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Child Advocates Take Aim at Ore. Health-Care Plan

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Oregon's unique effort to develop a priority list of health services the state intends to provide to its low-income residents is continuing to draw fire from those who warn it could deny needed care to many poor women and their children.

Under the plan, adopted by the legislature last year, the state's Medicaid program would be expanded to include more poor people. But the state also would pay for only as many medical services as its budget allowed--thus leaving uncovered services that had been determined to be relatively less necessary or cost-effective.

Child advocates and some health groups maintain that the program would be unfair because poor women and their children could wind up receiving fewer services than they do now. The groups also say the program would be discriminatory, since services for the elderly and the disabled--which consume more than two-thirds of the state's Medicaid budget--would be exempt from the ranking scheme.

"We don't think that the Oregon method makes sense," said Molly McNulty, a senior health specialist for the Children's Defense Fund, which is working with several other groups to defeat the proposal.

"Although it's an entitlement program, [Medicaid] has always been very thinly funded," Ms. McNulty added. "There is just not a lot of fat in the program."

Supporters of the proposal, meanwhile, say that it would ensure that health-care dollars are spent more rationally. They also predict that about half of the 118,000 people who would be added to the Medicaid rolls as a result of the new plan would be women and children.

"At the moment, we are completely unsystematic in the way we spend health-care dollars," said Donald Hoagland, director of the Center for Health Ethics and Policy at the University of Colorado. "Presumably, a legislature would not cut into the list at the point where services are medically necessary."

Debate over Oregon's proposal has intensified and drawn national attention since May, when the 11-member Oregon Health Services Commission released a preliminary ranking of the 1,600 health services and conditions that could be covered under the new program. The serL vices were ranked according to their costs and benefits, as well as the preferences of 1,001 state residents polled by telephone.

The commission was criticized for not including certain preventative measures, such as immunizations or family planning, and for ranking services for people with aids near the bottom of the list.

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services--predominantly long-term care in institutions--are not rising as quickly as regular medical costs.

State officials, meanwhile, are working to get an exemption from federal Medicaid regulations in or der to implement the program. Al though officials of the division of the U.S. Department of Health and Hu man Services that oversees the Med icaid program have hinted that they might approve the Oregon experi ment, the agency has yet to formally examine the issue.3

The Congress could also approve an exemption for the new plan. But Senator Robert Packwood said this summer that he would delay seek ing a Congressional exemption for his state's proposal until the new ranking of health procedures is com plete.

The exemption is opposed by a loose coalition of groups that in cludes the cdf, the American Academy of Pediatrics, and the Na tional Association of Children's Hospitals and Related Institutions.

At the heart of the debate, both sides agree, is the question of how best to allocate the limited amount of public money available for health care for the poor.

Proponents of the Oregon plan say it represents a fair trade-off: cover age for everyone with an income at or below the federal poverty level, but only for services that the state can afford.

Backers of the proposal point out that Oregon currently provides Medicaid coverage only to the very poor--those with incomes up to 58 percent of the federal poverty level. The only exception to that limit ap plies to pregnant women and chil dren up to age 6, who can be in households that make up to 133 per cent of the poverty level.

Federal law requires state Medic aid programs to provide all medical ly necessary services. It allows states to put limits on the amount or duration of a health service, howev er. For example, they can limit the number of days a person can spend in the hospital, or how many times a prescription can be refilled.

Opponents of the program fear that the Oregon plan will set a dan gerous precedent by allowing states to ration health care based upon medical condition. They note that the Colorado legislature this year narrowly defeated a similar proposal to overhaul its Medicaid program.

But other health-policy analysts praise the Oregon effort for confront ing a difficult issue from a new per spective.

"There's implicit rationing going on, and Oregon is trying to clarify that and deal with that explicitly," said Michele Solloway, a senior re search associate with the Intergov ernmental Health Policy Project at George Washington University. "I think they should be commended for putting the debate on the table."

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