respiratory depression and ventilatory failure was notdiagnosed, resulting in a profound, life threateningrespiratory acidosis. The diagnostic problem may havebeen compounded by the supplemental oxygen, whichmay have maintained the oxygen saturation in spite ofrespiratory depression.

Ideally, the only satisfactory method of monitoringventilation is to measure both the adequacy of oxygen-ation and the adequacy of carbon dioxide elimination.Pulse oximetry is non-invasive, easy to use, and widelyavailable. End tidal carbon dioxide concentration,however, is more difficult to measure (capnography),and, although routinely measured in the operatingtheatre, is not widely measured elsewhere. The alter-native of measuring arterial blood gases will indicateP02 and Pco2, but the procedure is more invasive andat best is performed only intermittently.

As this case shows, respiratory depression maydevelop insidiously, may not be revealed by routinemonitoring of vital signs, and may be present despite anormal oxygen saturation. Clinicians should beaware of the limitations of oximetry and not rely on thistechnique as the sole means of assessing the adequacyof ventilation, be it in a critically ill patient in theintensive care unit or a patient receiving sedation forminor surgery. Moreover, if respiratory depression orfailure is suspected the adequacy of carbon dioxideelimination should be assessed.

1 Brown EB, Miller FA. Ventricular fibrillation following rapid fall in alveolarcarbon dioxide concentration.Am7Physiol 1952;169:56-60.

2 Severinghaus JWl, Astrup PB. History of blood-gas analysis VI: oximetry.Journal of Clittical Monitoring 1986;2:270-88.

(Accepted 29 March 1993)

Rationing in Action

Prioritising health services in an era oflimits: the Oregon experience

John A Kitzhaber

This paper is based on a speechgiven at the conference onPriority Setting in the HealthService, London, March 1993.A collection ofpapersfrom theconference will be published inbookform later this year.

The Hundredth MeridianLtd, PO Box 961, Salem,OR 97308, USAJohn A Kitzhaber, president;past president, Oregon StateSenate

BMJ 1993;307:373-7

How do we decide who should receive the benefitsthat medical science has to offer? One approach tothis decision process, that used by the state ofOregon, is described: who and what are covered, andhow health care is financed and delivered, areconsidered. Oregon's priorities were set on the basisof broad consensus. The objective of health carereform, it was agreed, is to improve, maintain, orrestore health-not universal coverage, access tohealth care, or cost containment. A Health ServicesCommission was created to consider clinical effec-tiveness and, through public involvement, to attemptto integrate social values into the priority list.Oregon's legislature can use the list to develop anoverall health policy which recognises that healthcan be maintained only if investments in severalrelated areas are balanced.

As we approach the end of the twentieth century,health care systems around the world are strugglingwith the dual problems of cost and access. Althoughthere are vast differences between the British systemand the American system-and between these systemsand those in Canada, Germany, or New Zealand-there is a central issue shared by all nations: what arewe buying with our health care dollars and what isthe relationship between these expenditures andhealth?As populations age and technology expands the cost

of health care rises. At the same time we find ourselvesfacing the need for increased investments in education,in infrastructure, in transportation systems, and inaddressing a host of other pressing social problemssuch as environmental pollution, crime, and substanceabuse. The competition for limited public resourcesbetween these diverse needs means that we can nolonger afford to do everything that medical science hasto offer for everyone who might benefit from it. Inshort, we must set priorities. The question is, how dowe decide?

In this paper I will examine how this question wasanswered in the state of Oregon. My purpose is not toconvince you of the merits of the Oregon process, norto draw any conclusions about its possible relevance tothe United Kingdom. Rather, my purpose is todescribe our experience as objectively as I can and toshare with you what insights I have gained through the

experience from my dual perspective as both anAmerican politician and a primary care physician.

Framework for health care reformHealth care reform can be viewed as a debate over

how to answer three questions-Who is covered? Whatis covered? How is it financed and delivered?-askedin the context of an ultimate objective. (This frame-work is drawn from Aristotle's "teleologic" view ofchange, according to which change (or reform) must bedriven by a clear objective, or final cause, and by threesubsidiary factors: the material cause, the formalcause, and the efficient cause.) Successful reform,then, must start with consensus on a clearly articu-lated objective and must explicitly answer these threequestions in a way that is consistent with that objective.The need for consensus on an objective may sound

obvious, but consider the current national health carereform debate in the United States, where the objectiveseems to be to reduce cost, to improve access, or both.But is reducing cost really the end or is it the means toan end? Why do we want to reduce costs? Because costis a major barrier to access. Why do we want people tohave access to health care? Because we want people tobe healthy, which is important to individuals and toour society. Thus, both reducing costs and improvingaccess are actually means to an end-the end, orobjective, being to improve, maintain, or restorehealth. I will elaborate further on this point later.

Who is covered?Now let us tum to the three questions. The first

question-"who is covered?" is not really at issue-orat least is not particularly controvesial. Currently in theUnited Kingdom, for example, or in Canada, or NewZealand, the answer to this question is "everyone."These countries have developed systems in whichvirtually all citizens have coverage for some level ofhealth care: universal coverage-with eligibility basedgenerally on citizenship.The United States, however, has never had a

national policy of universal coverage. In fact, eligibilityfor coverage under the two major govemment financedprogrammes, Medicaid and Medicare, is based noton citizenship but rather on category. These two

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programmes were enacted in 1965 in reaction toPresident Johnson's Task Force on Health, whichreported that elderly people and children in lowincome families faced the greatest financial barriers toaccess to good health services. The task force recom-mended that Congress expand matemal and childhealth programmes for the poor and enact publiclyfinanced hospital insurance for the elderly. Thusthe objective was not universal coverage but rathercoverage only for those interest groups or "categories"which, in 1965, were perceived to have the greatestdifficulty gaining access to the system.As a result Medicaid is a programme that provides all

"medically necessary" services to certain "categories"ofpoor people but not to all poor people. To be eligibleone must fit into a congressionally designated "cate-gory" such as families with dependent children or theblind or disabled. Just being poor is not enough. Poormen and women without children, for example,are ineligible even though they may be deeply im-poverished. In other words, the United States hasdeveloped a system that makes an artificial distinctionbetween the "deserving poor" (those who fit into acategory) and the "undeserving poor" (those whodon't). Medicare, on the other hand, is a federallyadministered "entitlement" programme for those inthe category over the age of 65. It is not means tested,so everyone over the age of 65 receives publiclysubsidised health care regardless of whether they retirein poverty or on $2 million a year.Under this categorical approach to eligibility wealthy

retired citizens, such as former presidents JimmyCarter and Ronald Reagan, are entitled to publiclysubsidised health care that is paid for in part by the taxcontributions of working poor citizens who have none.Under this system, millionaires over the age of 65are entitled to coverage for all the latest medicaltechnology while poor childless women are entitled tono coverage whatsoever-not even for basic preventivecare of proved effectiveness-until or unless theybecome pregnant.

What is covered?Due in large part to these gross inequities, there is

broad and growing consensus in the United States thatuniversal coverage for some level of health care must bea central part of reform. For that reason, most of thecurrent debate revolves around the third question, howis it financed and delivered? The debate over globalbudgets and managed competition, over "pay or play"

mechanisms or a single payer system-all are varia-tions on the answer to this question. The crucialquestion of what is covered, however, goes largelyunaddressed.

In the United Kingdom the issue of priority settingin the National Health Service (the focus of a recentconference in London) is an attempt to come to termswith the question of what is covered? Answering thisquestion is the fundamental common challenge ofhealth care systems around the world. The UnitedKingdom has a system of universal coverage butin order to afford it people are beginning to askthemselves what they are buying for their health caremoney and what the relation is between those expendi-tures and health. In the United States, although thecurrent administration continues to shy away from thisissue, it is clear that to achieve universal coverage wemust ultimately come to terms with the question of"coverage for what?"

Hospitalisation only? prescription drugs? immuni-sations? organ transplants? new technologies? experi-mental procedures? facelifts? liposuction? sex changeoperations? everything? nothing? Is it significant thatadvocates for reform are very vague on this issue. Wehear such words as "comprehensive" or "basic" or"medically necessary," but nowhere do we hear adefinitive explanation of exactly what that means interms of real health services. President Clinton haspromised to provide all Americans access to a "basic"level of health care, but he has not defined exactly whatconstitutes "basic" care, nor has he outlined a processby which it can be clarified.

Unless we define basic care as "everything foranyone who might possibly benefit from it"-which isincompatible with both deficit reduction and makingother important social investments, some ofwhich alsoaffect health-then some difficult choices will have tobe made. And of course we are reluctant to take thisstep because when we define what constitutes basiccare we must also define what is not basic, and I can tellyou from personal experience that confronting thisissue is very controversial. Yet to avoid it is to continuethe futile debate over how to pay for "something" for"someone," which is like debating the budget for abanquet for which there is no defined menu and noguest list.We are reluctant to come to terms with this issue, at

least in the United States, because, although we areunwilling (and increasingly unable) to pay for every-thing, we are also unwilling to set limits. Not only issetting limits politically unpopular, in the process ofdoing so-in the process of determining the level ofcare to which all citizens will have access-society mustcome to terms with the relationship between theprovision of health care and the pursuit of health;with the relative effectiveness and appropriatenessof medical services and procedures; with issues ofadministrative costs and medicolegal liability; withissues of social expectations and individual responsi-bility; and with a host of difficult moral and ethicalquestions.

Clearly, the question of what is covered is the most, difficult, the most controversial, and yet perhaps the2 most important of the three. It is the sine qua non ofm lasting health care reform, and for that reason there

must be a process by which it can be answered-aDprocess that involves the public, is linked to the realityof fiscal limits, and has clear lines of accountability

| Setting Oregon's objectivesz As I mentioned earlier, to answer meaningfully the8 three questions ofwho is covered, what is covered, and| how it is financed and delivered, there must first be

consensus on the objective. Reaching broad based

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consensus on the objective was the starting point of theOregon Health Plan. We asked ourselves whether theobjective was to give all Oregonians access to healthcare, or to keep Oregonians healthy. We determinedthat the objective must be health-not universal cover-age, not access to health care, not cost containment,but rather, health. Health care is a means to an end, notan end in itself-that is, health care is not necessarilysynonymous with health.

Infant mortality, for example, reflects more than justa lack of prenatal health care. It also reflects housingproblems, environmental problems, teenage preg-nancies, and the growing problem of substance abuse.The point is that we cannot achieve the objective ofhealth as long as we spend money only on the medicalcomplications of substance abuse, yet ignore the socialconditions that lead to addiction in the first place. Andthat means having the budgetary flexibility to invest insuch things as housing, education, and economicopportunity.Beyond that, it should also be clear that medical

procedures are not of equal value and effectiveness inproducing health. For example, nearly half of theMedicare budget is spent on the last few months of lifeand it is estimated that well over half of the costs ofintensive care units are expended on non-survivors. Byno stretch of the imagination could these expendituresbe said to be effective or to produce health. Too oftenthey merely prolong the process of dying.Thus, the primary objective of health care reform

efforts must be to develop not merely a strategy topurchase health care, but rather a health policy-anintegrated approach in which expenditures for healthcare are balanced with expenditures in related areaswhich also affect health. In addition there must besome criteria by which to ensure that the expenditureswe make for health care actually produce health.

Let us assume, for the purpose of argument, that weagree on a policy objective of health. This means thatthe three questions must be answered in a way thatmaintains, improves or restores health. The OregonHealth Plan represents a process and a framework bywhich this can and was accomplished (box 1). As Idescribe this process, I will touch only briefly on howwe answered the questions of who is covered andhow it is financed and delivered; I will focus most ofmy attention on the question of priority setting-onanswering the central question ofwhat is covered.

Who is covered? How is it financed?

To the question "who is covered" Oregon answered"everyone" since access to some level of health care isclearly necessary to achieve the objective of health.Universal coverage was accomplished through theenactment of two bills in 1989. Senate Bill 27 extendedeligibility for Medicaid to all those with a familyincome below the federal poverty level ($991/monthfor a family of three). Senate Bill 935 mandatedcomparable employment based coverage for full timeworkers and their dependants with family incomesabove the federal poverty level. That is, we expandedthe role of government in subsidising care for the poorand built on our existing employment based system ofcoverage. (As currently written the Oregon HealthPlan will provide coverage for 95% of Oregoniansunder the age of 65 (those over 65 are covered by

Medicare). It misses part time workers with incomesabove the federal poverty level and seasonal workers,who may spend part of the year outside the state.)Thus, to the question of how is it financed, Oregon

answered: "through a public-private partnership."Society, through general tax revenues, was responsiblefor those without the ability to pay, while those withincomes above the federal poverty level would receiveworkplace based coverage with the costs split betweenthe employer and the employee.

What is covered?The move toward universal coverage (a policy Great

Britain has already achieved) shifted the debate from"who is covered?" to "what is covered?" To answer thequestion of "what is covered?" in Oregon, a HealthServices Commission was created, consisting of fiveprimary care physicians, a public health nurse, a socialworker, and four consumers. The members wereappointed by the governor and confirmed by the senateafter public hearings. The commission was chargedwith developing a "list of health services ranked inpriority from the most important to the least important,according to the comparative benefits of each service tothe entire population being served" and judged by aconsideration of clinical effectiveness and social values.To carry out the requirement to consider clinical

effectiveness, the commission used medical "condition-treatment pairs" gleaned from two widely recognisedclassifications of diagnosis and treatment, the CurrentProcedural Terminology (the CPT-4 codes) and theInternational Classification of Diseases (the ICD-9codes). Examples of condition-treatment pairs areappendicectomy for acute appendicitis, antibiotics forbacterial pneumonia, and bone marrow transplant forleukaemia. The initial list of nearly 3000 pairs was

substantially reduced by combining those for whichtreatment and outcome were essentially the same. Forexample, there are multiple codes to describe variouskinds of uncomplicated fractures of the long bones ofthe upper arm. Since the treatment for such fractures isessentially the same, and since outcomes are similar,these codes were consolidated into a single condition-treatment pair. By this process the initial list of some3000 pairs was reduced to around 1000.The determination of clinical effectiveness was

based on the input of panels of physicians who wereasked to provide certain clinical information abouteach condition-treatment pair in their areas of practice.Over 7000 hours of volunteer time were given byOregon physicians to this effort. We recognise thatmuch of this information represents a consensus byphysicians rather than hard empirical outcomes data.None the less, it provided a snapshot on how medicinewas currently being practised in Oregon and offered a

starting point and a rational framework in which betterinformation on outcomes could be integrated as itbecame available. It is also important to note that theprioritisation process is dynamic and ongoing. That is,a new priority list is generated each budget cycle to takeinto consideration new technologies and new infor-mation on outcomes.

In addition to a consideration of clinical effective-ness, the commission set up a broad based publicprocess to identify and attempt to integrate socialvalues into the priority list. The statute specified thatthis public involvement take three forms. Firstly, thecommission was required to "actively solicit publicinvolvement in a community meeting process to builda consensus on the values to be used to guide healthresources allocation decisions." Secondly, the commis-sion was required to hold a series of public hearingsaround the state and to solicit "testimony and infor-mation" from a full range of health care interests

BMJ VOLUME 307 7 AUGUST 1993

Box 1-The Oregon Health Plan

Objective: HealthWho is covered? Everyone (universal access)What is covered? Uniform basic benefitHow is it financed? Public and private partnership

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including all recognised advocacy groups for variouspopulations and illnesses and all recognised health careproviders. Finally, the legislation required that theHealth Services Commission and all of its proceedingsbe subject to full public disclosure under Oregon'sopen meetings laws, which govern public bodies.

Involving the publicThe Health Services Commission, aware of the

importance of public involvement to the success of itswork, went well beyond the outreach process requiredby the legislature. It immediately contacted the varioushealth care interest groups in the state (especiallyadvocates for the poor, the uninsured, and forconsumers in general) and enlisted their assistancein generating public participation. By encouragingattendance at Health Service Commission meetingsand hearings, and by soliciting testimony, we sought toensure that the commission received input and infor-mation from the broadest possible citizen base. Whileit is clear that our initial efforts to involve a representa-tive cross section of citizens can and must be improved,the level of public participation in the commission'swork was unprecedented, even in a state that pridesitself on open and accessible government.To fulfil the legislative requirement for a community

meeting process, the commission turned to OregonHealth Decisions, a grassroots bioethics organisationfounded in 1983 by Ralph Crawshaw, a Portlandpsychiatrist, and Michael Garland, an ethicist at theOregon Health Sciences University. Dedicated toeducating Oregonians on the health policy choicesconfronting them and on the consequences of thesechoices, Oregon Health Decisions had been con-ducting community discussions on a variety of ethicalissues for nearly 10 years. Under the auspices of thisgroup the Health Services Commission organisedthe most extensive town hall meeting process ever

conducted in the state. The initial objective was to haveat least one town hall meeting in each of Oregon's 36counties. Not only was that objective met but multiplesessions were conducted in more densely populatedareas, bringing the total number of town hall meetingsto 47.

After the meetings were completed, the resultsand opinions of the participants were tabulated andassembled into a report for use by the Health ServicesCommission and the legislature. The resulting docu-ment, Health Care in Common, was used extensively bythe Health Services Commission in its deliberationsand stands as an exceptional example of constructiveactivism by a dedicated group of citizens.The first priority list, completed in February 1991,

consists of 709 condition-treatment pairs divided into17 categories. The priority of the categories is based on

the Commission's interpretation of the social valuesgenerated from the public involvement process.Within each category the ranking of the condition-treatment pairs reflects the benefit likely to result from

each procedure and the duration ofthe benefit. (Mentalhealth services as well as physical health services are

included in the plan; a somewhat different prioritysetting process was needed for chemical dependencyservices.)

Services in the highest category were those for acute,fatal conditions where treatment prevents death andreturns the individual to his or her previous health state(such as an appendicectomy for appendicitis) (box 2).Because of the high value placed on prevention bythose participating in the community outreach process,the categories of maternity care (including prenatal,natal, and postpartum care) and of preventive care forchildren ranked very high. Also ranked high as a directresult of the outreach process were dental care andhospice care. At the bottom of the list were categoriesof services for minor conditions, futile care, andservices that had little or no effect on health status.The final priority list was given to an independent

actuarial firm, which determined the cost of deliveringeach element on the list through capitated managedcare. The list and its accompanying actuarial data weregiven to the legislature on 1 May 1991.

Balancing the health care budgetSince the legislature is statutorily prohibited from

altering the order of the priorities as established by theHealth Services Commission, it was required to start atthe top of the list and determine how much could befunded from available revenues and what additionalrevenues would be needed to fund an acceptable"basic" package (box 3). In this way, the question"what is covered?" was directly linked to the reality offiscal limits.

Furthermore, since the state could no longer arbi-trarily "ration people" for reasons of budgetaryexpediency, everyone retained coverage (universalcoverage) and the debate centred on the level of thatcoverage: on the answer to the critical question, what iscovered?-on what we as a society are willing to fund,and thus guarantee, to all of our citizens.

Because of Oregon's constitutional requirement fora balanced budget, it was clear that increases in thehealth care budget must come at the expense of otherprogrammes such as education or corrections. Thisenabled the legislature to begin to develop an overallhealth policy which recognises that health can bemaintained only if investments in several related areas

are balanced.Finally, because of the list and the explicit nature of

the process, the legislature is clearly and inescapablyaccountable not just for what it funds in the health care

budget but also for what it chooses not to fund. Thiskind of accountability is a major departure from thecurrent system.As a result of this accountable and explicit process

the 1991 Oregon legislature reached consensus on thedefinition of basic care by appropriating $33 million innew revenue, which funded all condition/treatmentpairs through line 587 on the list of 709. The resultingbenefit package, with its strong emphasis on primaryand preventive care, is eminently defensible (box 4).

BMJ VOLUME 307 7 AUGUST 1993

Box 3-Results of the Oregon Health Plan'sprocess

* Recognition of fiscal units* Universal coverage* Health policy* Clear accountability* Consensus definition of "basic care"

Box 2-High ranking priorities* Acute, fatal conditions where treatment prevents

death and leads to full recovery* Maternity care

* Acute, fatal conditions where treatment preventsdeath but does not lead to full recovery

* Preventive care for children* Chronic, fatal conditions where treatment prolongs

life and improves its quality* Comfort care

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It covers the initial evaluation and diagnosis for allconditions, virtually all current Medicaid mandates,including all preventive and screening services, as wellas a number of important services not required byMedicaid, including dental services, hospice care,prescription drugs, routine physicals, mammography,most transplants, and physical and occupationaltherapy. (Because the prioritisation process is dynamicand ongoing, a new list was submitted to the 1993legislature. This second list consists of 494 line items.Funding the new list through line 563 would beequivalent to the benefit level originally funded by the1991 legislature. At the time of this writing, thelegislature had not yet completed its deliberations on

funding the new list.)It is important to recognise that the benefit package

we have funded serves as the minimum standard notonly for the Medicaid programme but also for the360 000 Oregonians who will come into the system on

the employer side by 1995. By then the package willbecome the standard benefit offered by all privatepolicies in the state.

Finally, the Oregon Health Plan includes a "liabilityshield" for providers-a statutory distinction betweenactual medical malpractice and not providing a servicethat society has determined not to fund. This will helpreduce defensive medicine and will allow society, notthe courts, to determine the level of care it wishes toguarantee to all of its citizens. Furthermore, it willallow the development and actual implementation ofpractice standards without substantially increasingthe risk of medical malpractice suits. Perhaps mostimportantly, however, it will allow health care pro-viders to continue to be patient advocates within thecontext ofthe resources society has made available.This then, is the Oregon Health Plan. On 19 March,

1993 the Clinton administration granted Oregon the

ANY QUESTIONSAre there any health hazardsfrom baggage scanners?

The question presumably relates to x ray examinationof baggage, such as that found in airports. The systemsare subject to the requirements of the Ionising RadiationsRegulations 1985 and the associated approvedcode of practice. This code requires the doserates at positions where members of the publiccan have access to be less than 1 ,uSv/h. For com-

parison, the dose rate in a jet aircraft at cruisingaltitude, due to cosmic radiation, is approximately5 ,uSv/h.The highest dose rates exist close to the lead rubber

flaps at the entrance and exit points, but these are

accessible only to the hands of the operators and over

a year the integrated exposure time at these positionsis relatively short. The equipment will have several

federal waivers necessary to proceed with implementa-tion. At the time of writing, the Oregon legislature wasin the process of funding the new priority list, and theprogramme is expected to be operational by 1 January1994.

Results ofconsensusAlthough viewed as controversial outside the state,

the plan was enacted with broad based support. It wasnot achieved through confrontation nor by trying tofind villains and scapegoats. Rather, it represents a

consensus building exercise that was supported bythe Oregon Medical Association, the Association ofOregon Hospitals, consumer groups, organised labour,and the business community. It passed both houses ofthe Oregon legislature with huge majorities in bothparties.Our success was due in large part to our willingness

to challenge openly two of the underlying assumptionsof the current American health care system: that healthcare is synonymous with health and that all medicalservices are of equal value and effectiveness. We may

pretend that this is not so, but as Thomas HenryHuxley pointed out, "Facts do not cease to exist justbecause we choose to ignore them." The fact is that wehave become obsessed with the delivery of health care

rather than with the pursuit of health. It may becontroversial and politically unpopular to reduce"benefits," but if by benefit we mean something thatmaintains, restores, or improves health then much ofwhat we currently spend our health care budget on

would not qualify as benefits and could thereforebe eliminated without "rationing" health care andwithout adversely affecting health.As I stated at the beginning of this paper, it has not

been my purpose to convince you of the merits of theOregon process nor to draw any conclusions about itspossible relevance to the United Kingdom. I believe,however, that ultimately Britain too must explicitlyanswer the question, what is covered. Whether thisanswer is arrived at through a process such as the one

we used in Oregon or by some other means is notimportant-what is important is that it be done. And ifthere is one thing we have shown in Oregon, it is thatit can be done-through a process which bringsthe public and the medical community together incommon cause to work for the common good.

Copies of Health Care in Common can be purchased from

Oregon Health Decisions, 921 SW Washington (Suite 723),Portland, Oregon 97205. Copies of the priority list and of thereport of the Health Services Commission can be purchasedfrom the Office of Medical Assistance Programs, Writer'sGroup, 500 Summer NE, Salem, Oregon 97310-1014.

engineered safety features that limit the potential forexposure to radiation and will be subject to routineinspection, including the measurement of accessible doserates. Staff operating this type of equipment are unlikelyto exceed a few tens of p.Sv in a year or a percentage or so

of the 2200 ,uSv a year that is routinely received on averagefrom natural sources of radiation.The equipment is designed such that photographic film

passing through the x ray beam will not be noticeablyaffected by the radiation. To achieve this the x rays are

collimated to a fine pulsed beam that scans across theconveyor belt, and sensors build an image of the baggage.The worst case scenario is of a young child getting on theconveyor and being carried through. Measurements haveshown that in such circumstances the radiation dosewould only be a few ,uSv.Thus there are no important radiation hazards.

JR cRoFr, head, Southern Centre National RadiologicalProtection Board

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Box 4-Consensus definition ofbasic care

* Initial evaluation and diagnosis* All preventive and screening services* Dental services* Hospice care* Prescription drugs* Routine physical examinations* Mammography* Most transplants* Physical and occupational therapy* Virtually all Medicaid mandates

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