Correspondence
The Oregon Health Plan
N Engl J Med 1998; 338:395-396February 5, 1998
- Article
To the Editor:
Bodenheimer's portrait of Oregon's Medicaid rationing scheme (Aug. 28 and Sept. 4 issues)1 uses dubious data to argue that the program has reduced the number of uninsured Oregonians and too blithely dismisses matters of ethical concern. The article cites Census Bureau data showing a fall in the proportion of the population that is uninsured from 14 percent to 12 percent between 1991 and 1995. The Oregon Health Plan did not begin operation until February 1, 1994. According to Census Bureau figures,2 Oregon's uninsurance rates for 1994, 1995, and 1996 were 13.1 percent, 12.5 percent, and 15.3 percent — none of which are significantly different from the 1993 rate of 14.7 percent, and which certainly show no downward trend. As in the rest of the nation, the expansion of Medicaid coverage in Oregon has apparently coincided with, even facilitated, a decrease in employer-paid coverage. Eight years after Governor John Kitzhaber's statement that rationing for the poor was the necessary first step toward universal coverage, rationing has arrived, and more people are uninsured.
The state-sponsored survey that found a dramatic drop in the proportion of uninsured people in Oregon echoes rosy surveys in Tennessee and Hawaii in which uninsurance rates of 5 percent and less than 4 percent, respectively, were claimed,3,4 less than half the Census Bureau's figures of 15.2 percent and 8.6 percent for these states.3 Single-state surveys — the usual source for state officials' sanguine claims — are not valid for between-state comparisons and are often plagued by methodologic errors.
The Oregon program rations care for the poor but asks no sacrifice of the powerful. The law's original provision requiring employers to cover their workers was quickly scuttled. Health care profits and chief executive officers' incomes escape scrutiny, and Oregon insurers and hospitals continue to waste hundreds of millions of dollars annually on useless paperwork. Indeed, the shift to Medicaid managed care undoubtedly boosted administrative overhead; overhead is typically three times as high in health maintenance organizations as in fee-for-service Medicaid. Meanwhile, prenatal care rates for Medicaid patients have fallen, and the rate of low birth weight has increased from 6.2 percent to 7.7 percent.5
Curiously, Bodenheimer seems to accept that painful trade-offs like Oregon's represent the only health policy option. Yet he and we have calculated that national health insurance could cover the uninsured and improve coverage for most others, without increasing costs.6 Strategies such as Oregon's that invoke unmet needs to justify cutting care for the vulnerable are politically convenient and ethically execrable.7
7 ReferencesDavid U. Himmelstein, M.D.
Steffie Woolhandler, M.D., M.P.H.
Cambridge Hospital, Cambridge, MA 021391
Bodenheimer T . The Oregon Health Plan -- lessons for the nation. N Engl J Med 1997;337:651-5, 720
Full Text | Web of Science | Medline2
Health insurance coverage: 1996. Washington, D.C.: Bureau of the Census, 1997.
3
Mirvis DM ,Chang CF ,Hall CJ ,Zaar GT ,Applegate WB . TennCare -- health system reform for Tennessee. JAMA 1995;274:1235-1241
CrossRef | Web of Science | Medline4
Lewin JC ,Sybinsky PA . Hawaii's employer mandate and its contribution to universal access. JAMA 1993;269:2538-2543
CrossRef | Web of Science | Medline5
Morrissey J. Oregon plan covering Medicaid patients is off to rough start. Modern Healthcare. September 4, 1995:90-2.
6
Grumbach K ,Bodenheimer T ,Himmelstein DU ,Woolhandler S . Liberal benefits, conservative spending: the Physicians for a National Health Program proposal. JAMA 1991;265:2549-2554
CrossRef | Web of Science | Medline7
Alexander L . Medical science under dictatorship. N Engl J Med 1949;241:39-47
Full Text | Web of Science | Medline
To the Editor:
Dr. Bodenheimer reported that in 1990 the American Academy of Pediatrics (AAP) opposed the Oregon Health Plan. After review at the Annual Chapter Forum meeting of the AAP leadership held earlier this month, we now support the plan.
The AAP is pleased with the way the plan has been implemented, its evenhanded treatment of low-income beneficiaries of all ages, the reasonableness of the Medicaid benefit package that emerged from the prioritization process, and the plan's success in reducing the number of uninsured children in Oregon. Given this evolution, the AAP state-chapter presidents voted overwhelmingly to withdraw our opposition to the plan. We would like your readers to be apprised of our current position.
Robert E. Hannemann, M.D.
American Academy of Pediatrics, Elk Grove Village, IL 60009-0927To the Editor:
Dr. Bodenheimer misses two of the Oregon Health Plan's essential lessons while demonstrating a less than balanced historical understanding of the plan's genesis.
The plan developed in conjunction with grass-roots action resulting from the 1982 statewide Health Coordinating Council's conference, “Society Must Decide.” In 1983, Oregon Health Decisions, a spinoff civic organization, took the issue of rationing to Oregonians with six months of community-outreach activities, including 300 grass-roots meetings with 5000 citizen-participants. The culminating Citizen's Health Care Parliament in 1984 defined the health values Oregonians wished to have used in rationing health care.1-4
At the behest of Oregon Health Decisions, then–Senate President Kitzhaber included a Health Services Commission in the legislation creating the Oregon Health Plan, with the power to meld the findings of the citizen parliament with respect to values with experts' testimony about the facts of health care delivery. The grass-roots effort of the Health Services Commission, noted in the article, was a mandated continuation of a standing grass-roots effort to establish consensus about the equitable allocation of scarce health care resources.
The two lessons for the nation that Dr. Bodenheimer fails to draw are these: successful legislation on health care allocation cannot exceed the understanding of the public, and citizens are capable of making complex policy judgments if properly assisted in arriving at their basic values.
4 ReferencesRalph Crawshaw, M.D.
2525 N.W. Lovejoy, Portland, OR 972101
Crawshaw R ,Garland MJ ,Hines B ,Lobitz C . Oregon Health Decisions -- an experiment in informed community consent. JAMA 1985;254:3213-3216
CrossRef | Web of Science | Medline2
Crawshaw R . `Society must decide' -- Oregon Health Decisions: biovaluation beyond bioethics. West J Med 1986;144:246-248
Medline3
Crawshaw R ,Garland M ,Hines B . Organ transplants -- a search for health policy at the state level. West J Med 1989;150:361-363
Medline4
Crawshaw R . Grass roots participation in health care reform. Ann Intern Med 1994;120:677-681
Web of Science | Medline
Author/Editor Response
Dr. Bodenheimer replies:
To the Editor: Drs. Himmelstein and Woolhandler are correct in pointing out that the real story behind the increase in national uninsurance rates is the decline in employment-based private insurance. Whether the uninsurance rate in Oregon has dropped or not, the fact remains that the number of uninsured Oregonians would be substantially higher had Oregon not expanded its Medicaid program in 1994. Will Medicaid expansions and the 1997 legislation to insure more children solve the nation's uninsurance problem? If the economic trend toward part-time jobs with no benefits continues, the newly insured will barely keep up with the newly uninsured. I agree with Drs. Himmelstein and Woolhandler that publicly financed universal health insurance, breaking the link between employment and health insurance, is the solution.
How about the matter of rationing care for the poor? Thus far, Oregon's benefit package has not rationed care in a meaningful way. In fact, as I argued in the article, the Medicaid benefit package has expanded under the Oregon Health Plan. This could change, and substantial rationing — only for the poor — could develop in Oregon. If this occurs, Oregon will be in violation of the ethical principle of social justice in health care. An important issue with regard to rationing, as Drs. Himmelstein and Woolhandler note, is the advent of compulsory Medicaid managed care, which is galloping across the nation and is dominated in most states (but not Oregon) by for-profit managed-care corporations.
Why single out Oregon as ethically suspect? The nation's entire social structure — with so many millions of low-income uninsured people receiving inadequate health care while profits and waste abound, and with the gap between rich and poor steadily growing — is an ethical nightmare.
Thomas Bodenheimer, M.D.
University of California at San Francisco School of Medicine, San Francisco, CA 94143
