The Oregon StoryWhat Happened in Oregon?Oregon Health DecisionsOregon Health Decisions-- IIOregon Medicaid RationingMedicaid in Other 49 StatesMedicaid in OregonArgument for InequalityHow to Decide?How to Decide?-- IIHow to Decide?-- IIISlide 12Moral ClaimAssess the overall level of justice or injustice represented by the Oregon Medicaid rationing plan.Menzel’s ArgumentMenzel’s Argument-- IIMenzel’s Argument-- IIIMenzel’s Argument-- IVThe Oregon StoryHealth Care Rationing: A Case StudyWhat Happened in Oregon?A process: Oregon Health DecisionsA specific policy outcome: Medicaid rationing programOregon Health DecisionsInaugurated in late 1970’s“Town meetings” to discuss health care prioritiesStatewide assembly with representatives from town meetings to draft state health care “constitution”Statements of desired health care prioritiesOregon Health Decisions-- IILed to highly educated voters who understood health issuesLed to elected officials not afraid to say the “R-word”Oregon Medicaid RationingBegun in 1980’s but could not get Federal waiver to implement until 1993“Ration care not people”Medicaid in Other 49 States“Poorest poor”-- all care coveredOther poor--no carecoveredMedicaid in OregonAll poor covered by programNot allcareis coveredby programArgument for InequalityIdeally would ration care for all citizens of Oregon under uniform statewide planHowever current reality is that only Medicaid program is under state controlMakes sense to improve the justice of Medicaid by covering all poor citizens, even if system as a whole is not perfectly justHow to Decide?Developed list of about 700 disease/treatment pairsIntravenous antibiotics for bacterial pneumoniaSurgery for coronary heart diseaseLiver transplant for end-stage cirrhosisetc.How to Decide?-- IIComplex multi-stage process of rank-ordering pairs based on:Likelihood of benefitCostFrequency of problemValue judgments on resulting quality of lifeHow to Decide?-- IIIRank-ordered list sent to legislatureLegislature could appropriate money for Medicaid but could not change ranking of itemsAmount of money appropriated would set a cut-off point, below which care would not be funded by Medicaid572573574575576577578579580581CoveredNot coveredMoral ClaimOregon Medicaid covers all poor peopleOregon Medicaid covers a reasonable package of care which includes the most effective and the most costworthy treatments for the most common health problemsSome pressure placed on state to improve overall Medicaid fundingAssess the overall level of justice or injustice represented by the Oregon Medicaid rationing plan.Menzel’s Argument The fact that the program rations care for the poor but not for the rich does not by itself make the plan unethicalArguments for egalitarianism in medical spending are weakPoor would rationally choose to spend less of their limited resources on healthMenzel’s Argument-- IIHypothetical Case:Rationing for all OregoniansPlan funds treatments up to #578Insurance rider can be purchased which covers treatments #579 and upCost of rider:•To rich-- $1000 annually•To poor-- $200 annuallyMenzel’s Argument-- IIIRich person probably has $1000 left over after paying for all necessities of life; may readily decide to buy riderPoor person may still lack some basic necessities of life and would prefer to spend $200 on some of them, not on riderIf so, not unfair to poor to deny them treatments #579 and higherMenzel’s Argument-- IVEven if ethics does not demand egalitarian spending for rich and poor, it does demand fair representationOregon plan may be flawed if poor were under-represented when key decisions