Oregonians "Drawing Lots for Health Care"

[Guardsman Bass]

BEND, Ore. — Last month, right after he had the heart attack and then the heart surgery and then started receiving the medical bills that so far have topped $200,000, Melvin Tsosies joined the 91,000 other residents of Oregon who had signed up for a lottery that provides health insurance to people who lack it.

“They said they’re going to draw names, and if I’m on that list, then I’ll get health care,” said Mr. Tsosies, 58, a handyman here in booming Deschutes County. “So I’m just waiting right now.”

Despite the great hopes of people like Mr. Tsosies, only a few thousand of Oregon’s 600,000 uninsured residents are likely to benefit from the lottery anytime soon. The program has only enough money to pay for about 24,000 people, and at least 17,000 slots are already filled.

“Maybe we can hope that as time goes on,” said Jim Edge, the state Medicaid director, “there will be state money added back to this program and it can grow again.”

The challenge of providing health care in Oregon, once a trailblazer in the field but now facing soaring numbers of uninsured, is vivid here on the eastern edge of the Cascade Range. About 19 percent of the 150,000 people in Deschutes County are uninsured, compared with about 16 percent statewide and nationally.

The region has roared with development in recent years, driven by wealthy retirees and transplants from California who have turned old ranching outposts like Bend into stark counterpoints in comfort and struggle.

The area has been dependent on seasonal and service workers who do landscaping and construction, on single mothers who wait tables and on Hispanic immigrants who might come to work one farming season in a town like Madras, up the road, but stay after finding other jobs that often offer no health care benefits. A recent slowdown in construction work has made it even harder for some workers to pay for health care

“There’s so much need that there’s really no way you can meet it,” said Chris Coon, the outreach manager for the Community Clinic of Bend and the two other clinics that make up the nonprofit Ochoco Health Systems.

“Using a random process to decide who gets health care is a sign of profound desperation,” Mr. Coon said of the lottery in an e-mail message after an interview in his office here.

The lottery was born out of a consensus among state officials and advocacy groups that small steps can help. As part of the state’s Medicaid program, known as the Oregon Health Plan, the lottery is intended for low-income adults who lack private insurance and do not qualify for Medicaid or Medicare. Although the plan once served more than 100,000 people, budget cuts in 2004 reduced the number to about 17,000.

State officials now say they can expand the program to serve 24,000 residents. Because more than 130,000 of the 600,000 uninsured in the state meet the program’s criteria on income, age and other factors, the question became how to choose fairly the few thousand new enrollees.

“We thought about other options, such as should we try to pick all of the sickest people or the kids or the people with cancer or heart disease,” Mr. Edge said. “But the Feds won’t allow that, and there’s just no way to guarantee the fairness of that. Why would cancer be more deserving than heart disease?”

The state led a promotional effort that culminated with a one-month window, ending in late February, in which people who wanted to be considered for the program had to submit basic information. Of the more than 91,000 who have asked to enroll, about 3,000 initially will receive applications based on a computer selection. Those applications will then be reviewed for eligibility. Mr. Edge said more applications would be distributed over the coming months in batches of 3,000 until the program reached an average of 24,000 participants.

Oregon once sought to serve a far larger population of those in need.

It has been more than a decade since the innovative Oregon Health Plan became a forerunner of state health care reform as it pursued universal health coverage. Conceived on a restaurant napkin in the late 1980s, the program had by 1996 reduced the number of the uninsured to about 11 percent of all residents, down from more than 18 percent in 1992. But then, early in this decade, the state endured a wrenching recession.

“Oregon was way ahead of everyone else,” said Charla DeHate, the interim executive director of Ochoco Health Systems. “And then we went broke.”

Late this year, a special state board plans to present an outline for how to put Oregon back on the path to universal health coverage as similar efforts in other states continue to meet political and financial obstacles.

Barney Speight, who is director of the board, was present when the rough outlines of the Oregon Health Plan were sketched out. Mr. Speight said that many of the dynamics present two decades ago were present today, including a slowing economy and declining state revenues. But he said the challenge was even greater now because health care costs were rising at a greater rate than they were then.

“I think we still have to aspire to great goals,” Mr. Speight said, “but I think we have to temper that with a dose of reality.”

I thought it was particularly interesting that the federal government isn't letting them even try to direct this funding to more critical cases among the group, but what can you do? Oregon gets props for at least trying to keep up some coverage (this isn't Medicare and Medicaid; it's for people who don't qualify for either but can't afford health insurance).

[Uraniun235]

The really big problem we have is a lack of sales tax, which makes state tax revenues much more volatile and sensitive to the state of the economy. It's something that really needs to be implemented but it's unpopular in part because of a really dedicated (and stupid) band of anti-tax scammers (Bill Sizemore can go to hell), and in part because we're dumb and like the fact that we're one of only two states that doesn't have a sales tax.

(Although personally I think that a sales tax would probably be instantly more popular if it were drafted in a way that prices listed were after tax.)

We're also constitutionally forbidden from deficit spending, although I'm inclined to view that as a positive.

[Guardsman Bass]

Is that solely applied to operating expenses, or can your state government over-run its budget in case of emergencies or in case they need to make a structural investment (like issuing bonds to finance the construction of a road)? I know that there are a bunch of states that have a similar "balanced budget" clause.

[Uraniun235]

Yeah, that was imprecise on my part. It's a "balanced budget" thing; we can issue bonds and (probably) overrun the budget in the event of a major disaster. We just can't say "well this is how much we're spending regardless of what the tax revenues are this year" like how Congress does it.

Nobody wants to face it but frankly we need more taxes in Oregon. There's already a critical shortage of funding in certain areas (the state police, and mental health services come to mind immediately) and it's going to get much worse once the economy really tumbles over. I figure I might actually get politically active if anyone has the balls to come forward and argue for a sales tax or something, because any such movement will need all the help it can get in the face of the anti-tax fanatics.

[brianeyci]

Taxes?

No: call it a premium. Make it happen the first year you're in office, so the people have four years to forget (make sure not to make it the first thing you do in office since people remember that.) Have it happen once a year on the income tax return, and not sales tax or payroll tax, because that reminds people every time they buy something or get a pay stub, and not once a year.

It's what our Premier in Ontario did and get this: he made a baldfaced lie by saying directly to the cameras, "I won't increase taxes, but I won't cut them either." The opposition has been hammering at him for it since day one, but it doesn't stick because A. many people forgot about it on their tax returns so the delay is actually more than a year, two years in, and a lot of people got caught in tax audits (they never forget.) And B. apparently the public doesn't care about baldfaced lies and are too politically lethargic.

Of course the argument may go that Canadians are smarter than the average Oregonian in terms of tax. I don't buy that -- everybody here fucking hates taxes and are short sighted to shit. No, I think the strongest argument is you need to find better politicians. An Oregonian who is successful in business and has a degree from an Ivy league school in math could work. Our current left-wing mayor is one of Harvard's math.

Just avoid the economics majors and lawyers.

[brianeyci]

ghetto edit: B.Sc. turned lawyer is OK. You need some ability to bullshit, as I alluded to in my post, to convince the masses.