Oregon Plan Shows Dangers of Political Priorities
Publication date: 06/01/2009
Publisher: The Heartland Institute
In becoming the first government health care program in the world to draw up a formal procedure for rationing care to consumers (see article on page 1), the Oregon Health Plan has significantly shifted priorities away from lifesaving measures, instead favoring politically popular ones.
After comment from interested parties, the state health program for low-income people ranked treatments for various diseases and conditions in order of priority. The health care dollars available determine which priorities are met, and as program costs have grown, the list of covered procedures has become shorter.
In 2009 the state will pay for only the first 503 procedures. It won’t pay to remove ear wax, treat vocal cord paralysis, or repair deformities of one’s upper body and limbs. It will fund therapy for conduct disorder (age 18 and under), selective mutism in childhood (a prolonged refusal to talk in social situations where talking is normal), pathological gambling, and mild depression and other mood disorders.
Reordering Priorities
Between 2002 and 2009 there was a fairly radical reordering of priorities. A great many lifesaving procedures that ranked high in 2002 have been relegated to much lower positions in 2009, while procedures only tangentially related to life and death have climbed to the top.
In 2002 there was far more emphasis on actual medical care and measurable interventions that save lives and improve individual functioning. Various interest groups have spent the past seven years reordering the political priorities embodied in the list.
For example, medical treatment for Type I diabetes, which ranked second in 2002, was demoted to 10th place in 2009, even though not providing treatment for it is a death sentence. And this is not an isolated case.
Routine, Preventive Care First
Now the rapid and complete treatment of medically correctable problems and diseases has taken a back seat to routine and preventive care. For instance, bariatric surgery for people with Type II diabetes and a 35 or greater Body Mass Index number is ranked 33rd, with the rationing board judging it more important than surgery to repair injured internal organs (88), closed hip fractures (89), and hernias indicating obstruction or strangulation (176).
Similarly, abortions now rank 41st, showing the state considers using public money for abortions more important than treating an ectopic pregnancy (43), gonococcal infections and other sexually transmitted diseases (56), and infections or hemorrhages resulting from miscarriage (68).
U.K. Lesson
The Oregon Health Services Commission’s Web site explains the 2009 list emphasizes preventive care and chronic disease management because these services are less expensive and often more effective than treatment later in the course of a disease. However, there is no evidence preventive care will reduce expenditures. Good evidence for the cost-effectiveness of disease management programs beyond those currently offered by physicians, individuals, insurers, and patient groups also remains elusive.
So what is driving the move away from procedures to save lives in immediate danger? Oregon’s list increases expenditures for politically popular care, meaning preventive care for the healthy and treatment of diseases with active political constituencies. This drift in rationing appears to be unavoidable when political processes are given control over medical decision making.
Britain’s National Health Service uses utilitarian analyses of cost effectiveness that often conflict with the “rule of rescue,” the presumption that saving a life in imminent danger is more important than improving the quality of life of someone who is not in immediate danger, or of saving hypothetical future lives through prevention efforts. In 2008 the rule of rescue was officially removed from any status in decisions about health care rationing.
The decisions in Oregon and Britain show the results of ceding health care rationing to political bodies.
Linda Gorman is a senior fellow with the Independence Institute. An earlier version of this article was published by the National Center for Policy Analysis. Reprinted with permission.
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Posted by Jeff Emanuel (Profile)
Friday, July 24th at 4:35PM EDT
13 Comments
If you haven’t, read Erick’s post about an Oregon public health plan (“public option”) administrator responding to a cancer patient’s request for subsidized chemotherapy with a denial of treatment but an offer to fund a physician-assisted suicide.
Now, know this: over the course of this decade, the state of Oregon has put in place a formal procedure for rationing care to patients whose health coverage is subsidized by government (i.e., who are enrolled in some form of the state’s “public option”). To date, they are the only government in the world to have formally done this, though many — from Britain to Canada to states here in the U.S. — work “cost-effectiveness” into their official denials of medical treatment.
After beginning the process of determining the cost-effectiveness (to the state) of hundreds of medical treatments and procedures in 2002, the Oregon Health Services Commission narrowed down the number they were willing to entertain offering coverage for to 680, ranked in order of state priority. This year — 2009 — the state will only reimburse physicians for performing procedures and offering treatments ranked in the top 503, in ascending order of priority.
Recipe for Denial of Care
WHAT THIS MEANS, of course, is that a patient enrolled in the “public option” who was in need of a treatment or procedure the commission decided to rank 503rd or below in priority would be ineligible for that procedure — period. Further, state bureaucrats balancing Oregon’s figurative checkbook could decide that the Beaver State only had enough health care dollars to fund some of the procedures on the list. This is where the prioritization comes in: under the state’s rationing procedure, a person in need of an emergency appendectomy (prioritized 84th by the the state of Oregon) would be denied that treatment before an individual in need of treatment for “tobacco dependence” (ranked 6th).
Does that sound a bit perverse to you? How about this: the state rationing board ranked abortion 41st overall in state-funding priority, meaning the bureaucrats who designed the priority structure in this “public option” program determined that the use of taxpayer funds for abortion is more important (and more medically necessary) than covering injuries to major blood vessels (ranked 86th), surgery to repair injured internal organs (88th), a “deep wound to the neck” or open fracture of the larynx or trachea (91st), or a ruptured aortic aneurysm (306th).
Also of note is the fact that treatment for esophogal, liver, and pancreatic cancers take up priority slots 337 through 339, with treatment for stroke at 340 — all over 300 places behind Obesity (8!), Depression (9), and Asthma (11).
That Pesky “Prolonging of Life Issue”
In the “Intent” section of the state’s rationing guidelines, the bureaucrats responsible for the prioritization and denial of care make clear their view on end-of-life treatment and treatment for the chronically ill. It is, in a nutshell, “make them comfortable, but do not extend lives” — because these bureaucrats have determined, apparently, that the state’s “public option” health care dollars need to be saved for use on the healthy (or the tobacco-addicted), rather than on those who desperately need them.
From the report:
It is the intent of the Commission that comfort/palliative care treatments for patients with an illness with <5% expected 5 year survival be a covered service. Comfort/palliative care includes the provision of services or items that give comfort to and/or relieve symptoms for such patients. There is no intent to limit comfort/palliative care services according to the expected length of life (e.g., six months) for such patients, except as specified by Oregon Administrative Rules.
That all sounds fine and dandy — until you get to the fine print (page 97 of the 143-page rationing guide), where what is and isn’t covered is listed. What is covered includes:
1) Medication for symptom control and/or pain relief;
2) In-home, day care services, and hospice services as defined by DMAP;
3) Medical equipment (such as wheelchairs or walkers) determined to be medically appropriate for completion of basic activities of daily living;
4) Medical supplies (such as bandages and catheters) determined to be medically appropriate for management of symptomatic complications or as required for symptom control; and
5) Services under ORS 127.800-127.897 (Oregon Death with Dignity Act), to include but not be limited to the attending physician visits, consulting physician confirmation, mental health evaluation and counseling, and prescription medications.
And, more importantly, what is not covered:
1) Chemotherapy or surgical interventions with the primary intent to prolong life or alter disease progression; and
2) Medical equipment or supplies which will not benefit the patient for a reasonable length of time.
“Reasonable length of time” is, of course, an arbitrary measure left entirely up to the bureaucrats counting the change in that year’s budget. In other words, if everybody in the state with all 503 conditions has been treated (in order of priority, of course) and there is money left over in the “public option” cookie jar, then a “reasonable length of time” that drugs or treatments would benefit a patient may be defined as a bit longer than it would be if there weren’t enough funds to go around for those whose illnesses and conditions qualify them for preferential treatment under the state’s official rationing policy.
Either way, folks’ health care — and, ultimately, length of life — is being left up to state bureaucrats.
Politics and Medicine Make Poor Bedfellows
State administrators say they chose to focus on “less costly” preventive care (whose money-saving bona fides are dubious at best) when devising the state’s rationing program, rather than on medical conditions and emergencies in hopes of saving more money in the long run. However, much like the often-ridiculous mandated coverages on state health insurance policies that serve to drive up health insurance costs across the country, the determination of what will be covered and where it falls in the priority list was heavily influenced by special interest groups that have the ear of state government officials and cost-effectiveness-regulating bureaucrats.
In other words, this politician-run medicine has fallen victim to…politics. As the Pacific Research Institute’s indispensable John Graham posted yesterday on Twitter, “the best way to keep politics out of medical decisions is to keep politicians out of medical decisions.”
Oregon residents like Randy Stroup are finding that out the hardest way possible. Despite the President’s persistent push to remake America’s health care system in Oregon’s image, we as a nation can’t afford to learn the same lesson as Oregon the hard way.
So under this scenario, writ nationwide, I’d not be given chemotherapy because multiple myeloma is deadly within five years.
I hate these people.