オバマ大統領はどう医療制度改革をすべきか?(2)/米国医療事情

 社会科学者はこうした過去の経験を基に発展するパターンを“path-dependence”と呼んでいる。ベータとVHS、MacとPC、QWERTYタイプライタキーボードとその他、といった競争ではデザインというよりもちょっとした初期の出来事が市場の勝敗に決定的な役割を果たす。ポール・クルーグマンは工業生産において貿易パターンと地理的位置がpath-dependentであることを示して、ノーベル経済学賞を受けた。1991年にクルーグマンは米国北東部の6,000万人の人口集中が歴史的に衣裳装身具工場の集積によりもたらされたのは明白であると書いている。
 スイスのように米国は国内インフラの損害なしで戦争を戦い、スイスと違い労働力の多くを海外での戦闘に送り出した。このためにルーズベルト政権は、人件費のインフレ増加を防止するために全国的な賃金コントロールしようとし、労働者雇用のための競争で雇用者は商業用の健康保険を提供した。そのことが、私達が60年間格闘するトラブル(雇用者と同様に失業者の)の基である私的保険に対する顕著な信頼を駆り立てた。
 弱いリーダーシップの結果だという人がいるが、それは単純化しすぎている。変化に伴う危険もリーダーの責任となる。
 2003年の高齢者に対する処方薬保険補償の問題がある。メディケアで約1,000万の高齢者に薬剤費保険負担を提供するものであるが、ホワイトハウス、議会共和党員と製薬会社は反対し、新たにオンライン提供の市場指向プログラムを提供し、理論上は妥当なアプローチだった。しかし、2500万人が新たな薬剤プランを立て、6万の薬局が契約請求システムを設立する必要が出た。2006年1月に発効し、ひどい混乱が生じた。37州で公的医療危機となり、弱者に対し緊急薬剤支払いを提供しなければならなくなった。このために亡くなった人も出た可能性はある。
 繰り返し医療制度改革の議論がなされ、唯一の本当の解決策は、医療制度の交換であると専門家は言う。しかし、誘惑の言葉である。
 米国の医療制度は、腐った梁に、水漏れがあり、傭兵を乗せ、15%の乗客を海上に放り出したまま浮遊する、つぎはぎだらけの船である。しかし、数億の人々がそれに依存している。年間で、3500万回の入院、6400万回の手術、9億回の外来受診、35億枚の処方がなされていて、国内の経済活動の1/6を占めている。改造するにあたって半日たりとも止めることは許されない。計画の失敗やそこから学ぶといったことは許されない。悪化すれば人々の死を意味する。野心的な改革に手が届かないと言う意味ではなく、現在持っているものから出発する必要があるということである。
 こうしたことは医療制度に限らない。1世紀前、現代の電話システムは、P.S.T.N.(公衆電話交換網)と呼ばれる構造の上で構築された。この自動化システムは1日24時間接続され、時間とともにアップグレードされる必要があるが、消して再起動というわけにはいかない。技術者は次々とパッチを加え、最も毛羽立ち複雑なシステムである。次々と変化を提供してきたpath-dependenceの究極であり、21世紀を可能とした。
 医療制度はpath-dependentな性質を持つことを認めた上で、今まで築かれた土台の上に構築する方がよい。ゴールは、3つの基本的な属性を持つシステムを設立することにある。医療費の借金を誰にも残すべきではなく、個人破産の原因として消さなくてはいけない。雇用者のための経済的災難とすべきでない。医師・看護士・病院・製薬医療機器会社・保険会社が医療を改善し安全を保ちより安価にするように一緒に責任を持つべきである。
 新旧システムのそっくり入れ替えは不可能であり、古いものの上に新システムを構築することが可能である。例えば2011年1月1日に新しい医療制度開始されたとしても、大部分のアメリカ人にとっては信頼できるしっかりとした医療を目立った変化なく提供できる必要がある。しかし、除外され外に放り出された人にも一種の救助船を組み立てることはできる。
 退役軍人健康保険制度は国中いたるところ(ちょうど英国同様の)すべて1200の政府経営病院や他の医療設備を持つプログラムである。他の人々にもそれを広げることが可能である。メディケア(高齢者公的医療保険)は政府管掌の(カナダにあるような)プログラムであり、参加する機会を与えることができる。また、連邦の労働者加入私的保険(スイスのような)もある。
 退役軍人保険は低価格だが医師の選択は制限され、施設が遠いかもしれない。メディケアはどの医師や病院にもかかれるので人気があるが約1/3ほど医療費が高く、医療の質と安全を保つのに苦労している。連邦の労働者保険は助成金により私的保険選択の範囲が保証されるが、保険会社はコストに対しメディケアより厳しく、医療の改善がほとんどない。
 こうしたプログラムのどれでも、25才未満の無保険アメリカ人の場合は数週間で加入の機会が与えられる。時間と経験を積めば、無保険の全ての人に適応可能となるだろう。現在、オバマ政府と議会のリーダーによる議論は、低収入の人に対して助成金を与えられたプレミアで、連邦の労働者保険オプションとメディケア(またはそれに相当するもの)をこうした方法で拡大することに集中するようである。それなりのコストが必要となる。主な提案として、様々な方法(治療費が高価な慢性疾患をより良い管理により)で医療費を抑制する、雇用者が従業員に保険提供しない場合に追加税を支払う、など。容易なものは何もないが、受け入れが必要だろう。最終的なシステムがどうなるかは不明瞭で、理想家が考案するものとはかけ離れた乱雑なものだろうが、結果はほぼ確実により良いものだろう。
 マサチューセッツは最近、住民への皆保険制度を採用する最初の州となった。州政府は病院や保険会社を組織することなく公営化に向かったわけでもない。既にあったものを基にしている。2007年7月1日、州は無保険の人に4つの私保険プランのオンライン選択を提供し始めた。貧困者のコストは0で、他の人は上限が収入の約8%に制限した。無保険の人はプログラムに加入するか罰金を支払う必要があり、1年後には住民の97.4%が保険を獲得した。2/3の住民が制度改革を支持した。医療費に対する対策はなく、雇用情勢の悪化により州の予測より多くの助成が必要となり保険料が上昇している。最近1年では必要な検査にいくらかかるかと尋ねる患者が減ったので、著しい変化である。しかし、自己負担とプレミアの問題に直面するだろうし、非標準医療への保険補償について厳しい論争も起こるだろう。
 完全を得ようとするわけではないが、変化することができる機能する医療制度を持つことは可能であり、現在いる場所からそれを開始して次の場所に到達する方法はある。
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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

(continued)
画像Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” In the battles between Betamax and VHS video recorders, Mac and P.C. computers, the QWERTY typewriter keyboard and alternative designs, they found that small, early events played a far more critical role in the market outcome than did the question of which design was better. Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area―even if prices, taxes, and competition are stiffer. “The long shadow cast by history over location is apparent at all scales, from the smallest to the largest―from the cluster of costume jewelry firms in Providence to the concentration of 60 million people in the Northeast Corridor,” Krugman wrote in 1991.

With path-dependent processes, the outcome is unpredictable at the start. Small, often random events early in the process are “remembered,” continuing to have influence later. And, as you go along, the range of future possibilities gets narrower. It becomes more and more unlikely that you can simply shift from one path to another, even if you are locked in on a path that has a lower payoff than an alternate one.

The political scientist Paul Pierson observed that this sounds a lot like politics, and not just economics. When a social policy entails major setup costs and large numbers of people who must devote time and resources to developing expertise, early choices become difficult to reverse. And if the choices involve what economists call “increasing returns”―where the benefits of a policy increase as more people organize their activities around it―those early decisions become self-reinforcing. America’s transportation system developed this way. The century-old decision to base it on gasoline-powered automobiles led to a gigantic manufacturing capacity, along with roads, repair facilities, and fuelling stations that now make it exceedingly difficult to do things differently.

There’s a similar explanation for our employment-based health-care system. Like Switzerland, America made it through the war without damage to its domestic infrastructure. Unlike Switzerland, we sent much of our workforce abroad to fight. This led the Roosevelt Administration to impose national wage controls to prevent inflationary increases in labor costs. Employers who wanted to compete for workers could, however, offer commercial health insurance. That spurred our distinctive reliance on private insurance obtained through one’s place of employment―a source of troubles (for employers and the unemployed alike) that we’ve struggled with for six decades.

Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge, allowed our choices to be constrained by history and by vested interests. But that’s too simple. The reality is that leaders are held responsible for the hazards of change as well as for the benefits. And the history of master-planned transformation isn’t exactly inspiring. The familiar horror story is Mao’s Great Leap Forward, where the collectivization of farming caused some thirty million deaths from famine. But, to take an example from our own era, consider Defense Secretary Donald Rumsfeld’s disastrous reinvention of modern military operations for the 2003 invasion of Iraq, in which he insisted on deploying far fewer ground troops than were needed. Or consider a health-care example: the 2003 prescription-drug program for America’s elderly.

This legislation aimed to expand the Medicare insurance program in order to provide drug coverage for some ten million elderly Americans who lacked it, averaging fifteen hundred dollars per person annually. The White House, congressional Republicans, and the pharmaceutical industry opposed providing this coverage through the existing Medicare public-insurance program. Instead, they created an entirely new, market-oriented program that offered the elderly an online choice of competing, partially subsidized commercial drug-insurance plans. It was, in theory, a reasonable approach. But it meant that twenty-five million Americans got new drug plans, and that all sixty thousand retail pharmacies in the United States had to establish contracts and billing systems for those plans.

On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.

This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions. It represents a sixth of our economy. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.

That kind of constraint isn’t unique to the health-care system. A century ago, the modern phone system was built on a structure that came to be called the P.S.T.N., the Public Switched Telephone Network. This automated system connects our phone calls twenty-four hours a day, and over time it has had to be upgraded. But you can’t turn off the phone system and do a reboot. It’s too critical to too many. So engineers have had to add on one patch after another.

The P.S.T.N. is probably the shaggiest, most convoluted system around; it contains tens of millions of lines of software code. Given a chance for a do-over, no self-respecting engineer would create anything remotely like it. Yet this jerry-rigged system has provided us with 911 emergency service, voice mail, instant global connectivity, mobile-phone lines, and the transformation from analog to digital communication. It has also been fantastically reliable, designed to have as little as two hours of total downtime every forty years. As a system that can’t be turned off, the P.S.T.N. may be the ultimate in path-dependence. But that hasn’t prevented dramatic change. The structure may not have undergone revolution; the way it functions has. The P.S.T.N. has made the twenty-first century possible.

So accepting the path-dependent nature of our health-care system―recognizing that we had better build on what we’ve got―doesn’t mean that we have to curtail our ambitions. The overarching goal of health-care reform is to establish a system that has three basic attributes. It should leave no one uncovered―medical debt must disappear as a cause of personal bankruptcy in America. It should no longer be an economic catastrophe for employers. And it should hold doctors, nurses, hospitals, drug and device companies, and insurers collectively responsible for making care better, safer, and less costly.

We cannot swap out our old system for a new one that will accomplish all this. But we can build a new system on the old one. On the start date for our new health-care system―on, say, January 1, 2011―there need be no noticeable change for the vast majority of Americans who have dependable coverage and decent health care. But we can construct a kind of lifeboat alongside it for those who have been left out or dumped out, a rescue program for people like Starla Darling.

In designing this program, we’ll inevitably want to build on the institutions we already have. That precept sounds as if it would severely limit our choices. But our health-care system has been a hodgepodge for so long that we actually have experience with all kinds of systems. The truth is that American health care has been more flotilla than ship. Our veterans’ health-care system is a program of twelve hundred government-run hospitals and other medical facilities all across the country (just like Britain’s). We could open it up to other people. We could give people a chance to join Medicare, our government insurance program (much like Canada’s). Or we could provide people with coverage through the benefits program that federal workers already have, a system of private-insurance choices (like Switzerland’s).

These are all established programs, each with advantages and disadvantages. The veterans’ system has low costs, one of the nation’s best information-technology systems for health care, and quality of care that (despite what you’ve heard) has, in recent years, come to exceed the private sector’s on numerous measures. But it has a tightly limited choice of clinicians―you can’t go to see any doctor you want, and the nearest facility may be far away from where you live. Medicare allows you to go to almost any private doctor or hospital you like, and has been enormously popular among its beneficiaries, but it costs about a third more per person and has had a hard time getting doctors and hospitals to improve the quality and safety of their care. Federal workers are entitled to a range of subsidized private-insurance choices, but insurance companies have done even less than Medicare to contain costs and most have done little to improve health care (although there are some striking exceptions).

Any of the programs could allow us to offer a starting group of Americans―the uninsured under twenty-five years of age, say―the chance to join within weeks. With time and experience, the programs could be made available to everyone who lacks coverage. The current discussion between the Obama Administration and congressional leaders seems to center on opening up the federal workers’ insurance options and Medicare (or the equivalent) this way, with subsidized premiums for those with low incomes. The costs have to be dealt with. The leading proposals would try to hold down health-care spending in various ways (by, for example, requiring better management of patients with expensive chronic diseases); employers would have to pay some additional amount in taxes if they didn’t provide health insurance for their employees. There’s nothing easy about any of this. But, if we accept it, we’ll all have a lifeboat when we need one.

It won’t necessarily be clear what the final system will look like. Maybe employers will continue to slough off benefits, and that lifeboat will grow to become the entire system. Or maybe employers will decide to strengthen their benefits programs to attract employees, and American health care will emerge as a mixture of the new and the old. We could have Medicare for retirees, the V.A. for veterans, employer-organized insurance for some workers, federally organized insurance for others. The system will undoubtedly be messier than anything an idealist would devise. But the results would almost certainly be better.

Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents. It didn’t organize a government takeover of the state’s hospitals or insurance companies, or force people into a new system of state-run clinics. It built on what existed. On July 1, 2007, the state began offering an online choice of four private insurance plans for people without health coverage. The cost is zero for the poor; for the rest, it is limited to no more than about eight per cent of income. The vast majority of families, who had insurance through work, didn’t notice a thing when the program was launched. But those who had no coverage had to enroll in a plan or incur a tax penalty.

The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close. Despite the requirement that individuals buy insurance and that employers either provide coverage or pay a tax, the program has remained extremely popular. Repeated surveys have found that at least two-thirds of the state’s residents support the reform.

The Massachusetts plan didn’t do anything about medical costs, however, and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here, just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance, even though, on average, premiums amount to twice that much. The experience has shown national policymakers that they will have to be serious about reducing costs.

For all that, the majority of state residents would not go back to the old system. I’m among them. For years, about one in ten of my patients―I specialize in cancer surgery―had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.

I once took care of a nineteen-year-old college student who had maxed out her insurance coverage. She had a treatable but metastatic cancer. But neither she nor her parents could afford the radiation therapy that she required. I made calls to find state programs, charities―anything that could help her―to no avail. She put off the treatment for almost a year because she didn’t want to force her parents to take out a second mortgage on their home. But eventually they had to choose between their daughter and their life’s savings.

For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage. And that’s a remarkable change: a glimpse of American health care without the routine cruelty.

It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation―which is to say, a health-care system that works. And there are ways to get there that start from where we are. ?


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