Last month, President Trump signed an executive order directing federally run insurance programs, including Medicaid and TRICARE for military families, to drop coverage for gender-affirming care. Last week, Oregon’s attorney general joined a lawsuit with Washington State and Minnesota against the Trump administration over that order, which also seeks to cut off federal funding from institutions that provide hormone therapy, puberty blockers and surgical treatment for people under 19.
The state’s largest Medicaid provider, CareOregon, covers medically-necessary, transition-related health care, which is currently required under state law. Eric Hunter, President and CEO of CareOregon, joins us to discuss how the health insurer is responding to the demands of the federal government.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Last month, President Trump signed an executive order directing federally run insurance programs, including Medicaid and TRICARE for military families, to drop coverage for gender-affirming care. Last week, Oregon’s attorney general joined a lawsuit with Washington and Minnesota to challenge that order.
Eric Hunter is the president and CEO of CareOregon – that’s the state’s largest Medicaid provider. It covers medically-necessary, transition-related healthcare as required under Oregon law. Eric Hunter joins us now. It’s good to have you on the show.
Eric Hunter: Thank you, Dave. Happy to be here.
Miller: Can you give us a sense for the kinds of treatments that fall under the broad umbrella of gender-affirming care?
Hunter: For CareOregon, we really do follow the requirements of the Oregon Health Plan under the Oregon Health Authority. So for gender-affirming care, for all of the care we provide to people, it’s what’s medically necessary, as defined by the patient, their physician and the people that work around them. For gender-affirming care, it could be anything from surgical issues to hormone therapies. It could be something as simple as making sure the proper notations are made of name and gender identity on forms. A lot of the work is behavioral health counseling, also a big piece of a lot of this work.
Miller: What does Oregon law require insurers to cover in terms of this care?
Hunter: Basically, everything that’s asked for, to be honest with you. I think that they will define the care at the physician provider level of what’s necessary for the individual well-being. It could include what’s necessary to help them transition or to manage the behavioral health issues related to determining how they can best function in society to feel comfortable and feel happy.
So there are very few limitations to what can be covered, but again, it has to be medically necessary. There have to be protocols that the provider goes through to make sure that no one jumps the gun, to make sure it’s very thoughtful, considered a whole person care as well.
Miller: I’m curious about some of the numbers here. There’s been a lot of focus nationally on surgical interventions for trans youth. The Lund Report reported recently that of about 7,600 patients statewide who received gender-affirming care back in 2019, only 700 of them – so less than 10% – had any kind of surgery. And of those, only 35 were under the age of 18. So that’s less than 0.5%. But as I noted, that’s from 2019. That data is a number of years old at this point. Do you have a sense for the extent to which those numbers have changed?
Hunter: My sense is that those numbers are similar, if not a little bit higher than in the past. One thing we have seen is that the majority of the care provided is not surgical because that’s a step towards the end of a process, typically. So early on, hormone therapies, counseling, those kinds of services help folks make sure that they’re comfortable with what’s happening and what they want to do. That’s most important to make sure the right decision is made. So over the years, CareOregon has provided services for about 9,000 people for gender-affirming care. I don’t have the exact breakdown on numbers of surgeries or not, but it’s primarily services around that care.
Miller: Health coverage, in and of itself, by itself means nothing, if it’s not paying for actual care. What has access to trans healthcare in Oregon been like before this new federal order?
Hunter: We’re lucky to be in Oregon, right? I think that, historically, people in Oregon have recognized the need for people to get the care that they find best, and what their families and their physicians think they really need. So they’ve built in systems and benefits that will allow us to provide care across the spectrum, for what people need.
So we could always use more, particularly in behavioral health. The system is still woefully inadequate for the needs across the system. But we’ve got some great partners across the state that we work with to try to make sure that folks get the care they need and, if necessary, we’ll go out of state. But the demand that we’ve seen has been managed fairly well so far.
Miller: Is that the case outside of the Portland metro area, because I know that you operate in Jackson County and in parts of the coast as well. Can somebody get gender-affirming surgery on the coast?
Hunter: On the coast, I do not believe so. Unfortunately, because of the rural nature of much of the coast, and possibly proximity to Portland, a lot of services are provided in the Portland metro. So those folks have access, and if necessary, we’ll provide transportation. We won’t let someone do without necessary care because of where they happen to live or where they were born. We think it’s important that we get those services to them, preferably in their community. Because that’s where the strongest care can happen, but if necessary, we’ll take them wherever they need to be.
Miller: So let’s turn to the order itself. It came out on January 28 and includes this language: “It is the policy of the United States that it will not fund, sponsor, promote, assist or support the so-called ‘transition,’” they put that word in quotes, “of a child from one sex to another. And it will rigorously enforce all laws that prohibit or limit these destructive and life-altering procedures.”
What went through your mind when you read that order?
Hunter: The first thing that went through my mind was a lack of surprise. I believe that the second thing was that executive orders, while on their face, can express the intent or desire of an executive. They aren’t by, in and of themselves, force of law. I think the executive order even references enforcing laws related to those issues, so that’s really where the federal government will come in.
So far, there have been no direct impacts to anything that we do with our members now who we provide care to. But there could potentially be some issues as the state looks to apply for waivers on the Medicaid program or funding that we get from the federal government, which provides the bulk of the funding for Medicaid. The Federal government has the authority and the power to really limit some of those things which could cause consternation on providing other services or more broad services, if we don’t toe the line as they expect.
But I think we have the good opportunity to continue to do what we’re doing for quite some time. And I do know that Oregon, along with other states, is being very active in making sure that when possible and when appropriate, the pushback happens to some of these laws … which, on their face, don’t make a lot of sense because it’s not talking about a lot of people. It’s not a crisis issue. It doesn’t even affect the vast majority of people in the country, even the finances aren’t ridiculously expensive in the grand scheme of things. Some of it is a cultural or political issue that is intruding on healthcare issues, and we think healthcare should be preeminent.
We’ll work with the Attorney General and anybody in Congress or in D.C. to say, “Let’s make sure that we continue to take care of people and treat everyone as a human being.”
Miller: Have you heard of any delays or deferrals of actual healthcare, healthcare that you would cover at CareOregon using Oregon’s Medicaid dollars? Any delays or deferrals of transgender healthcare coverage since this order came out?
Hunter: I have not heard of any delays in Oregon yet. I do know there are other states where some providers, in the entire kerfuffle of systems, are being shut down and portals opened or closed. While most of those came back up and people could access their funds, there’s still a number of community health clinics and certain providers that still have trouble getting access to funds that the federal government has appropriated for them. So they’ve had to scale back services or even stop providing appointments.
We’ve not seen that yet in Oregon. Were that to come down the pike, we are prepared to work with our community partners, our provider partners to say, “Let’s find a solution so that people can continue getting the care that they’ve been designed for, and has been determined by their provider and their family.”
Miller: You said, as far as you know, there have been no changes yet, actual repercussions from the federal government, I should say, based on this order. But one thing you said that could happen in the future would be changes in the way the feds deal with or respond to Oregon’s waivers. So how do Medicaid waivers work, in general?
Hunter: The Medicaid program was designed at the federal level, but much of the control is handled at the state level. It’s truly a partnership between the state and the federal government on a state by state basis. So the basic tenants and structure of Medicaid are defined in D.C. But each state, if they want to veer away from that and do something creative or innovative, add services or take away services, can get what’s called a waiver from the CMS, federal government. That’s a determination and discussion that happens every few years, typically every five years.
Oregon just recently got a waiver, which, we’re thrilled, allowed us to then provide services for food insecurity, housing, climate change, some of those services which are above and beyond the core Medicaid program.
Miller: That was in 2022 that the most recent five-year waiver was accepted. And that’s supposed to go through 2027?
Hunter: Correct. That is the plan. And again, we’ve learned that the federal government, should it desire, has the ability to go back and reopen existing waivers. So that’s why it’s so important that we’re very clear about what our intentions are, what’s important to us and that, when possible, we make the case not only for services based on clinical and medical need, but just general equity and quality issues, and even financial issues. A lot of the concerns we have right now are that the federal government will clamp down on the amount of money it matches the states to provide services. And should that happen, they say we’ll have tough conversations about what we can continue to pay for and what we can’t.
Miller: Those are across-the-board questions – If Elon Musk or Donald Trump wants to find billions and billions of dollars of savings, and is not interested in giving states a lot of money for low income people to get healthcare, that might be a place where they could achieve those savings. That might be across-the-board things and we can talk about that in a second. But how might the administration coerce blue states – for example, states like Oregon – to not offer transgender care for people, whether they’re 17 or 37, through this waiver system? What is a legal mechanism that you think might actually work?
Hunter: Well, I’m not a lawyer, luckily for a lot of people. But I do know that there are very specific requirements in submitting for a waiver and the approval processes of that waiver. Unfortunately, they are not evergreen, so we have to come back occasionally. And there is an ability for the federal government or the state to come back and ask for a tweak to that waiver, even once it’s in existence.
So the biggest concern I think, truly, and the greatest lever, is financial. We heard with the California wildfires, there was discussion in the administration about not providing funding to support recovery from the wildfires unless the state did things related to voters. Those kinds of unrelated issues are really the hammer that the federal government has. It’s coercion based on financial need and a lot of states are going to be in a position where they can’t really resist that.
Miller: And just to be clear, when you say that, for the last two-year budget cycle, Oregon alone got close to $16 billion from the federal government for Medicaid alone – that doesn’t include Medicare. That’s an amount of money that it seems just impossible for the state to make up. We are very beholden to the federal government. How likely is it that if that level of money were truly at stake, Oregon wouldn’t bend to federal will?
Hunter: I think one of the things about, as you mentioned, the amount of money that comes from the federal government Medicaid is that, particularly in the system that Oregon has built, that money doesn’t necessarily go to large for-profit entities. It doesn’t go to shareholders typically in Oregon. Companies like mine are not for-profit. I think what we’ve seen in Oregon is that, by and large, the economic impacts of Medicaid are real positive to the economy and not just blue areas, but in red areas as well.
One of the things that a lot of people are counting on is the fact that even in some of the reddest states, there is a recognition that if you cut rates on Medicaid, then that puts rural hospitals in jeopardy. That impacts everyone, not just the care that you find objectionable or questionable. The basics of care are at risk, and there are long term societal repercussions from not dealing with issues up front.
Really, I think part of the argument is to see how we make the case that everyone truly understands about the importance of Medicaid in particular … 21% of Americans are on Medicaid right now. It’s not just pregnant women and children anymore. It’s the disabled population. It’s people in nursing homes. Those folks have no other recourse.
Miller: But if I understand correctly, one of the things that’s giving you a glimmer of hope is that major cuts to Medicaid nationwide would prove to be extremely unpopular among Republicans?
Hunter: Yes, we’re already hearing some of that. I think the dilemma they have is their desire to support the economy of their local place and the support of their constituents with the realities of the federal budget. The Federal government can basically print money. It’s not a great idea. There must be a good stewardship of public funds. But at the expense of people is the wrong way to go about it.
Miller: Eric Hunter, thanks very much.
Hunter: Thank you.
Miller: Eric Hunter is the president and CEO of CareOregon.
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