SALEM, Ore. — Whose pain to ease? What sickness to treat? At how high a cost? For how long?
And, yes: Whose sickness not to treat? What pain must be endured?
In annual budget debates over dollars and cents, God-like health care questions like these seldom are raised.
But the state of Oregon, amid both great promise and grave doubt, stepped forward this weekend and put the finishing touches on a proposal that presumes to turn American health care on its ear and rewrite the basics of the "safety net" health care system for the poor, both those who work and those who cannot.
The philosophy of the Oregon plan is that if government is willing to decide which medical treatment is worthwhile--which is most effective for the most people, and which is or which is not too costly--then hundreds of thousands more citizens can be offered more reliable basic coverage, both through government Medicaid and private-employer insurance plans, without breaking the budget.
In other words, ration the treatment available, and make sure everyone is eligible to receive it, even if it means taking the controversial step of cutting off payment for some treatments.
"Most Americans believe that everyone should have access to health care and Congress has toyed for nearly half a century with the idea. Yet today, the number of Americans without coverage continues to grow. In Oregon, we've created an approach that provides coverage for everyone and we've reached the political consensus necessary to make it happen," says John Kitzhaber. He is president of the state Senate, an emergency room physician and the father of the Oregon health care revolution.
After four years of preparing its plan, a process remarkable for the consensus it brought, Oregon took the fateful step Saturday night of "drawing the line" and declaring exactly which treatments it could afford to cover from a priority list of 709 procedures.
In a legislative vote to increase Medicaid spending 10%, the line was drawn at No. 587. Every treatment above that line would be covered for all people in poverty, through the Medicaid program, and private employers would be required to provide coverage for those same treatments for their workers.
Everything below that line, beginning with surgery for a slipped disk, No. 588, the state would not cover and employers need not either, although they could if they wished.
Everyone would be entitled to visit a doctor for a diagnosis. After that, though, medical treatments with limited effectiveness would not be reimbursed in order to save money to cover treatable diseases for those who now are uninsured.
For instance, terminal cancer or end-stage AIDS patients without private insurance would be given comfort care but nothing more. Ditto for medical treatments for the common cold, or surgical repair of uncomplicated hemorrhoids, or heroic costly hospital campaigns to save the lives of premature babies born weighing less than 17.5 ounces and younger than 23 weeks in gestation.
"What we're excluding on the list are basically those things that will get better on their own or with home remedies and those things that are not likely to get better at all," says Cynthia Griffin, spokeswoman on the issue for the Legislature, the governor and Oregon's Health Care Commission.
The result, champions of the plan say, is that nearly all of the 450,000 uninsured Oregonians, nearly one-fifth of the state's population, will be eligible for basic health care coverage. Perhaps another 200,000 or so underinsured residents will be eligible for better coverage.
Right now, Medicaid eligibility is tightly drawn to cover primarily mothers and children in deep poverty. And private employers are not required to provide health insurance.
Under the new Oregon plan, basic coverage--the floor for everyone--also would be expanded to include some treatments not always associated with Medicaid and certainly not with indigent care--such as mammograms, dental visits and some other preventive services such as physicals. Additionally, the poor will be relieved of having to hunt for a doctor. The plan promises to assign each Oregonian a doctor or a group.
Well, actually, not yet.
Because Oregon wants to go its own way with a program partly financed by federal tax dollars, it needs waivers of federal Medicaid rules. And that means the debate is not over but that it merely advances to the Bush Administration and to the halls of Congress.
With broad support in the state Legislature and backed by Gov. Barbara Roberts, the plan also has slowly won over Oregon's large employers and some of its New Age health care thinkers.
"We set out to ask Oregonians about their values on health care. . . . It turned out they valued quality of life more than length of life," says Ian Timm of the group called Oregon Health Decisions, which views itself as the equivalent of a League of Women Voters on medical care issues. It conducted two rounds of community meetings that were influential in shaping the Oregon plan.