Howard M. Leichter

Oregon's bold experiment: whatever happened to rationing?

In 1994 Oregon began rationing health care for its Medicaid population, offering health policy makers and analysts around the country a view of one alternative future for health care delivery. The question now, four years after the experiment began, is what does that future look like? The short answer is that it does not look all that different from the present, but it looks different enough to offer important lessons to other states and the federal government. The Oregon experiment, including the prioritization of services and the aggressive use of managed care, has facilitated the expansion of health care coverage to over 100,000 additional Oregonians, helped decrease the percentage of the uninsured as well as reduce uncompensated care in hospitals, reduced the use of hospital emergency rooms, and reduced cost shifting. By most measures, the Oregon experiment appears to be a success.

Ethnic Politics, Policy Fragmentation, and Dependent Health Care Access in California

One out of every six nonelderly Americans without health insurance lives in California. The problem of access to competent and dependable health care is especially problematic among the states minority, and especially Hispanic, population. Because one-third of the countrys Hispanics live in California, how this state deals with health access issues will affect the practice and progress toward universal care in the nation as a whole. Expanding health care access to Californias dependent population will involve overcoming a number of well-known administrative and fiscal obstacles, including an underfunded, highly fragmented public health care system that has developed incrementally and incoherently over decades. However, a key to understanding the problem of access to health care in California involves a story of how ethnic conflict and partisan politics often conspire to deny or discourage access for eligible women and children.

The Poor and Managed Care in the Oregon Experience

To paraphrase Tolstoy, everyone is unhappy with Medicaid managed care in his or her own way: physicians fret about providing care to a population who lives fluid and often unstable lives, who consume more of their clinical time and other resources then their commercial patients, and for whose care they are underreimbursed by health plans; Medicaid clients complain about various barriers to timely and appropriate care, and the fact that primary care practitioners do not have the expertise to deal with their often complex and chronic health problems; the health plans bemoan the discontinuities in the care and behavior of the Medicaid population, which undermines the very concept of managed care; and safety net clinics and providers, who have long served the poorest of the poor in America, see managed care as a threat to their very existence as the Medicaid population is mainstreamed. These concerns feed into and on the general animosity toward managed care in the United States today, and are a reaction which is both reflected in and fueled by popular culture and academic commentary. The media have reported, for example, that audiences across the country responded audibly, enthusiastically, and sympathetically to the lambasting of HMOs by the Helen Hunt character (a working, single mother) in the movie As Good As It Gets (“Fucking HMO bastards, pieces of shit”).