Thinking and Deciding

DECISION ANALYSIS AND RELATED METHODS 313
The benefit of a health treatment is not something that comes in units like acres
or dollars. Health has value because people value it. Nor can we consult the market
price to determine how much people value health. There is no store where you can
buy a cure for migraines or a bad back. You can buy treatments that might help,
but their price is not determined by the free market. Most people who get these
treatments have insurance, so they do not pay the cost. Ultimately, the best way to
assign values to treatments is to ask people to judge their utility.
This is just what the state did. It appointed a commission to elicit utility judgments
from the public. The idea was to measure the benefit of various treatments.
Then the benefit would be divided by the cost, and each treatment would be assigned
a number representing its benefit per dollar, that is, its utility per dollar. The treatments
would then be ranked by this measure. Those with the highest benefit per
dollar would be at the top. The state would then go down the list, one by one, figuring
out how much money it would have to spend per year on each treatment. When
it ran out of money, it would draw a line. It would not cover anything below the line.
This way, the state would get the most total benefit for the dollars availalble. Notice
that any switching above and below the line would make things worse. If some treatments
below the line cost the same as some above it, then switching the two groups
would mean that less benefit was obtained for the same cost. (The estimates were
not exact, so it would not be possible to “cheat” by moving a rare treatment above
the line, on the ground that it just used up the small excess left over.)
Initially, opponents saw the plan as another way to pick on the poor, who were
already picked on enough. Indeed, the very poor who qualified for Medicaid got a reduction
in coverage. In 1987, Coby Howard, a seven-year-old boy, died of leukemia
after being denied a bone-marrow transplant under Medicaid because the legislature
had already decided not to cover such transplants. This was not part of the Oregon
Health Plan, but it raised fears of more of the same. This kind of treatment is exactly
what would be cut off. It was very expensive and very unlikely to succeed. (Now the
plan covers such transplants routinely.) But Kitzhaber and others rallied support for
the plan, and it went ahead.
The commission made up a list of 709 condition-treatment pairs. Each pair was
evaluated in terms of alleviation of symptoms, quality of life, and cost. To rate the
utility of the symptoms, the commission did a telephone survey of Oregon residents.
Each respondent rated twenty-three symptoms on a scale from 0 to 100, where 0 represents
“as bad as death” and 100 represents “good health.” The symptoms included
such things as “burn over large areas of face, body, arms, or legs” (rated about half
as bad as death), “trouble talking, such as lisp, stuttering, hoarseness, or inability to
speak,” and “breathing smog or unpleasant air” (rated closest to good health). The
respondent also rated descriptions of limitations in mobility, physical activity, and
social activity, such as health related limitation in some social role.
Experts then used these ratings to determine the average benefit of each treatmentcondition
pair. They took into account the duration and probability of the benefits
of treatment, compared to what would happen without the treatment under consideration.
Then these benefits were divided by the cost to get the average benefit per