TCS Daily

The Pacific Northworst

By Sydney Smith - October 22, 2002 12:00 AM

In the field of healthcare, Oregon has a reputation for being on the cutting edge. When managed care became the rallying cry for healthcare reformers in the early 1990¹s, the state's Medicaid program, the Oregon Health Plan, was held up as an example to the rest of the nation of how managed care and prioritized coverage could contain healthcare costs.

Today, Oregon is once again at the vanguard of the healthcare reform movement. As rising health insurance premiums increase the ranks of the uninsured and force more financial responsibility on the average healthcare consumer, Oregonians are being asked to vote on a state-sponsored single-payer healthcare system. If passed, it will become the first universal health insurance program in the United States. It could also very well be the beginning of the end for Oregon.

Universal health care coverage has long been touted as a solution to the high cost of medicine. Health care, the argument goes, is a necessity. It would be as wrong to deny a sick person medical care as it is to deny the hungry bread. We live in a wealthy nation. That wealth should be put to good use for the good of all.

But, not all medical care is of equal necessity - nor is it of equal goodness - and that's where Oregon's plan is doomed. The plan on the ballot calls for the state to pay for all health care for all comers. Need those wrinkles ironed out? Oregon will pay! Want to go to the emergency room for that pesky cold because you just can't find the time to go to the doctor before nine o¹clock in the evening? Oregon will pay! Opponents and supporters alike estimate that the plan will cost the state up to $20 billion a year.

Ironically, this movement is coming at the same time that the state's much touted, and much more restrictive, Medicaid plan is facing financial challenges of its own. Last month the plan was in trouble. Federal disability laws restricted its ability to ration care, state legislators refused to increase funding to cover escalating costs, and the state's largest managed care company announced it would no longer participate because of poor reimbursement. The federal government saved the plan this month by expanding its share of the plan's funding and allowing the state to cut services even further. It's hard to fathom how Oregon could cover a universal health insurance plan when it can't finance a limited, basic plan for those most in need.

Proponents of the single-payer system say that in the long run the new plan will save money by eliminating the insurance companies and their attendant administrative overhead. To some extent this is true. Doctors who stop accepting insurance report that they have been able to cut their fees by as much as thirty to fifty percent.

But those savings, and others, are only seen when it's the patient who pays. When a third party pays, money that could be spent on healthcare is spent on paying the administration of the third party. When a third party pays, manpower has to be devoted to filing claims, pursuing payments, and proving the necessity of care. When a third party pays, there's no motivation on the part of patients or doctors to spend healthcare dollars wisely. Why use an older, generic drug when there's a new "cutting edge" drug available that improves outcomes by two percent? When a third party pays, the doctor-patient relationship is tainted by suspicion - suspicion on the part of the patient that the doctor is more interested in saving the third party money than providing appropriate care, and suspicion on the part of the doctor that the patient thinks this. Had a bad headache
for the past two days? Sure, we'll do that MRI if it will give you peace of mind (and make you less likely to sue on the remote chance that it isn't a tension headache after all.) When a third party pays, too often special interest groups and lobbyists mandate the standards of medical care rather than evidence based research. Just look at the current mammogram controversy. All recent evidence suggests that they do little to improve mortality, yet Congress and the Department of Health and Human Services have proclaimed them necessary and useful. Private insurance companies have taken that a step further. They use them as benchmarks to monitor the quality of care that doctors deliver. Order too few, and risk being labeled a "bad doctor."

The nuances of medical decisions can only be honestly acknowledged when the patient shoulders at least some portion of their financial burden. That's why the movement toward consumer driven healthcare is, ultimately, the better answer to our current healthcare crisis than a single payer system. There are, of course, some circumstances when patients have no choice in their treatment - emergency surgery or trauma care, for example. But few of us ever have to face those sorts of costs. A health insurance system that made patients responsible for run-of-the-mill medical costs and provided back up only for expenses that exceeded a predetermined dollar amount would be a far better use of resources, and in the long run, more affordable for everyone concerned. Just keep an eye on Oregon. Come November, they may prove to us how expensive a single-payer system can be.

The author is a family physician who has been in private practice since 1991. She is board certified by the American Board of Family Practice, and is a Fellow of the American Academy of Family Practice. She is the publisher of MedPundit.

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