Hawaii’s World

By A.A. Smyser

Tuesday, August 4, 1998

Oregon's health

HAWAII'S percentage of residents with no medical insurance has climbed to 9 percent from around 6 percent. More people are in part-time jobs not reached by our QUEST-Medicaid program.

Oregon's percentage of residents without medical insurance is down to 10.5 percent from 18 percent in the early 1990s. Thanks go mostly to its Oregon Health Plan, started in 1994.

Despite our lower percentage of uninsured, Oregon may be better helping its medically needy. Even Hawaii's state health director, Dr. Lawrence Miike, has a hunch Oregon gets more bang for its bucks.

The Oregon Health Plan, covering about 10 percent of the state's 3.2 million people and steadily widening its reach, steps boldly into the controversy over health-care rationing.

It emphasizes prevention and cure. It spurns treatments likely to be futile, such as end-of-life cancer or AIDs interventions. It encourages such patients to seek comfort care, including hospice attention.

It has prioritized 743 conditions for treatment and gives state funding only to the top 574. Money saved from probably futile treatments helps cover more people more effectively.

With this and some added funding from a 35-cent levy on each pack of cigarettes, Oregon is expanding mental health and dental coverage and reaching out to more child care. It continues a policy started in 1989 of accepting people of any income with medical conditions that are uninsurable elsewhere. It encourages managed-care health plan membership over fee-for-service plans but funds both.

The Economist magazine recently gave the Oregon plan a rave report, with especial kudos to Gov. John Kitzhaber, a former emergency room physician. Kitzhaber helped enact the plan when he was a leader in the state Senate. He fosters it now as governor.

The Economist's main gripe about Kitz-haber is that he is so laid-back he won't beat the drums to sell the Oregon plan to other states. He wouldn't even cancel an Alaska fishing trip to be home when President Clinton visited Oregon while seeking re-election in 1996.

The Economist noted: "When Dr. Kitzhaber first advanced his plan, journalists dubbed him Dr. Death. They ferreted out patients who would lose some type of high-tech care and made headlines out of them. Far-off politicians joined in. Al Gore, then a senator, called Oregon's proposed reforms an assault on 'fundamental fairness and decency.'

"These days, however," The Economist added, "both sides have fallen quiet....The critics' silence reflects the plan's evident success. Many of the non-essential services it cut turned out to be, well, non-essential. Now, because fewer people go uninsured the infant mortality rate has dropped and immunization for toddlers is improving...

"The health plan is so popular, in fact, that Oregon's Republican legislature has financed the scheme generously, despite deep budget cuts elsewhere." Kitzhaber is a Democrat.

Medicaid payments that used to go only to families at two-thirds or less of the federal poverty level now cover 100 percent. Plan help, sometimes with co-payments, can go in designated situations, even to families at 129 or 170 percent of the poverty level.

Overuse of the plan by college students has been stemmed by using a federal rule requiring that their parents also be low income. The plan recently agreed to cover doctor-assisted suicide, now legal in Oregon, as part of comfort care.

I got materials on it from Robert S. DiPrete, director of the Oregon Health Council. They are some of the most lucid government documents I have encountered.

Hawaii has young people who stay uninsured deliberately because they feel so healthy they don't want to make even a co-payment. Oregon probably does, too. But there is still work to be done in reaching the marginal groups, such as the underemployed, who would welcome being insured.

A.A. Smyser is the contributing editor
and former editor of the the Star-Bulletin
His column runs Tuesday and Thursday.

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