Although public policy must take account of these cultural sensitivities, a willingness to recognize priorities and set limits seems to be proportional to the level of frustration with ever-increasing costs. 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.
The principal factors that determine the state of health of a population such as income, education, agricultural production and marketing, transportation, and housing, are not a direct part of the health sector at all. Within the health sector the most important elements are public health activities such as water supply and sanitation, food inspection, vector insect control, disease surveillance, reduction of industrial pollution, and regulation of pharmaceuticals. “Most people, who rarely come into direct contact with public health activities, do not think of these as health care functions” ((Frick, K., Jensen, P.L., Quinlan, M. and Wilthagen, T,