財政危機下で健康改善に取り組む知事／米国医療事情　ニューヨーク州医師の一分/ウェブリブログ

財政危機下で健康改善に取り組む知事／米国医療事情　ニューヨーク州

<< 作成日時： 2009/01/12 00:08 >>

　N.Y.U.ランゴーンメディカル・センターにCenter for Healthful Behavior Change健康によい行動変化のためのセンターと呼ばれる新しい研究センターができた。
　財政が厳しいときにはお金がかからない挑戦に挑むのがスマートな政治家である。ブルームバーグ市長とシュワルツネッガー知事の影響は大きい。
　州知事David A. Patersonの最も攻撃的な提案は、ソフトドリンクの砂糖に対して18%課税し、5%消費を減らし、収入を4億ドル集めることである。ニューヨーク市の主導をうけ、トランス脂肪を禁止し、レストランチェーンでのメニューにカロリー表示をさせ、貧困地域で健康食品を売る市場を増加させた。学校でジャンクフードを禁止したいと考え、また、州北部の5都市で中学生にもっと歩くような要請を妻を代理にして推し進めた。子どもから29才までの扶養家族をカバーする健康保険計画をたてた。現在典型的な保険では子どもは18才、または大学生なら22才までカバーし、ニューヨークの無保険者の1/3は19-29才である。
　過去40年の証拠から、リスクのある人の多くが発症しないことも理由の一部として、予防はほとんど医療費を下げないことを明確に示したと、Louise B. Russell教授は言う。しかし、予防により、メディケア・メディケイド医療費削減になると人々は主張している。
　禁煙と肺疾患の防止には関連するデータがあるが、ソフトドリンク課税やジャンクフード禁止と健康との関連を示すデータがほとんどない。ライフスタイル変化の効果を立証するものか、Bloombergが市長に選ばれた2001-2006年でニューヨーカーの寿命は15ヶ月延びたという。
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A Governor With No Money Seeks to Improve the People’s Health
By ANEMONA HARTOCOLLIS
Published: January 10, 2009
http://www.nytimes.com/2009/01/11/nyregion/11health.html

Snacking on shrimp and carrot sticks, doctors and nurses gathered at N.Y.U. Langone Medical Center to celebrate the opening of a new research center called the Center for Healthful Behavior Change.

They were tapping into the spirit of the times, and now Gov. David A. Paterson has done so as well, turning the familiar call for political change into an appeal for healthful living as he promotes a number of anti-obesity measures, from a sugar tax on soft drinks to posting calorie counts in chain restaurants.

He has joined what has become a movement looking inward, asking people to blame themselves for their bad health. But behind the governor’s agenda there is a truth as constant as failed New Year’s resolutions: Lifestyle changes are easier said than done. Changing ingrained behavioral patterns, doctors say, can be as hard as getting legislators to pass an income tax increase.

At the N.Y.U. opening, in mid-December, Dr. Robert I. Grossman, dean of the School of Medicine, said it was “relatively easy” to define molecules or understand abnormal conditions. But, he added, “Our failure as a society has really been to appreciate the difficulty in modifying behavior.”

It is hard to fault the governor for trying. When there is no money, the challenge for smart politicians is to present an agenda that does not seem to cost anything. His health agenda, much of it needing legislative approval, echoes public health campaigns pioneered by Mayor Michael R. Bloomberg in New York City and Gov. Arnold Schwarzenegger in California.

His most aggressive proposal is to charge an 18 percent tax on sugary soft drinks (but not diet drinks), which he estimates would reduce consumption by 5 percent and raise $400 million in revenue. Following New York City’s lead, he wants to ban trans fats in restaurants, require chain restaurants to post calorie counts, and increase the number of markets selling healthy foods in poor neighborhoods. He also wants to ban junk food in schools and has deputized his wife, Michelle Paige Paterson, to encourage children in middle school in five upstate cities to walk more.

In what may prove to be his most appealing proposal, at least for families, the governor wants to require insurance plans that cover dependents to insure children up to the age of 29. Typically, insurance plans now cover children through the age of 18, or 22 if they are in college, and nearly one-third of New York’s uninsured are 19 to 29 years old, according to the governor. He said the cost would be borne not by employers, but by families, who would be able to take advantage of group rates.

As Governor Paterson summarized it, “Preventing illness is a good investment.”

But experts say that while prevention has intuitive appeal ― everyone knows the old saw that an ounce of prevention is worth a pound of cure ― its ability to save money and lives may be overrated. The devil, as it is so often, is in the details.

“There’s a lot of buzz about prevention,” said Peter J. Neumann, director of research at the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center in Boston. “In general, I am sympathetic to that, but you have to be careful about what you’re claiming and about the science and the evidence.”

The evidence over the last 40 years has shown overwhelmingly that prevention rarely reduces medical costs, partly because many people who are at risk of a disease may not develop it, said Louise B. Russell, a research professor at the Institute for Health, Health Care Policy and Aging Research at Rutgers University. But, she said, “It’s what people keep claiming when they say we’ll just cover more prevention and that will save Medicare and Medicaid costs.”

While there is good data that links stopping smoking to preventing lung disease, she said that as far as she knew, there was little data on the health value of a soft-drink tax or of banning junk food in schools. This is partly because the value is so hard to measure. People who are deterred from buying soda might substitute other sugary drinks. Students deprived of junk food might still nibble some of the candy they sell for school fund-raisers.

Dr. Russell said that what struck her about the governor’s agenda was that it took health care outside of the medical sector, like food and water regulations. “You don’t go to a doctor’s office, you go to a greenmarket,” she said. “You’re not in a hospital when you get those calorie counts.” To some degree, she said, the governor’s seemingly low-cost proposals represent a subtle kind of cost-shifting, with little recognition of the impediments. It may be hard to walk in suburban neighborhoods with no sidewalks, or hard to leave work early to go to the gym or cook a healthy meal when jobs are scarce. “In fact, time is one of our ultimate scarce resources,” Dr. Russell said.

Ron Z. Goetzel, director of Emory University’s Institute for Health and Productivity Studies, agreed that institutional support, like opening up staircases at work or flexible scheduling, is important when it comes to lifestyle changes.

Still the evidence for the efficacy of lifestyle change may be trickling in, according to Mayor Bloomberg, who recently celebrated a 15-month increase in life expectancy for New Yorkers between 2001, when he was elected, and 2006.

The N.Y.U. center’s director, Dr. Olugbenga G. Ogedegbe, said his own studies showed that patients were turned off by being told that something terrible would happen if they did not take their medicine or eat right or exercise. “Positive psychology can help in the adoption of healthful behavior,” he said.

Of course, the beauty of the governor’s plan is that if you fail, you have only yourself to blame.

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　州知事デイビッド A. パターソンは、ニューヨークの皆保険へのステップとして、雇用者が提供する健康保険の扶養家族の年齢を19-29才に広げることを提案した。現在は、雇用者は18才(大学生なら22才)より以上なら扶養家族への健康保険提供義務はない。無保険の19-29才の約800,000人への保険を提供することになる。景気後退により社会のセイフティネットを強化することと、支出の大幅削減がセットである。
　無保険者の31%が19-29才であるという。大学を卒業して健康保険を提供する仕事に就くまでは無保険のままであり、求人市場が悪化する中で多くの若者が無保険のまま過ごすことになる。
　州ビジネス協議会の会長は、提案を「注目に値する」とした。
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Paterson Would Insure Dependents Up to Age 29
By JEREMY W. PETERS
Published: January 6, 2009
http://www.nytimes.com/2009/01/07/nyregion/07state.html

ALBANY ― Gov. David A. Paterson will propose that private employers be required to offer health insurance to workers’ dependents who are ages 19 to 29, part of what the administration hopes will be a step toward universal health care coverage in New York.

Mr. Paterson plans to call for the legislation during his State of the State address on Wednesday afternoon.

“This year, we will take another important step as we move toward increasing access to coverage for all New Yorkers,” Mr. Paterson said in a written statement on Tuesday.

Currently, employers are not required to offer health insurance to dependents who are older than 18 or, if they are in college, 22.

The proposal would amount to a wide expansion of coverage to some 800,000 people 19 to 29 years old who are uninsured. And it ties into a continuing initiative by Mr. Paterson, who is asking the State Legislature to approve deep cuts in spending this year, to enhance the kinds of social safety nets that are overwhelmed during an economic downturn.

According to the governor’s office, 31 percent of New York’s uninsured are ages 19 to 29. Many of them lose coverage once they graduate from college and remain uninsured until they are able to find a job that offers health insurance. But as the job market worsens, the state anticipates that the issue will become more pressing, with more and more young people unemployed and uninsured.

If the Legislature approves the proposal, the state expects that about 10 percent, or 80,000 people, will take advantage of it.

Paterson administration officials said that the plan would not cost the state or businesses anything. The only cost would be to families that chose to pay for the expanded coverage.

Kenneth Adams, president of the Business Council of New York State, a group that represents businesses across New York and was briefed on the plan by the governor’s advisers, called the proposal “compelling” and said that it would be especially critical given the economic climate.

“Out of the gate, a program that gets 80,000 New Yorkers health insurance is a good thing,” Mr. Adams said. “Considering where the economy is right now, and that by definition this is a tough period for this age group to obtain insurance, it is a very important issue.”

Mr. Paterson’s legislation would round out proposals to expand access to health care that he laid out in his budget for the 2009-10 fiscal year, which begins on April 1.

One proposal would simplify the application process for public health insurance programs by eliminating the requirement for face-to-face interviews, among other things. Another proposal would expand eligibility for the state’s Family Health Plus insurance program, which covers people who exceed the limits for Medicaid eligibility.