Setting health care priorities: Oregon's next steps.

Since the proposal was first broached in 1987, a storm of controversy has engulfed Oregon's plan to prioritize the health care services offered to its Medicaid recipients. After two years of debate, community consultation, and public opinion polls, the Oregon Health Services Commission was mandated in 1989 to study prioritization as part of a package of bills enacted as the Oregon Basic Health Services Act. In March 1990 the commission released a draft list of ranked health care services for public comment. Response nationwide was immediate and sustained, with proponents and critics hotly debating the virtues, or vices, of the proposed scheme for allocating scarce health care resources. As part of the ongoing debate, The Hastings Center and the Wesley Foundation sponsored a two-day meeting in January 1991 in Wichita, Kansas, to provide opportunity for thoughtful, in-depth, informal analysis of the OBHSA model for health care reform. In advance of the meeting, a document was circulated that outlined the three legislative bills constituting the Oregon Basic Health Services Act (see box p.3), the process of prioritization it initiated (box p.4), and a schema of the arguments that have been made by proponents and opponents of OBHSA. In brief, proponents' arguments for OBHSA include these claims: * The legislation substantially expands access to health care by creating virtually universal health insurance coverage in Oregon. * Unlike the process in nearly all other states, if funds are insufficient, low priority services are cut from Medicaid coverage, but eligibility for Medicaid is not cut. * A public process of prioritization of health services is created that focuses on clinical effectiveness and Oregonians' values. It will lead to a more stable and effective package of Medicaid services. * The prioritization process allows for the definition of basic health care and will reduce the provision of services that are medically ineffective and are not valued highly by the community. * OBHSA is a useful state experiment in health policy reform. Opponents' arguments include: * OBHSA rations health care for the poor and will have a disproportionately negative impact on poor women and children. * Prioritization is an inappropriate method for distributing health care. * Prioritizing health services and eliminating coverage for those with low priorities will distort the doctor-patient relationship and lead to poor care. * While the poor get less, Oregon's providers and taxpayers are benefitted. * There are better ways to expand access and cut costs. Each one of these arguments was presented in the advance document, objections to it developed, and rebuttals to those objections sketched. As a result, the Wichita meeting began with a common framework of arguments both for and against the OBHSA. Kitzhaber's Views The meeting opened with a presentation by Senator Kitzhaber, who claimed that critics of OBHSA had generally failed to place the legislation in its proper context. That proper context includes the status quo against which OBHSA was developed and the fact that these three bills are part of a process toward a larger goal. According to Senator Kitzhaber, the status quo is defined by five fundamental flaws in government health policy. First, too often health care is understood as an end in its instead of as a means to the end of health. Policy considerations are driven by the desire to extend access to health care with little attention to the outcomes of particular health care interventions. Indiscriminate demand for more health care services also means funding restrictions in other areas, including education and social programs. But spending in these areas can have a greater impact on health than health care itself. Thus reimbursement to acute care hospitals is an issue in health policy, for example, but efforts to keep teenagers in high school are not, in spite of the fact that the latter may have a more significant bearing on health status. …