And we’re not alone. No health system anywhere gives its citizens quality care that’s both universal and unlimited, says medical ethicist Daniel Callahan, director of the Hastings Center in Briarcliff Manor, N.Y. Even Canada restricts access, with long waiting lists for procedures that Americans want right now. So the challenge for this decade is to ditch the dream of easy, comprehensive access to care. Instead, we should work on an inclusive system with limits that everyone can live with. So far, only Oregon has seized this issue by the throat. But an unexpected objection by the federal government-charging the state with violating the 1990 Americans With Disabilities Act-is raising tough questions about how health-care reform will work.
Oregon has fashioned the country’s first overt rationing system. After broad deliberations among citizens and medical groups, it drew up a list of 709 medical services, ranked from highest to lowest priority. High-priority services range from treatments to prevent death in patients able to recover (appendectomy, medications for heart disease) to everyday preventive care (mammograms, blood-pressure screening). Low on the list are conditions that get better by themselves (head colds, mononucleosis) and conditions where treatment is generally futile (certain severe brain injuries, end-stage cancer).
This priority list, if it takes effect, will first be used to restructure Oregon’s Medicaid plan. At present, two thirds of the state’s poor receive a broad range of medical treatment. The other third gets nothing at all. No form of rationing could be more cruel, because it puts your life at risk. A study last year by Jack Hadley of the Georgetown University School of Medicine showed that uninsured patients arrived at the hospital sicker than those with health insurance, and died in the hospital more frequently.
The new plan will cover all Oregonians at or under the poverty line-but not for all 709 services. Patients will be eligible for as many treatments as the legislature decides to pay for. In the first year, the budget funds all the ranked services down through No. 587 (the 588th is low-back pain, of the sort you get from a muscle strain). Patients already on the Medicaid rolls may regret the loss of those lower-ranked treatments. But thanks to all of the money saved (plus an extra $30 million from the state), 120,000 uninsured people will finally be admitted to care.
Oregon’s list might pose ethical problems if it covered only the poor. But it will apply to others as well. A new state health plan, now in the works for small business, mirrors the benefits Medicaid gives. Ditto the basic benefits package, which all of Oregon’s employers will have to offer no later than 1995. So everything is tied together. If the legislature cuts back on Medicaid, mainstream coverage may slip, too.
But just when Oregon thought it had finally gotten everyone together, the federal government dropped its bomb. Health-care reformers, who had barely heard of the Americans With Disabilities Act, are now devouring its fine print, to see what the law will allow them to do.
It’s apparently OK for a state to set health-care priorities, as long as both “abled” and disabled get equal treatment, says Michael Astrue, general counsel of the U.S. Department of Health and Human Services. It’s also OK to ration treatment based on medical effectiveness. Where Oregon went wrong was to run a survey on what constitutes a good “quality of life.” Nowadays, those are fighting words. Fully functional people may be biased against, say, the quality of wheelchair life. If even a hint of such a judgment infects a health-insurance plan, its provisions may now be fatally flawed. That’s chiefly what nailed the Oregon proposal, although Astrue can’t name any service left unfunded because of bias against the disabled.
Critics charge that the ADA objection has a purely political purpose. The Bush administration, they say, might be loath to endorse any plan for universal care-at the very moment when the president is beating up on Clinton’s version. But to the Consortium for Citizens With Disabilities (CCD), this is a first shot across the bow. “Everyone should have access to medically necessary services,” says CCD leader Bob Griss, still pursuing the dream of virtually unlimited, universal care. “This gives us a basis for questioning all discrimination in coverage,” he says. But when plans like Oregon’s are challenged, the uninsured (including the disabled uninsured) are left to rot.
The ADA defines “disability” broadly. No bias is permitted against those who are physically or mentally impaired (including alcoholics and drug addicts), those with a past record of impairment and those “regarded as” being impaired, whether they are or are not (this protects a fully functional person infected with HIV). What all these words mean will be settled in court. Even from here, I can hear the lawyers counting their contingency fees.
The potential for lawsuits has shaken up the health-care cost-containment community, says Trish Riley, head of the National Academy for State Health Policy in Portland, Maine. Might HMOs fall afoul of the new law because they limit certain treatments? How about insurance plans that don’t cover mental health or substance abuse? Do organ transplants have to be paid for? Every universal-care proposal includes a basic benefits package. What has to be covered to make those plans legal, and what will it cost?
Oregon, bowing to government objections, will cleanse its landmark rationing plan of any judgments on quality of life, says Paige Sipes-Metzler, head ofthe state’s Health Services Commission. Then we’ll see how Americans really feel about universal but limited care. Paul Ellwood, president of InterStudy and one of the fathers of cost containment, says it’s absurd to think that overt rationing will ever be accepted here. Still, for health reform, the country has to trust in a working system of cost controls. Setting health-me priorities might be one of the ways to get there.
