Sunday, September 7, 2008

Oregon Moves Ahead with Health Care Reform

On September 3 the Oregon Health Fund Board (OHFB) posted a draft of its health care reform proposal - "Aim High: Building a Healthy Oregon." The OHFB will receive comments at a series of public meetings around the state and through written submissions during the month. It will then revise the draft into a final report to Governor Kulongoski and the legislature.

I won't try to summarize the very readable 78 page report. But if the legislature enacts the major recommendations, Oregon will again be in the forefront of health policy and health care reform.

Here are five of my initial observations about the proposal:

1. The proposal is ambitious, and recognizes that tinkering with the current system will accomplish nothing. Although it is replete with practical action steps, the proposal envisions "educative leadership" as a crucial necessity -"Your Board, on behalf of all Oregonians, believes that in order to address [the failings of the current system], we must transform our thinking about health care." In former governor John Kitzhaber, Oregon has a model of what "educative leadership" can mean.

2. The central paradigm in current U.S. health policy is competition and consumerism. Our thinking about health care is atomistic, focused on individuals making choices about treatment and benefit plans, with providers competing with each other to sell themselves. The Oregon proposal focuses on improving the health of the entire population, and emphasizes collaboration more than competition, as in its concept of "learning collaboratives":
Sharing by those doing the delivery of care with each other is a key tool to improve the delivery of care. Improvement efforts are at the core of collaborating with those doing similar types of work to understand how to look at systems of clinical settings and improve the quality and efficiency of each step...Learning collaboratives allow healthcare providers and their clinical staffs to share information about quality improvement and best practices."
3. The proposal retains private insurance, but it envisions a strong role for state government, largely through its proposal for an Oregon Health Authority. The overarching strategy for the Authority " for the state - in partnership with communities - to act as a smart purchaser, an integrator of health care and community services, and an instigator of community-based innovation." Whereas Medicare Part D forbids Medicare from using its purchasing power to bargain over prices, the Oregon proposal would have the Oregon Health Plan (Medicaid) and the public employees plan, which together would represent 1,000,000 people, more than 1/4 of the state population, use the leverage prohibited to Medicare.

4. Oregon received world-wide attention for its use of a prioritized list of health services to conduct an open, explicit rationing process. The proposal envisions using the prioritized list, but rather than bifurcating its benefits into covered/uncovered, it would institute a system of value based benefit design. Services that provide substantial benefit would be covered in full. Services less well supported by evidence or more optional in nature, would require progressively more cost sharing. All this would be put onto a graded basis in accord with individual income level.

5. The states are clearly where the current action is in U.S. health policy. States are learning from each other. Massachusetts, Minnesota, Vermont and other states figure prominently in the rationale for the Oregon proposal. My impression is that the systematic dissing of government that has dominated the national scene since the start of the Reagan presidency has less force at the level of state government. In particular, the ethical imperative to get a grip on health care costs appears to be more discussable within states. State governments are required to balance their budgets, making the fantasy that only greedy insurance "bean counters" care about cost harder to sustain in state-level discussions.

I hope that we will be able to welcome Oregon back into its earlier leadership role in health policy as the current reform process proceeds!