Monday, March 05, 2007

Gang of Seven

Q: How many people does it take to fix a broken healthcare system?
A: A Gang of Seven.

About a year ago, Karen Whitaker Knapp, outgoing director of the OHSU Center for Rural Health, sat down with interviewer Dr. Reid "Sam" Connell for our Oral History Project. After talking about the circuitous route that had brought her into a career in healthcare, Knapp fielded this question from Connell:
CONNELL: Karen, you've kind of hit upon a pivotal event that occurred in 1988 and around Joseph, Oregon, with the Enterprise group. I also—and you’ve talked about that a bit, but I've heard another kind of an expression of a group of people that met, and it was called the Gang of Seven.

KNAPP: Oh. [Laughs]

CONNELL: I think something that followed the 1987 Oregon legislative session. Can you tell me, what is the Gang of Seven?
While it may sound like a group of gangsters, the Gang was committed to a very worthy goal. Knapp went on:
Well, this was a group of us who were lobbyists. One of the members, well, actually there were a couple of state officials and a person who was staffed to one of the legislative committees who also participated in this group. But we got together and decided that it was time to have a different healthcare system in Oregon. Sort of a young, ambitious, arrogant way of looking at things. So we all were in some way indebted to an organization or a point of view. We agreed to take our hats off at the door, come in the door, and begin to examine, explore, what an ideal healthcare system would be composed of. And we met weekly for, I think, into the next session, so probably about a year and a half. We probably didn't make it every single week, but that was our goal. And we had some very lively debates. So for people who enjoy health policy, it was great fun to sit down with some of these people who had wonderful minds. I felt like I really didn't measure up to the caliber of the rest of them, but I was very happy to be a part of it.

So we came up with a model that we called the compression model. And we had a sort of a straight line of people who were privately insured on one side, and government-sponsored on the other side, and the uninsured people in the middle, with a gap maybe this big [demonstrates]. So the idea was that you put pressure on both sides, and you bring it together in the middle so that the little gap is only this big, instead of this big.

And recognizing that there are always going to be people that you cannot enroll, even if the resources are available. And I think, like the Canadian health system, recognizes that about five percent of the population never gets enrolled because of their lifestyle. You know, they may be very transient; they may not have access to regular kinds of services. So you have primary care clinics, for safety net clinics, for those people.

We envisioned that not only would we grow the Medicaid program, we'd also grow the employer-sponsored programs. And so part of that would be to require employers to provide health insurance to their employees. And to provide tax credits, particularly for small businesses, to be able to make that leap into providing health coverage. And to support the safety net clinics. And also to change the state Medicaid system in some way that would make it run more efficiently.

So we were quite proud of ourselves. And we pitched this idea to John Kitzhaber and Vera Katz at the Night Deposit Café in Salem. It has since closed. But it used to be quite a hangout for legislators. And John was the Senate President, and Vera was Speaker of the House. So John liked it, and he took it. And he added some of his own elements to it, making it his own. And that was, most especially, the ordered list of services, which hadn't occurred to any of us. That was a whole new idea to us.

But when he introduced the Oregon Health Plan in the '89 session, it included all of those components, including a risk pool for people who are uninsurable, who could not get standard insurance because of preexisting conditions. And that risk pool is still in existence, by the way. It included a mandate for employers to provide health insurance and tax credits. And it raised participation in state Medicaid to 100 percent of the federal poverty level. And completely eliminated categories of coverage that were federally defined, like aid to dependent children, foster children, the elderly and the blind and the disabled. Anyone who was less than 100 percent of the federal poverty level could join the Oregon Health Plan. And they were subject to a restriction of coverage that had to do with the list of paired diagnoses and treatments that the state actually came up with during a series of statewide meetings. So there was a lot of public input to this whole process.

And it all passed. Which was astonishing. Associated Oregon Industries even supported it. And, you know, we were all euphoric. We thought that was probably the best thing that ever happened. But they did put a later implementation date on the employer-mandated insurance. And sure enough, leadership had changed by the time the next legislature came into session, and they repealed that part of it. So there could not be overwhelming success without all—you know, it's like a three-legged stool. You had to have all of the parts working together, or it just couldn't work. Because the idea was to eliminate the cost shift. And if it had actually happened, it would have done that.
Who were the members of this revolutionary group? Knapp could come up with only five of the names: Barney Speight, Dick Grant, Tom Lundberg, Bruce Bishop, and Ed Patterson. The last member of the Gang will apparently remain anonymous pending further investigation...

So, let this be a lesson for the bright-eyed activists out there who might be lamenting the current state of affairs in Oregon, the plight of those who remain uninsured, and the political hurdles that face reform at both local and federal levels. Get six of your friends together, stand ont the backs of giants, and hammer out a compromise--because where there is a will, there can be a way!

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