AIDS TREATMENT NEWS #137, October 18, 1991
John S. James

If Oregon is allowed to adopt this health-care rationing plan, other states are "waiting in line" and may essentially copy it for their own use. This Oregon plan could also become a national model, perhaps adopted as a Republican approach to health-care reform.

Because AIDS and other organizations may have only until mid November to bring their concerns to HCFA, we are publishing this short article now, even though we received the following information shortly before deadline and could not do an in-depth analysis.

The main argument in favor of the Oregon plan is that health-care rationing decisions are being made in any case, in that those who cannot afford health care and do not have insurance are denied access. Oregon wants to replace this haphazard health rationing with a rational system drawn up by health-care experts, ethicists, and the public. "Excluded, for example, are medical treatment for infertility, medical treatment for a viral sore throat, routine screening (e.g., colon cancer) for adults not otherwise at risk, and aggressive treatment for the end-stages of AIDS and cancers and for newborns weighing less than 500 grams and having less than 23 weeks gestation" (quoted from Oregon's application to HCFA for waivers to allow the state to implement the plan). Advocates say that the plan will cover all the poor, and provide them with basic benefits through managed care at reasonable rates.

Here are some of the concerns we have heard from opponents of the plan:

* While early treatment of HIV infection is given a fairly high priority, as is treatment of opportunistic infections when the treatment is not "experimental," "end stage" HIV disease (which is never defined) is rated very low and will not be funded, except for "comfort care" such as pain management.

"Diagnosis -- End Stage HIV Disease; treatment -- Medical Therapy...represents those cases where there is very little likelihood that the patient's quality of life will be at all improved by any known aggressive treatment for HIV disease. In these cases, comfort care will be offered as a replacement for ineffective or experimental treatments which hold little promise of stopping the disease (quoted from an explanatory attachment to the Oregon plan, emphasis in original).

Oregon patient advocates have been unable to get State officials to give definitions of "end-stage HIV disease," "end- stage AIDS," or "end-stages of AIDS," all used interchangeably throughout the Oregon Medicaid Demonstration Project. This vagueness could be reserving the right to defund most AIDS care, especially since many treatments for opportunistic infections are "experimental." Advocates are worried because of the history of the plan; early drafts did attempt to defund AIDS by providing only "comfort care" unless there was judged to be a 10 percent chance of survival in five years.

* Another concern is that well-organized groups such as the elderly can lobby for better treatment, whereas other groups such as infants cannot. Senator Albert Gore (Democrat, Tennessee), a leading opponent of the Oregon plan, commented on a TV documentary, "The Health Quarterly with Roger Mudd: The Oregon Experiment," that "They've picked out only poor women and poor children, and they say: 'You've got to bear the full brunt of this entire rationing scheme.'"

The Children's Defense Fund, in a September 10, 1991 memorandum, concluded that "rather than adding women and children to the Medicaid program and improving its performance in the areas of maternal and child health, the waivers, if granted {by HCFA}, would not only diminish coverage for the women and children now enrolled in Medicaid but could result in the denial or termination of any benefits whatsoever for thousands of children and women currently eligible for assistance (emphasis in original).

* Mike Isbel of Lambda Legal Defense is concerned with long- term implications:

"The overall purpose of the plan has been to put resources into early care, and not pay for end-stage care, which is often expensive. But it has always been understood that a few who are very sick consume most of the health-care resources. The Oregon plan -- likely to be copied by other states and perhaps proposed nationally -- is an attempt to peel off the bad risks.

"Such attempts are based on the myth that the United States does not have the money to pay for health care for everyone. But we pay a much larger percentage of our gross national product for health care than other industrialized nations, which have health plans covering everyone. The problem is inefficiency and how resources are allocated, not lack of resources. For example, administrative costs consume twice as large a share of healthcare expenditures in the United States as they do in Canada, because of the hodgepodge of U. S. providers, each with its own rules designed to shift the cost burden to someone else. To reduce benefits instead of correcting such inefficiencies is completely disingenuous.

"The Oregon plan is frightening because it could become a national pattern for conservative health-care 'reform'. We as a nation cannot live with a health-care system which takes care of the healthy and abandons those who become seriously ill."

For more information

For more information on the concerns about the Oregon Medicaid Demonstration Project, and how your organization can become involved, contact:

* Lambda Legal Defense, attn: Mike Isbel, 666 Broadway, 12th Floor, New York, NY 10012, 212/995-8585.

* AIDS Action Council, attn: Laura Fogt, 2033 M Street NW, #802, Washington, DC 20036, 202/293-2886 ext. 21.

* Vanguard, P. O. Box 231261, Portland, Oregon 97223, 503/245-6799.

911018
ATN13704

AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.

Copyright ©1980, 1991. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content. .