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Health care in common: setting priorities in Oregon.

Health Care in Common: Setting Priorities in Oregon

The Problem. The 1989 Oregon Legislature passed a package of statutes that will substantially alter the health care system in Oregon, and may provide a model for similar reforms in other states. These laws expand access to health care by broadening Medicaid eligibility, by creating incentives for businesses to provide health insurance, and by creating an insurance pool to cover persons now "uninsurable" because of preexisting health conditions. The laws also create a process whereby health care priorities will be established so that Medicaid and state-encouraged private coverage can provide the most cost-effective and beneficial forms of care for the greatest number of people.

Whether these changes will be implemented remains to be seen; in part, this depends on the federal government's willingness to permit Oregon to design Medicaid benefits on the basis of explicitly prioritized health services. Whatever the outcome, Oregon has taken a bold step in grappling with a national problem. Oregon Health Decisions (OHD), the grassroots community health decisions group in the state, has played a key role in the search for answers to our health care access and priority-setting dilemmas.

The innovation is not without risk. Some opponents argue that the proposed changes are unfair, that they place too much burden on the poor. Radical critics object that this process merely tinkers with a fundamentally defective system that requires complete restructuring. Technical critics argue that health care services are too complex to be prioritized with scientific validity. Still, the Oregon experiment is going forward, warily trusting the intuition that the goals of access and cost control can and must be served simultaneously.

The process of setting priorities has been undertaken by a newly created Health Services Commission (HSC), which is required by law to "actively solicit public involvement in a community meeting process to build a consensus on the values to be used to guide health resource allocation decisions." The HSC also held public hearings, conducted a telephone survey, and consulted with medical and technical experts as it worked to devise a priority list of medical services to submit to the state legislature. OHD's special role in this process related to the community meetings, which will be the focus of our article.

Guided by a twenty-nine-member Project Advisory Committee, and aided by sixty volunteers, OHD conducted forty-seven meetings throughout the state involving over a thousand citizens from mid-January to mid-March 1990. Seventy percent of the participants were college educated, a third had household incomes of at least $50,000, slightly more than half were between the ages of twenty-one and fifty, and ninety-three percent were Caucasians.

The purpose of the meetings was to develop information on why members of the community judge certain health services particularly important for the community. They sought to discover whether Oregonians do in fact share a living tradition of values about health care that can help define some package of health services as constituting a common good.

At the meetings a brief slide show described the problem of simultaneously expanding access and setting limits. Demographic information was collected and then participants, in small groups of about ten, focused their attention on health service priorities. Group discussion took up the bulk of the meeting as each small group compared individual rankings, explored the values that guided their priorities, and actively examined whether they had consensus about important values. The groups then reassembled in a plenary session. This permitted further examination and clarification of the question of value consensus.

Values. Several basic themes emerged as participants articulated their value judgments. At every meeting, the goal of prevention was vigorously advanced. The notion of prevention as conceived by the public involves several values. Preventive care is seen as cost-effective, it enhances the quality of individual lives, improves community life, and benefits large numbers of people. It also promises to save resources in the long run.

A second omnipresent, complex value was that of enhancing quality of life. Component meanings of this value include enhancement of productivity, social functioning, emotional well-being, restoration of vigor, reduction of pain or suffering, and capacity for independent living. Participants tended not to oppose quality of life to duration of life, but to intertwine them. A value for pure length of life without concern for some identifiable quality dimension was not strongly evident in the community discussions.

Though somewhat less prominent, cost-effectiveness was another recurrent theme. This value focused on the degree of benefit flowing from various services relative to the costs of providing them. Participants were perturbed both about extravagant, inefficient medical services that add no "health benefit" to patients, and about services that are effective but only marginally beneficial. The caveat emerging from the meetings was that although cost-effectiveness is important, it ought not to be considered the all-determining value.

Ability to function, clearly a component of quality of life, was often singled out by participants. This value category includes emotional well-being, productivity (including, but larger than, economic productivity), independence, and the restoration of vigor despite some disability.

The theme of equity was displayed in discussions appealing to a premise that persons should not be excluded from health care when they need it. The premise was usually felt to ground an obligation on the part of government to guarantee a basic or adequate level of health care to all. Participants used terms like justice, social decency, and humaneness to articulate their judgments on this theme.

Reflections. OHD plays the role of an engaged "social critic" whose constant task, as Michael Walzer has so well described it, is to stay connected with the process of change, to be a continuing participant, "keeping in touch with common complaint,"...and staying attentively ready. When policymakers wish to be guided by community values, OHD provides one process for expressing those values.

The community meeting mandate that OHD implemented in conjunction with the HSC embeds in the priority-setting process an opportunity for exercising community responsibility that too often withers when confronted with the complexity and opacity of the U.S. health care system. At these meetings we experienced a living interface between theoretical discussions about ethics and the practical development of the social instruments of ethics. We listened for and heard evidence of what John Rawls has called the "overlapping consensus." The consensus-seeking dynamic of the community meeting offers an excellent opportunity for testing the practical strengths and limits of theoretical inquiries into questions of allocation and rationing in health care.

The community meetings also test the validity of the conviction that ordinary persons have sensible and important moral intuitions relevant to moving society through the challenging dilemmas that confront U.S. health policy. We see and hear the wisdom ordinary persons derive from their experience. Because of these meetings we can confirm that there is a pervasive concern that we, the entire American community, should hold ourselves accountable for the fairness, prudence, and common welfare created by our health care institutions and practices.

Perhaps the most important observation derived from listening to community explorations of ethical values is that it is extremely important to ask the right experts the right questions. The task of prioritizing health services involves a judgment composed of facts and values. The HSC has turned to relevant experts for technical facts--health care providers and health service researchers, economists and actuaries. It has also turned to the relevant experts on community values--members of the community.

Expressing community health values cannot be a one-time event, but must be a long-term process. With each successive outreach project, OHD renews and widens the network of civic groups throughout the state that can be called upon to bring their members into the community meeting process. Outreach is critically important for OHD because increasing the number of citizens actually involved in the meetings increases the components of the overlapping consenus OHD seeks to create.

Moreover, diversity is as important as sheer numbers. The most challenging task before OHD is to develop strong links of trust and collaboration with those Oregonians who are de facto disenfranchised from meaningful participation in the system's institutions and arenas of authority, power, and responsibility. Despite efforts to be more effective in enlisting members of disadvantaged groups to participate in the community meeting process, we had only meager success. New connections have to be made with groups in the community where the disenfranchised feel themselves at home and respected. In the next few years that dimension of OHD involvement will be critical as we continue to facilitate the exercise of community responsibility for our common welfare in fairly and prudently allocating our health care resources.

Michael J. Garland is president of Oregon Health Decisions and Associate Director of the Center for Ethics in Health Care at Oregon Health Sciences University, Portland, OR. Romana Hasnain is community meetings project coordinator of Oregon Health Decisions.
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Title Annotation:Grassroots Bioethics Revisited: Health Care Priorities and Community Values
Author:Garland, Michael J.; Hasnain, Romana
Publication:The Hastings Center Report
Date:Sep 1, 1990
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