There are questions
that pierce deeper than policy.
Questions that cannot be answered
with charts or numbers alone.
Who should receive care?
When resources are finite,
who gets helped
and who is asked to wait?
In the early 1990s,
the state of Oregon
did not look away from this question.
It stepped forward—
not with a perfect answer,
but with the courage to ask.
This was the beginning of
The Oregon Health Plan:
an attempt to make health care decisions
explicit,
transparent,
and justifiable.
And in doing so,
it walked into the tender terrain
where ethics meets economics.
The Radical Act of Ranking
Oregon’s idea was simple,
and deeply controversial.
- Define a basic level of care
the state could afford for everyone. - Rank medical treatments by cost-effectiveness
and potential to improve life. - Cover the highest-ranking treatments first—
and draw a line where the budget ended.
It was a rationing system,
but one done in the open.
Not hidden in backlogs
or in who could afford to wait.
For the first time,
a government asked out loud:
If we can’t do everything,
what should we do first?
And the silence that followed
was heavy with discomfort.
When Numbers Meet Lives
In theory, the plan made sense.
Use data.
Use public input.
Build a system that treats the most people
with the most benefit.
But people are not data.
And suffering is not easily ranked.
What happens when a child’s rare disease
falls below the cutoff line?
When a treatment is effective
but not “efficient”?
What is the value of one more month
of life,
of clarity,
of goodbye?
These were no longer academic questions.
They were real.
And they broke hearts
even as they balanced budgets.
The Dignity in Choosing With Eyes Open
The Oregon Health Plan
did not solve the healthcare crisis.
It faced backlash.
It required revisions.
It struggled with implementation.
But it did something
most systems avoid:
It admitted that choices are being made every day—
whether we name them or not.
Because when resources are limited,
not choosing
is still a choice.
The plan chose transparency
over pretense.
It asked for public voice
instead of quiet exclusion.
It said:
Let us name what we value.
Let us choose together.
That, in itself,
was a kind of justice.
The Questions That Still Echo
The Oregon experiment is decades behind us now.
But the questions remain:
- What does fairness look like
when not everyone can be helped at once? - How do we balance compassion
with sustainability? - Can a system be both rational
and humane?
There are no perfect answers.
But there is a deeper wisdom
in asking the questions anyway—
in building systems that are accountable
not just to logic,
but to the lives they touch.
A Closing Reflection
If you find yourself frustrated
with the way help is given—
who receives care,
who is left out—
pause.
Ask:
- Do I believe that every life has equal value?
- If we must choose,
how do we choose with courage and transparency? - What would it look like
to design not just a system,
but a shared ethic of care?
Because the hardest part of compassion
is not feeling it—
it is structuring it.
Making it real.
Making it last.
And in the end, the Oregon Health Plan reminds us
that decisions are always being made—
about who is seen,
who is served,
who is saved.
And when those decisions are brought into the light—
imperfect, painful, human—
we move one step closer
to a world where care is not silent,
but spoken.
Not hidden,
but shared.
And in that speaking,
we begin to build a more honest
kind of justice.