Talk of the Town
It's time to walk people through the choices they have to make in order to get health care that works for everyone.
More than a decade ago, when Oregon wanted to edge closer to universal health care coverage, the state held a series of town meetings. All the stakeholders--citizens, health care providers, insurers, legislators--met at forums around the state to talk about priorities. The idea was to produce a consensus around health care reform. Oregon residents were asked to weigh in on the state effort to expand the base of Medicaid recipients. The state would do so by limiting coverage for beneficiaries but wanted Oregonians to decide where to draw the line. Intensive care in case of a heart attack? That was a top priority. Surgery for a backache? Much lower on the list.
Critics called Oregon's slimmed-down benefits package a case of rationing. To which John Kitzhaber, who was a state legislator at the time and an emergency room physician by training, answered that yes, it was rationing, but so was the present system that rationed not by service but by personal income. Kitzhaber, who went on to become governor of the state, argued that it was better to make the choices clear, to use analysis to set a menu of covered services and to involve the community in making those choices.
My purpose in recapping Oregon's experiment in health care consensus is to give you some context for a new proposal: At a briefing in November sponsored by Health Affairs, Ron Wyden, a U.S. Senator from Oregon, talked about how he wants national town meetings--online, in person and in any other feasible forum--to discuss the key issues that need to be resolved en route to coming to consensus on national health care reform.
"Reaching consensus" is a phrase that makes the pragmatist in me cringe, but maybe Wyden is onto something. Health care reform is so economically and politically charged--so deep in red ink for businesses and so riven by nasty partisanship in the U.S. Congress today--that maybe it would be a good idea to step back and educate citizens about what's at stake and how complicated the issues are. As Wyden put it, it's time to "take health care reform outside of Washington and walk people through the choices you have to make to get health care that works for everybody."
His view, with which many others concur, is that the country is spending enough on health care--$1.8 trillion a year or $25,000 for every family of four--but that spending is not necessarily in the right places, and there are going to be tough calls ahead on how to reallocate it.
Wyden then ticked off the big questions he thought these forums should deal with:
--What's a decent package of benefits? (That's the issue Oregon's citizens were able to reach consensus on.)
--How do you pay for it? (Oregon was markedly less successful here; when the state went into recession and money was tight, the program was abandoned and the broadened Medicaid base was narrowed.)
--Do we want to emphasize preventive services over the acute-care orientation we now have? (It might mean giving up some interventions we take for granted.)
--What do we do about end-of-life care? (Wyden said that physicians tell him that existing care is expensive, ineffective and does little to improve patients' quality of life.)
Wyden is far from alone in pressing for genuine health care reform. Allies are beginning to line up, starting with big businesses, such as General Motors, that complain that health care premiums are raising the costs of their products and making them less competitive in world markets. Then there are everyday people who cling to jobs out of fear of losing coverage and the uninsured who live in fear of becoming ill. A Kaiser Family Foundation survey this summer found Americans ranked health care as the second most important problem for the government to address--right behind war and foreign policy issues but ahead of the economy, terrorism, taxes and crime.
And then there's Kitzhaber. He may no longer hold public office (although he's weighing another run for governor), but he's clearly back in the public eye in Oregon on health care reform. He wants his state to add up all the public money available to its citizens and businesses for health care (that would include Medicare and Medicaid as well as tax subsidies for employer-provided health care) and redirect that money--$6.3 billion or $1,800 per person. Naturally, he'd want the good people of Oregon to reach consensus on the best way to reallocate the money so that everyone gets basic coverage.
With some prodding from Oregon's senator and former governor, we may yet find a way to knock some sense into our national health care system.