Problems go beyond paying to cover the uninsured
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We've been here before.

We've heard the words 'health care crisis.' The health care system is broken - we've been told that before, too. We've even watched Salem legislators and lobbyists haggle over a new model for delivering health care. Everyone remembers the Oregon Health Plan, circa 1994.

The Oregon Health Plan seemed like a good idea at the time, with its emphasis on prioritizing medical interventions and its intent to deliver at least basic care to everybody. But here we are, looking at a number of new models for delivering health care to Oregonians, including the nearly 600,000 uninsured. Whatever the Legislature comes up with, it won't be enough.

The hard truth is, not much is really going to change if all we do is provide care to the uninsured. Increasing the number of people getting insurance certainly isn't going to solve the problems of skyrocketing health costs.

It is impossible to reconfigure something if you don't know its real cost.

In this issue of Rethinking Portland we look at the latest proposals for new health plans and two places - Massachusetts and San Francisco - that are about a year ahead of us. We start by examining some of the costs of health care that often get overlooked.

A case in point:

A little over a year ago, a Medford medical transport car took a patient who lived three blocks from a hospital in Medford all the way to Portland for treatment. The patient was mentally ill, suffering psychosis, and there were no available beds for psychiatric patients in the Medford hospital. Its last one had just been taken - by a psychiatric patient transferred to Medford from a Portland hospital.

There are a number of reasons such an inefficient game of musical hospital beds can and does occur regularly in Oregon, including a lack of beds for psychiatric patients.

But forget the reasons. Consider the costs - both overt and hidden. Consider the human cost of taking two people suffering psychotic episodes, strapping them into transport cars and driving them five hours to hospitals far away from anything they might consider home. And consider the costs to the hospitals and, down the line, to insured Oregonians, who end up footing the bill for most of the care for these two patients.

Another cost: The two psychiatric patients, before their transfers, were housed in hospital emergency departments, where doctors and nurses had to keep a close watch on them when they could have been attending to other patients.

This issue of Rethinking Portland examines:

All of us

Rethinking health care doesn't mean looking exclusively at hospitals and doctors. It also requires that we all take a long hard look in the mirror.

Every time we take an elevator even though the stairs are nearby, every time we stop at a fast-food restaurant because we're just too tired to think of a healthy diet tonight, every time we approve a housing development that's not within walking distance of a grocery store or school, we're opting for spending more dollars on our health care down the road.

The failure of nearly a decade of public education to stem the rising obesity rate is fueling our high rates of chronic diseases. It appears likely that soon we will witness a new era of public health initiatives to tackle the lifestyle choices that we have been unable to handle ourselves. In the '80s and '90s, public health policy took on smoking. Diet and exercise probably are next.

The shortsightedness of traditional attitudes toward the mentally ill

When policymakers in Salem talk about redesigning health care, they rarely spend much time on the mentally ill. But our section on mental illness reveals how the costs of not providing adequate treatment for the mentally ill is one of the great hidden expenses not only in health care, but for city, county and state social services as well.

We look at how some other cities are addressing the same problems, and we explore why, if you are young and destined to suffer serious mental illness, Salem is a better place to live than Portland.

What top hospital executives most fear

We asked them, and they agree it is a projected shortage of doctors, nurses and technicians that may leave them unable provide the level of care we expect. We examine the causes, and possible fixes.

Places where efficiency rules

There are fundamentally different models of health care worth looking at, including one in Portland. The federal Department of Veterans Affairs has pioneered high-tech primary care that is measurably better for most patients, and at lower per-patient cost, than the care at our private hospitals. We take a look at Portland's Veterans Affairs Medical Center to see how they're doing it.

The immeasurable: quality of life

One of the rarely-talked-about issues affecting health care costs is the technology that increasingly allows us to perform ever more expensive medical miracles. No answers here - there is no formula to calculate the value of a few extra days or weeks or months in an individual's life. But we offer a provocative personal story by one woman watching the medical costs pile up as she cares for her dying mother.

We conclude Rethinking with our own list of suggestions for improving the health of Oregonians, and also the system by which health care is delivered. But don't expect those recommendations to focus on the game of give and take currently being played out in Salem.

The health care problems facing Oregonians run deeper than who will pay for what. And the costs of our current outdated attitudes is much greater than can be measured in dollars and cents.

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