C O L L A B O R A T I V E C A S E M A N A G E M E N T

Universal Health Care – Developing a Just Solution

By Cynthiane J Morgenweck MD, MA

Increasing all Americans’ access to preventive, acute, chronic and routine health care without barriers created by lack of health insurance is an
important step to improving our health care system. Once again in this election year, Presidential candidates are discussing the need for wider
access to health care insurance in the United States. Case managers in acute care settings are often at the front lines of this issue, as they
encounter and coordinate care for unfunded and underfunded patients. They see the real costs to the diverse parties involved – to the patients
in need of care yet without a source of funding and to the health care provider organization. Because case managers become involved with
patients and their families, they see and understand the difficult decisions patients and families must make. Yet case managers also understand
better than most the real costs to the health care provider – their employer – of providing uncompensated care.

What is the correct balance? Is there a fiscally sustainable yet
empathetic solution? In forming an opinion on this issue, what
elements – both conceptual and historical – must be considered?
This article examines the issue in its most current form – the debate
surrounding a system of universal health care in the United States –
and reviews early attempts by some states to develop such a system.
CAN THEORY HELP?
Allocation of health care services is a form of distributive justice,
and most advocates for universal coverage believe receiving health
care is an issue of justice. Individuals need access to quality health
care, and a just government would
distribute the resources necessary to
deliver health care to its citizens in a
fair manner. Affordable health
insurance is often looked to as the
vehicle to allow fair access to
DISTRIBUTIVE JUSTICE:
services, so that the cost is covered.
The details of how to finance the Principles of distributive justice
insurance create tensions for policy are normative principles
makers. Who pays the cost, and for
how much universal insurance?
designed to guide the allocation
What are the services to be provided? of the benefits and burdens
Who decides the payment schedule,
and for which individuals? Who
of economic activity.
decides which services should be Source: Stanford Encyclopedia of Philosophy3
provided? These questions and many
others have to be answered in order
to develop a system of allocation.
When evaluating policies for
allocating health care resources, multiple goals come into conflict:
excellence of care, equality of care, efficiency of care and the freedom
of choice for both patient and health care provider. As a society, we
have not prioritized these goals, and attempts at prioritization have
caused further conflict and yielded minimal progress toward the
overarching goal of health care.1 Without agreed-upon priorities,
policy development will not have a clear direction.
On the surface, healthcare in the United States appears to operate
as a free-market system – with the unique distinction that in most
cases a party other than the one consuming the services is paying for
the services. This creates distorted relationships between providers,
patients, and payers. Patients and payers pay significantly different
prices for the same services delivered by the same provider, and these
prices paid or reimbursed may be very different than the provider’s
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actual cost of delivering care. Furthermore, the actual market prices
for health care services remain expensive, and unaffordable for a
significant portion of the population.
The customary guideline for resource allocation is the general rule
of formal procedural justice, which seeks to treat “Likes” alike and
“Unlikes” differently. 2 Principles of formal justice suggest giving to
individuals according to a characteristic that can be quantified. The
quantifiable characteristics usually raised in discussion of health care
are: need, demonstrated effort, equal share, contribution, and merit.
However, there are problems with using each of these as defining
criterions. If health care is given according to need
need, there may be vast
differences in the amount and type of
health care any person needs. One
person may insist that a plastic
surgery is needed while another
person will insist the surgery is not
necessary. If health care is given
according to effort there will be lively
discussion and potentially
irresolvable issues of how hard a
person is working (for example, to
stay in shape or manage chronic
conditions) in contrast to how hard
he/she ought to be working. If each
person is accorded an equal share –
each person receiving the same
allocation of care – then some with
chronic illness will not receive
sufficient services while a healthy
person may have services that go
unused. If health care is given according to personal contribution, a
value will have to be placed on the person’s contribution – engaging
another potentially irresolvable issue. How will we value the
contribution of the stay-at-home parent in contrast to the spouse who
works at an office? If health care is given according to merit
merit, there will
have to be an assessment of merit. Does a mediocre artist deserve as
much health care as a dedicated garbage collector? Are merits received
for a healthy lifestyle while an unhealthy lifestyle receives demerits?
PARTIAL SOLUTIONS
Conversations about how to distribute health care, how much care,
and who funds care have gone on for many years. National health
coverage has been discussed since the 1960’s. Although not often
recognized as such, there actually is some national coverage for certain
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Universal Health Care – Developing a Just Solution (continued from page 3)
groups of citizens. EMTALA laws (Emergency Medical Treatment and
Active Labor Act) require that any person going to an emergency room
receive sufficient treatment such that they are in stable condition.
Medicare and Medicaid provide some level of services for all of the
subscribers who meet their criteria. The prison population in the United
States is entitled to and receives health care. American Indians/Alaska
Natives who are a member of a federally recognized tribe, or descendant
of a member, are eligible for healthcare through Indian Health Service.
Additionally, almost any person with kidney disease requiring dialysis is
also afforded health coverage by the federal government. The funding of
dialysis in the 1960’s was seen as a first step toward national health
insurance.4 For a variety of reasons, however, a national health insurance
program never materialized past these programs, and we still struggle
with questions of what kinds of care and how much of it to provide.
Several states have attempted to provide some basic universal
health care, with limited success at sustainability. Important lessons
can be learned from these bold experiments in health care policy.
Oregon implemented legislation providing universal access to basic
health services that has now been in place for approximately 15 years.
Massachusetts recently attempted a universal health care solution
by requiring that all of its citizens must have some form of insurance.
Closer examination of these two states will highlight two different
approaches, as well as demonstrate some of the difficulties involved in
setting up such programs.
OREGON
Difficult Choices
In the late 1980s, the Oregon legislature had to make a difficult
choice between two very different kinds of health care.5,6,7 The state had
a limited sum of money to spend on its state Medicaid program.
Legislators had to choose, therefore, between committing these
resources to fund a projected 34 organ transplants over the next two
years (Oregon’s legislature functions on a biennial budget), or to enroll
approximately 1500 people not previously covered by the state
Medicaid program.
The state legislature voted on June 1, 1987 to enroll the 1500
persons who had no coverage and to forego transplants. This decision
generated only minimal response until November 1987, when a seven
year-old boy was denied a bone marrow transplant. While this was
actually the third transplant denial since the legislative decision, this
one caught the media’s attention. Two lawsuits were initiated, a boycott
of organ donations was organized, the national press covered the story
for months, and at least two national television programs dedicated
time to the issue.
Oregon’s Division of Adult and Family Services presented a formal
response to the criticisms, and significant debate ensued in the Oregon
legislature over the next year surrounding funding issues.
Oregon Basic Health Services Act of 1989
The Legislature passed the Oregon Basic Health Services Act in
1989. This act mandated universal access to basic health care services,
and made all Oregonians with income below the federal poverty level
eligible for Medicaid. It created the Oregon Health Services
Commission (OHSC) to help establish priorities amongst available
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health services. For the next two years the OHSC deliberated the
ranking of health care services – fundamentally, they were working to
define “basic health care services,” and therefore the specific services
that would be provided to all state citizens. The commission gathered
community input through town-hall style meetings, and eventually
developed a ranking of available services.
Essentially, the list pairs a diagnosis with a treatment plan. Over
700 diagnosis and treatment pairs are listed8 and ranked. With each
state budget cycle, available state funding resources determine a
cut-off line. Above the line, services are provided. Below the line,
services are not provided. As with all Medicaid plans, this approach had
to be approved at the federal level because Medicaid is funded with
federal dollars. After several revisions to the list, federal approval was
granted, and the plan went into effect on February 1, 1994.
The passage and implementation of this Act was aided by the
backing of an emergency room physician, John Kitzhaber, who was a
state senator and leader of the legislature at the time of these initiatives.
He later became governor, so the project continued to be nurtured by
an involved, knowledgeable person.
Several states have attempted to
provide some basic universal
health care, with limited success at
sustainability. Important lessons
can be learned from these bold
experiments in health care policy.
Evolution and Adaptation
Since the passage of the Oregon Basic Health Services Act in 1989
and implementation in the early 1990s, Oregon’s program has
undergone changes and modifications. At the time the program was
developed and initiated, Oregon was in a time of prosperity. However,
the economy has not faired as well since then – combined with the fact
that Oregon law requires a balanced budget, further tinkering has
occurred. In late 1995, a sliding scale premium was instituted for
enrollees. The program continued to be a much more affordable health
care coverage option than private insurance, but no long provided free
coverage to all Medicaid enrollees. If the premium was not paid, the
enrollee was dropped. Estimates vary as to how many no longer have
insurance, but it is certain that some have decided that they cannot
afford the premiums.
 C O L L A B O R A T I V E
Another initial provision of the program required Oregon
employers to provide health insurance for employees equivalent in
coverage to that offered to Medicaid recipients. Small business owners
objected, and in 1996 this requirement was dropped. Oregon
experienced an increase in the number of Medicaid applicants, which
may have been associated with this change.
Diagnosis/treatment pairs have also been modified to reflect
advances in medicine since the implementation of this plan.
Oregon – Lessons Learned
Fundamentally, the Oregon system rejected the concept of
rationing health care by exclusion of persons, and relied instead on
rationing by evaluation of the benefit of the service offered –
prioritizing the most important benefits. The key feature of Oregon’s
plan for universal health care is the list of diagnoses and corresponding
treatments. This list was developed with the following criteria:
• A treatment should be reliable – it should consistently alleviate
the symptoms.
• Diseases that are included should occur frequently. There is
minimal reason to provide services for diseases that are highly
unlikely to occur.
• Treatments should be inexpensive, if possible. This allows
organizations to provide a greater quantity of health care within
budget constraints.
The organization of the diagnosis/treatment list set up by the OHSC
during 1988-1992 involved these considerations.
A problem with this kind of approach is that a treatment is tied
to a diagnosis. What if, however, there is no treatment for a particular
diagnosis? In the case of Huntington’s Disease (HD), for example,
there is a genetic test for the disease, but there is no curative treatment.
On this basis, in Oregon, there is no reason to list HD. However, some
individuals might want to know if they have the HD gene so they can
seek genetic counseling before starting a family. Another example is
that of women who request prenatal diagnostic testing – for example,
testing for Down Syndrome – so they can plan ahead for special needs
in child rearing.
Initially, this plan was favorably received in Oregon, however
at the turn of the century it was less favorably perceived9 and the
sustainability of the plan is now in question. The primary
advocate for this system, Kitzhaber, is no longer governor. The
unemployment rate in Oregon has also increased, which
increases the number of potential enrollees and creates a state
revenue shortfall. With less tax revenue than was previously
available, premiums must rise and benefits be reduced.
Furthermore, the state began to offer different programs of
benefits, which confused many enrollees. New legislators have
since been elected, and state politics has shifted focus to other
priorities. Attention to a state health care plan that demands
ongoing budgetary and benefit definition oversight by a political
body, such as a legislature, has proven difficult to sustain. The
overall plan is still in place, but is now significantly different than
its original implementation.
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C A S E M A N A G E M E N T
MASSACHUSETTS
The state of Massachusetts is currently attempting a different
approach to securing health care insurance for all of its citizens –
insisting that they buy it.10,11 Legislation passed in April, 2006 required
that as of July 2007, all state residents must carry a minimum level of
health insurance, which is monitored by required reporting of
insurance coverage on the citizen’s income tax filing. Citizens who are
found to have no insurance will be fined.
Much of the cost of providing this coverage falls on employers in
the state. For companies with greater than 11 full-time employees (or
equivalents) that do not already provide health insurance, an annual
$295 per employee fee will be assessed payable to the state
government. The state then provides financial support on a sliding
scale basis for those individuals who cannot afford health insurance
premiums. Parents are responsible for their children’s coverage, and
low cost, high deductible policies are permitted in this system. Thus,
for young, healthy citizens it might seem reasonable to purchase only
catastrophic coverage.
Criticisms
There have been several public criticisms of the Massachusetts
approach to providing health care insurance. First, individuals can
buy from any insurance provider available in the market. The
multiple options may encourage some to buy insurance, but, critics
argue, it also creates a greater burden for the state in verifying who
has and has not complied with the rules. A single payer plan might
have been less expensive.
A second criticism is that the $295 per-employee fee may be less
expensive than providing health insurance for employees, so a
company might choose to pay the fine. This could decrease the number
of employers that choose to offer health insurance to their employees.
It is questionable whether the $295 is an adequate amount to allow the
state to provide financial support to individuals who cannot afford
health insurance premiums.
Thirdly, some have argued that requiring insurance violates
autonomy; it is up to individuals to decide whether or not they wish to
purchase health insurance. The choice of whether or not to make a
purchase, and from whom, is fundamental to the concept of a
free-market society. This argument is countered by the precedent of
required car insurance. Requiring vehicle insurance has demonstrated
public safety benefit, but critics question whether this precedent
clearly applies to requiring health insurance.
Finally, Massachusetts enacted this legislation with sizable
safety net funding already in place and a proportion of uninsured
residents much lower than the national average.12 Developing a
similar program in another state would require much more financing
than did Massachusetts’ program. Primarily, this refers to the
state’s Uncompensated Care Pool, a $600 million fund originally
created in 1985 and modified multiple times since, that partially
reimburses hospitals and care centers for unfunded patients and
non-residents.
Early Outcomes
Reports from the program’s first 18 months have indicated
success in reducing the number of uninsured in Massachusetts.
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Universal Health Care – Developing a Just Solution (continued from page 5)
The number of people enrolled in private or subsidized health
insurance products has increased by 256,000 people since the
legislation’s implementation.13 More than 340,000 formerly
uninsured citizens of MA – more than half of the estimated
600,000 who were uninsured in 2006 – now have coverage.14
Nearly three-quarters of Massachusetts employers offer health
insurance to their employees. This percentage increased from 70%
to 72% from 2005 to 2007, while the employer offer rate nationally
declined from 68% to 60% between 2001 and 2007. The number of
hospital inpatient discharges and outpatient visit claims
submitted to the Uncompensated Care Pool declined by
approximately 13% overall during October through June 2007
(compared to the same period in 2006). The cost of acute hospital
claims submitted during this same period declined by 8%
compared to 2006.13
These early outcomes – primarily the greater than expected
enrollment rates in the program’s first 18 months – have generated
extensive hope for the program’s success. However, a consequence of
the high enrollment is that the program is projected to cost $153
million more than budgeted, even before taking into account the
continued growth in enrollment expected over the next several
months. The newly insured also seem to be increasing the volume of
overall medical visits, generating reports of shortages of primary care
providers.14
LABORATORY OF THE STATES
The states provide a valuable testing ground for solutions to
sustainably increase the accessibility of health care to the community.
As such, it is important to this overall effort that state governments
– and we as health care professionals – not resist trying something new,
generating or testing innovative solutions. Taking carefully calculated
risks and learning from the outcomes drives progress toward more
accessible care for all.
Hospital case management professionals have a unique viewpoint
to add to the discussion. Their collective voice can only be heard
through seizing opportunities to advocate to politicians for health care
coverage and for funding of specific projects that will provide health
benefits for the communities that they serve.
It is clear, however, that an efficient and satisfactory model to
provide all individuals access to health care – either backed by the state
government, federal government or privatized – has not yet been
developed. The laboratory of the states is still struggling with the
appropriate mechanism for coverage.
Additionally, the changing limits of medicine change the needs
and wants of the public – and therefore public perceptions regarding
what constitutes “basic” health care and should be provided to all. For
example, a 1962 Life Magazine article described the difficulties of
deciding who would receive life-saving dialysis treatments. The
limitations on dialysis candidates and treatments have changed
drastically since then.15 Antiviral medications have changed HIV/AIDS
from a rapidly fatal disease to a chronic disease. On the other hand, the
limits of medicine must also be acknowledged, and what medicine can
accomplish should not be overpromised. The growing public
expectations and other important public needs necessitate
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compromises. Truly universal care remains a lofty goal. Pursuit of this,
however, must be carefully crafted within the context of what is
important to the community being served.
Cynthiane J Morgenweck
Morgenweck, MD, MA, is currently a Clinical Ethicist
at the Center for the Study of Bioethics at the Medical College of
Wisconsin in Milwaukee, WI. She was previously an anesthesiologist at
St. Nicholas Hospital in Sheboygan, WI for 13 years. Dr. Morgenweck earned
her MD and MA at the Medical College of Wisconsin. She is board certified
in Anesthesiology.
ENDNOTES
1 Putsch, RW, and Poloti, L. “Distributive Justice in American
Healthcare: Institutions, Power and the Equitable Care of Patients.”
American Journal of Managed Care. 2004; 10:SP45.
2 Beauchamp, TL, and Childress. Chapter 6, “Justice,” in Principles of
Biomedical Ethics. 1994, 4th edition, Oxford University Press.
3 Stanford Encyclopedia of Philosophy.“Distributive Justice.”
Downloaded June 2, 2008.
http://plato.stanford.edu/entries/justice-distributive/
4 Rothman, DJ. Chapter 4, “Dialysis and National Priorities,” in
Beginnings Count
Count. 1997. Oxford University Press.
5 Garland, MJ, and Hasnain, R. “Community Responsibility and the
Development of Oregon’s Health Care Priorities.” Business and
Professional Ethics Journal. 1992; 9:183.
6 Bodenheimer, T. “The Oregon Health Plan – Lessons for the Nation,
First of Two Parts.” New England Journal of Medicine. 1997;337:651.
7 Bodenheimer, T. “The Oregon Health Plan – Lessons for the Nation,
Second of Two Parts.” New England Journal of Medicine. 1997;337:720.
8 http://www.oregon.gov/DAS/OHPPR/HSC. Prioritized list of
health care services for Oregon, downloaded October 15, 2007.
9 Oberlander, J. “Health Reform Interrupted: The Unraveling of the
Oregon Health Plan.” Health Reform, 2007; 26:w96.
10 Altman, SH, and Doonan, M. “Can Massachusetts Lead the Way
in Health Care Reform?” New England Journal of Medicine.
2006;354:2093.
11 Steinbrook, R. “Health Care Reform in Massachusetts – A Work in
Progress.” New England Journal of Medicine. 2006;354:2095.
12 McDonough, John E.; Miller, Michael; Barber, Christine. “A Progress
Report on State Health Access Reform.” January 29, 2008.
Downloaded June 4, 2008. http://www.allhealth.org/
briefingmaterials/HealthAff-McDonough-1207.pdf.
13 Massachusetts Division of Health Care Finance and Policy.
Health Care In Massachusetts: Key Indicators. January 1, 2008.
http://www.mass.gov/Eeohhs2/docs/dhcfp/r/pubs/08/key_
indicators_0108.pdf.
14 Alliance for Health Reform. “Massachusetts Health Reform:
Bragging Rights and Growing Pains.” May 19, 2008. Downloaded
June 4, 2008. http://www.allhealth.org/briefing_detail.asp?bi=128.
15 Alexander, S. “They Decide Who Lives, Who Dies.” Life Magazine.
November 9, 1962.