A Memo from Oregon to the U.S. Healthcare System:

Lessons Learned in the Ethics of Rationing

In the absence of a coherent and purposefully architected health care policy, the default policy that has emerged in the United States is a market-based, employer-sponsored system featuring a broad variety of managed care plans serving both the public and private sectors. As one might predict, unintended public policies frequently result in unintended civic tragedies. In this talk we will begin with a review of the mounting, disturbing signals and trends that portend the failure of our present system in the absence of significant reform. Nearly 44 million persons now lack health insurance-- one out of six Americans overall and one out of five living in large, urban areas. In addition, the threat of inadequate coverage or loss of coverage now looms an increasing reality for a growing number of Americans as the economy continues a downward spiral.

No other industrialized nation in the world has made the choices, either by design or default, which we have. An intractable social blind-spot appears to prevent us from confronting the unpleasant task of dealing with the difficult ethical, political, and economic trade-offs that are necessarily a part of any responsible dialogue about our common obligation to ensure access to adequate, affordable healthcare to all citizens.

Yet, we cannot continue to abdicate critical resource allocation decisions to private industry and subsequently decry the consequences of those decisions. If we claim to be fundamentally dissatisfied with the ability of the invisible hand of the market to achieve distributive justice, we are saying that our policies are unaligned with our values, and should be recast.

In a demonstration of extraordinary civic maturity, the State of Oregon undertook this very task beginning in 1989 seeking to provide “basic medical services” to all Oregonians, including the working poor, through a bold redesign of the Medicaid benefit package. The aim of the Oregon approach was to generate profound change in public opinion through community-based, well-informed and honest discourse about setting healthcare priorities. It began with the fundamental recognition that it is not possible to provide every conceivably beneficial medical service to everyone—especially not through public programs. We will explore and elucidate the lessons learned in Oregon example from more than a decade’s worth of public reflection on some of the most critical healthcare issues of our time.