Saturday, April 19, 2008

Oregon Health Care Reform & the Ethical Imperative to Contain Costs

Oregon is in the health policy & ethics spotlight again.

In the 1990s the Oregon Health Plan (OHP), with its (a) prioritized list, (b) unique honesty about the fact that US health care was and always will be rationed, (c) determination to ration on the basis of clinical evidence, and (d) an ethically justifiable framework of values, received worldwide attention.

OHP reduced the uninsured from 18% in 1992 to 10.7% in 1996, but a stretch of bad economic times resulted in a rise back to 16% at the end of 2006. In this context Oregon has launched a new health care reform process, embodied in Senate Bill 329, passed last spring. Senate Bill 329 extends Oregon’s explicitness about the ethical imperative to control health care costs. The preamble states:

Whereas Oregonians cannot achieve the objective of health unless the state invests not only in health care, but also in education, economic opportunity, housing, sustainable environmental stewardship…and other areas that are important contributing factors to health; and Whereas the escalating cost of health care is compromising the ability to invest in those other areas that contribute to the health of the population…Oregon cannot achieve its objective of health unless Oregonians control costs in the health care system.

On April 10-11, 100 leaders from the Oregon ethics community gathered at the Kinsman Conference, in Medford, Oregon, together with leaders of the Oregon Health Fund Board, which spearheads the health care reform process. I was honored with the opportunity to kick off the conference with a keynote talk and to participate in other ways during two days of hard work.

The conference deliberations have been summarized in a White Paper that identifies the key values underlying health care reform and pinpoints the major areas where ethical controversy may arise. Among the many conclusions, these four stand out:

1. Unlike Massachusetts, which postponed confronting the cost of its health care reform process for the first two years, the Kinsman group concluded that Oregon's effort "must meet its obligation to operate within reasonable financial boundaries, thereby preserving state resources for other public services." Focusing on the individual access without stewardship of shared resources at the same time would be ethically myopic.

2. Because stewardship of funds is a fundamental ethical requirement, "equitable distribution of resources requires acceptance of a finite global budget for health care services." The Kinsman group endorsed the use of a "prioritized list, based on the relative cost-benefit of the service."

3. The Kinsman group urged the Oregon Health Fund Board to promote "a balance between interests of self and those of society" in the reform process. Social justice values protect disadvantaged individuals by insisting on universal access. Market justice values protect efficiency by demanding value for money. The group concluded that success and sustainable reform requires "a sustainable balance between social justice and market justice."

4. Perhaps most boldly, the Kinsman group argued that compassion for those in need will require a shift in medical culture. "Current technology-dominated medical care is rewarded far out of proportion to its ability to improve population health outcomes. An explicit transfer of resources from medical care to public health will be necessary to accomplish [the goal of enhanced population health]."

As I was musing about how to end this posting, Leonard Cohen's haunting song - "Everybody Knows" - kept playing in my mind. I thought about the lyrics to see what the song was telling me:

"Everybody knows that the dice are loaded
Everybody rolls with their fingers crossed
Everybody knows that the war is over
Everybody knows the good guys lost
Everybody knows the fight was fixed
The poor stay poor, the rich get rich
That's how it goes
Everybody knows...

Everybody (almost) who thinks about the US health care "system" knows it is fatally broken. Oregon, more than any other state, has had the guts to say it like it is and take bold action in the health sector, as with the Oregon Health Plan prioritized list and the Death with Dignity Act. The Oregon Health Fund Board is on a tight schedule - its proposals to the Governor and Legislature are due in October/November. Let's hope that Oregon can act with the same boldness and moral clarity in 2008 that it applied in the 1990s. I'll be following its health care reform process through the eyes of the friends I made at the Kinsman Conference, and will have more to say about it in the months to come.


Anonymous said...

Jim, didn't know how else to reach you other than this comment forum. I wonder if you would provide a post about medical indigence, discharge medication and healthcare providers. I wrote a small piece today on my site posing the question. Would love to read your thoughts on this as this issue comes up almost daily in emergency department settings.


Jim Sabin said...

Hi Mike -

Thanks for this note. Your posting about EDs and the medication needs of indigent patients raises an important issue, and I will write about it in the next week or so. Ethical observations from the front line, like yours from the ED, provide important quality improvement feedback for the health system. I've added a link to your excellent blog.



Unknown said...

Very few people in the USA know that circumcising always cuts off and destroys forever a recently discovered, highly complex, highly vascularized, highly innervated human sense organ.

Oregon Drug Addiction

Jim Sabin said...

Hi Kate -

The topic of circumcision has been part of the health insurance debate over the years. In the past, some insurers questioned whether circumcision should be covered as a "medical" procedure. Then more recently there has been evidence that circumcision reduces HIV transmission. As you say, the perspective you've presented is a minority view, but health systems should be prepared to look at minority views in light of the available evidence.



george said...

This very important medical health care. The people are care with health.



Oregon Alcohol Addiction Treatment

Jim Sabin said...

Hi George

I see that your post comes from Oregon Alcohol Addiction Treatment, and Kate's, written a few days before yours, comes from Oregon Drug Addiction. I'm glad that two people involved in the important substance abuse sector are thinking about the organization and ethics of our health care system. Thanks for joining in!