Oregon Debate Shows Choices in Health Reform are Difficult Ones


Nothing is simple about this country's health care system -- least of all reform.

For proof, take a look at reaction to the Bush administration's decision to deny the state of Oregon a federal waiver for a Medicaid reform plan that would extend coverage to more people by paying for fewer benefits.

The Oregonian, the state's major newspaper, summed up the stunned reaction of many supporters of the plan in an editorial headlined, "Health care ambush." A New York Times editorial lamented "A bold medical plan, derailed."

The outcry was not surprising. After explicitly encouraging states to experiment with reforms, the administration then squelched a program seen by many people as a courageous effort to face the hard choices that will be necessary to implement significant change.

Meanwhile, an odd group of allies applauded the move.

Advocates for the disabled were pleased, because the administration justified its decision by saying the Oregon plan would violate provisions of the Americans with Disabilities Act prohibiting discrimination against the disabled. Right-to-life groups and Oregon's Roman Catholic bishops also claimed a victory.

But lest people begin to see partisan overtones here, the plan's critics also included such prominent Democrats as Sen. Al Gore, the Democratic vice-presidential nominee, and Rep. Henry Waxman, D-Cal.

The Children's Defense Fund, a non-profit lobbying group whose board is chaired by Hillary Clinton (now on leave to concentrate on her husband's presidential campaign), has also been outspoken in its opposition to the Oregon approach.

The fact is, Oregon is paying the price of the pioneer for its willingness to get out front on controversial issues like "rationing" -- a word used frequently in descriptions of the plan.

But while Oregon should be lauded for its willingness to tackle the health care morass, it's worth remembering that pioneers don't always get it right. If fairness is an important standard for judging health care reform, this plan had some serious flaws.

Most serious was the target population. The plan was limited to Medicaid recipients who, by definition, are poor and vulnerable. The Medicaid rolls are largely limited to infants, young children, single mothers and pregnant women who are at the bottom of the economic ladder -- and at the bottom of the political pecking order as well.

In crafting the plan, state legislators specifically voted to exclude themselves and state employees from any reforms. That left only the poor and politically powerless to be affected by a system that would rank 709 health care procedures and, initially at least, provide payment for 587 of them.

There was no promise that in subsequent years more procedures would be covered. More important, neither was there any guarantee that benefits would not be further cut. Given the way state budgets are looking these days, what fool would bet there would never be pressure to lop off coverage for another couple dozen procedures -- especially when the people affected probably don't even vote?

Lesson one from the Oregon effort: Effective -- and fair -- reform should be broadly based. Don't say to any group, how about letting us experiment with your care?

Lesson two has to do with that infamous ranking system. No one can fault the crafters of the Oregon plan for lack of effort or for failing to seek out a wide range of opinions on the plan.

But the methodology for ranking medical procedures was rightly criticized by the federal Office of Technology Assessment for its non-scientific aspects. Community meetings and public opinion polls were used to gauge community sentiment about the value of various medical interventions.

As Sharon Daly of the Children's Defense Fund points out, "If you ask people what they would want done if they had a stroke, a lot of people would say, 'Just shoot me.' But in fact, most people who have strokes want to be treated."

Until people actually encounter the painful choices inherent in medical care today, it is easy to overlook the subtle prejudices we all carry around about disability and disease.

Sure, telephone polls and community meetings are democratic. But Oregon would have had a stronger case for its ranking system if it had based it solely on objective data linking treatments to actual outcomes for patients. But this method presents its own political problems. A ranking based on outcomes would exclude a number of futile treatments most people believe should be available -- such as treatment for liver cancer.

The good news is that the derailment of the Oregon plan does not end the momentum for health care reform. In fact, as some observers see it, political reality has passed Oregon by. Other states have picked up the reform crusade and learned from Oregon's mistakes.

Arthur Caplan, head of the University of Minnesota's Center for Biomedical Ethics and another critic of the Oregon plan, says he maintained all along that the best way to stop the Oregon plan was not to criticize it on ethical grounds but to produce a better plan.

He thinks Minnesota has done that with its "HealthRight" legislation, an ambitious reform effort enacted this past April that targets insurers and health care providers as well as consumers. Unlike the Oregon plan, which did not attempt to rein in spiraling costs, HealthRight explicitly links cost containment to the goal of expanding access.

Will HealthRight work? On its face, it passes the fairness test in ways that the Oregon plan did not. Whether it will succeed is yet to be seen.

But it's an experiment worth watching, and the spotlight now shifts to Minnesota -- as well as Massachusetts, Washington, Florida, Vermont and other states that are seriously testing the dangerous waters of health care reform.

Despite the Oregon derailment, health care reform is alive and well.

Sara Engram is editorial-page director of The Evening Sun. Her column appears here each Sunday.

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