"As the fractious debate over reforming the American health care system gets underway, the discussion should take its' cue from an unlikely source: the late author, Gertrude Stern. Grappling on her deathbed with the mysteries of the cosmos, Stern asked, 'What is the answer?' Hearing no response she rephrased it: 'In that case, what is the question?'"

The sad fact is that there are more easy answers circulating than there are tough question about the health system's problem. The majority of Americans are insured either by employment-related, private, or government health insurance. However, this arrangement leaves about one-sixth of the nonelderly, about 37 million people, totally uninsured. The problem of the uninsured is one of this country's most prominent flaws.

Large numbers of uninsured people pose a major national health problem for several reasons. Most important, there is much evidence that the uninsured have difficulty in gaining access to the health care system and, if and when they do gain access, it is too late or too expensive to treat their health problems.

The uninsured are the heterogeneous group, varying in income, employment, and age. To provide insurance for the uninsured, three wide courses of action are possible: leave the situation as it is, restructure the existing system, or use a step-by-step approach to the problems. Keeping the situation as is would be the most expensive course of action, and restructuring, proposed during the late 1970s, was never adopted. Therefore, a series of policies designed to fill in the gaps on a step-by-step program seems to be the only remaining alternative.

The state of Oregon has been considering a way to become the first American state to guarantee basic health care to each and every one of its' citizens. This step-by-step program was originally developed by State Senate President, John Kitzhaber, a physician familiar with the problems of delivering health care to the poor. The program would be funded from current Medicaid funding plus, undoubtedly, some funding from the federal and state government. This program offers the uninsured a basic level of care. The main problem is that serious decisions must be made because the proposed program would only emphasize preventive care and curable, life threatening diseases and illnesses. The Oregon plan divisers set up a commission to prioritize diseases. Based on "common sense" and what they learned through public hearings, the commissioners established a list of diseases on which the available money would have the "highest benefit" and a list of diseases on which the available money would have the "lowest benefit."

The diseases with the "highest benefit" are pneumonia, tuberculosis, appendicits, hernias and injuries to the major blood vessels of the upper body. Those diseases with the "lowest benefit" include benign cysts, minor cuts and bruises, breast and kidney enlargement, terminal AIDS, and birth defects in which the infant has very little or no chance of surviving. Overall, the concept is to spend a limited amount of money where it can do the most good for the society.

The program has generally been supported throughout Oregon. Some critics are concerned that the proposed program rations health care, but supporters of the program note that health care is already rationed by whether a patient is insured or not. This way everybody receives a basic level of health care. Others believe the state government should not be making such life and death decisions.

On the other hand, supporters feel that Oregon is just the first state ready and willing to make these decisions. The increasing cost of health care, combined with strained state budgets, will inevitably lead other states to implement similar plans of basic health care for everyone. In fact, at least ten other states are currently considering legislation to extend health care to all its citizens.

Currently, health care services for the uninsured are being paid for primarily from out-of-pocket expenses, by clinics and public hospitals, and to a lesser degree, by private hospitals. The new approach shifts part of this burden to employers, the insurers, or the state and federal government.

It is clear that the United States government should implement a program similar to that of Oregon. This program will work for us because it will discourage over-utilization and abuse of health care services, yet it will not prevent uninsured individuals from obtaining necessary health care. This new program very well may be an answer to on of our nation major health care problems.

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