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Six Months Along, Oregon Health Rationing Plan Working Out the Kinks With AM-Not the

July 30, 1994

Six Months Along, Oregon Health Rationing Plan Working Out the Kinks With AM-Not the President’s, Bjt

SALEM, Ore. (AP) _ Two years ago, Mark and Dyan King felt they had no choice but to live apart so Dyan could go on welfare and get Medicaid to pay for their year-old daughter’s heart surgery.

In Portland, Pauline Long had suffered for years with migraines and severe allergies because she couldn’t afford to see a doctor on her $350-a-month apartment manager’s pay.

Sandra Spiegel went without treatment for high blood pressure and bad back problems, pre-existing conditions that private insurers told her would cost $300 a month for coverage. ″That was more than I earned″ in a part-time job, Spiegel recalled.

Today, Spiegel, Long and the Kings are among 81,000 ″working poor″ who have signed up for their first medical insurance, six months into an experiment known as the Oregon Health Plan. That’s well above the 60,000 people who were expected to enroll by this point.

″What that says to me is how critical not having health coverage is for so many people,″ said Jean Thorne, Oregon’s director of Medicaid. ″We are dealing with people who have been really desperate.″

The plan is still working out some kinks: The extra enrollees are jamming paperwork channels and crowding some clinics; some dentists are balking, saying the state’s reimbursement for their services is too low; and there has been some minor erosion of the plan’s famous rationing line for Medicaid recipients.

That line is drawn under No. 565 on a prioritized list of 696 medical conditions and treatments. By paying only for treatments above the line, Oregon stretched its existing health care dollar. By increasing the cigarette tax by 10 cents a pack, the state could afford to qualify more people for Medicaid. The combination will eventually allow Oregon to extend health care to 120,000 previously uninsured people.

Amid the dissonance over national health care reform and how to pay for it, many in government and medicine have applauded the Oregon plan as a realistic way to provide basic coverage to more people at a time of soaring costs.

While the Clinton administration generally approves of Oregon’s innovations, it doesn’t embrace rationing.

″The Oregon plan is one approach, but it doesn’t seem to me to speak directly enough to the core issues of cost containment,″ said Bruce Vladeck, head of the U.S. Health Care Financing Administration.

For herself, Mrs. King has no doubts. ″It’s like a cloud lifting. It’s the scariest thing in the world not to have health care for your kids,″ she said.

The Kings were separated for more than a year, Mrs. King staying in Salem with Kaitlyn, now 3 1/2 years old, and her husband moving in with his parents in Portland. Mrs. King says she later learned she could have qualified for Medicaid through less drastic measures, but going on welfare seemed the only option at the time.

″When you have children with medical problems, and no insurance, it sends you into a tailspin,″ she said.

The cutoff line continues to make many people uneasy, although major diseases and preventive services are generally covered. Not covered are cosmetic surgeries, high-priced, heroic treatments for terminal ailments, and remedies for conditions that get better on their own, such as head colds.

The sanctity of the line, and thus the feasibility of the rationing system, was challenged in April when two boys’ hernia operations were approved for coverage. Such surgery was initially listed below the cutoff, with health officials reasoning that hernias were generally not life threatening and many people with hernias never need surgery.

Both boys’ parents appealed to their state senators, and Oregon ultimately agreed to pay. State officials say political pressure had nothing to do with the decision, which they say was based solely on medical evidence from surgeons that untreated hernias could cause long-term complications, especially in children.

Thorne dismissed concern that these isolated cases would encourage appeals from other patients who want the state to pay for treatments below the cutoff line. ″Any change in the priority list will have to be medically supportable from a broad view, not from an individual view,″ she said.

Not so surprisingly, the still-green Oregon health plan is a featured player in this year’s governor’s race.

The Democratic candidate, John Kitzhaber, a former emergency room doctor and ex-state senator, wrote the health plan and took part in the effort to gain federal approval.

The Republican candidate, former congressman Denny Smith, is campaigning against the health plan. Smith says Oregon can’t afford the Medicaid expansion and predicts the state is doomed to become ″a destination resort for people looking for health care.″

State officials say there’s no indication people are moving to Oregon just for its health plan. Thorne says just 2.5 percent of those enrolled in the program have lived in Oregon less than three months. ″That doesn’t sound unusual to me,″ she said. ″That’s just probably normal migration of people into Oregon.″

Kitzhaber says his emergency room experience convinced him the state needed to increase the number of people eligible for Medicaid health coverage so they would seek earlier, preventive care. The way to do that was to restrict the range of treatment they could receive and permit more people to get that basic package.

″We’re now providing basic health care services to tens of thousands of Oregonians who had no coverage six months ago,″ Kitzhaber said. ″We’ve demonstrated that you can successfully prioritize medical services.″

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