Health care reform.  OK, I said it.  If you are like most Americans, you have reacted with either hope or horror.  That is because, in my view, millions of dollars have been spent to turn this phrase into a symbol of everything you like or don't like about modern life.

One thing most Americans don't like is being told what to do.  If doing that thing also costs money, it will be downright disgusting.  Telling an American that s/he HAS to buy health insurance fits this description to a tee.  

A very small minority of Americans are health policy nerds.  These folks understand that Americans spend more on health care and get less for their money than any other citizenry.  They also understand that costs are escalating at an alarming rate and this not only affects the health of Americans but also the competitiveness of American business in the world economy.  Not only do Americans not want nerds to run their lives, the don't think nerds HAVE lives.

I mention all this because on August 26, Oregon Senator Ron Wyden sent a letter to Bruce Goldberg who is the director of the Oregon Health Authority.  Ron (I can call him "Ron" not only because everyone else does but we used to play basketball together a few centuries ago), said that he wants to help Oregon get a waiver from the federal health care reform law.  For any nerds reading this, that law is the "Patient Protection and Affordable Care Act (PPACA).  The waiver would allow Oregon move forward with an insurance exchange and minimum benefit package without requiring people to buy insurance.

Ron states: "the heart of real health reform is affordability and not mandates."  Not, apparently, being one to dawdle, Dr. Goldberg (I usually call him Bruce because this is Oregon and everyone does) replied two days later.  He agreed!  He says that Oregon is a perfect place to test the idea that families will choose to purchase insurance policies if they are affordable.  Oregon, he states, is well underway in creating a "value based benefit package" and a health insurance exchange that can provide an excellent testing ground for the nation.

Is this a good idea?  Some national critics think not.  If Oregon is allowed to sidestep the individual mandate, they say, other states that are less well-intentioned will follow.  Insurance companies may throw huge resources into lobbying future (less progressive) administrations for waivers that undermine the expansion of health care coverage for Americans.

I'm inclined, however, to side with Ron and Bruce (they can just call me Bob).  I'm totally convinced that we must have health care reform in order to improve America's health, eliminate injustice against those with disabilities and other pre-existing conditions and "bend the cost curve" of medical coverage.  But I recognize that, as Americans, we don't like being told what to do.  We don't mind, however, being shown what works.  

The laws governing Medicaid are still based on outdated preferences for institutional care.  But waivers have allowed progressive reforms to move forward that improve people's lives, honor their civil and human rights and save money.  Waivers do not allow (in most cases) states to "throw grandma under the bus" even though it may seem that way at times.  

Lastly, in order to bend that curve, some tough decisions will need to be made.  Oregon has worked hard to get public participation at all levels of decision-making.  This will continue to be essential and may provide a model for other states.  (Even I have sat with the nerds to explain why disability rights must be factored in.)

In this grown-up game of show and tell, the special interests have done a lot of telling.  Now it's time to let Oregon show how it's done.