Sunday, May 25, 2008

Health Care Reform and Ethics in Oregon

Keep watching the Oregon health care reform process. I expect that Oregon will be teaching new lessons about health system policy and ethics very soon.

The Oregon Health Fund Board, which was appointed in the fall of 2007, will present a comprehensive reform plan to the Governor and legislative leaders in the fall of 2008, with the aim of legislative action in the 2009 session. The process couldn’t be more different from the Clinton reform effort – open all along the way, always with an eye on building political support.

The Committee developing the Essential Benefits Package has proposed a “basement level” package – a floor for universal coverage in Oregon. The guiding principles point in a more ethical direction than we are accustomed to. Here's what stands out for me:

1. “All parts of the body are treated equally.” This means that mental and dental services compete for coverage on equal footing with other physical health conditions, rather than being selectively disadvantaged.

2. Oregon will continue to use its famous prioritized list process to guide coverage. Paradoxically, the reason the state can end arbitrary exclusion of "mental and dental" is because it has the guts to set limits on coverage openly, in accord with its judgment of the value a service provides.

3. Oregonians describe the state as having two populations - a liberal, communitarian-minded group centered in the area between Portland and Eugene, and a highly individualistic-minded group from the more rural areas of the state. The reform plan draws on both sets of values. The focus on covering all Oregonians reflects the communitarian strain. The focus on asking individuals to take responsibility for themselves - through deductibles - reflects the frontier individualism strain.

4. While I haven't seen the details, the blending of communitarianism & individualism shows up in the approach to the deductible. Basic diagnostic services, comfort care, and effective interventions for costly conditions will not be subject to the deductible. But the further down the prioritized list a service falls, the higher the cost sharing will be.

Oregon has been cultivating a distinctive health care ethic of "tough love" for twenty years. Its determination to be explicit about rationing reflects toughness. The state doesn't pretend - as so much U.S. health policy does - that limits can be avoided. Its determination to cover all citizens and to emphasize comfort care reflects love.

Oregon has also been distinctive in the degree to which it has drawn Oregonians into deliberation about the health system. For twenty years it has asked citizens all around the state about their values for health care. I saw this process in action at the statewide conference on ethics and health care reform last month. Leaders from the Health Fund Board sat with ethicists, community physicians, and a range of ordinary citizens for two days, chewing over ideas for reform and the values connected to the reform process. There have been open meetings all around the state doing the same thing.

Bringing individualism and communitarianism together into an ethic of tough love hasn't been done by the professional ethics community. It has come from recurrent conversations at all levels of the population, orchestrated over many years. I may be a cockeyed optimist, but I think that in the next 12 - 24 months, the other forty nine states will be learning from Oregon again!