A much-cited example of rational priorities for medical care comes from the state of Oregon, where a commission was appointed in 1989 to make recommendations to the state legislature on how to expand coverage and set priorities in the Medicaid program. Underinsured people were to be added to the Medicaid list to cover every resident whose income was below a certain level, but this could be afforded only by reductions in the benefit package. After much consultation with health professionals and public hearings and community meetings held throughout the state, the commission produced a list of almost 700 condition-treatment pairs grouped in 17 categories and ranked according to priority. According to the plan the Medicaid program would pay only for items above a certain cutoff point on the list, to be determined from time to time by the legislature. The plan was implemented in 1994 and has been politically popular among the general public and with Medicare recipients. As of 1998 it is limited to relatively poorer persons eligible for the state Medicaid program, and has not been extended to the general public. "Managed care has been the single most dominant force which has fundamentally transformed the delivery of health care in United States since the 1990s" (Shi, L. & Singh, D., 2004, p. 324).
Once each year there is a major conference of representatives of the funds, the regional associations of physicians, hospitals, and pharmaceutical companies, to work out the contribution rate and other details for the underinsured. The government does not provide any funding to the system but is very active in regulating and monitoring it.
The basic features of the social-insurance-based health system have been adopted in many parts of the country. The welfare-oriented systems have been greatly modified. As the social security movement developed, with sickness insurance as a general priority, a great variety of plans for indemnification, prepayment of costs, and contracts with providers has emerged, each a product of intense negotiations. Four parties emerged with major roles:
Participants or fund members (often represented through a group such as a labor union).
Employers and their organizations (usually when unions were involved).
Providers, especially the medical profession but also including hospitals and therefore often religious and charitable organizations.
Governments at various levels.
It is mainly because of the tugging and pulling of these diverse interests that US had really been able to integrate or even to coordinate fully the diverse health programs accumulated over the decades. Nevertheless, a general consensus in the country holds that health care and insurance for under and uninsured are a community responsibility, and participation of all parties in these programs has broadened in various directions.
Some states have merged existing insurance schemes into more comprehensive national programs. Nevertheless, private insurance and fee-for-service programs may continue to operate vigorously in these states. Sometimes there are several parallel systems: a percentage of inhabitants are classified as group I members with free access to the services provided, while the remaining were