The national politics of Oregon's rationing plan

Medicaid, a program that pays providers of medical and chronic care on behalf of eligible beneficiaries, was created in 1965 as a part of Lyndon B. Johnson's ''Great Society.'' But in the ensuing years, one of the great inequities of American health care has evolved not between the nonpoor and the poor, but between the insured poor and the uninsured poor. Medicaid provides financial protection against the consequences of illness not to ''the poor,'' but to selected groups of low-income individuals and families who meet its arbitrary and confusing eligibility standards. In 1990, at any given time, 29 percent of adults whose income was below the federal poverty standard ($6,620) were covered by Medicaid, 14 percent had employer-provided health insurance, and 40 percent had no private or public health insurance. Enter Oregon, and what a New York Times editorial called its ''Brave Medical Experiment'' (12 May 1990): providing all its poor population with some health care benefits, rather than the current inequities that bedevil the poor there and elsewhere. If Medicaid was the exclusive preserve of states, as Lawrence Brown underscores in this article, Oregon's exercise in explicit rationing may well have been implemented by now. But since Medicaid is a federal/state enterprise, Oregon must seek a Washington waiver from federal program requirements to implement its proposal. Brown, who holds a doctorate in government from Harvard University, is no stranger to examining or provoking controversy. His critique, coauthored with Catherine McLaughlin, of community-based cost containment initiatives (Health Affairs, Winter 1990) engaged some readers and enraged others with their assessment of the potential of a decentralized health cost containment approach. Brown, a political scientist, is more involved with policy concerns than is common within that discipline.