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Feasible Models of Universal Health Insurance in Oregon According to Stakeholder Views

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Feasible Models of Universal Health Insurance in Oregon According to Stakeholder Views Portland State University PDXScholar Dissertations and Theses Dissertations and Theses 1-1-2012 Feasible Models of Universal Health Insurance in Oregon According to Stakeholder Views Terry Richard Hammond Portland State University Follow this and additional works at: https://pdxscholar.library.pdx.edu/open_access_etds Let us know how access to this document benefits ou.y Recommended Citation Hammond, Terry Richard, "Feasible Models of Universal Health Insurance in Oregon According to Stakeholder Views" (2012). Dissertations and Theses. Paper 500. https://doi.org/10.15760/etd.500 This Dissertation is brought to you for free and open access. It has been accepted for inclusion in Dissertations and Theses by an authorized administrator of PDXScholar. Please contact us if we can make this document more accessible: [email protected]. Feasible Models of Universal Health Insurance in Oregon According to Stakeholder Views by Terry Richard Hammond A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Urban Studies Dissertation Committee: Margaret Neal, Chair Neal Wallace Chad Cheriel Anthony Rufolo Barbara J. Friesen Portland State University ©2012 i Abstract This study collects the views of 38 health policy leaders, answering one open-ended question in a 1-hour interview: What state-level reforms do you believe are necessary to implement a feasible model of universal health insurance in Oregon? Interviewees represented seven groups: state officials, insurers, purchasers, hospitals, physicians, public interest, and experts. About 370 coded arguments in the interview transcripts were condensed into 95 categorical topics. A code outline was constructed to present a dialogue among stakeholders in one comprehensive narrative. Topical sections include the cost imperative, politics, model systems, insurance, purchasing, delivery system, practice management, and finance. Summary results show the prevalence of group attention to each topic, group affinities, and proximity correlations of different arguments mentioned by individuals. The most common arguments related to problems of low-value care and delivery system reform. There was a generally felt imperative to control costs. Regarding universal health insurance, stakeholders were split between two main alternatives. One model, favored mostly by insurer and purchaser groups, supported the state-sponsored individual mandate. This plan, embodied in the current Oregon Action Plan to implement universal health insurance, involved managed competition for insurers and clinical governance over professional practice. A separate set of arguments, favored mostly by expert and physician groups, emphasized the need for a unified public system, or utility model, possibly with centralized funds and regional global budgets. ii The ability of the individual mandate plan to control costs or manage quality appears doubtful, which strengthens opposition. The utility model is more likely to work at cost control and governance, but it disrupts the status quo and its details are vague, which strengthens opposition. Neither model is endorsed by a majority of the stakeholders, and political success for either one alone is not promising. Possibly, a close analysis of the two models could find a way to combine them and generate unified support. iii Acknowledgments I am grateful to my committee members for helping me through this long process, and for their enduring patience. I especially want to acknowledge the long mentor role delivered to me so graciously by Dr. Margaret Neal; the propelling forces applied by the late Dr. Elizabeth Kutza and Dr. Craig Wollner, who both helped shape and deepen my understanding of important issues related to the policy context in Oregon; and to Dr. Neal Wallace and Dr. Chad Cheriel for knowing best what in the world I am talking about; and foremost to the disputed passage presented to me as a challenge and inspiration by my past committee chairs, Dr. Sherril Gelmon and Dr. Anthony Rufolo. iv Table of Contents Abstract ................................................................................................................................ i Acknowledgments .............................................................................................................. iii List of Tables .................................................................................................................... xii List of Figures .................................................................................................................. xiii Acronyms ......................................................................................................................... xiv Chapters 1. Introduction ......................................................................................................................1 2. Civic Capacity in Oregon ...............................................................................................18 3. Principal Models of Universal Health Insurance ...........................................................49 4. Cost and Quality Reforms ............................................................................................101 5. The State Policy Arena ................................................................................................136 6. Methods........................................................................................................................170 7. Results ..........................................................................................................................188 8. Discussion ....................................................................................................................300 9. Conclusion ...................................................................................................................324 References ........................................................................................................................331 Chapter Sections Chapter 1. Introduction ........................................................................................................1 Defining the Problem .....................................................................................................6 Access ......................................................................................................................7 Cost Control ...........................................................................................................10 Quality of Care .......................................................................................................13 The Problem of Value ............................................................................................15 Addressing the Problem ...............................................................................................15 Chapter 2. Civic Capacity in Oregon .................................................................................18 v Social Welfare ..............................................................................................................19 Eligibility ...............................................................................................................20 Public Finance ........................................................................................................23 Federal Share..........................................................................................................25 Public Administration ............................................................................................27 Patronage ..........................................................................................................27 The old regime .................................................................................................29 Public contracts ................................................................................................30 Negative monopolies .......................................................................................32 Positive monopolies .........................................................................................33 The Idea of Insurance ...................................................................................................34 Social Insurance .....................................................................................................37 Model Diffusion ...........................................................................................................39 The Oregon Plan ....................................................................................................41 Federal Patronage ...................................................................................................43 Public Education as a Model Social Contract ........................................................45 Chapter 3. Models of Universal Health Insurance .............................................................49 Voluntary Incrementalism ............................................................................................49 Public Welfare .......................................................................................................51 Public High-Risk Pools ..........................................................................................53 Public Subsidies .....................................................................................................54 Commercial Markets ..............................................................................................55
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