With more than 35 million Americans uninsured for medical costs, there is no question that this country faces a health-care crisis. And although nobody likes to talk about it, that crisis costs lives every day.
When the Bush administration refused recently to grant Oregon a federal waiver necessary to implement an extensive program of Medicaid reform, many people saw the action as politically motivated. Some critics charged that instead of encouraging urgently needed health-care reform, the President was more interested in protecting himself from political criticism for appearing to endorse the rationing of medical care.
But nothing is simple about the American health-care system, and the same is true about attempts to reform it. Sure enough, the Oregon story is more complicated than political cynics would suggest.
The Oregon system would have extended benefits to 120,000 more poor people. That was the good news. But there was plenty of bad news, too. For one thing, the extent of coverage to be provided each year would depend on the state's budget situation.
For the first year, the state would cover only the first 587 procedures on a list of 709. In other words, it would pay for fewer kinds of medical treatment but it would reach more people.
But given the fiscal crises in many states, it would be hopelessly naive to think that coverage could expand every year, allowing treatment for procedures further down the list.
Moreover, without a strong political constituency to protect the existing level of benefits, it would probably be optimistic to assume that all 587 procedures initially covered would make the cut in following years.
For those concerned with fairness, that was a major flaw in the plan. Rather than mounting a broad-based effort at health-care reform, Oregon limited its efforts to one group: Medicaid recipients.
Eligibility requirements restrict Medicaid almost entirely to poor women and young children, and these people have virtually no political power. And it wasn't encouraging that state legislators had specifically voted to exempt themselves and all state employees from the rationing plan.
Because of that action, critics could rightly question their commitment to making sure that Medicaid coverage didn't get cut in future years. Rationing health care is one thing, but rationing it only for other people -- people who are poor and, as in the case of infants or pregnant women, at a particularly vulnerable stage in their lives -- doesn't quite meet the moral expectations we like to set for ourselves.
Moreover, the method for ranking medical procedures was based not on objective evidence that certain treatments were more effective than others, but in part on public opinions about the costs and benefits of various procedures. That's not very scientific, as the Office of Technology Assessment pointed out in a critical report criticizing the plan.
It's true that the current patchwork health-care system produces its own form of inequities, and -- as Oregon officials rightly point out -- that doing nothing is its own form of injustice. But in rationing health-care resources, we must be careful not to do it only to those who don't have enough power to object.
For millions of Americans, health-care reform is literally a matter of life and death. Fortunately, the failure of the Oregon plan to pass federal muster is not the end of such efforts to provide health care to people who desperately need it. Other states -- Minnesota is one -- are already well on the way to implementing reforms that go far beyond Oregon's narrow focus on Medicaid.
In fact, that's the best way to counter a flawed plan: Produce a better one.
Send your comments and questions about death and dying to Sara Engram, Mortal Matters, The Evening Sun, P.O. Box 1377, Baltimore, Md. 21278.