オバマ大統領はどう医療制度改革をすべきか?(1)/米国医療事情

画像 全ての先進国では、医療制度改革の動きは残酷な話から始まる。カナダの場合は、1946年Toronto Globe and Mailの支払い能力がなく3人の医師に相次いで治療を断られた女性労働者の話。オーストラリアでは、1954年Sydney Morning Heraldへの肺疾患の若い女性の手紙。英国では、ジョージ・バーナード・ショーが高名な医師を訪ねたときに、助手から病人が治療を求めて来ていることを告げられた医師が「治療に値するか?」と言ったことにショックを受け、1906年の戯曲「医師のジレンマ」を書いた。英国の医療制度は民衆のだまされやすさと人間の苦悩が相乗されていると非難した。
 米国では、クリスマス前にタイムスに載った人のことがある。会社が廃業し解雇される300人の従業員をの一人として通知を受けたが、妊娠しており出産休暇を取ろうとしていた矢先であった。健康保険補償を失うことになる。2005年の出産時に請求書は約9,000ドルであったので自力では払えないとわかっていた。仕事中に出血し、帝王切開となり、母子は無事だったが、保険業者は支払いを拒否して、1万7000ドル以上の借金が最終的に必要だった。
 英国では1945年、カナダは1966年、オーストラリアは1974年に皆保険制度を導入した。米国が現在最終的なその時点にあるのかもしれない。2003年に1400万人、2007年には5700万人以上が医療費の支払い困難に直面している。平均して医療費の借金が2000ドルあり、少なくとも一度集金業者からの連絡を受けている。支払い不足で病院の半数は損失をかかえている。現在、雇用者の多くは、病院受診を抑制するために保険補償を制限している。
 人々は大幅な変化が思いがけない結果になることを恐れている。ひどい制度だが、既に充分な保障が得られ良い医師や病院にアクセスできる人にとっては一層悪くなるだろうとわかっている。
 多くの自称改革者は、「真実の」改革はこうした恐怖を乗り越えるに違いないと考えている。新制度がほとんどの人に良くなるだろうし、想像力不足や狭い利己主義ではなく老人にとってもそうだろうと信じている。
 左派の、情熱家は、唯一の首尾一貫した解決策が私的保険を止めて国民皆保険と交換することであると主張する。右派の、自由市場主義者は、唯一の首尾一貫した解決策が公的保険と雇用者保険の中止であると主張する。
 非人道的で、無駄な継ぎ接ぎ細工の制度を、新しいより理性的なものと交換するチャンスはあると理想家は主張する。全ての他の西洋民主主義国がしたような豪快なオーバーホールの準備をするべきである。
 いかにして医療制度改革が他の地域で発生したかという現実は、驚きでもあり教育的でもある。
 英国は先進国の中で最も社会化された医療制度を作った。1948年7月5日、NHS国民健康保険は病院・血液銀行・救急搬送の大部分を所有し、ほとんどの専門家医師を有給の公務員として雇い、無料で全ての住民に医療を提供可能にした。システムは完全に政府によりコントロールされた。翌日のロンドン・タイムズ紙面には、予想された混乱はなく、スコットランドの休日から帰った女王とドイツの通貨問題などがあった。プログラムに登録させられた英国医師会メンバーの90%にはより多額の収入が保証された。明らかになった最も大きな問題は今まで放置されていた数十万人に及ぶ小児の歯科治療の需要だった。プログラムは成功し続いたと歴史家は言う。NHSは第二次世界大戦直後の英国に特有な状況の現実的な結果だった。
 ドイツとの緊張が高まり、陸海の戦闘だけでなく未曾有のスケールの都市空襲に準備する必要があることに気づき、宣戦布告の前日に英政府は巨大な避難を指揮し、350万人が地方に引っ越した。両親が戦争準備に居残るため、数十万人の子どもたちの食料や教育、輸送や宿泊の手配をする必要があった。そして、受け入れにより人口が増加する地域と都市の両方に戦争負傷者を含め総数で約200万人に医療サービスを保証する必要があった。戦時のため地域に国家緊急事態医療サービスを開始し、数ヶ月で数百の病院を整備した。外傷・火傷・救急に対応した基本的な検査医療設備を揃えた。保健省を昇格し、こうしたサービスを管理するようにした。
 戦争は、戦闘員のみでなく民間死傷者に無料の病院治療を提供することを政府に強制した。都市の病人を地方の個人病院に転送依頼し、治療費の多くを政府が負担した。戦時医療サービスのために医師は政府から給与を受けた。1940年9月の爆撃開始から膨大な数の個人病院とクリニックが破壊され、政府の医療費負担が増大した。私的医療機関は閉鎖寸前となった。チャーチルはこのプログラムを一時的なものと考えていたが、古い医療体制は破壊され、戦争被害にもかかわらず、人々の健康は改善し、死亡率は減少した。歯科医療でさえ以前より良かった。1944年の終わりには、戦時医療システムの解体を望む市民は無く、個人病院も政府による支出を望んだ。
 NHSが提案された1945年までに、既に必須の医療制度であった英国のシステムは、社会主義の理想により策定されたものではなく、保守的な実用的な方法を元にしたプログラムだったので、違う状況では他のどのような国もこのシステムを採用しなかった。
 フランスでは、1945年の冬にド・ゴール大統領が、戦後の荒廃の中でどのように医療を保証するかを熟考していた。解放後引き継いだシステムは、有効な公的保険や病院を全く持っていなかった。人口の75%は私的医療に現金で支払い、多くの人は医療さえ受けられないほどの貧困だった。戦争のずっと前から主要な企業と組合は設定したプレミア・セットというより自ら課した給与税を通して資金提供された従業員のための集合的な保険資金を編成した。これが事実上の唯一の保険制度であり、フランス医療制度の足場になった。食料や電力の不足、人口の1/4が難民というド・ゴール政府では、新しい医療制度を作る時間も能力もなかったため、全ての労働者やその家族と退職者をカバーするために、既存の給与支払台帳税を元に出資の私的保険制度を拡大してそれを基礎とした。自営業は1960年代に追加された。無保険の住民の残りは2000年に最終的に含まれた。
 現在、Se'curite' Socialeは144の地域保険資金を通して全てのフランス住民に給与支払台帳税で資金提供された保険を提供している。このフランス医療制度は先進国の中でも最も満足度の高いものであり、米国に比べ平均寿命は長く、乳児死亡率は低く、医師は多く、医療費は低い。2000年のWHOのランキングでは、世界一の医療制度とされた(米国は37位)。
 スイスは戦時には中立を守ったので破壊は免れ、私的商業用の保険補償に頼ってきた。しかし、保険補償ギャップと矛盾の問題のため、最終的には1994年に皆保険法を成立させた。既にあったシステムの上に作成した。全ての居住者は私的な健康保険を購入する必要があるが、そのコストを収入の約10%に制限して補助金を出している。
 米国を除く全ての先進国は全ての国民のために利用可能な医療を保証する全国的なシステムを持っている。ほとんど全てが成功している。しかしそのシステムには極めて大きな制度の相違があり、理由はイデオロギーではない。不完全で不自然、乱雑のように見えても、それぞれの国自身の歴史を元にして構築されたものである。
(続く)
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トム・ダシュレの医療制度改革/米国医療事情 オバマ政権
http://kurie.at.webry.info/200901/article_15.html
ブッシュの遺産を拡張する医療制度改革/米国医療制度 地域保健医療センター
http://kurie.at.webry.info/200812/article_44.html
医療改革プランの財源はどこに?/米国医療事情 議会予算局
http://kurie.at.webry.info/200812/article_38.html
保険業者グループが中央管理型皆保険制度を提案/米国医療事情
http://kurie.at.webry.info/200812/article_14.html
私的メディケア・プランは高価で利点少ない/米国医療事情
http://kurie.at.webry.info/200811/article_50.html
医療制度改革への政治的好機/米国医療事情
http://kurie.at.webry.info/200811/article_43.html
上院議員主導の医療制度改革/米国医療事情
http://kurie.at.webry.info/200811/article_25.html
オバマ新大統領に迫られる医療制度改革/米国医療事情
http://kurie.at.webry.info/200811/article_23.html
米国医療制度改革/パーフェクトストームへの挑戦 オバマ大統領
http://kurie.at.webry.info/200811/article_18.html
マサチューセッツ州 無保険者が1年で半減/米国医療事情
http://kurie.at.webry.info/200806/article_4.html
クリントンとオバマの医療制度改革/米国医療事情
http://kurie.at.webry.info/200802/article_42.html
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Annals of Public Policy
Getting There from Here
How should Obama reform health care?
by Atul Gawande January 26, 2009
http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

Keywords
Health-Care Reform;
Universal Health Care;
Pragmatism;
Great Britain;
Phone Systems;
Path-Dependence;
Idealism

In every industrialized nation, the movement to reform health care has begun with stories about cruelty. The Canadians had stories like the 1946 Toronto Globe and Mail report of a woman in labor who was refused help by three successive physicians, apparently because of her inability to pay. In Australia, a 1954 letter published in the Sydney Morning Herald sought help for a young woman who had lung disease. She couldn’t afford to refill her oxygen tank, and had been forced to ration her intake “to a point where she is on the borderline of death.” In Britain, George Bernard Shaw was at a London hospital visiting an eminent physician when an assistant came in to report that a sick man had arrived requesting treatment. “Is he worth it?” the physician asked. It was the normality of the question that shocked Shaw and prompted his scathing and influential 1906 play, “The Doctor’s Dilemma.” The British health system, he charged, was “a conspiracy to exploit popular credulity and human suffering.”

In the United States, our stories are like the one that appeared in the Times before Christmas. Starla Darling, pregnant and due for delivery, had just taken maternity leave from her factory job at Archway & Mother’s Cookie Company, in Ashland, Ohio, when she received a letter informing her that the company was going out of business. In three days, the letter said, she and almost three hundred co-workers would be laid off, and would lose their health-insurance coverage. The company was self-insured, so the employees didn’t have the option of paying for the insurance themselves―their insurance plan was being terminated.

“When I heard that I was losing my insurance, I was scared,” Darling told the Times. Her husband had been laid off from his job, too. “I remember that the bill for my son’s delivery in 2005 was about $9,000, and I knew I would never be able to pay that by myself.” So she prevailed on her midwife to induce labor while she still had insurance coverage. During labor, Darling began bleeding profusely, and needed a Cesarean section. Mother and baby pulled through. But the insurer denied Darling’s claim for coverage. The couple ended up owing more than seventeen thousand dollars.

The stories become unconscionable in any society that purports to serve the needs of ordinary people, and, at some alchemical point, they combine with opportunity and leadership to produce change. Britain reached this point and enacted universal health-care coverage in 1945, Canada in 1966, Australia in 1974. The United States may finally be there now. In 2007, fifty-seven million Americans had difficulty paying their medical bills, up fourteen million from 2003. On average, they had two thousand dollars in medical debt and had been contacted by a collection agency at least once. Because, in part, of underpayment, half of American hospitals operated at a loss in 2007. Today, large numbers of employers are limiting or dropping insurance coverage in order to stay afloat, or simply going under―even hospitals themselves.


Yet wherever the prospect of universal health insurance has been considered, it has been widely attacked as a Bolshevik fantasy―a coercive system to be imposed upon people by benighted socialist master planners. People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse―especially for those who already have dependable coverage and access to good doctors and hospitals.

Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have. The country has this one chance, the idealist maintains, to sweep away our inhumane, wasteful patchwork system and replace it with something new and more rational. So we should prepare for a bold overhaul, just as every other Western democracy has. True reform requires transformation at a stroke. But is this really the way it has occurred in other countries? The answer is no. And the reality of how health reform has come about elsewhere is both surprising and instructive.

No example is more striking than that of Great Britain, which has the most socialized health system in the industrialized world. Established on July 5, 1948, the National Health Service owns the vast majority of the country’s hospitals, blood banks, and ambulance operations, employs most specialist physicians as salaried government workers, and has made medical care available to every resident for free. The system is so thoroughly government-controlled that, across the Atlantic, we imagine it had to have been imposed by fiat, by the coercion of ideological planners bending the system to their will.

But look at the news report in the Times of London on July 6, 1948, headlined “FIRST DAY OF HEALTH SERVICE.” You might expect descriptions of bureaucratic shock troops walking into hospitals, insurance-company executives and doctors protesting in the streets, patients standing outside chemist shops worrying about whether they can get their prescriptions filled. Instead, there was only a four-paragraph notice between an item on the King and Queen’s return from a holiday in Scotland and one on currency problems in Germany.

The beginning of the new national health service “was taking place smoothly,” the report said. No major problems were noted by the 2,751 hospitals involved or by patients arriving to see their family doctors. Ninety per cent of the British Medical Association’s members signed up with the program voluntarily―and found that they had a larger and steadier income by doing so. The greatest difficulty, it turned out, was the unexpected pent-up demand for everything from basic dental care to pediatric visits for hundreds of thousands of people who had been going without.

The program proved successful and lasting, historians say, precisely because it was not the result of an ideologue’s master plan. Instead, the N.H.S. was a pragmatic outgrowth of circumstances peculiar to Britain immediately after the Second World War. The single most important moment that determined what Britain’s health-care system would look like was not any policymaker’s meeting in 1945 but the country’s declaration of war on Germany, on September 3, 1939.

As tensions between the two countries mounted, Britain’s ministers realized that they would have to prepare not only for land and sea combat but also for air attacks on cities on an unprecedented scale. And so, in the days before war was declared, the British government oversaw an immense evacuation; three and a half million people moved out of the cities and into the countryside. The government had to arrange transport and lodging for those in need, along with supervision, food, and schooling for hundreds of thousands of children whose parents had stayed behind to join in the war effort. It also had to insure that medical services were in place―both in the receiving regions, whose populations had exploded, and in the cities, where up to two million war-injured civilians and returning servicemen were anticipated.

As a matter of wartime necessity, the government began a national Emergency Medical Service to supplement the local services. Within a period of months, sometimes weeks, it built or expanded hundreds of hospitals. It conducted a survey of the existing hospitals and discovered that essential services were either missing or severely inadequate―laboratories, X-ray facilities, ambulances, care for fractures and burns and head injuries. The Ministry of Health was forced to upgrade and, ultimately, to operate these services itself.

The war compelled the government to provide free hospital treatment for civilian casualties, as well as for combatants. In London and other cities, the government asked local hospitals to transfer some of the sick to private hospitals in the outer suburbs in order to make room for victims of the war. As a result, the government wound up paying for a large fraction of the private hospitals’ costs. Likewise, doctors received government salaries for the portion of their time that was devoted to the new wartime medical service. When the Blitz came, in September, 1940, vast numbers of private hospitals and clinics were destroyed, further increasing the government’s share of medical costs. The private hospitals and doctors whose doors were still open had far fewer paying patients and were close to financial ruin.

Churchill’s government intended the program to be temporary. But the war destroyed the status quo for patients, doctors, and hospitals alike. Moreover, the new system proved better than the old. Despite the ravages of war, the health of the population had improved. The medical and social services had reduced infant and adult mortality rates. Even the dental care was better. By the end of 1944, when the wartime medical service began to demobilize, the country’s citizens did not want to see it go. The private hospitals didn’t, either; they had come to depend on those government payments.

By 1945, when the National Health Service was proposed, it had become evident that a national system of health coverage was not only necessary but also largely already in place―with nationally run hospitals, salaried doctors, and free care for everyone. So, while the ideal of universal coverage was spurred by those horror stories, the particular system that emerged in Britain was not the product of socialist ideology or a deliberate policy process in which all the theoretical options were weighed. It was, instead, an almost conservative creation: a program that built on a tested, practical means of providing adequate health care for everyone, while protecting the existing services that people depended upon every day. No other major country has adopted the British system―not because it didn’t work but because other countries came to universalize health care under entirely different circumstances.

In France, in the winter of 1945, President de Gaulle was likewise weighing how to insure that his nation’s population had decent health care after the devastation of war. But the system that he inherited upon liberation had no significant public insurance or hospital sector. Seventy-five per cent of the population paid cash for private medical care, and many people had become too destitute to afford heat, let alone medications or hospital visits.

Long before the war, large manufacturers and unions had organized collective insurance funds for their employees, financed through a self-imposed payroll tax, rather than a set premium. This was virtually the only insurance system in place, and it became the scaffolding for French health care. With an almost impossible range of crises on its hands―food shortages, destroyed power plants, a quarter of the population living as refugees―the de Gaulle government had neither the time nor the capacity to create an entirely new health-care system. So it built on what it had, expanding the existing payroll-tax-funded, private insurance system to cover all wage earners, their families, and retirees. The self-employed were added in the nineteen-sixties. And the remainder of uninsured residents were finally included in 2000.

Today, Se'curite' Sociale provides payroll-tax-financed insurance to all French residents, primarily through a hundred and forty-four independent, not-for-profit, local insurance funds. The French health-care system has among the highest public-satisfaction levels of any major Western country; and, compared with Americans, the French have a higher life expectancy, lower infant mortality, more physicians, and lower costs. In 2000, the World Health Organization ranked it the best health-care system in the world. (The United States was ranked thirty-seventh.)

Switzerland, because of its wartime neutrality, escaped the damage that drove health-care reform elsewhere. Instead, most of its citizens came to rely on private commercial health-insurance coverage. When problems with coverage gaps and inconsistencies finally led the nation to pass its universal-coverage law, in 1994, it had no experience with public insurance. So the country―you get the picture now―built on what it already had. It required every resident to purchase private health insurance and provided subsidies to limit the cost to no more than about ten per cent of an individual’s income.

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

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この記事へのコメント

bloom@花咲く小径
2009年08月26日 18:34
初めまして。インフルエンザによる休校措置の効果に関する抄録を作る上で、こちらの記事を参考にさせて戴いています。

和訳はご自身で行っているのでしょうか?
和訳のレベルが高いので感心しています。

私のブログでもこちらのブログを紹介させて戴きました。

http://blogs.yahoo.co.jp/bloom_komichi/62165412.html

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