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The state of the great Northwest.

Health care reform proposals dominated Washington State's recent legislative session. Outgoing Governor Booth Gardner and fellow Democrats managed to pass a very tough cost-containment and access bill in the House but fell one vote short of passage in the Republican-controlled Senate. Political hardball has become the name of the game, with insurance companies and many providers weighing in heavily against the House bill, while Democrats and the Governor blame Republicans for the lack of final legislation and vow to go directly to the electorate this fall.

Reform gathered steam last year when a highly touted Health Care Cost Containment and Access Commission released its preliminary recommendations. With only a few dissenting votes, it narrowed the field of options to two: something very close to single-payer system, and a "play-or-pay" approach with strong statewide premium controls on a minimum benefits package. Gardner quickly made the second, seemingly more moderate approach his plan, but opposition from small business, among others, lost him support in a key House committee. The Governor, pledging not to let the legislature adjourn until they had produced some major reform legislation, promptly compromised. After some tortuous intraparty politics, a globally budgeted system that still uses multiple insurers passed the House in late February.

The bill's powerful Health Services Commission would establish a uniform benefits package and set for that package the maximum premium any certified health plan could charge. Initially the premium would be set to reflect the actual average cost in the state for such coverage, but then the key cost-containment device would kick in: subsequent premium increases would be limited to the rise in the Consumer Price Index. Universal access would be phased in by 1997 as cost containment began to bite; every state resident would receive a voucher sufficient to purchase a uniform benefits package from any certified health plan. Employers and paying individuals would funnel contributions into a general fund, augmented by federal and state dollars for the elderly, poor, and near-poor. The fund would pay competing health plans an age- and sex-adjusted premium for each enrollee. Plans would compete on the basis of service and supplementary benefits, not price for the benefits package. Balance-billing would not be allowed for items in the benefits package, though premium increments for more inclusive packages would be. No plan could deny coverage for preexisting conditions, and no premiums could be experience-rated.

Opponents charge that the plan would involve unnecessarily centralized government control and eventually ration services and restrict choice of provider. Republicans in the Senate proposed a more incremental change, providing a standardized claim form and incentives for physicians to serve Medicaid patients; insurers would be barred from rejecting coverage for small employers and limited to charging group premiums 25 percent above the average. Both plans make a great deal of data collection and the encouragement of efficient practice parameters.

Critics of the Republican approach note that it has very weak cost-containment provisions and no plan for eventual universal access. Business has so far lined up largely against the Democratic plan; supporters hope, however, that business interests will eventually turn their way when they realize that the provision limiting premium increases to the Consumer Price Index will save them considerably, compared to the current annual 10 percent increase in employer-paid premiums. Senate Republican leaders refused a last-ditch appeal from Governor Gardner to negotiate for an extra legislative session to act on reform plans. There is talk of a statewide initiative to place the entire matter on the fall 1993 ballot, and the gubernatorial and state legislative campaigns this fall will not be able to avoid the debate.--Paul Menzel, Pacific Lutheran University, Tacoma, Wash.

Good to the Last Drop

In an effort to improve the city's supply of safe blood, Beijing's People's Congress has decided to make blood donation compulsory (Lancet, 29 February 1992). The ruling will apply to all male residents between the ages of 18 and 55 and all women aged 18-50, providing they pass a medical screening meant to ensure the "quality" of the donated blood. This decree, also affecting those whose "temporary stay" in the capital has exceeded one year, takes effect in July.

Concerns about the enforceability of the ruling have led the powers that be to add incentives. Those who donate will not only get a day off from work and a reasonable "nutrition allowance," but the city will also provide "priority services" to the donors, and they and their families will get priority treatment in medical emergencies that involve the use of blood.

A letter in the same issue of Lancet reported on a German study finding that a policy of buying blood involved an 8 times higher risk of seropositivity in the blood of the seller than when there was no remuneration. The Beijing policy avoids commodification of human tissue and decreases the chance of AIDS transmission. How often do such goods come together so conveniently?

There is a drawback, however. It appears that, with the age and health restrictions in the Beijing donation policy, the major parties unable to obtain the priority care will be the chronically ill, the elderly who lack a child of working age, and those whose blood does not meet adequate safety standards, including hepatitis B and HIV carriers.

Might Oregon's efforts to prioritize health care services have been less tortuous had they too based their decision not on need and degree of benefit from treatment, but on contribution to the community ...?--Julie Rothstein, research assistant
COPYRIGHT 1992 Hastings Center
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Author:Menzel, Paul
Publication:The Hastings Center Report
Date:May 1, 1992
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