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zoom RSS 医療制度改革法案が下院委員会を通過/米国医療事情

<<   作成日時 : 2009/08/02 00:16   >>

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 約1兆ドルの医療制度改革問題を残したまま、下院メンバーは金曜日に帰郷した。しかし、もっと多くのアメリカ人に医療保険を提供しようとする合意形成の始まりに至りつつある。
画像 下院のエネルギーと商業に関する委員会で、アメリカ人の約95%に健康保険を付与する医療制度改革法案が通過した。金曜日の午後、民主党の5人と共和党23人全員が反対にまわり、31対28で可決された。議会は9月以降に多くの課題が残っているが、医療制度改革への提案で多くの共通の基盤を見出した。
 数百万人の人々に適切な保険への加入を拒絶する保険会社の習慣を制限する必要性については合意がされた。保険会社は全ての希望者の加入を受け入れる必要があり、病歴や持病のために高い保険料を要求することができなくなる。また全ての保険会社は連邦政府が定める最小パッケージを提供する必要があり、ほとんど全てのアメリカ人が保険加入を要求される。
 中所得層が保険加入するのを助けるための連邦助成金の必要性についても議員の合意は得られた。貧困層にはメディケイドの適応が拡大される。
 制度改革に伴う予算をどうするのかという点と、公的プランの役割については意見がまとまっていない。
 民主党は、ある種の政府保険プランまたは非営利的な協同組合を作るべきとしているが、これは私的保険業と競合する。オバマ大統領は公的保険プランが私的保険業者を正直にしておくだろうというが、共和党は市場から私的保険業者を閉め出すことになると主張している。
 病院への支払いを減らして数千億ドルをメディケアから絞り出す提案についても議員らは合意している。サービスの量より質に代金を払うことで医療の高品質化を狙っている。
 慢性疾患を持つ人の保険加入が可能になる。これにより、健康保険維持のために転職をとどまる必要はなくなる。自己負担が軽減され、多くの予防医療での負担もなくなる。
 しかし、高所得者や事業者は新税に直面する。
 議会予算局の概算では、今後10年で保険を取得しない人はペナルティとして290億ドルを支払い、保険を提供しない事業者は1630億ドルの罰金を支払うことになる。
 1994年のクリントン政権で皆保険制法案を試みたが、エネルギーと商業委員会は成立させることができなかった。
 今回はどこが違うかといえば、「オバマ大統領のリーダーシップ」であるという。また、1990年代よりも医療問題が危機的であり、「国を倒産させる」状況にある。
 下院民主党リーダーは、3つの委員会での承認案を併合して、9月に医療法案として完成するだろうという。
 上院来週開会中だが、財務委員会で審議の準備ができていない。
 下院での動きはオバマ大統領に政治的勝利をもたらしたが、8月休会前の両議会承認という目標には届かなかった。
 高価なバイオテクノロジー薬品のジェネリック版の連邦認証制度の確立は、エネルギーと商業委員会で47対11で可決された。これにより、今後10年で連邦予算を90億ドル節約できるという。
 一定以上のプレミアの引き上げは政府の事前承認を保険業者に義務づけることを民主党は提案した。プレミアの引き上げを抑制することができるだろうという。最近10年で個人と小規模事業者は2桁の増加を経験し、無保険の増加に寄与してきたという。
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Health Bill Clears Hurdle, and Hints at Consensus
House Panel Approves Landmark Health-Care Bill
http://www.nytimes.com/2009/08/01/health/policy/01health.html
By ROBERT PEAR and DAVID M. HERSZENHORN
Published: July 31, 2009

WASHINGTON ― House members headed home on Friday, leaving behind the outlines of a nearly $1 trillion health care overhaul that is sure to draw fire from a variety of interests, but also shows the beginnings of a consensus that would provide insurance for more Americans and give them new rights in dealing with insurers.

As a final act before recessing until September, one crucial panel, the House Committee on Energy and Commerce, approved landmark health legislation that could ultimately lead to coverage for about 95 percent of Americans and create a new government-run insurance program.

The 31-to-28 vote occurred at 9:05 p.m. Friday, at the end of a session that began at 10 a.m. Five Democrats joined all 23 Republicans on the panel in voting no.

Congress still has plenty of work to do in September to blend competing, sometimes contradictory health measures, but lawmakers have found a good deal of common ground on proposals that would profoundly change the health system.

Lawmakers of both parties agree on the need to rein in private insurance companies by banning underwriting practices that have prevented millions of Americans from obtaining affordable insurance. Insurers would, for example, have to accept all applicants and could not charge higher premiums because of a person’s medical history or current illness. All insurers would have to offer a minimum package of benefits, to be defined by the federal government, and nearly all Americans would be required to have insurance.

“The glory days are coming to an end for the health insurance industry,” Speaker Nancy Pelosi said Friday.

Ms. Pelosi predicted that insurers would not block passage of the legislation, President Obama’s top domestic priority.

Lawmakers also agree on the need to provide federal subsidies to help make insurance affordable for people with modest incomes. For poor people, Medicaid eligibility would be expanded.

The chaos on Capitol Hill, combined with bitter disagreements over how to pay for the legislation and the role of a public plan, has obscured the areas of potential consensus.

“There is wide agreement on the two elements of the legislation that the public cares about most: insurance market reforms and the expansion of coverage, with subsidies,” said Drew E. Altman, the president of the Kaiser Family Foundation, which focuses on health policy.

Details of the major House and Senate bills differ, but most employers would have to provide insurance or contribute to the cost of coverage for employees, with exceptions for some small businesses.

Democrats also agree that Congress should create some type of government insurance plan or nonprofit cooperative, which would compete with private insurers. Mr. Obama says the public plan would keep insurers honest, but Republicans say it could eventually drive private insurers from the market, leaving consumers with fewer choices.

Members of both parties in both chambers want to create health insurance exchanges, where people could shop for insurance and compare policies.

Lawmakers also agree on proposals to squeeze hundreds of billions of dollars out of Medicare by reducing the growth of payments to hospitals and many other health care providers. They are committed to rewarding high-quality care, by paying for the value, rather than the volume, of services.

The major bills offer the promise of more affordable insurance for people who are uninsured, including those with chronic illnesses. Under the legislation, it might be easier for people to switch jobs because they would not have to stay in less desirable jobs just to retain health insurance. The bills promise relief to people with huge out-of-pocket health costs and would eliminate co-payments for many preventive services.

But high-income people and some businesses would face new taxes. In an analysis of the House bill, the Congressional Budget Office estimated that people without insurance would pay $29 billion in penalties over the next 10 years, while employers not offering insurance would pay penalties totaling $163 billion.

The Energy and Commerce Committee was unable to deliver a bill when the nation last tried to guarantee universal coverage, under President Bill Clinton, in 1994. Asked what was different this time, the current chairman, Representative Henry A. Waxman, Democrat of California, said: “The leadership of President Obama. He made it a very strong, clear priority. He had a mandate from the American people to pass legislation that would provide every American with affordable coverage.”

Moreover, Mr. Waxman said: “The issue is a lot more severe than it was in the 1990s. Fewer stakeholders ― doctors, patients, hospitals or insurance companies ― want the present system to continue. It will bankrupt the country.”

House Democratic leaders said the health care bill would be on the floor in September, after they meld versions approved by three committees. The Senate will be in session next week, but the Finance Committee chairman confirmed Thursday that his panel was not ready to take up the issue.

Action by House committees gives Mr. Obama a fragile political victory. But it fell far short of his original goal, which called for both houses of Congress to approve the legislation before the August recess.

The Energy and Commerce Committee voted, 47 to 11, to establish a procedure for federal approval of generic versions of expensive biotechnology drugs. Representative Anna G. Eshoo, Democrat of California, said this change could save the government $9 billion over 10 years.

Democrats on the Energy and Commerce Committee cleared the way for approval of their bill by adopting a package of amendments bridging differences among liberal, moderate and conservative members of the party.

Mr. Waxman said the latest agreement supplemented a deal struck Wednesday with fiscally conservative Blue Dog Democrats on the panel.

To avoid cutting premium subsidies for low-income people, Mr. Waxman said, Democrats found additional savings elsewhere.

Representative Diana DeGette, Democrat of Colorado, said the Blue Dog deal would hold down costs. But, she said, “it was paid for on the backs of people who cannot afford health insurance,” so liberals objected.

Under the Democratic proposals, insurers would be required to get “prior approval from the government before increasing premiums over a certain amount.”

Representative Tammy Baldwin, Democrat of Wisconsin, said this requirement was needed to curb the growth of premiums.

“Over the last decade,” Ms. Baldwin said, “small businesses and individuals have experienced double-digit increases in premiums, and that contributes mightily to the level of uninsurance.”

The Democratic amendments stipulate that “savings generated by this package must go toward making premiums more affordable for lower-income people.”

Democrats on the Energy and Commerce Committee would also authorize the health and human services secretary to negotiate prescription drug prices for Medicare beneficiaries.

Carl Hulse contributed reporting.

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