Oregon’s Plan for Universal Access to Health Care”” Will It Happen?
What I wrote in the November issue of the Oregon Health News is even more relevant today. The 2007 legislative session has the opportunity to enable average Oregonians to have access to affordable, quality health care. Universal access to health care for Oregonians is a legislative priority, yet the challenge will be””after finishing the various committee hearings””can Oregon’s political leaders agree on a workable solution for access to health care that is sustainable, reasonable, affordable, and acceptable to the majority of Oregon voters?
first step for all of us is to clearly understand the issue. Approximately 600,000 Oregonians are uninsured. Many of these uninsureds have access to medical care through Federally Qualified Health Centers and other private nonprofits. Yet, far too many Oregonians and illegal immigrants use hospital emergency rooms and ambulance EMT’s as their sources for primary health care. This leaves hospitals and fire districts with millions of dollars of unpaid emergency care costs every year. Such uncompensated medical costs are then transferred to Oregon taxpayers and to self-paying individuals and insurance companies. The result has been increasing consumption of tax revenues and family wages, increasing numbers of personal bankruptcies due to medical bills, and double digit increases in employer health insurance costs over the past decade. Add to those increases the sky-rocketing escalation in medical and pharmaceutical costs and decreasing reimbursement rates for medical providers, and we have a perfect storm that threatens to bankrupt our entire health care delivery system.
During the legislative interim several groups and legislators””especially Senators Alan Bates and Ben Westlund””have worked diligently to identify the causes of the health care crisis and components of potential solutions. Individually, I invested much of my time studying proposed solutions and reforms including those piloted by Maine, Massachusetts, Vermont, New Jersey, Wisconsin, New Mexico, New York City, and even Switzerland and New Zealand. Recently, California and Washington State announced broad health care reforms for their populations. As a result of the research, it is apparent that for successful Oregon health care reform bipartisan support from a strong coalition of stakeholders will be required.
We must also recognize the need to lessen the financial burdens on employers if they are going to remain competitive internationally. Oregon’s health access plan must also face the reality that we must stop the cost shifting that requires Oregonians who have health insurance to pay the freight for services provided to uninsured patients. This cost shift is breaking Oregon employers and families alike. It is a driving force in the double digit rate increases that are making the monthly cost of health care higher than the home mortgage payments for many Oregon families. All Oregonians need basic, portable health care coverage, and all of us must share in the costs for that health care””just like having car insurance.
The state can assist with tax and cost-containment incentives for individuals, families and small groups. Other components for successful reform must include a plan to address the causes of spiraling health care costs and a mechanism to coordinate with federal health care financing reforms. Stable funding must also be a key component. Finally, meaningful health care reform should consider end of life and cost versus outcome issues, as well as costs incurred by illegal immigrants and other ineligibles.
Nearly a third of the 2007 Legislative Session has elapsed, and I am concerned about whether or not the opportunity to craft a workable, statewide health plan will be lost. There is much discussion about establishing a board or other entity that will be assigned responsibility to design the new Oregon statewide health access plan. I do not agree with this approach. Oregon’s voters elected 60 Representatives and 30 Senators with instructions to go to Salem and work together to solve Oregon’s most challenging issues, such as the health care crisis. The legislative process requires working together in committees, sub-committees and work groups, listening to experts, asking questions, doing research, and, hopefully, reaching a consensus on and voting for the best possible solution. I believe the legislative approach should be used to resolve the issue of health care reform.
The citizens of Oregon did not elect some faceless entity whose political composition will be controlled by those who name its members. They elected us Legislators. Some will say the Legislature does not have the expertise to evaluate health plan alternatives for Oregon. If experience and training were the deciding factor, we would not have the constitutional duty to prepare Oregon’s multi-billion dollar budgets and make the many other decisions that affect every aspect of the lives of 3.6 million Oregonians. I believe the Legislature has the duty and the responsibility to accept the charge, get focused and start evaluating the health system alternatives and craft a system that will meet Oregon’s unique health, economic and political components.
Finding a health system that is Safe, Effective, Patient-centered, Timely, Efficient, Equitable, Transparent, Affordable, Sustainable and Acceptable to the citizens of Oregon requires a plan. The first step is to adopt a matrix or list of questions that can be applied to each health care system proposal. Such a matrix enables a structured way to compare and contrast the strengths and weaknesses of each alternative. With the help of CareOregon and the Institute of Medicine (IOM) the following is a proposed matrix for evaluating the candidates for Oregon’s statewide health care access for the 21st century. Next week we can start applying the matrix and working toward Oregon’s solution to our statewide health care crisis.
IOM “Principles for Evaluating Health Care Coverage”
It should be universal.
– Are individuals required to obtain coverage or are employers required to offer it?
– Who is eligible for which types of coverage?
– Who is not eligible for coverage?
– How easy or difficult is it for eligible people to enroll?
– What kinds of subsidies are available for lower-income individuals and families?
It should be continuous.
– Is re-enrollment required? If so, how frequently?
– Is the process streamlined?
– Can individuals continue the coverage if they change jobs?
– Can individuals continue the coverage if they have a change in income or circumstances?
– Can children who reach the cut-off age for coverage continue coverage?
– Can early retirees continue coverage?
It should be affordable to individuals and families.
– Are the premiums affordable for families and/or individuals?
– Do the co-payments and deductibles vary by criteria, i.e. family size or individual health status?
– Are criteria based subsidies available to individuals or families?
The health insurance strategy should be affordable and sustainable for society.
– Are the cost/coverage assumptions reasonable?
– Do all stakeholders contribute to the new system?
– Is there one group that bears a significant burden to support the coverage, i.e. employers?
– Is there a plan for a sustainable revenue/funding source (even during an economic downturn)?
– Will the current uninsured system funding and adjustments (like Disproportionate Share) be shifted to the new system?
– Are utilization control and cost-control mechanisms built into the new program?
– Is the benefit package designed to encourage the use of cost-effective services?
– Does the new program emphasize simplicity and administrative efficiency?
It should enhance the health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient centered and equitable.
– Does the benefit package include preventive, screening, mental health services, outpatient prescription drugs, hospital and outpatient medical care?
– Are there incentives for enrollees to fully use essential services, such as screening and preventive services?
– Are there incentives for enrollees to avoid overuse and inappropriate use of services?
– Are there incentives for providers to offer high-quality care consistent with medical guidelines and scientific evidence?
The information above is adapted from the IOM’s 2004 Uninsurance Checklist “Assessing Proposals for Major Health Insurance Reform, Principles for Eliminating Underinsurance”. The points are primarily focused on insurance reform.
Additional Oregon Focused Questions:
– Does the reform include a Primary Care Home?
– Is behavioral health integrated with physical health?
– Is there a provision for a shared, comprehensive information technology platform?
– Is Oregon’s Prioritized List (and procedure) used?
– Is this a patient-centered model?
– Does the model include dental and vision?
– Has the payment and/or reimbursement system been modified to provide incentives to promote healthy patients, not merely treating sick patients?
– Are public resources allocated in a way that maximizes the health benefit across the population?*
– Does the reform increase health as measured at a community level?
– Are decisions about the expenditure of public resources transparent?
– Are private insurance providers the primary source of coverage?
Does the plan address primary concerns of:
Taxpayers and voters?
Health care providers?
Insurance Industry Representatives?
Managed Care Organizations?
Federally Qualified Health Care and other safety net clinics?
from Drs. Kilo and Eby 2006, IHI conference