Dr. Sejal Hathi, the nation's youngest state health director, discusses Oregon's groundbreaking Medicaid transformation that expands coverage beyond traditional healthcare to include housing, climate health, and nutrition. Learn how this innovative model achieved 97% coverage while addressing social determinants of health and setting new standards for healthcare policy nationwide.
Sejal Hathi, MD, MBA, Director, Oregon Health Authority
Megan Antonelli, Chief Executive Officer, HealthIMPACT Live
Welcome 0:01 Welcome to Digital Health talks. Each week we meet with healthcare leaders making an immeasurable difference in equity, access and quality. Hear about what tech is worth investing in and what isn't. As we focus on the innovations that deliver. Join Megan Antonelli, Janae sharp and Shahid Shah for a weekly no BS, deep dive on what's really making an impact in healthcare.
Megan Antonelli 0:29 Hi and welcome to digital health talks health impact. I'm Megan Antonelli, and today we're joined by a true pioneer in healthcare transformation, Dr Sejal Hathi, director of the Oregon Health Authority and the youngest state health director in US history. Under her leadership, Oregon has revolutionized Medicaid by expanding coverage to include housing, climate, health, nutrition, and achieving remarkable 97% coverage rate from her personal journey with the healthcare system to driving nation leading policy innovation. Dr Hathi, story exemplifies how diverse perspectives and bold leadership can reshape American healthcare. Hi, Dr Hathi, how are you today?
Sejal Hathi 1:08 Hi, Megan. I am doing well. Thank you for having me. I'm
Megan Antonelli 1:13 so excited to meet you and hear about your amazing journey. You know, I know a little bit about about it, and it's just such a pleasure to finally meet you, but share with our audience a little bit about, you know, your journey, and you know, becoming the youngest state health director in the US what you know, congratulations. It's such an amazing achievement. Oh,
Sejal Hathi 1:38 well, thank you. There's a lot of work to do, and I'm focused on the impact that our full team, our full agency, it really takes a village to advance some of these policy goals. Really focus on the impact that we can collectively create. But if I were to comment on my journey, I would say that it requires me to travel a little back in time to my teenage years, and in particular experiences that I had then with chronic illness. So when I was 15, I was diagnosed with an eating disorder, anorexia, and in that one judgment, that one moment, my world shattered, and it took my family and me years to recover, years for me to get the treatment and supports that I needed. But that years long battle really taught me that countless succumb to mental illness because they could not recognize their intrinsic worth. It also showed me how indispensable health is to achieving self actualization, and my physicians throughout this process were transformative. They gave me back my dignity and really supported me in charting a path to recovery. So I decided I wanted to pay it forward. I wanted to become a healer, a care provider myself, and also to look at some of those upstream drivers of poor health, the societal factors that I know had perpetuated my own illness by fostering health systems that build trust and embody a more holistic definition of health and thereby empower as many folks as possible, including and especially young people and young women, to fulfill their full potential. So that's how I became interested in health care delivery and public health, and I just continued to further plumb that world throughout my years in college and medical school, doing work across the globe on behalf of women's rights and women's reproductive health for the UN And the WHO getting involved in domestic health policy, especially in the wake of the 2016 election, when I felt that certain rights to healthcare, as enabled by the Affordable Care Act, were put at risk. And throughout this time, I realized that policy is an incredibly powerful lever to enact intergenerational change and to build the type of health systems that I knew I wanted to see and support and experience myself. And so I decided to couple my clinical work with work as far as was possible in policy, which is why I'm living that duality today. Yes,
Megan Antonelli 4:44 well, that's amazing. And I think, you know, think, think, thank you, right? Because it is. You know, lots of people have a healthcare journey, and not everybody decides they have to get into healthcare to fix it and to make it better. So I appreciate that. And. It is, you know, I think one of my, you know, I think one of the most interesting things is, is this intersection between public health policy and then what healthcare is actually delivered. So, you know, tell us a little bit about, you know. I know we are at a very critical juncture of that right now. And you were a senior policy advisor to the Biden White House. Tell us a little bit about in your role, you know, at the Oregon Health Authority, with what is coming with the administration changing, you know, how are you safeguarding some of the improvements and some of the work that you're already doing?
Sejal Hathi 5:40 Yeah, so firstly, a little bit about what the Oregon Health Authority is. It's it's the state's effectively Department of Health. So we oversee all healthcare delivery, policy, regulation, services, all public health policies and services for the state of of Oregon. So it's a wide gamut of regulation and operation that the agency collectively undertakes. But you're right that we are especially attending to the potential impacts and harms that a change in federal administration may present to our values as well as priorities. And what I mean by that is a few different things. I think, first and foremost, we're concerned about access to health coverage. The change in administration has talked about rolling back Medicaid access. Medicaid covers more than one in four residents, some of Oregon, 50 plus percent of births in Oregon, and I think those statistics are true of much of the country, and we're concerned about maintaining that access. I think you mentioned at the start that we've achieved this historic milestone of 97% of people covered in Oregon, and that was in part, through partnership with the federal government, who shared our interest in seeing as many people as possible covered. So we want to protect that access. I think Oregon also pioneered several groundbreaking Medicaid benefits, using federal health insurance or Medicaid dollars to pay for social needs. So for instance, paying for medically tailored meals and access to fruits and vegetables, paying for climate resiliency devices. So folks who need refrigeration units to store their insulin because they have diabetes but they don't have enough money to pay for that. Folks who you know, live in areas that are especially prone to extreme heat, but don't have air conditioning systems. In Oregon, we use Medicaid to pay for that, and then also leveraging those dollars to pay for housing and rental assistance to prevent homelessness and those groundbreaking social benefits, which we've been able to institute with the approval and support of this past Biden Harris administration. We are fearful, similarly, are under threat, and there is a whole gamut, again, of policies and services that we're worried about and we're inventorying. And you know, I think that if, if this administration focuses on on expanding access to coverage and care and tackling the core drivers of chronic disease as some of its intended appointees a test to be interested in, then we'll be okay. But just in case, we're thinking about all the possible ways that we can continue to make gains and progress on those programs and policies that have historically made Oregon one of the healthiest states to live in.
Megan Antonelli 8:59 Amazing, yeah, and that, you know, that's an incredible list of accomplishments that you've done, and in areas that I think, you know, we talk about a lot on the show, in terms of, you know, the nutrition programs and, you know, helping people where they are and with what they need. Let's talk a little bit, just in general, about that 97% coverage rate. And what does that mean? And what is that you know, and how does that translate to enrollment and all of that?
Sejal Hathi 9:25 Yeah, sure. So Oregon just announced a few weeks ago that we reached our highest coverage rate in state history, and among the highest rates of coverage in the country, at 97% and that means that 95% of people in Oregon are insured, have access to some form of health insurance. Now we know that insurance doesn't always equal access, and we're doubling down on efforts to make it easier to access affordable care, but I think this milestone is still something to be incredibly proud of, and it's the direct result. Of having worked or having worked relentlessly to unlock access for people of all ages, no matter their income, criminal justice, background or immigration history, and I'll share a few of the ways that we've done that. Just earlier this year, we received federal approval, one of very few states to extend healthcare coverage to incarcerated folks for up to 90 days pre release. These are folks who typically lose access to coverage and therefore find it extremely difficult to obtain health care, both when they're incarcerated in the days immediately falling release, who received federal approval to extend coverage to them a couple years ago and since 2022 we've we've been offering health coverage also to all eligible Oregonians, no matter their documentation status. That's close to 100,000 people, including more than 10,000 children, who now have access to preventative care and other important health services where other states would decline them. The those those services that right? We also introduced, we're the first state to do so continuous eligibility for health insurance coverage to children through their sixth birthday, meaning that we remove the burden of annual renewals, which typically cause folks to turn off insurance coverage during those most formative years of life, and we spaced those, similarly, those renewal or eligibility checks to for adults to every two years, where typically it's it's done every year. And then during the COVID 19 pandemic, when the federal government froze Medicaid disenrollments, we observed that 10s of 1000s of people who historically had the highest uninsurance rate in a very specific income range were suddenly covered in record numbers and taking advantage of preventative care where previously they had delayed it due to cost so improving their health outcomes and decreasing the overall cost of care. We wanted to keep this group covered, so we became the first state in the country to both extend Medicaid to a higher income limit, 200% of the federal poverty level, instead of 133% and to do so at no cost to the member. That means that no premiums, no CO payments, no deductibles, thereby preserving coverage for this additional population. We were named the number one state in the country for renewing Medicaid in the wake of the public health emergency during the so called Medicaid unwinding process through a variety of creative policy choices. And you know, on top of that, we're working to ensure that the coverage that we do provide is expansive, it's comprehensive, it's affordable, and addresses members upstream needs, which we know, again, are responsible for worsening health outcomes and increasing health care costs. And I mentioned a few of those innovative social benefits earlier.
Megan Antonelli 13:00 Wow, that's great. I mean, and I think, you know, when, when you think of coverage, I mean, as you said, that the churn is often, that's a lot of the problem, right? That Medicaid can be available, but then actually getting folks enrolled and keeping them enrolled is some of, you know, part of the biggest challenge. You also mentioned costs, though, right? So the cost of enrollment, the, you know, cost to the members. What about the cost of the program? I mean, as have you been able to kind of manage that, as the you know, funding and stuff is that, is that where the administration has helped? Is that where the concerns are coming from, coming down the as you look to the future?
Sejal Hathi 13:38 Yeah. So you know, across all of these programs covering more people, generally means doing so at higher total Medicaid costs. And some of these programs, for instance, our healthier organ program through which we cover folks who are undocumented, we do at it cost exclusively to the state. So where Medicaid typically entails a Federal and State Partnership, a match, where the state pays for part of the care that the federal government pays for the rest some of our programs, because they are unique, are exclusively paid by the state. And you know, those numbers rack up, and so I will, I will own, or will concede, that our very success in getting more and more people covered has come with A greater budgetary footprint than perhaps some of our colleagues in the state legislature and otherwise initially anticipated, but we view that as a good thing, because we do know studies have consistently shown over the past many years that expanding access to health coverage, Medicaid expansion across the country. Results in better health outcomes and lower health care costs overall for this very vulnerable population. And so this we view, is not only aligned with our values of extending access to a basic human right for all Oregonians, but we know will help us at the end of the day long, choosing we keep costs down overall.
Megan Antonelli 15:24 Of course, yeah, you know, you have to spend money to one, save lives, but also save money in the long run. For sure, when you look at some of the programs, like the you mentioned, the nutrition program and the you know, how are you measuring the success of these programs. What are some of the benchmarks that have come out of there that that you're like, This is great, you know, if you're talking to other state health directors, what you know? What are some of the programs you would say, look at these outcomes. You know, do this in your own state.
Sejal Hathi 15:58 Yeah. So some of these more innovative social benefits are through what we call a section 1115 waiver, which is a fancy way of saying a federal pilot program. These are five year pilot programs, and in our case, our pilot program runs through 2027 and we're tasked by the federal government with conducting a thorough evaluation of the impact of the pilot program, on our costs, on federal costs, on health care outcomes and on social outcomes. And so there is a comprehensive array of metrics that are actively being measured by a third party for neutrality reasons through the course of this five year period that we then have to report on. And the goal is, of course, that if we can show indeed, that this holds down costs and it improves health outcomes, that we can make this not only not just a pilot benefit, but an entitlement like institutionalize it as part of the benefit program, and make it more likely that other states will follow in
Megan Antonelli 16:59 terms of, you know, it's not easy to change. It's certainly not easy to expand programs that do cost more. Do you have any, you know, words of wisdom or thoughts around the challenges you faced and how, you know, you're able to kind of get, you know, create the environment within both, you know, the you know, the Health Authority's office. But also, of course, I'm sure there's collaborative partners and such that you've worked with to kind of make, to make the challenges either easier or make the change happen easier.
Sejal Hathi 17:33 Yeah, well, maybe I'll respond to this by actually sharing that. Well, firstly, it takes, it takes a village, to to move some of these programs forward and our own, our 1115 Medicaid program was in part inspired by some work that health systems and health insurance had piloted with housing benefits in one part of the state, demonstrating to us how it improved health outcomes and lowered costs for their members, and encouraging us to apply for a waiver from the federal government to expand this to a statewide pilot. And so we take inspiration from the work that some of our CCOs or coordinated care organizations have long done to improve health equity and access across the state. And also I, you know, I want to mention that through governing all of these programs is a cost growth target. And so our cost growth target is 3.4% has been a key health strategy over the years since 2019 in keeping our total health care spending in line with wages and with economic growth to improve the affordability of care. So all of these programs, pilots, innovative new benefits, are done with that overall cost growth target in mind, and we both measure the cost growth every year, and we institute real accountability from healthcare payers and provider organizations every year. And that means implementing a mix of transparency measures, performance improvement plans, and for the first time this year, like financial penalties to ensure that health plans and provider organizations are taking meaningful action to meet the state's target. And so there are a number of levers that we have at our disposal and that we've been deploying to both improve equity and access while also maintaining or lowering costs right?
Megan Antonelli 19:42 That's great. It in terms of, of course, our, um, our audience, and a lot of what we talk about here on on digital health talks, is technology and the digital side of things. And I've always been struck, you know, in Medicaid, that there was certainly early on. Adoption of texting patients adoption, you know, you had to be more innovative in some way in terms of technology adoption, because you had to go to where your patients were, you know. And it's taken the rest of the healthcare system, maybe a little bit longer decades, to to get there, and we're not fully there yet. But as you look at the program, and you look at some of these, particularly the ones that are having that impact. That's maybe a little bit less traditional medicine platforms, or maybe, or maybe even more with, or more traditional, are there particular ways that technology is making some of this more you know, possible, and it you know, and hopefully less expensive but but also more effective.
Sejal Hathi 20:45 Yeah, so technology, it's just in the water, it's it's a part and also of everything that we do, obviously, we use digital tools and platforms to to coordinate some of these social benefits, housing supports, nutritional assistance and climate related healthcare needs, and integrate them with medical care with our EHR so that CBO is both providing these social services and healthcare systems providing the care are talking to each other and ensuring that we have a singular patient record that all are aware of. But we also use technology in expanding access to care, especially for our rural and underserved communities. We continue to invest in and grow telehealth services, especially in rural areas, especially for maternity services, which are increasingly under threat, and for behavioral health services to extend access to folks who otherwise would have difficulty getting that care.
Megan Antonelli 21:44 Yeah, that's great. And I do think I've seen a lot of innovative things around mental health, and particularly as your journey that, you know, adolescent mental health, you know, meeting patients where they are with those types of tools is so important. So I imagine there's, there's a lot in that. But as we talk about that, and kind of your journey, and we only have a few minutes left, and I want to be mindful of that, is there anything that you would share with kind of other young leaders? I mean, you know, I look at the healthcare landscape, and I see a lot of young physicians going into more entrepreneurial, startup type environments. And, you know, I want to see more in public health and policy and action, because that's where reform and change can happen. Is there, you know, some words of wisdom or advice that you would share with with young leaders looking at Ed healthcare as their career option?
Sejal Hathi 22:39 Yeah, so I'll say I've heard that growing trended is both a good thing that more physicians are standing up, speaking out and speaking up, and a potentially bad thing as we siphon away clinical talent and more physicians are engaging in ancillary pursuits, from policy to entrepreneurship. But I'll say, whatever the interest of the young person in healthcare, lead, lead with purpose, policy is not the only arena in which to make positive social impact. You can do that through entrepreneurship. There are so many companies that were spurred by the Affordable Care Act. These are so these fields are so intertwined, and are doing amazing work to expand access to equitable care. I look at city block health, and I think you had someone Dr Matthews on from city block a few years ago, and they've really changed the paradigm of what's possible and encourage investors to look at Medicaid, the Medicaid population, as one worthy of investment, right? And so whatever you do, start with that deep commitment to social justice and to equity. Think about, how do I want to make the system better? And there are multiple levers and arenas in which to shape that positive impact, and don't be afraid to be unconventional or iconoclastic, that there are healthcare has been changed and transformed by those who are willing to think differently. And while thinking differently isn't always rewarded. In fact, it can be actively marginalized, maligned or discouraged by clinical leaders. It's just not the way that we are taught to be as clinicians. It's what moves the field forward. So don't be afraid to step out of line, to think differently and to challenge conventional wisdom.
Megan Antonelli 24:42 Well, I love that, because it's aligned absolutely with what we what we think over here at purpose events and health impact is that we have to start with purpose, and then we can really make an impact. And so it's just it's a pleasure to meet you and to speak with you and to hear about the great work. Are doing in Oregon, and so thank you so much for joining us. Dr Hathi, I look forward to both following what you're doing in Oregon and seeing what you continue to do across the nation, and I hope you'll join us again to tell us about that soon.
Sejal Hathi 25:14 Thank you very much Megan for having me absolutely.
Megan Antonelli 25:18 Thank you for joining us at health impact and digital health talks a special thank you to Dr sujala Hathi for sharing Oregon's groundbreaking approach to healthcare transformation. Her vision of integrating social determinants of health into Medicaid demonstrates what's possible when we reimagine healthcare delivery for more conversations with healthcare innovators who are reshaping the future of health Follow Digital Health talks on your favorite podcast platform. This is Megan Antonelli, signing off.
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