I know this is just a misdemeanor. I’ll be back in two hours to finish the job.”

Some legislators questioned the value of adding more felonies, knowing how crowded the prisons are. But testifying on a related bill, Eric Hasselman, Assistant District Attorney in Lane County said, “These are crimes that do not have a motive other than rage, hatred or acting out in a violent way.” He said stronger sentences for these actions have merit and “we do not mind prosecuting them.” The bill could not gain traction and died in committee.

HB 3090 & 3091 – ED Release for BH Crisis and Case Management Passed

In 2015, Rep. Alyssa Keny-Guyer (D-Portland) worked with the Hospital Association to ensure that patients discharged after mental health crises were connected to outpatient supports. HB 3090 would expand those supports and referrals to patients being released from the Emergency Department. HB 3091 adds to this by, “Requiring payers (CCO and commercial) to pay for medically necessary services” including behavioral health assessments and care coordination,” says Keny-Guyer. Julie Majors, a family support specialist, said, “We’re not seeing uniform practices and responses to crisis across our state or even from hospital to hospital.” Psychiatrist Ajit Jetmalani, MD told the Senate Human Services Committee, “Commercial payers have lagged behind Medicaid in paying for acute care services.” The Hospital Association, PacificSource and Regence all expressed their support for both bills, which passed quickly and unanimously.

CCOS & INSURANCE

7SB 558 – Cover All Kids Passed

An estimated 15,000 undocumented immigrant children under age 19 will be eligible for the Oregon Health Plan. Democrats pushed through the new program in the closing days of the session. Unlike other Medicaid programs, this one is not eligible for federal matching funds. So the $36 million price tag for 2017-19 is all state General Fund dollars. The cost of the program is expected to escalate to $55 million in 2019-21. Proponents say it’s worth it, giving children access to health care services, especially prevention and primary care.

HB 2340 – Discontinued Areas of Coverage Passed

Currently, if an insurer discontinues offering health benefit plans in part of the state, there is a 5-year ban on re-entering that area. This bill will allow the Department of Consumer and Business Services (DCBS) some discretion in reducing that ban after reviewing market conditions and the reasons an insurer left a market. Insurance Commissioner Laura Cali Robison says it is important to incent carriers to stay in a market. But there are certain times when an insurer leaves a market, that it may be in the public’s best interest to allow that carrier to re-enter the market sooner than 5 years. For example, if a carrier needs to shore up business so as not to overextend themselves. “It is simply another tool in our tool box,” says Commissioner Cali.

HB 2122 – CCO Version 2.0 Failed

Speaker Tina Kotek (D-Portland) and Rep. Mitch Greenlick (D-Portland) tried hard to pass legislation to alter the makeup of Oregon’s 16 CCOs, but were unsuccessful. Even with more than 20 amendments and multiple trips to the House floor, legislators could not agree on the future of CCOs. Various versions of the bill addressed whether for-profit CCOs should be allowed, who should control CCO reserves, public representation on CCO boards, and the expanded use of alternative payment methodologies.

SB 387 – OEBB Opt Out Failed

Four school districts in Oregon have some teachers, administrators or classified employees in OEBB (Oregon Educators Benefit Board) and some in commercial group insurance. Those not in OEBB are saving the districts millions of dollars each year. In presentations to the Senate Education Committee they said:

Corvallis has saved $9 million since 2010 by keeping certified staff out of OEBB and could save an additional $1.5 million each year if it could pull administrators and teachers out of OEBB. And its’ non-OEBB plan has richer benefits than OEBB. That would be enough savings to add 20 teachers.

Portland Public Schools have 1,000 employees in OEBB and 6,000 out of OEBB. They would have saved $15.5 million since 2010 if they could have put all of their employees in their insurance trust. Benefits Director Terri Burton said, “The OEBB employees are jealous of those covered by a trust” because those in the trust “pay less out of pocket and have better coverage.”

Bethel School District says it saved $5 million in the last two years by keeping half of its employees out of OEBB.

Given these savings, the districts ask through SB 387 that any school district that is self-insured or has an insurance trust be allowed to get out of OEBB. Sen. Sara Gelser (D-Corvallis) championed the effort saying, “The kids in Corvallis are giving up an awful lot if they could have 20 more teachers.” In response, Tyler Pittman, Oregon School Employees Association, said, “Shrinking the pool would increase the cost to those left in the pool.” OEA spokesman Jerod Gere Mason said if just 10% of the 150,000 members left OEBB, it would increase costs in the pool by 3%. “Do you let some districts go out at the expense of others?” he asked. He went on to say, “I would suggest you amend this bill to force those who stayed out of OEBB to come in and bring down the costs for everyone.” Committee chair Sen. Arnie Roblan (D-Coos Bay) asked why every group that stays out of OEBB negotiates better coverage at lower costs. “How are we not using our purchasing power to get better rates?” OEBB Director Kathy Loretz responded that OEBB has been a big success. The bill never moved out of policy committees. 

HB 2339 – Balance Billing Passed

The Department of Consumer and Business Services (DCBS) sought to solve the issue of a consumer who seeks health care services from what they think is an “in- network” provider but receives a bill for “out-of-network” services.

This usually happens in one of three ways:
1. Planned surgery
2. Outsourced work such as an in-network lab that sends work to an out of network 
processor

3. Emergency departments Insurers and providers agreed that this is a major problem, and that the patient should be held harmless. But they were unable to agree on what the reimbursement should be. Insurers wanted to use a percentage of medicare, providers wanted to use a percentage of “usual and customary.”

There was likewise disagreement about the use of dispute resolution. Specialists say there could be a cutoff, e.g., only claims more than $500 can be taken to dispute resolution. Consumer advocates proposed “baseball” style mediation where each side makes its best offer and a mediator picks one of them. Insurers say if we have a clear reimbursement methodology that everyone understands there is no need for an expensive, time-consuming dispute resolution process. Department of Consumer and Business Services Director Pat Allen garnered support for an amendment that will ban balance billing beginning in March 2018 and directs DCBS to convene a workgroup to determine at what rate insurers shall reimburse providers who are out of network but working at an in network facility. The idea is that this work group will figure out the reimbursement rate before the ban on balance billing begins. If they don’t, providers will be reimbursed at whatever the going out-of-network rate is.

SB 233 – CCO Rate Setting Failed

SB 233 would have required the Oregon Health Authority to make public the information regarding their rate setting for CCOs. It would also allow a CCO to appeal the OHA’s rates with DCBS, which oversees commercial insurers. FamilyCare requested the bill in response to the claw-backs they experienced in 2016. They say there is no process to appeal a rate change currently. “We believe this is a good bill for all CCOs as it improves transparency and accuracy,” says FamilyCare’s COO, William Murray. The bill passed out of the Senate Health Committee but never received a hearing in Ways and Means.

SB 234 – Mandated CCO Contract Renewals Failed

FamilyCare wanted the Oregon Health Authority (OHA) to automatically renew CCO contracts for another 5-year term if the CCO has accomplished the terms of its previous contract, met federal law, and made meaningful progress toward meeting the outcome and quality measures required of CCOs. Opponents said that the bill all but guaranteed a contract renewal for a CCO unless they substantially fail to carry out the terms of its contract. They worried such a policy would limit the OHA’s ability to move forward with the Oregon Health Policy Board’s recommendations on contract renewals.

SB 783 – User Friendly Coverage Info and Prior Authorizations Failed 

Proponents say that patients are often covered for a procedure for a limited amount of visits. After that, the insurer refuses to cover the procedure and the patient is left with the bill. The purpose of this is to provide more transparency and accountability. The bill requires insurers to provide enrollees and health care providers with information on covered benefits in a format that is user-friendly. Insurers opposed the bill; it did not ultimately move forward.

HB 2882 – Adds DCO Representative to CCO Boards Passed

Each CCO must now include at least one dental care organization (DCO) representative on their board. The original proposal would have required that the DCO rep come from the DCO with 50% or more market share. The final bill was changed so any DCO rep can fill the board position.

SB 237 – Plans with Co-Pay Only for Rx Failed

A group of Oregonians who use high-cost prescription drugs want 25% of Oregon’s commercial insurance plans to be co-pays only — no co-insurance, no deductibles — for prescriptions. The bill never made it out of the first committee. Patrick Stode told the Senate Health Committee, “This would provide affordable options for those living with chronic disease.” Elise Brown representing AHIP (America’s Health Insurance Plans) said, “This bill does nothing to solve the underlying problem and will only drive up premiums.” Tom Holt, Cambia, said bills like this, “Insulate Rx manufacturers from the one thing they fear most – consumer pressure.”

HB 2342 – DCBS Rulemaking for Changes in Federal Law Passed

After stumbling in the House, the legislature found a path forward for the Department of Consumer and Business Services’ (DCBS) ACA flexibility bill. The bill allows DCBS to alter state regulations should a change at the federal level threaten the stability of the market. The bill has significant sideboards says DCBS Director Pat Allen, as the changes would only stay in effect for two years before the legislature would have to re-approve them. There is an additional amendment, which patients’ rights groups and DCBS came to an agreement on, that limits what DCBS can change.

HB 3391 – Reproductive Health Insurance Mandate Passed

Health insurance plans will have to cover women’s reproductive health services with no cost sharing. Most already do that. But the bill became controversial because it includes abortions. The bill’s $11 million price tag is generated by costs to OEBB and PEBB, and coverage for undocumented women. Services covered by the bill include birth control, prenatal and postpartum care, screenings for sexually transmitted diseases, breastfeeding support and supplies, and counseling for domestic violence victims and tobacco cessation. Republicans objected to new state funding for abortions that could pay for about 300 procedures. Providence threatened to withdraw from the Oregon insurance market if it was required to cover abortions. So Providence was carved out of that requirement. Rep. Mike McLane (R-Powell Butte) complained that Providence was given a monopoly on insurance plans in Oregon that do not include abortion coverage. Supporters argued that reproductive health services are threatened at the federal level and Oregon needs to do all it can to protect and provide these valuable services. 

HB 2660 – Insurance Coverage for Breast Cancer Patients Passed

This bill requires the Oregon Health Authority and the Department of Consumer and Business Services to create and implement an educational campaign about options available to breast cancer patients. Insurance that covers breast cancer care is required by federal law to cover breast reconstruction surgery, breast prostheses and breast forms. The Oregon Women’s Health and Wellness Alliance provided written testimony that said despite required insurance coverage for breast reconstruction post-mastectomy, “70% of women who are eligible for this are not informed of their care options.”

HB 2838 – OHP Enrollment Failed

This bill creates a fund at the Oregon Health Authority (OHA) consisting of donations from CCOs. The fund will be spent in the form of grants to organizations to help enroll Oregonians who are eligible for the Oregon Health Plan.

HB 3398 – Dealing with $50M surplus in OMIP Passed

It comes as no surprise that Democrats and Republicans disagree on what to do with the $50M left in OMIP (Oregon Medical Insurance Pool). The funds come from an insurance assessment and would have been returned to insurance carriers on July 1 unless legislators took action. Jeremy Vandehey, the Governor’s Health Care Advisor, says the plan is to use it to kick-start the new reinsurance pool for the individual market. “The idea was to comply with the original intent of these funds, essentially to use the funds in a future year but for the same purpose,” he told the Human Services Subcommittee. Rep. Cedric Hayden (R-Cottage Grove) said, “I think there is a more direct and bipartisan approach to buy down the Medicaid funding gap.”

SB 860 – Mental Health Parity analysis Passed

J.L. Wilson, representing the Oregon Independent Mental Health Professionals, proposed SB 860 saying, “Do we have mental health parity in the commercial insurance market? Our contention is that we have mental health parity in name only.” The Department of Consumer and Business Services (DCBS) says it will use market conduct examinations to analyze how 12 commercial insurance carriers handle mental health reimbursement and utilization management. They plan to look at four issues raised in the bill:

1.Review office reimbursement rates over time between medical and mental health counselors.

2.Look at how time-based office codes are treated by carriers, including differences between 30-minute, 45 and 60-minute visits.

3.Policies that restrict longer visits.

4.Establish how reimbursement rates are determined. DCBS Director Pat Allen said they will use funding from the $1.2 million federal grant they received for mental health parity enforcement to pay for this project.

HB 2015 – Doula payment Passed

House Speaker Rep. Tina Kotek (D-Portland) brought this bill that requires the Oregon Health Authority to periodically review reimbursement rates for doulas. The bill also requires CCOs to make information on doulas available online and in print. 

PROVIDER ISSUES

SB 456 – EMS Interstate Compact Failed

This bill proposes that Oregon join the EMS Interstate Compact. “There is a high demand for EMS providers to work on wildland fires,” compact proponents told the Senate Health Committee. “This would allow out-of-state EMS providers to help out on Oregon fires [as long as they are from a compact state].” Currently seven states, including Idaho, are compact members. Union representatives objected saying they fear this would weaken their bargaining position and could erode Oregon’s efforts to elevate the EMS profession. “This means a provider from another state could meet an inferior standard. “That is unacceptable,” they told the Senate Health Committee.

SB 737 & HB 2807 – Damage Caps Failed

Trial lawyers with help from the Governor spent all session pushing to eliminate the cap on noneconomic damage awards. They took out full-page ads and ran radio ads targeting specific legislators. They even heckled one senator when she was speaking at a science rally in Portland. But their tactics did not work. Oregon law caps noneconomic damages in some personal injury or property damage cases at $500,000. Trial lawyers wanted to raise that to $10 million. There are new amendments to one of the bills dealing with non-economic damages. Neither bill could garner enough votes to pass the Senate.

SB 487 – Wrongful Death Cap and Damages Caps Failed

In 2016, the Oregon Supreme Court imposed a $500,000 limit on non-economic damages in a bodily injury case. This bill increases the cap on non-economic damages in a wrongful death case from $500,000 to $1,000,000 and eliminates the cap entirely on non-economic damages arising from bodily injury. The bill would also raise the $1 million cap annually for inflation. Victims of sexual assault testified in support of the bill. Jim Dorigan, The Doctors Company, testified that Oregon doctors currently pay more for professional liability than California doctors. He added that 16 of the 19 states surrounding Oregon cap damages at $500,000 or less—“We are not an outlier on this,” he said. Dorigan also noted that rural malpractice premiums are unaffordable in Oregon and that the state has recognized this by providing rural malpractice subsidies. “The majority of cases brought against health care providers are brought because of bad outcomes not bad medicine.” Oregon Trial Lawyers Association lobbyist, Arthur Towers, argued that this increase would make a huge difference to grieving families, but “in the health care industry, that’s a rounding error.”

SB 857 – Provisional License to Practice Medicine Failed

An OHSU medical school graduate who did not match into a residency proposed a new provisional license to practice medicine in rural areas for people like her. “Medical school graduates who do not do a residency are a lost labor force,” Sara Bubenik told the Senate Health Committee. “They have more training than PAs, NPs or Naturopaths. Bubenik said 2% of OHSU’s medical school graduates do not match to a residency program. David Walls, representing the Osteopaths’ Association, said, “Rather than circumventing the residency requirement, what can we do to help medical school grads match to a residency?” Sen. Laurie Monnes Anderson (D-Gresham) asked whether Bubenik has talked to the Oregon Medical Board about her idea. She said she has not.

SB 934 – Primary Care Payment Reform Passed

“Colleagues, SB 934 is a strong step forward in improving our health care system,” said Rep. Knute Buehler (R-Bend) on the House floor. There was broad support from primary care providers including the Oregon Academy of Family Physicians, the Children’s Health Alliance, and the Oregon Primary Care Association for the bill that requires commercial insurers, CCOs, OEBB and PEBB to increase their spending on primary care to 12% by 2023. The bill passed every step in the legislature unanimously.

The bill also extends the sunset on the Primary Care Payment Reform Collaborative, created in SB 231 (2015). This collaborative, made up of insurers, CCOs, and various providers, will among other goals, continue to work to increase investment in primary care without increasing costs to consumers or increasing the total cost of health care, promote value-based payment methods that are not paid on a per claim basis, and align primary care reimbursement by all purchasers of care.

SB 48 – Suicide CME Reporting Passed

During a hearing on the bill, Ann Kirkwood, Suicide Interventions Coordinator, Oregon Health Authority, said, “In 2015, 762 Oregon residents died by suicide. Suicide is the second leading cause of death for Oregonians between the ages of 15 and 34... Unfortunately, the very people we task with intervening and treating people contemplating suicide have little or no training in suicide assessment, management and treatment of suicide risk.”

The original bill required behavioral health providers to take suicide training once every 6 years and physical health providers to take suicide training once. The bill was amended however to require licensing boards to require their licensees to report whether they have taken any suicide CME when they apply for re-licensure every two years. Rep. Alyssa Keny-Guyer (D-Portland) says this information will then be submitted to the OHA, which will use it to address areas that are not receiving adequate suicide prevention education.

SB 50 – Pain Management CME Failed

This bill would have added a pain management continuing medical education (CME) requirement every four years for a long list of health care professionals including pharmacy technicians, optometrists, clinical social workers, professional counselors, marriage and family therapists, massage therapists, expanded practice dental hygienists and speech-language pathologists. The bill also gave state boards that regulate practitioners the authority to impose penalties on providers who violate the law.

SB 74 – Medical Treatment Orders Passed

Currently, statute specifies that registered nurses and licensed practical nurses may execute medical orders issued only by a physician or a dentist. Ruby Jason, Executive Director of the Oregon State Board of Nursing says, “In the decades since that language was adopted, the health care team has expanded to include nurse practitioners, clinical nurse specialists, certified nurse anesthetists, and other independent practitioners.” SB 74 allows registered nurses and licensed practical nurses to execute medical orders given by these other health professionals.

SB 217 – Concussion Release for Student Athletes Failed

Chiropractors, athletic trainers and naturopaths wanted to expand who may sign concussion release forms for student athletes. There were various iterations of the bill discussed, but one would have required any provider who wants to sign these release forms to complete a training developed by the OHSU Center for Sports Medicine and to obtain medical liability insurance of at least $1 million. Stakeholders could not come to agreement about the details of the bill.

SB 856 – Naturopaths as physicians Passed

Naturopaths introduced what they describe as a 127-page technical fix bill. Laura Farr told one committee, “Our scope has evolved a lot but Oregon statute has not evolved at the same pace.” For example, she said a patient brought her POLST form to her naturopath but under Oregon law only MDs and DOs can sign a POLST. The bill adds naturopaths to hundreds of Oregon statutes that refer to “providers”, “doctors” and “physicians.”

SB 269 – Non-Resident Nursing at School Sponsored Events Passed

SB 269 adds an exemption so out-of-state nurses can accompany their students into Oregon during school-sponsored events.

SB 423 – PA Prescribing Passed

Current law allows physician assistants (PAs) prescribing authority based on whether they practice in a rural area, not on their competence or ability. This bill removes that limitation from statute and allow PAs to prescribe schedule III and IV drugs “under strict supervision” statewide.

SB 831 – DOs and Podiatrists Supervise PAs Passed

This change the definitions of “supervising physician” to allow osteopathic physicians and podiatrists to supervise physician assistants. The DOs were described as “enthusiastically neutral” on the bill.

HB 2103 – NP Vasectomies Passed

This bill adds nurse practitioners to the list of providers in statute who are authorized to perform vasectomies. Urologists were vehemently opposed. Dr. Eugene Fuchs, Professor of Urology at OHSU, on behalf of the Oregon Urologic Society, testified in opposition to the bill. “Every urologist will tell you that vasectomy is the most difficult office procedure to master,” says Fuchs. After reviewing the coursework of 25 nursing schools in the country, he found none that had training in basic surgerySen. Lee Beyer (D-Springfield) asked the Oregon Nursing Association’s Jenn Baker what kind of training a NP would have to have to perform the procedure. Baker responded that there is a credentialing process that providers undergo with their licensing boards and with insurers to demonstrate that they can competently perform the procedure.

HB 2527 – Expands Pharmacist Contraceptive Authority Passed

Oregon was the first state to allow pharmacists to prescribe contraceptives. Oregon’s law and program have become a model for other states. HB 2527 expands on that effort by adding hormonal contraceptives including vaginal rings and injectable Depo-Provera that pharmacists could prescribe and dispense. The new law took effect June 14, 2017.

HB 3355 – Psychologist Rx Passed

The Board of Psychologist Examiners will now be able to issue a certificate of prescriptive authority to psychologists who complete additional training and 12-months of clinical supervision. Some psychologists who work in clinics with other providers want to be able to prescribe from a limited formulary for the treatment of mental health conditions. They argue that this will increase access to mental healthcare in Oregon for the “48% of Oregonians do not have access to a psychiatric prescriber and the need is increasing.” The Oregon Psychiatric Physicians Association and some psychologists opposed the bill. They say that psychologists have inadequate medical training to prescribe these drugs.

HB 3363 – DOs as Physicians Passed

The committee passed the bill that clarifies that doctors of osteopathic medicine are “physicians” by law.

PHARMACEUTICALS

SB 272 – Prescription Drug Formulary Transparency Failed

This bill would require insurers to provide a complete list of drugs covered by each of their health plans. It would also require that insurers provide the average cost sharing for a member and to notify members of any changes to their formulary. Cancer advocates, mental health advocates, and multiple sclerosis advocates all testified in support of the bill. Providence’s Jessica Adamson opposed the bill. “We look at this bill as a small piece of what we need to address to deal with this problem.” She urged the Senate and House Health Committees to look at all of the Rx transparency and cost reduction bills together. Representatives from Kaiser Permanente and Cambia testified in opposition as well.

SB 526 – Prohibits Step Therapy Failed

Step therapy protocols require a patient to fail on “preferred drugs” before certain drugs will be reimbursed. Advocates said the bill it would prevent insurers from requiring a patient who is stable on a drug to go through step therapy protocols each year. Tom Holt, Cambia, testified in opposition. “We make decisions about our formulary by looking at peer reviewed research,” he told the committee. “It is not our intent to keep patients from getting the drugs they need.” Elise Brown, America’s Health Insurance Plans, added, “If you pull the layers back, the real issue here is the rising cost of prescription drugs... Because of that, cost management tools [such as step therapy] are so important.”

SB 792 & 793 – Rx pricing Failed

SB 792 required drug manufacturers to disclose wholesale prices of Rx in advertising. “We want consumers to be aware of the cost of prescription drugs,” Sen. Elizabeth Steiner Hayward (D-Portland) said. SB 793 required Rx manufacturers to report prices and increases to the Department of Consumer and Business Services. Those with increases greater than 3.4% would have to justify the prices through a rate review process. DCBS could require Rx manufacturers to rebate excessive price increases to purchasers. Consumer groups and insurers support the proposals. John Santa, MD, who used to work with Consumer Reports said, “Buyers are hungry for price information.” Pharma told the committee that SB 792 violates both Federal and State Constitution “free speech” guarantees and SB 793 “does nothing to help consumers.”

HB 2114 – Opioid Prescribing Passed

This bill and SB 270 both started as 7-day prescribing limits for opioids with potential criminal penalties for providers who violated that standard. OMA worked hard to convince legislators that it was a mistake to put prescribing guidelines in statute. So HB 2114 was changed so health-licensing boards must provide opioid prescribing guidelines no later than January 1, 2018.

HB 2387 – Rx Price Controls Failed

Rep. Rob Nosse (D-Portland) led an interim work group that was looking for ways to control the skyrocketing cost of prescription drugs. New, specialty drugs are a particular problem but Nosse says so are generics. “In 2012, the generic antibiotic Tetracycline cost .07¢ per pill. By 2016 it was up to $8.54 per pill. That’s a 12,000% increase.” Nosse and insurers spent all session trying to find the right mix of “carrots and sticks” but could not find the votes needed for passage. Pharma position was “pharmaceuticals aren’t the problem. Among other ideas, Nosse tried:

Capping Rx co-pays for consumers at $100 and paying for that by requiring pharmaceutical companies to pay rebates to insurers if they charge more in the US than in other developed countries.

Requiring manufacturers to rebate “excessive costs” to carriers.
Requiring manufacturers to give at least 60-day notice if the price of a drug will 
increase by more than 3.4%.

Requireing manufacturers to report on drugs that have an introductory price of more than $10,000 or if a drug’s price has increased by more than 3.4% in 12 months.

Allow DCBS to apply civil penalties to manufacturers who fail to comply with the reporting piece of this bill.

HB 2386 and HB 2645 – Rx Take Back Program Failed

These bills would have required pharmacies to administer pharmaceutical take-back programs as one way to tackle the opioid addiction epidemic in Oregon. Supporters said every year in Oregon, 280 million opioid pills are prescribed. Even if just 10% of those pills go unused, that is a significant amount of opioids left in circulation. Pharma said they are concerned about how the cost of implementing such a take back program might affect the cost of pharmaceuticals. Rep. Knute Buehler (R-Bend) says, “Having one in every single pharmacy seems overblown as these things are expensive.” He proposed a public education campaign and Rx take back kiosks at a rate of one for every 50,000, but his bill, HB 3315, didn’t fly either.

HB 2128 – Removes Pseudoephedrine Rx Requirement Failed

Rep. Bill Post (R-Keizer) says there has been a 99% decrease in meth lab incidents in Oregon but much of that decrease came before Oregon started requiring a prescription for pseudoephedrine, a precursor drug for meth manufacturing. Post wants to get rid of the prescription requirement, move pseudoephedrine back behind the counter, so you’d still have to show ID and sign a registry when purchasing, and require pharmacies to use an electronic sales tracking system call NPLEx. “Oregonians want their pseudoephedrine products back in a simpler way,” Post told the House Health Committee. A coalition of groups including Associated Oregon Counties, Oregon Nurses Association, Chiefs of Police, District Attorneys and others oppose the bill saying it “would result in a resurgence of local toxic meth labs in Oregon.” They said other states that use the NPLEx system still have big meth problems.

HB 2388 – PBM Regulation Passed

In 2013, the legislature passed HB 2123 that required PBMs to register with DCBS. This bill enhances that regulatory framework for PBMs and allow DCBS to revoke or suspend a licensed PBM that is a bad actor.

HB 2395 – Add Purpose of Drug to Rx Label Failed

The idea behind this bill was to help people managing multiple prescriptions by allowing the patient to ask a physician to add the purpose of a drug to the label of their prescription. A pharmacy consultant said a pharmacist would add this info to the label if it were included in the prescription. The House Health Committee agreed that it could be helpful to have this information included on prescriptions, but they did not think they needed to pass a law to make that happen.

HB 2397 – Public Health and Pharmacy Formulary Committee Passed

This bill creates a 7-member Public Health and Pharmacy Formulary Advisory Committee to establish a formulary for drugs and devices that pharmacists may prescribe and dispense to patients. This would include such things as diabetic testing supplies, asthma inhalers and smoking cessation aids.

OTHER HEALTH CARE BILLS

SB 235 – Retail Tobacco Licensing Amendment Failed

Public health professionals worked to pass a statewide tobacco licensure program but were met with strong opposition from retailers. As one storeowner put it, “I am not in Multnomah County but paying $580 to be told I am not selling to minors is not a very good use of my resources.” The licensure provision was ultimately stripped late in the session. The bill passed as a technical fix to the indoor clean air act.

SB 754 – Tobacco 21 Passed

After months of languishing in the House, the Tobacco 21 bill moved in the final days of the session. A final amendment to the bill makes it clear that it is illegal to sell tobacco products or vaping supplies to anyone under age 21 but it is not illegal to possess those products. Rep. Mike McLane (R-Powell Butte) said, “I don’t want to cross this line from impairment to unhealthy; making decisions for citizens about what is healthy and unhealthy. Once we head down that road, God help us.” He said just because the state chooses to spend money on health care, doesn’t mean it can now make decisions on which legal products citizens can use.

Rep. Rob Nosse (D-Portland) sympathized with Rep. McLane’s position but told the story of his son who started smoking at age 16. “People who smoke take on a lifetime of really tough health challenges,” he said. “This makes it just a little bit harder for them to get started.”

SB 785 – Antibiotics in Animals Failed

Farmers often treat a whole flock or herd with antibiotics, sometimes for their entire life, as a tool for disease prevention and growth promotion. SB 785 would prohibit this type of antibiotic use except when recommended by a veterinarian to treat disease in an animal or facility. Proponents argue that liberal use of antibiotics in animals increases antibiotic resistance. The agricultural community opposed the bill. They say federal changes imposed in 2013 prohibit the use of antibiotics for growth promotion. A veterinarian told the committee that in order to use an antibiotic for treatment or prevention, the labeled use for that drug must be present in the population of animals.

HB 2644 – Vitamin K Administration Passed

Currently, Oregon statute says that the nurse midwife at a birth is responsible for administering, either orally or through injection, vitamin K within 24 hours of birth. This bill requires vitamin K be administered through the “most effective means.” The original bill would have required injection. Rep. Knute Buehler (R-Bend) voiced concern however about putting medical best practice in statute. “Say a nasal spray were to come on the market in 6 months. We would have to wait until the next legislative session to change the statute. This seems like a bad use of our time and a bad use of your time.” Parents’ rights advocates testified that there are real risks to vitamin K injections and suggested that the bill include a requirement that parents be notified of the risk.

HB 2540 – Bachelors Nursing Degrees at Community Colleges Failed

Oregon’s eleven community college nursing programs would be able to expand their offerings to include a Bachelor of Nursing degree under this bill. Rep. Jodi Hack (R- Salem) said it would, “make it more affordable to get a nursing degree.” Charlie Tveit, Lakeview Hospital CEO, said, “We need help. The best way for nurses to get training is through our local Klamath Community College.” Karen Brady from Legacy Health said, “If community colleges offered a RN-BSN program, we would have a better chance of recruiting locally-prepared nurses.” The bill never moved out of committee.

HB 3418 – PEBB would pay Medicare rates Failed

House Speaker Rep. Tina Kotek (D-Portland) told the House Health Committee the state could save $30M per year by paying health care providers less for Public Employee Benefit Board (PEBB). She proposes capping provider payments at 200% of Medicare. This would apply to both PEBB’s self-insured and fully insured plans. “We don’t have consistency in quality or price,” she said. PEBB provides health insurance for 133,000 state employees and their dependents. In written testimony for the hospital association, former PEBB board chair Sean Kolmer said, “By mandating a reimbursement rate for health care services, HB 3418 would limit PEBB's purchasing power and remove incentives for health plans and providers to coordinate care and focus on prevention. HB 3418 would lock in the fee-for- service model for hospitals that provide health services to public employees and we believe this model takes health system transformation in the wrong direction.” The hospital provisions of HB 3418 were folded into SB 1067 which did pass.

HB 2303 – QMHP/QMHA Registry Amendment Failed

HB 2303 started out as an Oregon Health Authority (OHA) housekeeping bill. A proposed amendment would have expanded it to include registration for QMHPs and QMHAs with the Health Licensing Office. Royce Bowlin, OHA Behavioral Health Director, said, “There is no statewide, centralized oversight of these staff. This will create a statewide registry for them.” Sen. Elizabeth Steiner Hayward (D-Portland) who introduced the amendment, said, “We simply want to know where everybody is. All of these folks can have a significant impact on people’s mental health.” Cherryl Ramirez, AOCMHP testified, “Registry is important to us and is a pathway to licensure for those who qualify. We are also working with ACCBO on a parallel certification process.” The amendment would also require alternative behavioral health providers to register. This caused hypnotherapists to come out in force in opposition to the amendment saying no one consulted with them about the proposal.

HB 2675 – CHIPS Focus on Health Integration Passed

The legislation that created coordinated care organizations (CCOs) required community advisory councils (CACs) to oversee and develop Community Health Improvement Plans (CHIPS) “to serve as a strategic population health and health care system service plan for the community.” This bill adds a requirement that CHIPS include a plan and strategy for integrating oral health as part of its overall plan.

HB 3353 – School Dental Screening Permission Slips Change Passed

Sharity Ludwig told the House Health Committee, “Today if one of the school districts wants to do a dental screening on 100 3rd graders, they must send out a written consent packet and hope parents completed it in its entirety. Typically, three quarters to one-half of the parents do not complete and send the consent for screening packets back.” The bill changes the process from opt-in to opt-out. It allows schools to simply send a written notice to a parent/guardian informing them of their right to withhold the services from their child.

SB 833 – Refer attempted suicides to peer support Failed

The bill would have required hospitals and law enforcement to try to refer attempted suicides to peer support services. Hospitals would encourage patients to sign a release of information when they are being discharged, so the hospital could contact a peer support program on their behalf. Rep. Alyssa Keny-Guyer (D-Portland) told the Senate Human Services Committee, “There is no mandate; no teeth. It is encouragement.” Craig Campbell, representing the Hospital Association, said they are concerned about the availability of peer support. “There is a peer support network but it needs to be more robust,” he said. The bill passed the Senate but died in a House committee.

HB 2304 – Peer Support Specialists Passed

Peer, family and youth support specialists will be added to the Traditional Health Workforce Commission, which also includes community health workers, peer wellness specialists, personal health navigators, peer support specialists and doulas. The bill also requires the Attorney General and OHA to develop and implement a plan to incorporate sexual and domestic abuse survivor advocates into the traditional health workers workforce.

HB 2408 – School Based Health Centers and Mental Health Failed

Rep. John Lively (D-Springfield) proposed appropriating $1 million for new school- based health centers and $3 million to increase student access to school-based mental health providers. Some were concerned about funding going to the school districts to operate medical clinics, rather than be integrated with the rest of the health care system. The bill died in Ways and Means.

OTHER ISSUES OF INTEREST

Business Tax Reform Failed

Democrats tried all session to find a way to modernize and reform the corporate tax structure. Ultimately, none of them worked. Sen. Mark Hass (D-Beaverton) proposed eliminating the corporate income tax and replacing it with a broad corporate activity tax on all businesses, regardless of type. It would have stabilized corporate taxes and raise about $200 million more than current taxes. House Democrats wanted more revenue, so they proposed much higher rates for the corporate activities tax. Leadership then tried a compromise that would have raised corporate income tax rates in the short term, then replace it with a tiered corporate activities tax in the future. Senate Republicans said these proposals were just rehashed versions of Ballot Measure 97 that was soundly defeated by voters in 2016. House Republican Rep. Greg Smith (R-Heppner) said, “I don’t know when a corporate activity tax became a partisan issue. Ohio passed its corporate activity tax with a Republican legislature and Republican Governor. But none of the proposals could garner enough support, so there were no major changes to the corporate tax structure. This sets the stage for another bruising, multi- million dollar ballot measure fight between unions and business in November 2018.

HB 3087 – Paid Family Leave Failed

“Every employer and employee would be covered, no matter how much they work,” advocates told the House Early Childhood Committee. Their paid family leave proposal included an employee and employer payroll tax at 0.5% each. That works out to $25 per month for an employee making $60,000/year. Supporters of the plan say nationally, as of 2015, only 12% of Americans have access to paid family leave through their employer. Employers are concerned about another cost on top of the paid sick leave and minimum wage increases that were recently added. Because of the payroll tax, the bill would have required a three-fifths majority vote in both the House and the Senate, meaning Democrats needed at least one Republican in each chamber. A glut of tax votes this session however made this too heavy of a lift

ORHA 2016,

Oregon Rural Health Association is a 501(c)6 non-profit organization. PO Box 11954 Portland, OR 97211

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