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C O L L A B O R A T I V E C A S E M A N A G E M E N T
continued on page 4
What is the correct balance? Is there a fiscally sustainable yetempathetic solution? In forming an opinion on this issue, what
elements – both conceptual and historical – must be considered?
his article examines the issue in its most current form – the debatesurrounding a system of universal health care in the United States –and reviews early attempts by some states to develop such a system.
CAN THEORY HELP?
Allocation of health care services is a form of distributive justice,and most advocates for universal coverage believe receiving healthcare s an ssue o ustce. Invuas nee access to quaty eat
care, and a just government would
distribute the resources necessary toever eat care to ts ctzens n aair manner. Affordable healthinsurance is often looked to as thevehicle to allow fair access toservices, so that the cost is covered.he details of how to finance theinsurance create tensions for policy akers. Who pays the cost, and for
how much universal insurance? What are the services to be provided?
Who decides the payment schedule,and for which individuals? Who
decides which services should be
rove? Tese questons an many
others have to be answered in order
o develop a system of allocation.Wen evauatng poces orallocating health care resources, multiple goals come into conflict:excellence of care, equality of care, efficiency of care and the freedomof choice for both patient and health care provider. As a society, wehave not prioritized these goals, and attempts at prioritization havecaused further conflict and yielded minimal progress toward theoverarching goal of health care.
1
Without agreed-upon priorities,
olicy development will not have a clear direction.On the surface, healthcare in the United States appears to operateas a free-market system – with the unique distinction that in mostcases a party other than the one consuming the services is paying forhe services. This creates distorted relationships between providers,atients, and payers. Patients and payers pay significantly differentrces or te same servces evere y te same prover, an teserices paid or reimbursed may be very different than the provider’sactual cost of delivering care. Furthermore, the actual market pricesfor health care services remain expensive, and unaffordable for asignificant portion of the population.The customary guideline for resource allocation is the general ruleof
ormal procedural justice
which seeks to treat “Likes” alike and“Unlikes” differently. Principles of formal justice suggest giving toindividuals according to a characteristic that can be quantified. Thequantae caracterstcs usuay rase n scusson o eat careare: need, demonstrated effort, equal share, contribution, and merit.However, there are problems with using each of these as defining crterons. I eat care s gven accorng to
nee
tere may e vastdifferences in the amount and type of health care any person needs. Oneperson may nsst tat a pastcsurgery is needed while anotherperson will insist the surgery is notecessary. If health care is given
according to
ffort
there will be lively discussion and potentially irresolvable issues of how hard aperson is working (for example, tostay in shape or manage chronic
conditions) in contrast to how hard
he/she ought to be working. If each
person is accorded an
qual
share –each person receiving the same
aocaton o care – ten some wt
chronic illness will not receive
sufficient services while a healthy person may ave servces tat gounused. If health care is given according to personal
contribution
, avalue will have to be placed on the person’s contribution – engaging
another potentially irresolvable issue. How will we value thecontribution of the stay-at-home parent in contrast to the spouse who works at an office? If health care is given according to
merit
, there will
have to be an assessment of merit. Does a mediocre artist deserve as
much health care as a dedicated garbage collector? Are merits received
for a healthy lifestyle while an unhealthy lifestyle receives demerits?
PARTIAL SOLUTIONS
Conversations about how to distribute health care, how much care,
and who funds care have gone on for many years. National healthcoverage as een scusse snce te 1960s. Atoug not otenrecognized as such, there actually is some national coverage for certain
Universal Health Care – Developing a Just Solution
By Cynthiane J Morgenweck MD, MA
Increasing all Americans’ access to preventive, acute, chronic and routine health care without barriers created by lack of health insurance is animportant step to improving our health care system. Once again in this election year, Presidential candidates are discussing the need for wideraccess to health care insurance in the United States. Case managers in acute care settings are often at the front lines of this issue, as theyencounter and coordinate care for unfunded and underfunded patients. They see the real costs to the diverse parties involved – to the patientsin need of care yet without a source of funding and to the health care provider organization. Because case managers become involved withpatients and their families, they see and understand the difficult decisions patients and families must make. Yet case managers also understandbetter than most the real costs to the health care provider – their employer – of providing uncompensated care.
DISTRIBUTIVE JUSTICE:
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groups of citizens. EMTALA laws (Emergency Medical Treatment and Actve Laor Act) requre tat any person gong to an emergency roomeceive sufficient treatment such that they are in stable condition.Medicare and Medicaid provide some level of services for all of thesuscrers wo meet ter crtera. Te prson popuaton n te Untetates is entitled to and receives health care. American Indians/AlaskaNatives who are a member of a federally recognized tribe, or descendanto a memer, are ege or eatcare troug Inan Heat Servce. Additionally, almost any person with kidney disease requiring dialysis isalso afforded health coverage by the federal government. The funding of dialysis in the 1960’s was seen as a first step toward national healthnsurance.
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For a variety of reasons, however, a national health insurancerogram never materialized past these programs, and we still struggle with questions of what kinds of care and how much of it to provide.
everal states have attempted to provide some basic universal
health care, with limited success at sustainability. Important lessonscan be learned from these bold experiments in health care policy.
Oregon mpemente egsaton provng unversa access to asc
health services that has now been in place for approximately 15 years.Massachusetts recently attempted a universal health care solution y requrng tat a o ts ctzens must ave some orm o nsurance.Closer examination of these two states will highlight two differentapproaches, as well as demonstrate some of the difficulties involved insettng up suc programs.
OREGON
Diicut Coices
In the late 1980s, the Oregon legislature had to make a difficultchoice between two very different kinds of health care.
,
6
,
The state had
a mte sum o money to spen on ts state Meca program.Legislators had to choose, therefore, between committing theseesources to fund a projected 34 organ transplants over the next two years (Oregons egsature unctons on a enna uget), or to enroapproximately 1500 people not previously covered by the stateMedicaid program.he state legislature voted on June 1, 1987 to enroll the 1500ersons who had no coverage and to forego transplants. This decisiongenerated only minimal response until November 1987, when a seven year-old boy was denied a bone marrow transplant. While this wasactually the third transplant denial since the legislative decision, thisone caught the media’s attention. Two lawsuits were initiated, a boycottof organ donations was organized, the national press covered the story or monts, an at east two natona teevson programs ecateime to the issue.Oregon’s Division of Adult and Family Services presented a formalesponse to te crtcsms, an sgncant eate ensue n te Oregonlegislature over the next year surrounding funding issues.
Oregon Basic Health Services Act of 1989
he Legislature passed the Oregon Basic Health Services Act in
989. This act mandated universal access to basic health care services,and made all Oregonians with income below the federal poverty levelege or Meca. It create te Oregon Heat Servces
Commission (OHSC) to help establish priorities amongst available
health services. For the next two years the OHSC deliberated theranng o eat care servces – unamentay, tey were worng todefine “basic health care services,” and therefore the specific servicesthat would be provided to all state citizens. The commission gatheredcommunty nput troug town-a stye meetngs, an eventuay developed a ranking of available services.Essentially, the list pairs a diagnosis with a treatment plan. Over700 agnoss an treatment pars are ste
8
an rane. Wt eacstate budget cycle, available state funding resources determine acut-off line. Above the line, services are provided. Below the line,services are not provided. As with all Medicaid plans, this approach hadto be approved at the federal level because Medicaid is funded withfederal dollars. After several revisions to the list, federal approval wasgranted, and the plan went into effect on February 1, 1994.The passage and implementation of this Act was aided by thebacking of an emergency room physician, John Kitzhaber, who was astate senator and leader of the legislature at the time of these initiatives.He later became governor, so the project continued to be nurtured by an involved, knowledgeable person.
Evolution and Adaptation
Since the passage of the Oregon Basic Health Services Act in 1989and implementation in the early 1990s, Oregon’s program hasundergone changes and modifications. At the time the program wasdeveloped and initiated, Oregon was in a time of prosperity. However,the economy has not faired as well since then – combined with the factthat Oregon law requires a balanced budget, further tinkering hasoccurred. In late 1995, a sliding scale premium was instituted forenrollees. The program continued to be a much more affordable healthcare coverage option than private insurance, but no long provided freecoverage to all Medicaid enrollees. If the premium was not paid, theenrollee was dropped. Estimates vary as to how many no longer havensurance, ut t s certan tat some ave ece tat tey cannotafford the premiums.
Universal Health Care – Developing a Just Solution
(continued from page 3)
w w w . a c m a w e b . o r g
Several states have attempted toprovide some basic universal health care, with limited success at sustainability. Important lessons can be learned from these bold experiments in health care policy.
C O L L A B O R A T I V E C A S E M A N A G E M E N T
Another initial provision of the program required Oregonempoyers to prove eat nsurance or empoyees equvaent ncoverage to that offered to Medicaid recipients. Small business ownersobjected, and in 1996 this requirement was dropped. Oregonexperence an ncrease n te numer o Meca appcants, wcay have been associated with this change.Diagnosis/treatment pairs have also been modified to reflectavances n mecne snce te mpementaton o ts pan.
Oregon – Lessons Learned
Fundamentally, the Oregon system rejected the concept of ationing health care by exclusion of persons, and relied instead onationing by evaluation of the benefit of the service offered –rioritizing the most important benefits. The key feature of Oregon’slan for universal health care is the list of diagnoses and corresponding reatments. This list was developed with the following criteria:• A treatment should be reliable – it should consistently alleviatehe symptoms.•Diseases that are included should occur frequently. There isnma reason to prove servces or seases tat are gy nlikely to occur.•reatments should be inexpensive, if possible. This allowsorganizations to provide a greater quantity of health care withinudget constraints.he organization of the diagnosis/treatment list set up by the OHSCduring 1988-1992 involved these considerations. A problem with this kind of approach is that a treatment is tiedo a diagnosis. What if, however, there is no treatment for a particulardiagnosis? In the case of Huntington’s Disease (HD), for example,here is a genetic test for the disease, but there is no curative treatment.On this basis, in Oregon, there is no reason to list HD. However, someindividuals might want to know if they have the HD gene so they canseek genetic counseling before starting a family. Another example ishat of women who request prenatal diagnostic testing – for example,estng or Down Synrome – so tey can pan aea or speca neesin child rearing.Initially, this plan was favorably received in Oregon, howeverat te turn o te century t was ess avoray perceve
9
an te
sustainability of the plan is now in question. The primary advocate for this system, Kitzhaber, is no longer governor. Thenemployment rate in Oregon has also increased, whichincreases the number of potential enrollees and creates a stateevenue shortfall. With less tax revenue than was previously available, premiums must rise and benefits be reduced.Furthermore, the state began to offer different programs of benefits, which confused many enrollees. New legislators havesince been elected, and state politics has shifted focus to otherriorities. Attention to a state health care plan that demandsongoing budgetary and benefit definition oversight by a politicalbody, such as a legislature, has proven difficult to sustain. Theovera pan s st n pace, ut s now sgncanty erent tanits original implementation.
MASSACHUSETTS
Te state o Massacusetts s currenty attemptng a erentapproach to securing health care insurance for all of its citizens –insisting that they buy it.
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,
11
Legislation passed in April, 2006 requiredtat as o Juy 2007, a state resents must carry a mnmum eve ohealth insurance, which is monitored by required reporting of insurance coverage on the citizen’s income tax filing. Citizens who areoun to ave no nsurance w e ne.Much of the cost of providing this coverage falls on employers inthe state. For companies with greater than 11 full-time employees (orequivalents) that do not already provide health insurance, an annual$295 per employee fee will be assessed payable to the stategovernment. The state then provides financial support on a sliding scale basis for those individuals who cannot afford health insurancepremiums. Parents are responsible for their children’s coverage, andlow cost, high deductible policies are permitted in this system. Thus,for young, healthy citizens it might seem reasonable to purchase only catastropc coverage.
Criticisms
There have been several public criticisms of the Massachusettsapproach to providing health care insurance. First, individuals canbuy from any insurance provider available in the market. Themultiple options may encourage some to buy insurance, but, criticsargue, it also creates a greater burden for the state in verifying whohas and has not complied with the rules. A single payer plan mighthave been less expensive. A secon crtcsm s tat te 295 per-empoyee ee may e essexpensive than providing health insurance for employees, so acompany might choose to pay the fine. This could
decrease
the number
o empoyers tat coose to oer eat nsurance to ter empoyees.It is questionable whether the $295 is an adequate amount to allow thestate to provide financial support to individuals who cannot affordeat nsurance premums.Thirdly, some have argued that requiring insurance violatesautonomy; it is up to individuals to decide whether or not they wish topurchase health insurance. The choice of whether or not to make apurchase, and from whom, is fundamental to the concept of afree-market society. This argument is countered by the precedent of required car insurance. Requiring vehicle insurance has demonstratedpublic safety benefit, but critics question whether this precedentclearly applies to requiring health insurance.Finally, Massachusetts enacted this legislation with sizablesaety net unng areay n pace an a proporton o unnsureresidents much lower than the national average.
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Developing a
similar program in another state would require much more financing tan Massacusetts program. Prmary, ts reers to testate’s Uncompensated Care Pool, a $600 million fund originally created in 1985 and modified multiple times since, that partially remurses osptas an care centers or unune patents annon-residents.
Early Outcomes
Reports rom te programs rst 18 monts ave ncatesuccess in reducing the number of uninsured in Massachusetts.
continued on page 14
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