Education And Debate

Retracing the Oregon trail: the experience of rationing and the Oregon health plan

BMJ 1998; 316 doi: (Published 27 June 1998) Cite this as: BMJ 1998;316:1965
  1. Chris Ham, professor of health policy and management (
  1. Health Services Management Centre, University of Birmingham, Birmingham B15 2RT
  • Accepted 13 May 1998

A decade ago the state of Oregon attracted worldwide interest when it began an ambitious attempt to set priorities for health care on a systematic basis. Stimulated by the death of a 7 year old boy who had been waiting for a bone marrow transplant operation, and led by John Kitzhaber, a doctor turned politician, Oregon passed legislation in 1989 designed to provide access to health insurance for all residents. A key part of the strategy was to increase eligibility for Medicaid, a publicly funded programme of health care for people with low incomes, by including in the programme all citizens with an income at or below 100% of the federally defined poverty level. To keep the costs of this policy within affordable limits, the legislature determined that the services provided should constitute a basic healthcare package, and it sought to ensure that Medicaid recipients were, whenever possible, enrolled in managed care plans. These plans, often known as health maintenance organisations, have developed rapidly as an alternative to fee for service medicine, and provide services to those enrolled on a prepaid basis. By managing the use of services by both patients and doctors, health maintenance organisations seek to reduce the overall cost of providing care while maintaining high standards of provision.

Summary points

The basic healthcare package available to those eligible for Medicaid coverage under the Oregon health plan has been expanded. Enrolment in Medicaid has increased by over 100 000 since 1994 but eligibility criteria have been tightened in response to rising costs

The proportion of the population that remains uninsured has fallen from 18% in 1993 to 11% in 1996 as a result of implementation of the plan and economic growth

Providers of safety net services may not be able to continue to provide such services under the plan's payment …

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