DATE: Sunday, September 21, 1997            TAG: 9709200130

SECTION: COMMENTARY              PAGE: J1   EDITION: FINAL 

SOURCE: BY DEBRA GORDON

                                            LENGTH:   96 lines

DYNAMIC OREGON PLAN COULD BE CURE FOR VIRGINIA

You've just gone grocery shopping and bought $250 worth of food. At the checkout line, however, you discover you only have $200 in your checking account. Back goes the expensive bottles of wine, the pickled artichoke hearts, the pound of extra-large shrimp. These are luxuries, you decide, you can forgo without affecting your family's nutrition. Instead, you pick up another pound of hamburger and some macaroni. Now you can fix more meals for the same money.

Apply this same method to health care. And you will understand the Oregon Health Plan.

I recently spent a week in Oregon with a dozen other health and medical journalists from around the country exploring the development, implementation and results of perhaps the most innovative, albeit controversial, health policy program in the country.

The plan, implemented in 1994, provides a basic health-care package of benefits for low-income people and those denied coverage for medical reasons, and helps small employers provide coverage to their employees. It includes reforms to make insurance more affordable. It has enabled the state to cover an additional 323,000 residents without spending any additional money. The plan relies heavily on managed care; contracting with 15 HMOs to provide prepaid health care to more than half-a-million residents.

As Hersh Crawford, who oversees the plan for the state, told us: ``The process may have been the most significant part of the reform; since it included labor, business providers, insurers, legislators and simple citizens all buying into the idea of a comprehensive health policy that would insure as many people as possible.''

They did it by creating a list.

You've probably heard about the list - usually in conjunction with the word ``rationing.'' The list, created and managed by the Oregon Health Services Commission, a group of medical professionals and community advocates, is a prioritized ranking of 744 condition/treatment pairs. Every two years, the legislature sets a budget for the Medicaid plan and draws a line on the list. Above this line we will fund; below, we will not.

Currently, Oregon covers the first 578 of the condition/treatment pairs. The package stresses prevention, including maternity and newborn care, immunizations, well-child exams and preventive dental care. It also covers all major diseases of women and children, reasonable diagnostic services, dental services, prescription drugs, many transplants, hospice care and mammograms, as well as outpatient chemical dependency services.

What it doesn't cover are treatment of diseases that get better on their own, like colds; conditions for which home treatments are effective, like calluses and corns, and conditions for which treatments are generally ineffective, like advanced cancer, although it does provide for comfort care.

Rationing? Sure. But every health-care plan is rationing. Pull out your health insurance policy and read it. Does it cover cosmetic surgery? Experimental treatments? Delivery costs if you are pregnant and travel out of the area after your 36th week? Probably not. Nor does Medicare, the federal health insurance program for the elderly, cover prescription drugs or many preventive tests.

Since Oregon implemented its plan, the number of uninsured has dropped from 17 percent of the population to 11 percent today. With the revenue from a 30-cent cigarette tax signed into law this summer, another 20,000 Oregonians will receive subsidized health coverage and an additional 29,000 will receive Medicaid coverage. Oregon's long-range goal is universal coverage for its entire 2.5 million population.

In Virginia, in contrast, since the government began requiring most women and children on Medicaid to join HMOs in January 1996, the number of Medicaid beneficiaries has dropped by 6,000. Where have these people gone? And what is being done with the savings the state has realized by moving to the managed-care system? Certainly the money is not being used to cover the thousands of uninsured in Hampton Roads.

In Oregon today, however, just 8 percent of the state's children lack health insurance, compared to 21 percent seven years ago. In Virginia, 10.5 percent of children are uninsured.

The Oregon plan is not perfect. Some HMOs complain that the rates they are paid don't take into account the high numbers of HIV and AIDS clients they cover; or the additional costs required by the large non-English speaking population they serve.

Many safety-net providers, like federally funded community health centers, are struggling to make ends meet as they find themselves providing more care to the uninsured while their Medicaid patients flock to private doctors. And, most concerning, the plan has not yet had any significant impact on infant mortality and the numbers of low birthweight babies in Oregon.

These are all problems that Crawford readily admits - even to a room full of reporters. But they are problems that, in the Oregon way, coalitions of community activists, bureaucrats and clients are working on.

``Many of us fought for the passage of the Oregon Health Plan and we will continue to fight for its funding,'' says Diane Bianco, with the Oregon Advocacy Center.

The rational way in which Oregon approached the problem of high numbers of uninsured and limited health-care bugets, the way it involved thousands of residents in the design of the plan, and the way it views the plan as a continually evolving program, one that is never ``finished,'' are lessons that other states, especially Virginia, should take to heart as they continue to grapple with thorny health-care issues. MEMO: Debra Gordon is a Virginian-Pilot staff writer. She is currently

on leave as a Kaiser Family Foundation media fellow, exploring the role

of community coalitions in childrens health.

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