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Opinion: Oregon Needs Significant Change To Achieve Universal Health Insurance Coverage

January 8, 2019

News from the “Universal Access to Health Care” workgroup wasn’t all bad. But those expecting revolutionary salvation for Oregon’s faltering health care system found the report peppered with cautionary phrases:

“Oregon’s current health-care system is not compatible with a state-based universal health care system;”

“…new governance models and incremental design considerations …could result in significant disruption and unintended consequences to the existing system.”

“…the work group did not achieve consensus on any of the policy approaches.”

Daunting. But meriting attention within this remarkable report are several good ideas we should consider and a few bad ones we should not. Our workgroup (I was a member) achieved neither a majority nor unanimity on any specific policy, but as Oregon’s health-care system decays, our report provides insight. Here are my suggestions for best and worst ideas.

First good idea: We agreed the goal of “universal care” is clear: Better care to more people for less money. Achieving any two is easy. Achieving all three is not. Acknowledging this “Iron Triangle” kept us focused.

Second good idea: “A statewide Primary Care Trust,” currently introduced in Rhode Island and Vermont. All private and public insurers would pay 10 percent of budgeted expenditures into a nonprofit organization responsible for financing all primary care services in the state. Senate Bill 934, now law in Oregon, already compels coordinated care organizations to spend 12 percent on primary care. The administrative efficiency of a trust’s statewide patient pool, single comprehensive care package and single statewide primary care provider network would recover a 10th of that administrative spending and free it for medical care.

Third good idea: “Plan uniformity.” Our committee was consistently distressed by the extraordinary administrative losses of health-care dollars as they traveled from patients to providers. These losses exceeded those of other industrialized countries by up to eight-fold.

Unlike other nations, Oregonians shuffle through thousands of different benefit schedules, each with different conditions, different treatments, and – importantly – different billing forms. The cost to insurance companies, providers and patients is enormous. And the cost of changing to a completely different schedule (as 20 percent of Oregonians do each year) adds to the administrative friction.

Using a single medical billing form by every provider and insurance company in Oregon looks very attractive.

Another administrative loss is Oregon’s unintelligibly complex method of purchasing drugs, though other states are no better. Attempts in multiple medical journals and advocacy websites to clearly explain how drugs get from manufacturer to patient fail miserably. The appeal of a single pharmacy benefit manager for all of Oregon which would negotiate prices, create a common formulary and make all medications available to every pharmacy in the state was obvious.

Here are ideas I found particularly bad.

First bad idea: “Shared responsibility.” This would compel every Oregonian to join an insurance plan. If ineligible for either a public or employer-sponsored plan, you must buy one.

This concept was a keystone of both the 2006 Massachusetts plan and its national spawn, the Affordable Care Act. In each case, families complied by purchasing the only policy they could afford – usually the worst. This gave us “skinny insurance:” perfectly legal policies with narrow networks, minimal drug coverage, massive deductibles and equally massive co-pays. Families paid for insurance they could not afford to use.

“Shared responsibility” should wait until all insurance policies provide completely pre-paid comprehensive benefits. That will not happen soon.

Second bad idea: “A public option.” We’ve already been there. Oregon’s two CO-OPs (both of them statewide public options) went bankrupt, as did 17 others of the original 23 CO-OPs formed nationally under the Affordable Care Act. Surviving CO-OPs depend critically on unreliable federal subsidies. Do Oregonians want our health care to depend on Congress behaving rationally?

Like my colleagues in the workgroup, I was disappointed we could not offer Oregonians an easy fix. Good ideas require, as we noted, “significant disruption.” The bad ideas failed before. So there’s our challenge: if we seek significant results, we need significant change. And change means providing health care differently.

Are we ready for change?

Dr. Samuel Metz is a Portland physician. He is a member of Oregon Physicians for a National Health Program and a founding member of Mad As Hell Doctors, both of which advocate universal health care. The opinions here are his own and do not necessarily reflect those of other members of the Universal Access to Health Care workgroup. He can reached at [email protected].