Michael Grady, MD

Michael Grady, MD

In 2009 the Oregon Legislature passed HB 2009, which would result in health insurance coverage for all Oregonians by 2015. As this 2011 legislative session winds down, it is worth examining how far we have progressed, and consider a couple of proposals that, together, could move Oregon far ahead of other states in transforming our health system.

Not much progress, or so it seems.

Yes, we have passed a health insurance exchange bill (SB 99) but it is difficult to see how this will significantly lead to either universal coverage or “bending the cost curve.” Absent a robust publicly-owned plan, the insurance exchange will just be another playground for insurance companies. Competition (its newest iteration in the form of insurance “exchanges”, “marketplaces” and “malls”) has failed miserably to find a solution to the problem of people who need health insurance but can’t afford it. Even if a plausible business plan emerges, the exchange will result in covering only a little more than half of the currently 600,000 uninsured in Oregon by 2015. What happens to the other uninsured Oregonians?

In HB 3650, the Health Care Transformation bill, we have a serious and needed attempt to change the delivery of health care, beginning with recipients of both Medicare and Medicaid. However, the details are murky to say the least, and how these Coordinated Care Organizations (CCOs) will function in smaller and more remote communities is even less clear. We also haven’t addressed how the global prospective payment will be divided among providers in one of these CCOs, which is crucial to figure out as far as I can see.

It is difficult to understand how we can get to a transformed system without an upfront investment to get us through the transition. Trying to achieve this in the current budget climate is laudable for sure, but may not be possible.

Which brings me to my proposal. Out of the legislative dumpster of dead bills and dash amendments, I found two ideas which, when combined, might lead to a more just and sustainable health care system for Oregon.

Originally a concept proposed by lobbyist John DiLorenzo, SB 972 called for the Oregon Health Authority to examine and bring back to the legislature in 2012 a bill that would create a dedicated sales tax to fund universal heath care in Oregon. Individuals and businesses would no longer pay health insurance premiums. Every Oregonian would be eligible for an essential benefits package paid for by a 5-7% sales tax. Disconnecting health insurance from employment would be liberating for both business and individuals, creating a more attractive business climate in Oregon and more mobility for employees. In addition, the dreadful double whammy of lost job and lost insurance, which is devastating families in this economy, could be avoided.

But what would that “essential benefits package” include, and given health care inflation rates, how can that package be sustainable, i.e. avoid a slowly increasing sales tax creep? In work sessions around the exchange bill, Sen. Alan Bates proposed that the Oregon Health Plan (OHP) could become the publicly-owned plan in an insurance exchange. I suspect that Sen. Bates, like me a family physician, understands from experience that OHP could serve as an adequate, ethically-defensible floor for health coverage for all Oregonians.

For over five years now, I have had a medical practice that is 95% OHP and no one has lost life or limb or had their life cut short because they had this level of coverage. Imagine if we could 1) maximize leverage of federal funds with the expansion of Medicaid called for by the Affordable Care Act, and 2) create an essential benefit by using the prioritized list of services inherent in OHP, along with 3) a sales tax dedicated to providing an OHP level benefit to all Oregonians that would be sustainable and perhaps even come under the 5-7 % number.

The short answer to what is wrong with our health care system has been clear for a long time. Everything. We have failed to provide a basic level of health care to all our citizens or define a sustainable benefit for publicly provided care. We deliver care in a largely fee for service model that has no hope of controlling costs or insuring quality, and we finance our system using mechanisms that guarantee gaps in coverage and the incessant cost shifting that ensues. Coverage, benefit, delivery and financing must all be addressed together. Starting over with a dedicated financing mechanism for a defined benefit, available to all, delivered using mechanisms from the health transformation process begun in the current session could lead out of this health care wilderness.

Of course there are many obstacles to this idea. Chief among them certainly, is the historical response of Oregon voters to a sales tax. I am not especially fond of a regressive tax that burdens poor people disproportionately, but there are no perfect solutions to avoiding the cataclysmic trajectory we are on. Oregon is one of the least taxed states and one of the few without a sales tax. This gives us an opportunity that other states do not have.

We desperately need new ideas. Mr. DiLorenzo and Sen. Bates have proposed novel approaches. Combining them would provide a just and sustainable health care benefit for all in this state, make Oregon more attractive to business and free the health of Oregonians from the vicissitudes of the general fund budget.

Michael Grady, MD, practices family medicine in Silverton, Oregon, and is a member of the Community Leadership Council here at We Can do Better.