Oregon's Value Judgment

By Edwin M. Reingold/Salem

Virtually every state in the U.S. is struggling to find ways to seal up increasingly leaky health-care systems. Hawaii was one of the first to strive for universal coverage and now reaches 98% of its residents. Florida, New York, Michigan, Maine and Wisconsin subsidize health-insurance coverage for some of their poorest citizens. South Carolina sponsors house calls for pregnant women. Alabama uses its school clinics to provide prenatal care. Despite this kaleidoscope of experiments, no one state can claim to have solved all its problems.

The newest and broadest attempt to improve access and contain costs is taking place in Oregon. The state is asking the U.S. government to approve changes in Medicaid rules to provide a limited list of medical services to all people below the poverty level, regardless of their current Medicaid status. A companion law in Oregon's comprehensive health plan requires all employers to provide health insurance for full-time employees and obliges insurance companies to renew those policies without excluding individuals considered too risky. The state also guarantees that doctors and hospitals are reimbursed for their services but makes them justify their purchases of costly medical diagnostic equipment.

The centerpiece and most controversial feature of the plan is a list of 709 medical conditions and their treatments, ranked according to their seriousness and the likelihood that treatment will restore the patient to long-term good health. Actuaries estimate that state and federal Medicaid money will pay for treatment of everyone suffering from the first 587 conditions on the list.

In effect, Oregon is promising to provide universal coverage in exchange for a system of financial triage. A child will get a liver transplant; a chronic alcoholic will not. An AIDS sufferer will get treatment in the early stages of his illness but in the terminal stages will get only "comfort care." The plan would not pay for so-called heroic measures, such as expensive life | support for babies born after less than 23 weeks of gestation and weighing less than 500 g (1.1 lbs.). Nor will it pay for self-curing ailments -- now covered -- like the common cold, food poisoning, sprains and simple diaper rash. And, of course, the patient who needs spinal disc surgery, No. 588 on the list, may be out of luck.

Oregon's list is not without critics. The Washington-based Children's Defense Fund is actively lobbying against the Medicaid waiver needed to put the plan into effect. Says CDF director Sara Rosenbaum: "We don't understand why the state's poorest children have to give up literally life-and-death benefits for the sake of this social experiment."

But many Oregonians are in favor of it. The pecking order of conditions was arrived at with the help of marathon discussion sessions that were organized by Oregon Health Decisions, a public interest group, and held in each of the state's 36 counties. But agreement on values does not guarantee fiscal manageability. "We're all together on this, but for many different reasons," says Amy Klare of the Oregon AFL-CIO. "Business will fall off if the plan's too rich. We'll fall out if the plan's too weak." Ellen Pinney, executive director of the Oregon Health Action Campaign, wonders whether coverage will be maintained at the initial levels. "Over time," she contends, "the ability of the state to fund an adequate plan will be constrained."

State officials admit that some changes are certain to take place in 1993, when treatments for mental health and chemical dependency are added, as well as coverage for senior citizens and the disabled. Then somebody with condition No. 587 may no longer qualify. But if the plan works, virtually every Oregonian will be assured decent primary care, and that is a goal with which every community could live.