CHICAGO. LTC — Chicago -- This is what health-care rationing looks like -- a least in Oregon, where the nation's first open, deliberate rationing system is scheduled to start for Medicaid recipients this summer:
It's a list of 709 medical conditions, coupled with treatment, arranged in a rough and arbitrary order of priority. Between numbers 587 and 588, there's a cutoff line. Medicaid money will pay for the health services above the line, but not for all the rest.
The cutoff is open, public, the result of long debate, consensus building and legislation in Oregon. Like it or not, the plan could be a model for widespread rationing of health care elsewhere in the United States.
High priority on the Oregon list goes to preventive care -- prenatal services, immunizations, medical and surgical care for treatable cancers, mammograms, dental services. Also near the top are repair of deep, open wounds, appendectomy, treatment for burns and services that could prevent death, restore health or improve the quality of life.
Below the cutoff, too far down to be paid for, are treatment for infertility, restorative breast surgery, medical treatment for diaper rash, stripping of varicose veins, health services that may have uncertain or limited value. Newborn care will be covered; intensive neonatal treatment for extremely premature babies (23 weeks' gestation, 500 grams in weight) will not. Drug therapy for HIV infection goes above the line. But only comfort and hospice care -- not aggressive treatment -- are included for those in the last stages of AIDS or cancer.
This first, specific proposal to ration health care drew criticism in Washington last month when a draft of a report being prepared by the congressional Office of Technology Assessment was leaked. The document purportedly criticizes the Oregon plan for making subjective decisions in drawing up its priority list and for intending to deprive Medicaid recipients of some forms of care.
But that, of course, is what rationing really means.
Rationing is also what is implied in those health-care plans circulating around Washington that promise ''basic health care for everyone.'' But, unlike the Oregon planners, their promoters don't get around to explaining what won't be included in their ''basic'' care packages.
Oregon's Medicaid rationing plan, which can't go into effect until the Health Care Financing Administration grants the state a waiver, is the most controversial part of a major effort to provide ,, health care for all Oregon residents.
Cutting the health services that Medicaid will cover would save enough money to expand coverage to include all those below the federal poverty level, planners estimate. The state will add about 120,000 people to the 200,000 who already get Medicaid. It will also increase the Medicaid appropriation by $33 million.
The state has also established a medical insurance pool to help those unable to get coverage at reasonable cost from conventional sources. And a play-or-pay system is being set up that would require employers to provide health insurance for all employees who work more than 17.5 hours a week or be assessed a payroll tax to go into an insurance pool fund to provide for them.
Is rationing justified as part of this comprehensive plan?
Its Oregon supporters make a strong case that it is. Covert rationing exists now, they point out, because so many people below the federal poverty line don't get any Medicaid services and have no insurance coverage. Providing the most beneficial kinds of medical care to all of the poor is fairer and more socially useful than the current system of funding a full slate of services for some and nothing at all for others, backers argue.
Even so, it is worrisome that the cutoff line for health services is to be moved up or down every two years, depending on state tax revenues and other appropriations.
Oregon has developed an unusual, strong, public consensus supporting the plan. But most of its backers will not be directly affected by the rationing. It is a fair criticism that most of the price for expanding Medicaid coverage to the uninsured poor will be paid by the poor people who are now getting full Medicaid services.
What will happen when the Oregon plan is in operation and some patients are denied medical care because their illness falls below the cutoff line is uncertain. Media coverage, politically savvy protests and clever use of human-interest stories by opponents could undermine existing support.
But some form of rationing seems inevitable, as health-care costs continue to grow despite all other efforts at containment and the demand for high-priced technology seems insatiable.
The Oregon plan, at least, will let the nation see on a limited scale how open and deliberate rationing works out. It may be preferable to having 35 million people without health insurance. Or signing up for a national health-care system that will ration by long waits for care or other covert strategies. Or losing our national competitive edge because of the burden of rising health-benefit costs.
Or maybe the stark reality of rationing will be the incentive to find a better alternative than any that's been proposed so far.
2Joan Beck is a columnist for the Chicago Tribune.