Does Oregon have the answer to rational rationing?

There is a serious cost problem in USA health care which no one denies.

Yet when it comes to suggested solutions, there is a wide divergence of opinion.  Attempts to use experts and evidence based guidelines for care are somehow viewed as government interfering with decisions which should be between the doctor and her patient.

States and insurance schemes have made varying attempts to deal with this.  The Oregon Health Plan is a good example of an attempt to match funding with needed care.  Unfortunately to date the need has far outstripped funding.  But Oregon had an interesting idea.

Why not bring physicians, consumers, advocates, interested groups and see where limited dollars should be spent – basically where can we get the best “bang for the buck” in a given population.  Long lists of preventable and treatable illness were made up and, in a transparent way, coverage was designed for best use of the dollars.  This is what I would call rational rationing.  We only have so much money for health care (currently up to 17% of GDP), it’s not infinite, and it’s already impinging out ability to funds schools, infrastructure, etc.

We are spending 50% more in health care services in the USA than other developed nations, yet our longevity and health outcomes are equivalent to Slovenia and Costa Rica, less developed nations.  About 35 million people in our country have no medical insurance.  It was suggested in political debates that they can go to any emergency room, but that of course is delayed and fragmented care which actually drives up costs.  I saw a 40 year old waitress in my office after she coughed up blood.  Her diagnosis was lung cancer.  There was no funding for radiation treatments or chemotherapy or even palliative care.  I felt so badly when I couldn’t effectively guide her care.

So it’s pretty obvious that we do ration care in the USA.  We do it by ability to pay, with a poor safety net for those unable to pay.  Several Presidents beginning with Theodore Roosevelt have tried to reform health care without success.  The current reforms, essentially modeled after those in Massachusetts promoted by then Governor Romney, are now under attack by none other than Romney himself.  Romney decries the attempts to control Medicare costs in the Affordable Health Care Act (now called Obamacare).

Here’s a thorough debate on the subject of end-of-life rationing.  A live audience is polled before and after to see which debating team “won.”

Jim deMaine is a pulmonary physician who blogs at End of Life – thoughts from an MD.

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  • Margalit Gur-Arie

    Does Oregon’s “interesting idea” apply to all Oregonians, or just to the poor, elderly and disabled?
    Rational rationing for the weak & vulnerable, by the rich & powerful, doesn’t strike me as an equitable solution.

    • PcpMD

      As “public health care” is essentially governmental charity for those who can’t provide for themselves, why is it surprising that it wouldn’t be as good as what you could buy on your own? Those with the means to pay more will always have access to better goods, and that’s perfectly alright (otherwise what’s the point of working hard to earn extra income?). If you can’t afford to eat, and someone gives you a cheeseburger, don’t grumble that it doesn’t come with fries.

      • Margalit Gur-Arie

        I think you know that this is a bit different than fries….

        I am not arguing that rich folks, whether they worked for it or otherwise endowed, shouldn’t be able to buy above and beyond amenities and niceties, compared to those who could be working as hard or harder, but had the bad luck of being born in the wrong zip code.

        It all comes to the definition of the “basic” package. I think it should include all but thrills and frills, and I don’t view this as charity, but as an obligation of an enlightened society.

        • Michael Chen

          That is what, I believe, the Oregon model is attempting to do (I live and practice medicine in Oregon, so I know the impact of “The Oregon Health Plan”, the previous incarnation of this change, the CCO change described above is the second stage of the first implementation in the 1990′s) . It’s clearly not perfect, but it is to define a set of basic set of services, “a prioritized list”, so that it is clear what services are covered for all Oregonians and what is fair and justifiable for situation where resources are finite (which it is, “rationing” is just a politicized term implying that resources “could” be infinite). Problem is, that this list only works on Oregonians who are on Medicaid. This leaves out those who are uninsured or underinsured who do fall under those guidelines. If this were to be applied to all instead of a few, we could see profound impacts on cost savings and possibly better outcomes from a public health perspective; but right now, we will never know because it is a partial implementation.

          • Margalit Gur-Arie

            Dr. Chen, what do you expect the overlap to be between the “basic package” mandated for the commercial exchanges, and the “prioritized list” provided to Medicaid members?

        • PcpMD

          Those in our society who feel “enlightened” to give to those with less should be free to do so – I complete agree! Forcing all productive members of society to give to those without, and then be prohibited from using any leftover money to buy better goods for ourselves…well, I think that was best summarized a long time ago. “From each according to his ability, to each according to his need” is a great populist slogan, and a lousy way to run a country.

          • Margalit Gur-Arie

            I don’t think anybody should be “prohibited” from using their wealth to buy whatever they wish to buy, and I don’t think that “productive” has a one to one relationship with wealth. For example Marine soldiers are rarely wealthy and sometimes homeless, but always more “productive” than most.

  • James deMaine

    Here’s the Oregon State’s web site which answers your question in detail:

    It is an attempt to reach the uninsured which wouldn’t include the elderly who have Medicare, but does include Medicaid, the uninsured poor including many children, and those rejected by insurance companies, etc.

    Here are their goals from the above link.
    “The workgroup agreed that:
    All citizens should have universal access to a basic level of care.
    Society is responsible for financing care for poor people.
    There must be a process to define a “basic” level of care.
    The process must be based on criteria that are publicly debated, reflect a
    consensus of social values, and consider the good of society as a whole.
    The health care delivery system must encourage use of services and procedures
    that are effective and appropriate, and discourage over-treatment.
    Health care is one important factor affecting health; funding for health care
    must be balanced with other programs that also affect health.
    Funding must be explicit and economically sustainable.
    There must be clear accountability for allocating resources and for the human
    consequences of funding decisions.”

    I would agree that the plan in not an ideal solution, and certainly not equitable since it allows the “rich and powerful” (plus those lucky enough to have Medicare, or a job with a good health plan) to have top-tier access to our medical-industrial complex which we call the “health care system”.

    But my point is that we still do ration by ability to pay are are the only modern developed economy in the world to use such irrational rationing. The Affordable Health Care Act remains in jeopardy and is far from perfect. But at least it may put us on a path that not only the “rich and powerful” have a fair system of access to care.

    • Margalit Gur-Arie

      Thanks for the response, Dr. deMaine. That paragraph you quoted, for some reason, makes me very uncomfortable with the Oregon philosophy. The fact that they devise a rationing system for the poor, which is transparent and based on a predefined process (conducted by the non-poor), does not alleviate the problem of rationing by ability to pay, because this is exactly what this is.

      The only difference being that rationing by ability to pay is now officially codified and dignified as a workable solution. This is not how things are done in other developed countries, unless that “basic” level of care is something along the Medicare FFS standards, and we know this is not the case.

      My concern is that the remedy Oregon is putting forward for this problem (funded by billions in federal taxpayer money), may very well be orders of magnitudes worse than the problem itself.

      • James deMaine

        I don’t think we disagree that the current system of rationing based on ability to pay is unfair and unethical. Oregon’s attempt is to have a “micro-fair” system in a “macro-unfair” system. This will likely be supplanted under the Affordable Heath Care Act so I’m not concerned that we will institutionalize the unfairness. Most admirable in the plan is the transparency and open process of deciding what’s covered.

        All modern economies except the USA have equitable health systems. When they do hear complaints, they basically say “let’s make sure we don’t end up like the USA”. In England and Canada their very popular health care systems (bashed by us) are clear up front about what’s covered or not. Private insurance or self-pay is still available for those with means (so it will never be totally equal access).

        The best explanation of what’s going on elsewhere is TR Reid’s book “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care.”

        • Margalit Gur-Arie

          I agree that we don’t disagree on the basics :-)
          What I find troublesome in Oregon and our Medicaid structure in general, is that unlike those other countries, we have a separate system for for the poor, with separate coverage rules and separate fee structures for services (and another one for the elderly). Separate but equal rarely works, and separate and hardly equal is by definition untenable. It will take much more than the ACA to fix this basic problem.

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