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The Oregon Experiment: Creeping Toward Universal Health Coverage

June 13, 2013

In May the New England Journal of Medicine published an encouraging report on early results from what is being called The Oregon Experiment, the 2008 expansion of Medicaid coverage based on lottery drawings. This quirky set of circumstances provided an opportunity to examine the effect of expanded health coverage under a randomized, controlled study, upon which some observers have already bestowed landmark status.

US Healthcare and Obama

President Obama at the University of Maryland 9/17/09. Photo courtesy of Daniel Borman.

The Oregon study emerged when the state found itself with enough money to provide additional Medicaid coverage to about 10,000 low-income adults. The state established a lottery to distribute coverage randomly, giving social scientists a chance to perform a randomized controlled experiment—a rarity in much of social science — isolating the effect that coverage had on health and broader well-being.

The study authors found no significant improvements in measured physical health outcomes in the first 2 years—no surprise there in such early days—but there was an increase in the use of health services, higher rates of diabetes detection and management, lower rates of depression, and a significant lowering of financial strain.

These latter two findings represent especially positive effects on mental and emotional health, given these anxiety-producing times of financial, food, job, and political insecurities, not to mention the changing climate and degraded environment, armed conflicts, acts of terrorism, and violence against women and children.

Any step in the direction of universal health coverage (UHC) is to be celebrated. Universal coverage is the umbrella concept that embraces some of the biggest problems facing global health systems, including:

  • rising healthcare costs yet poor access to essential medicines, especially affordable generic products
  • an emphasis on cure that leaves prevention by the wayside
  • costly private care for the privileged few, but second-rate care for everybody else
  • weak or inappropriate information systems
  • weak regulatory control, and schemes for financing care that punish the poor.

People consistently rate health among their highest priorities, behind only economic concerns, such as unemployment, low wages, and cost of living. However, while health spending has increased dramatically around the world, access to affordable, quality services has lagged, and over 25 million families descend into poverty each year because of catastrophic health expenses. UHC is particularly essential at a time of financial crisis when the poor are most vulnerable.

Equally troubling are the avoidable deaths due to lack of access to health care. In this country, Medicaid expansion is associated with significant declines in mortality, estimated in a new study by the RAND Corporation to be about 19,000 avoidable deaths per year.

The world’s richest country is a puzzling outlier among developed nations in its absence of some sort of universal healthcare plan—an ignominy shared only with Belarus and a couple of troubled Balkan countries. Meanwhile, the U.S. spends more on health than other countries, the details of which the New York Times is now exploring in a series of informative and disturbing articles. High costs are no guarantee of high quality.

It is therefore heartening to see, despite relentless political opposition and daft threats by some state governors to reject Medicaid expansion, government efforts to “get with the program.”

In 2010 the World Health Organization (WHO) published Health Systems Financing: the Path to Universal Coverage, prompting more than 70 developing countries to request WHO technical support for their plans to move toward universal coverage.

Last year the Rockefeller Foundation published The New Global Health Agenda, describing a shift in focus from disease-driven initiatives to projects aimed at increasing the sustainability and strengthening of health systems, a crucial component of which is UHC. Also in 2012 The Lancet ran an extended series on UHC, with papers showing the positive impact of universal coverage on health outcomes. Commentaries in the series offer a big-picture view of the historical significance of what is now perceived to be a movement.

Earlier this year officials from health and finance ministries from 27 countries joined high-level health and development stakeholders at a 2-day meeting in Geneva to discuss ways that countries are progressing toward UHC. The meeting was convened jointly by the WHO and the World Bank, and took place just weeks after the United Nations General Assembly adopted a resolution supporting UHC. The resolution was sponsored by more than 90 countries and adopted by consensus. In a move described by some as “momentous,” the resolution urges member states to develop health systems that avoid significant direct payments at the point of care.

Dr. Margaret Chan, Director-General of the WHO is an inspiring leader of the UHC movement. Brought up in Hong Kong, she benefited from a system modeled on the National Health Service in the United Kingdom. In the early 1970s she studied medicine in Canada where she witnessed a country putting the finishing touches to its UHC.

I’ll let her eloquently have the last words.

I regard universal coverage as the single most powerful concept that public health has to offer. Fear of new diseases can unite the world, but so can determination to relieve preventable human misery. This is what makes public health stand out from other areas of global engagement: the motives, the values, and the focus.

Universal coverage operationalizes the highest ethical principles of public health and is the ultimate expression of fairness. We know we have to influence people at the top, but it is people at the bottom who matter most. Nothing reflects this spirit better than the growing commitment to universal health coverage.

Universal health coverage is not only the best way to cement the health gains made during the previous decade, it also reflects the need to maximize health outcomes for everyone. Everyone, irrespective of their ability to pay, should have access to the quality health care they need, without risking financial ruin. Universal coverage is the hallmark of a government’s commitment, its duty, to take care of its citizens, all of its citizens.

By increasing fairness in access to care and equity in health outcomes, our work contributes to social cohesion and stability, assets that every single country in the world would like to have. At a time when policies in so many sectors are actually increasing social inequalities, I would be delighted to see health lead the world towards greater fairness in ways that matter to each and every person on this planet.

— Michael Lytton, AJPM Blog Editor

For Further Reading in AJPM

Gourevitch MN, Cannell T, Boufford JI, Summers C. The challenge of attribution: responsibility for population health in the context of accountable care.
Am J Prev Med 2012;42(6S2):S180-3.

Muennig P, Franks P, Gold M.  The cost effectiveness of health insurance. Am J Prev Med 2005;28(1):59–64.

Richman VV. The cost effectiveness of health insurance. Am J Prev Med 2005;29(4):377.

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