Let Them eat cake A debate on the Oregon health-care plan


LET THEM eat cake," Marie Antoinette said, when the poor complained they had no bread. Some people thought she was out of touch with domestic issues.

Today, 30 million Americans have no access to basic health care, and the Bush administration says, "Let them have liver transplants."

Or to be more precise, let cirrhotic alcoholics have liver transplants, even if they're still drinking and medical evidence shows the new liver won't last. Keep end-stage AIDS patients alive for a few more weeks, no matter how much they're suffering. Make sure the incurably ill spend their last days or weeks in intensive care.

As for the working poor, who aren't destitute enough to qualify for Medicaid and don't have the sort of jobs that include private health insurance, let their children suffer permanent hearing loss from untreated ear infections. Let men have strokes because they can't afford blood pressure screenings. Let women die of cancer because they can't afford pap smears and mammograms.

Let them go without preventive care until they're sick enough for high-priced emergency care.

Or make them quit their jobs when a family member falls ill, so they'll be poor enough to qualify for help.

If Marie Antoinette were alive today she'd be on TV explaining her moral opposition to a two-tier system of nutrition. "All citoyens deserve only the finest pastry, with double fudge, amaretto cream filling and pink roses on top, but with no fat, cholesterol or calories," she'd say. "The king and I will not let our people accept anything less!"

Oregon's health rationing plan, which was shot down last week, would have given basic health care to 120,000 people who live under the poverty line but still aren't poor enough to qualify for Medicaid. Oregon would have become the only state to offer care to all citizens living in poverty. Currently, a family of three earning more than $616 a month gets nothing. The money would have come from denying Medicaid coverage for ineffective or unessential treatments.

"We cannot keep people alive forever," explained state Senate President John Kitzhaber, a physician, when he got the plan through the Oregon legislature in 1989. "What we can do with our limited money is to try to reduce the number of deaths."

A commission spent years prioritizing treatment for 709 medical conditions. Uncomplicated hemorrhoids ranked low, because medical care isn't essential. Also low on the list was in-vitro fertilization, which requires high-tech care to solve a problem that's emotionally painful but is not a health threat. Primary and preventive care, especially prenatal care and care for low birth-weight babies, ranked high, because treatment makes a huge difference.

The Oregon legislature voted, in a bipartisan coalition, to accept the health commission's rankings and to fund as much of the list as the state budget could handle. The money ran out at 587.

So, no free treatment for the common cold or superficial wounds. No aggressive treatment for newborns of less than 18 ounces and 23 weeks of gestation, who aren't expected to live. No care for cancer, when treatment would give a less than 10 percent chance of five-year survival. No simultaneous kidney-liver transplants, because the odds of success are so low. No liver transplants for alcoholics.

Health Secretary Louis Sullivan denied Oregon the federal waiver it needed, saying the rationing plan discriminates against people with disabilities, for example, alcoholics with cirrhotic livers, and extremely premature newborns.

The Americans With Disabilities Act of 1990 says "no qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits" of any public program. Alcoholics are considered individuals with a disability who must be protected from discrimination.

Oregon's sin was factoring in judgments about the quality of life, not just the quantity. Does a person in the last stage of AIDS benefit from an extended death? Does an accident victim with severe brain damage benefit from aggressive treatment that keeps his body alive?

Anti-abortion groups and groups representing people with disabilities opposed the Oregon plan.

So did Bill Clinton's running mate, Sen. Al Gore, who said in April, "This plan is seductive to policy makers, but dangerous to the people who really need help."

Oregon claims it discriminates on the basis of prognosis, not disability. Since new medical research shows that recovered alcoholics who stay sober may do as well with a new liver as those with non-alcohol-related liver disease, Oregon is willing to take that into account.

But sensible decisions about when treatment is futile must be value judgments. Choices must be made.

It is quite true that under Oregon's health rationing plan, people covered by Medicaid would not be guaranteed the same level of medical services as people whose employers pay for their insurance. But rationing by priorities is fairer than the two-tier system in existence now: Some get all-you-can-consume care and some go without.

Politicians who oppose Oregon's health plan must explain why it's more unfair than denying all coverage to the working poor -- or how they'd pay for universal health insurance with unlimited coverage and no value judgments.

The first is "let them eat cake." The second is pie in the sky.

Joanne Jacobs is a member of the San Jose Mercury News editorial board.

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