Greetings to the 22 million Americans who receive federal health insurance assistance through the Affordable Care Act. Your premiums for next year are going to go up about 114%. That translates into an estimated additional $1,000 a month for many low and middle-income families.

OUCH! It is painful enough to send you to the doctor, except now you can’t afford to go there.

Considering that almost 3 million of these policies cover owners and employees of small businesses, it is bewildering that Republicans in Congress don’t seem to grasp the political landmine of their indifference to extending the provisions of the landmark health care law.

The spiraling cost of health care is not just confined to ACA recipients. Most people covered by commercial insurance have seen their premiums go up by double digits each of the past two years. Hospitals in Oregon are bleeding red ink, especially rural hospitals like Bay Area Hospital in Coos Bay, which is in default of a $45 million loan from the Bank of Montreal and struggling to keep its doors open. Providers of Medicaid services in Oregon, as with the rest of the country, are feeling the sting as well.

Medicaid Facing Headwinds

Coordinated care organizations (CCOs) are valiantly working to ensure health care coverage for hundreds of thousands of Oregonians while facing headwinds of reduced federal funding, increased delivery costs, and the Oregon Health Authority (OHA), which keeps them so awash in expensive bureaucracy and new polices that will increase costs further.

As an example, OHA leadership wants to eliminate or modify the Prioritized List, one of the key tools that has extended coverage to more citizens and reduced costs, and is the centerpiece of the state’s innovative health delivery system.

Last month, PacificSource of Springfield declared they had enough. Faced with losses that are expected to reach $100 million this year alone, they informed OHA they were not going to renew their Lane County contract with the agency in 2026, leaving 90,000 residents in the lurch.

Is this just an isolated circumstance limited to Eugene, or is it a telltale sign that something much broader and deeper is underway? Health Share of Oregon has slashed $100 million from its behavioral health spending — the Governor’s signature issue. Medicaid providers are concerned that the state is executing a sleight of hand to shift its failures with the state’s mental health system and woes at the Oregon State Hospital to others. Red lights are flashing everywhere, but does anyone hear the train whistle barreling towards them?

Trillium Steps Up

Fortunately for those residents in Eugene, the other CCO in the area, Trillium Community Health Plan, has agreed to continue coverage despite the financial challenge that comes with it.

There is an irony here. People often demand local ownership over national entities. But in this case, it is PacificSource, the local nonprofit in Springfield, that has thrown in the towel in Lane County while Trillium, owned by a national health care company, has agreed with OHA to cover those 90,000 residents who were abandoned and stand the gap — despite the financial risks such a move entails.

Trillium has been serving Lane County for over a quarter-century and last year scored near the top of the quality performance metrics established by OHA. Additionally, it donated more than $7 million to Lane County community initiatives last year.

But neither Trillium nor the other CCOs that deliver Medicaid services in Oregon can stem the tide of rising costs and declining federal revenues without intervention from members of Congress and the Oregon Legislature. If there is one bright spot, it is the return of Bruce Goldberg to the Governor’s Office to help strategize a response to the coming storm.

Bill Coming Due

Most of those now serving in Salem have never had to confront the need to make radical cuts in agency budgets and programs. But it may be time to revisit Maslow and his hierarchy of needs.

The foundation is ensuring basic needs are prioritized first — food, shelter and health.

The Legislature has committed tens of millions of dollars to very important agency goals and initiatives. Any effort to redirect those funds to foundational programs will be met with kicking, screaming, and gnashing of teeth from myriad advocates for those programs.

The bill, however, is coming due and the state cannot use a credit card to forestall the hard decision-making that lies ahead. There are no easy escape routes.