Nearly five years ago, Oregon began putting an idea to work that seemed both harsh and humane: In return for health insurance paid by the government, the poor would be required to join health maintenance organizations and have their care rationed.
Most tonsillectomies, infertility treatment, hernia surgery and removal of bunions would be denied. The program would support preventive and hospice care and, starting this month, doctor-assisted suicide, but rule out heroic intervention to stretch a life for a week or two.
With that, the state calculated, it could afford to provide basic care for all the poor _ the goal of universal coverage that eluded President Clinton four years ago. With rationing, Oregon became the sole U.S. outpost of an approach to care that is routine in most developed countries.
But the Oregon Health Plan is hitting roadblocks. The state has abandoned its promise of universal care. Doctors routinely find ways to get around the rationing. And conflicts with federal Medicaid regulators have impeded efforts to deny more treatments.
Spending for the plan climbed to $2.1-billion in the 1997-to-1999 state budget period from $1.7-billion in the 1995-to-1997 period.
Higher cigarette taxes have not offset the increase, requiring more money from the state's general fund. A program that was once free now charges premiums of $7.50 to $28 a month for a family of four, and purges from its rolls those who do not pay.
There are 340,000 Oregonians covered by the plan, with 350,000 still uninsured.
"Structurally, the plan is the right approach," said Donald Sacco, president and chief executive of Regence Blue Cross Blue Shield, the state's biggest health insurer and HMO company. But he added, "To get to the next increment, we're going to have to spend more money, and to do that is a question mark."
Policy analysts still call Oregon's program innovative and promising. From 15 percent, the state says the uninsured population has dropped in five years to 11 percent. The national average has remained about 16 percent.
Other states have looked at the program with interest, but want to see more results before experimenting with such a radical plan.