A Prescription Plan Hailed as a Model Is a Budget Casualty
The New York Times
March 5, 2003
By TIMOTHY EGAN
PORTLAND, Ore., March 3 - In a state that says it is already
so short of public money it does not have enough to keep all the schools open and
prosecute many criminals, Oregon took another drastic step this week
to cover budget shortfalls: it cut off medications to thousands of
schizophrenics, manic-depressives, drug addicts and others
who are poor and have no health care.
A decade ago, Oregon was widely hailed as a pioneer in providing
ealth insurance, including prescription drug coverage, not only to the poor but
also to people who make just enough money that they do not qualify
for most federal Medicaid programs.
Now, in a reversal that has stripped a once ambitious program to its core,
Oregon has pared back the insurance, and removed prescription drug
coverage for things like mental illness and drug addiction. Most of the cuts
went into effect March 1, but others started Feb. 1, just days after
Oregonians voted in a referendum against a tax increase to balance their budget.
And while state officials are looking for some way to restore some
of the health program, they admit that they will not be able to offer anything like
the expansive benefits of the past.
So throughout Oregon this week, about 100,000 poor people
are suddenly scrambling for the basic medications that allow them to function.
For Dave Cesario, 45, who is H.I.V. positive, diabetic and on methadone
to stave off addiction to heroin, it meant going cold turkey Saturday.
"I'm just numb; I don't know what to do," said Mr. Cesario, who lives
with his disabled wife and 12-year-old son. "My only hope is that the drug
companies will have mercy and I'll be able to get some free samples."
For Karen Hansen, 50, who has prescriptions for everything
from anxiety disorder to high blood pressure, the cutoff means taking only the few drugs
that will keep her alive. She lives on $689 a month
in Social Security disability payments,
and her monthly prescription bill, without assistance, is
$615.
"I don't buy the newspaper, I eat hot dogs that they give out free and
get other meals from the food bank," Ms. Hansen said. "But that only saves
about $200."
The step is the latest response to a budget crisis that led state
officials to make nearly $600 million in cuts in the last two years, and will require
another $2 billion in reductions, according to projections, in the new
budget cycle that begins this June.
Hit by a harsh recession after a series of tax-cutting measures
pared the budget to the bone, Oregon, which has no statewide sales tax, now lacks
enough money for health care, schools, prisons and criminal prosecution.
Portland schools had planned to cut nearly five weeks off the school
calendar this year. But teachers agreed on Monday to work two weeks without
pay, and that offer - together with a plan for a temporary business tax - looks
as if it will now save the school year. But the state has announced
plans to close a number of schools.
Prisons have let out some criminals early. And starting today,
prosecutions of people arrested for theft and drug crimes are being delayed because
there is not enough money for prosecution or legal defense. Officials say those
arrested are being released and may be tried later, in the summer, if
the legislature can come up with new funds.
The latest round of cuts came after Oregonians considered a
referendum in January on whether to raise taxes temporarily. The measure was
narrowly defeated, after opponents of the tax increase said the state
could find ways to cut without major consequences.
Unable to raise taxes, and having cut financing for police, prosecutors and schools,
state officials turned to the Oregon Health Plan. They ordered
the board that governs the plan to decide how and where to cut. It chose
to revert to more basic coverage, stop paying for many prescription drugs
and charge higher premiums and co-payments.
Dr. Patricia Kullberg, medical director of the health department
of Multnomah County, which covers Portland, said she just did something she had
never done in 21 years as a family physician: she advised a patient
which medications he could stop taking and suffer the least. The patient lost his
prescription drug benefit for arthritis, depression, high cholesterol and hypertension.
"I feel like I'm living in some foreign country where suffering is
routine," she said. "It's scary. What we're doing is condemning people to the
long-term consequences of their diseases."
The hardest hit, say state officials, are the mentally ill. Jim Underwood,
a mental health specialist with Cascadia Behavioral Healthcare in
Portland, said his patient Robert Seaman, 47, a paranoid schizophrenic,
was likely to become delusional again without his medications.
Mr. Seaman had trouble responding to questions in an interview.
"Without his meds, he has trouble with getting food, shopping, all the basic survival
things," Mr. Underwood said.
The legislature is working this week on a temporary patch. The proposal
would take video poker and cigarette tax money and drain a reserve fund to
make up an immediate shortfall of $250 million. If this passes, and
it appears it will, it would restore medications for only about two months.
Mary Ellen Glynn, a spokeswoman for Gov. Ted Kulongoski, a Democrat,
said the next two-year budget could be even worse, because voters refuse to
raise taxes. "We're in real double-bind," she said.
Advocates for the mentally ill put the issue more starkly.
David Eisen, clinical director for Central City Concern, a private nonprofit
agency that provides care for drug addicts and the mentally ill, said people
whose basic medical needs were met by prescription drugs costing
the state about $90 a month per person, were now going to start showing up in
hospital emergency rooms, or jail, where they will cost the state far more.
"The people who made this decision thought they could save a few million
dollars," Mr. Eisen said. "But the crime rate will rise, emergency rooms
will be flooded with people, and in the end, the state is going to pay
five to eight times more than they would have saved."
In most states, the federal Medicaid program covers the basic medical
needs of the poor. Oregon was given a waiver to shape its own program
because it promised to provide near-universal coverage for the poor,
something only a handful of states have tried to do. In good times, the plan
worked, and it was widely praised as a resourceful use of limited public funds for health care.
One measure of its success was that Oregon has one of the lowest percentages
of mentally ill people in institutions. Prescriptions and mental
health clinics have allowed people to work, or live in community settings,
without presenting a danger to themselves or others, state health officials
say.
Critics of the plan, however, said it was allowed to grow too fast,
and even though Oregon rationed out services - drawing up a list of what would be
covered and what would not - it still proved too generous.
State Representative Jackie Winters, a Republican, said that over the last 20 years,
social services in the state have quadrupled, far in excess of population growth.
"We expanded beyond the basics, and now we realize
you can't cover everything you want," Ms. Winters said.
Now a number of legislative committees are studying ways
to redo the Oregon Health Plan. Even if state revenues become less anemic, the plan is
unlikely ever to be as ambitious or far-reaching as it was, supporters and opponents say.
And for now, the cutbacks mean that most people
who were given coverage have lost their prescription drugs. Some are now wandering the streets
or screaming in public squares.
About one-fourth of the 400,000 people covered by the
Oregon Health Plan lost prescription coverage in two rounds of cuts
over the last month and half.
Tony Tescara, 66, who lives on $630 in Social Security, relies
on heart medication from the state. When he heard we was cut off - after his
pharmacists refused to fill a prescription - he says he panicked.
"It was a big shock," Mr. Tescara said. "I took extra nitro pills,
just worrying about this medical thing. I called my caseworker and said, `What am I
supposed to do now?' She said call the doctor and ask for samples."
Mr. Tescara said he was ashamed to beg for medicine.
"I feel like I'm a lowlife looking for handouts," he said.
"I'm not. It's the first time in my life I
have to ask for help."
State officials say relying on free samples, which thousands
of Oregonians are doing this week to get their medications, will help only the luckiest.
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