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Public input into health care policy: controversy and contribution in California.

Public Input Into Health Care Policy: Controvery and Contribution in California

The hypothetical case of "Unclke Ned" comes up as an illustration in point during a California Health Decisions (CHD) group discussions of principles for health care allocation. "Uncle Ned" is ninety-two years old and critically ill. The physician recommends inserting a pacemaker. What guidelines should be used to make this treatment decision? Where does age enter into the discussion? Ability to pay? Quality of life? Patient self-determination?

A white-haired man who has been silent until now raises his hand. "OK," he says, "We've talked about 'Uncle Ned' but I want to know where Uncle Sam comes into the picture." The discussion moves to federal support for health care funding so "Uncle Ned" can avoid "spending down to zero" in order to be eligible for long-term care.

The forty-three people attending this one meeting on this particular evening obviously won't solve the complex and thorny problem of allocating scarce resources. But their discussion is a valuable exercise in community participation. In the five years CHD has been holding these meetings, the message from the public is consistent: Everyone should have access to basic health care, regardless of ability to pay. Now we are preparing to take the next step in the process, a statewide round of community meetings in 1991 aimed at defining "basic" or "adequate" health care.

Developing explicit guidelines for health care allocation is a daunting prospect, intimidating to most policy-makers. The arguments that the task is best left to "experts" centers around a misguided belief that the complexities of the health care delivery system are beyond the understanding of the average citizen. However, our experience shows that public education designed to break the seemingly overwhelming "health care crisis" into manageable, understandable increments allows very constructive dialogue leading to specific recommendations. And while public understanding of the health care issues varies among different groups, we repeatedly find that people have a clear sense of their own values and welcome the opportunity to express them.

There is also concern that the process of developing explicit guidelines for health care allocation or rationing will prove bitterly divisive. Market-driven health care delivery, while less than perfect, seems safer to some than the prospect of squarely facing our limitations. This fear was underscored in 1989 when an acrimonious debate surrounded the effort by Alameda County to reach a consensus on Medi-Cal (Medicaid) spending. Alameda County Attempted to adopt explicit guidelines similar to those discussed in Oregon, but groups represening the poor, persons with AIDS, and the elderly were unable to agree on how limited funds should be prioritized.

Clearly, the process of allocating finite resources according to explicit guidelines, rather than arbitrarily, wil not be painless or without a price. It means confronting the unsettling reality that by design certain people, almost surely some of our friends and relatives, will not get all the medical treatment that might benefit them. This will leave some angry, bitter, or afraid. But significant social change or progress is always marked by contentious struggles with issues of personal choice, individual liberty, and balancing certain losses against the greatest common good.

Involving the public as full partners in shaping health care policy is the best hope for developing a basic blueprint of a more equitable health care system. True, some of the health care decisions we face as we move into the next century threaten some of our fiercest beliefs about individualism and technological supremacy. However, the expensive, labor-intensive, and time-consuming investment in educating the public about these issues and involving them in the design of health policy reforms and in making hard choices will pay off. In the long run, it is the only way such reforms can succeed.

Treacy Colbert is a staff writer for California Health Decisions.
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Title Annotation:Grassroots Bioethics Revisited: Health Care Priorities and Community Values
Author:Colbert, Treacy
Publication:The Hastings Center Report
Date:Sep 1, 1990
Previous Article:Community values in Vermont health planning.
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