It is conceded within the Bush administration that the most important experiments in health care reform will take place at the state level. So the administration's decision last week to deny a crucial waiver to the state of Oregon for a far-reaching reform of its Medicaid coverage came as a surprise.
As columnist Neal R. Peirce notes on the page opposite, Oregon's plan would rank medical procedures on a cost-benefit basis in order to extend coverage to 120,000 more poor people. The state would cover only the first 587 procedures on a list of 709; it would pay for fewer kinds of medical treatment but for more people.
Supporters of the Oregon plan are calling the administration's move cynical and politically motivated. Yet even Sen. Al Gore of Tennessee, the Democratic vice presidential nominee, urged the Republican administration not to approve the plan. Just as Oregon's proposal to ration Medicaid coverage has drawn bipartisan support in many quarters, it also has elicited bipartisan criticism.
The Bush administration's objections are based on legal opinions that in denying coverage for certain procedures -- in particular those that are deemed not to contribute to a high enough quality of life -- the Oregon plan would violate provisions of the 1990 Americans with Disabilities Act. That statute, which the president supported, forbids any discrimination in government-funded benefit programs against individuals with disabilities.
Rationing is a scary word, but the current system in which millions of Americans lack access to care is itself a form of rationing. Oregon officials describe their plan as a way of setting priorities rather than rationing. But the effect is the same.
Some critics argue the federal rejection proves that the hard choices in health care reform are too politically risky to gain widespread support. But Oregon's plan has its defects. To cite one, it makes no provision for minimum coverage. It would give short shrift to the need to ensure basic medical coverage for all women and children -- two groups lacking much political power that almost always end up shortchanged by public policies.
Those concerned with equity issues in medical care can take heart that the administration has now gone on record in favor of the idea that equal access to health care is a civil right for at least some Americans -- the disabled. The only thing lacking is to extend that concept to all Americans.
The failure of this plan to pass federal muster is not the end of attempts to ration health care. Nor should it be. Only by working for a more rational way of allocating health care dollars will this country achieve a medical system that is efficient, effective and fair.