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.
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).
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.