What if Lane County ran its own health plan?
6 min read
by Marty Wilde
President Trump has decided that poor people don’t deserve health care.
He signed the Big, Beautiful Bill Act into law last July after congressional Republicans passed it without a single Democratic vote. Despite the name, the bill is forcing very ugly cuts to health care.
Gov. Tina Kotek’s Advisory Group on Medicaid Sustainability estimates that Oregon will lose $9.4 billion in combined state and federal Medicaid funding through 2031 because of the law. For the 2027–29 budget alone, it creates an estimated $421 million hole in the state general fund.
Even if we fill the budget hole, 200,000 Oregonians will lose health care.
Our local health safety net is already fraying. Community Health Centers of Lane County is cutting expenses and positions as its projected deficit grows. PacificSource stopped managing Oregon Health Plan benefits here, so the Oregon Health Authority moved most of its roughly 90,000 Lane County members to Trillium Community Health Plan. Trillium is wholly owned by Centene Corporation, a publicly traded, for-profit company.
As federal cuts force hard choices, who should manage the care that remains: a corporate subsidiary accountable to its parent company and investors, or a public organization Lane County voters can question, pressure, and replace?
Public ownership would not restore the federal money, but it would make whoever manages our Medicaid dollars democratically accountable for what they preserve, what they cut, and whether the local network still works.
Oregon law already allows that choice. Lane County should decide whether to take it.
President Trump’s plan to force 200,000 to lose health care
The $421 million figure is the advisory group’s estimate of the General Fund gap that President Trump’s H.R. 1 creates for Oregon Medicaid in the 2027–29 biennium. That is a state-dollar hole, and it should not be conflated with Oregon’s separately rising costs for hospitals, drugs, and behavioral health.
The Trump administration’s changes also arrive in stages. Work and activity requirements have not yet pushed Oregonians off OHP. Federal law requires them beginning January 1, 2027 unless a state starts sooner, and OHA says Oregon’s rules will take effect in 2027. The expected coverage losses are a warning, not yet a result.
The longer-term numbers are worse: the advisory group projects losses of $9.4 billion in combined state and federal Medicaid through 2031, while cautioning that the estimates will shift as caseloads and federal rules become clearer. Oregon is especially exposed because ACA expansion adults on the Oregon Health Plan draw a 90% federal match, so changes to that population pull large sums out of the system.
To close the gap, the advisory group weighed cuts to adult dental, mental health therapy and other optional benefits, emergency and hospital review, the prescription drug system, and CCO administration, plus an across-the-board reduction. No single option is enough, and many overlap or cannot be adopted together, so Oregon cannot solve this even by checking every box.
Giving Trillium a fair hearing
The current system deserves a fair account. While Trillium is for-profit, the plan is not necessarily extracting an excessive profit from Lane County. Trillium operates under an OHA contract, must meet state and federal requirements, and has community advisory structures. The statewide financial data do not isolate Trillium’s Lane County results.
Oregon’s coordinated care organizations receive a monthly payment per member to manage physical, behavioral, and dental care. They process claims, contract with providers, coordinate care, and absorb financial risk under a long list of state and federal requirements.
In 2024, the 16 CCOs collectively spent 91.74% of revenue on member services and 8.26% on administration. Nine plans made money and seven lost money. Trillium had the state’s largest profit in its Portland CCO at 9.56% for 2024, but its Lane County operations lost 3.31%. Overall, considering enrollment numbers, their total operating margin for the state was just under 4%.
There is no guarantee that Lane County could do better, only that any profits, or losses, would be kept local.
Oregon law already allows it
Oregon would not need to invent a new kind of Medicaid organization. Under state rules, a CCO may be a corporation, a governmental agency, or a public corporation, and ORS 414.572 allows local, community-based organizations that can manage financial risk and maintain reserves.
The legal door is open, but the practical questions are hard. Lane County would have to stand up or designate an entity, assemble a provider network, build claims-processing capacity, meet federal managed-care rules, hold reserves, pass OHA’s readiness review, and win a contract. It could hire an experienced administrator, but outsourcing the machinery would not outsource the risk.
Timing matters too. OHA plans to post the next CCO procurement in fall 2027, award contracts in spring 2028, and begin them in 2029. A county plan is no answer to next year’s $421 million hole, but it is a structural option for the next contract cycle.
What local ownership could actually change
The strongest case for a county-owned CCO is integration. Lane County already owns much of the delivery system — Community Health Centers, Behavioral Health, LaneCare, and Public Health all sit within Health & Human Services, running primary care, addiction treatment, care coordination, jail health, and more.
Voters unhappy with how Lane County runs those services can express their concerns to commissioners and vote them out if the problem doesn’t get addressed. Trillium offers residents local advisory bodies, but voters cannot remove Centene’s directors or executives.
A county-owned CCO could align some of those incentives, making network decisions with direct knowledge of local shortages, coordinating Medicaid payments with county behavioral and public health priorities, and directing flexible spending toward locally identified needs.
Governed by the county commission or a public board answerable to it, it would make elected officials answer publicly for whether the network works. Public ownership would not erase federal law, state benefit rules, privacy restrictions, or FQHC payment requirements.
That authority is real but bounded. OHP benefits are largely set statewide, so the county could not preserve adult dental by trading away psychotherapy visits if Oregon dropped dental from the package.
Its discretion would lie mainly in how it builds its network, pays and supports providers, coordinates care, uses flexible spending, and reinvests any margin. Beneficiaries would still get care from a mix of public and private providers, so the county would gain meaningful local authority, not complete local control.
The clinic deficit is the stress test
Community Health Centers of Lane County serves more than 30,000 people. The county projects a deficit of approximately $2 million in FY 2026–27 and approximately $6.5 million the following year.
The county blames the CCO transition, lost 340B pharmacy revenue, softer patient volume and reimbursement, and rising costs. A county-owned plan would not have prevented the deficit, but it might stabilize contracting and reduce the risk that a private CCO simply leaves, trading that exit risk for the chance that a public plan misprices care and the county’s own balance sheet absorbs the mistake.
That trade is the heart of the question.
Other counties have made it
Lane County would not be the first local government to run a Medicaid plan. In Minnesota, Hennepin Health is a county-owned, state-certified HMO whose board is made up of county commissioners, and County-Based Purchasing organizations governed by their member counties serve 32 more counties.
California runs County Organized Health Systems as the sole Medi-Cal plan in 22 counties. In Los Angeles, a public reentry program connected people to services around jail release, and a county evaluation found higher primary-care use and lower emergency-room use among participants, though the study was a limited pre-and-post comparison.
This is a proven model, not an experiment. Where it’s been measured, the results lean favorable.
The question Lane County should answer
President Trump forced the Medicaid cuts, but Lane County can decide who manages the consequences: Trillium, a subsidiary whose executives answer to a national corporation and its shareholders, or a public entity governed by county commissioners whose decisions voters can examine at home.
That is not a choice between greed and virtue. Trillium may run the program better than a new county entity could, and public control also means public exposure — if the county prices the risk badly, taxpayers own the mistake. Democratic accountability is worth something only if government is candid about that risk.
Lane County should prepare a serious feasibility study before OHA posts the next procurement. Before that window opens, its commissioners should ask the public plainly: Do they want a for-profit company to manage a fraying safety net, or are they willing to put public money and their own accountability behind doing it locally?
Marty Wilde represented central Lane and Linn counties in the Oregon legislature. For more of his Letters From A Recovering Politician, subscribe at https://martywilde.substack.com/subscribe.
Copyright (c) 2026 Marty Wilde. All rights reserved. Reprinted with express written permission of the author.
