オバマケア － メディケイドの拡張問題、保険市場創設での難問
オバマケアのなかに、メディケイドを貧困層に拡大するという案、ならびに保険市場（exchange)の創設という案がある。これをめぐっていくつかの州ではそれを拒否したり、もしくは創設そのものが危ういという事態が生じている。
これらは国民皆保険制度に向けて来年の１月から実施が予定されているものである。
この問題をめぐってミシシッピ州では、メディケイド（貧者への医療補助）を年収１６０００ドル以下の人に適用を拡大する案を拒否した。オバマケアでは２０１６年まではその拡張費用の負担は政府が支払い、２０２０年には政府の負担は９０％になる、とされている。
もう１つは健康exchanges という新たな保険市場（州ベース）を創設して、個人はそこで保険を選択購入できるという制度設計がある。連邦基準の貧困レベルの１００－４００％の人は連邦政府からの補助金を受けることができる。
前者の拡張だが、昨年の最高裁決定で、州は選択できることになった（当初の案は、メディケイドの拡張は義務付けられていた）。
少なくとも２１週は拒否し、さらに多くがexchangeの創設を拒否している（この仕事は連邦政府に任されることになる）。
ちなみに、ミシシッピ州は全米でもっとも貧しい州である。５人に１人は未保険者である。
両案をめぐってミシシッピの議会では熾烈な争いを繰り広げていた。exchangeについては、激しい争いの結果、州での設置案はつぶれた。その結果、連邦
政府のexchange (federally facilitated exchange) が設立されることになる予定だが、現代のところわずか２社の保険会社が名乗りをあげているのみである。
拡張については、これが成立していたなら、貧民も治療費を支払うことができ、そうなると、オバマケアのもう１つの案である病院へのより低いレートでの支払いも可能になったであろうが、それも難しくなってしまっている。
というわけで、オバマケアの実施には非常な困難が待ち受けているのである。ミシシッピ州のようなケースの場合、健康保険の状況は、いまよりも悪くなる危険性すらある。
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Health reform
Mississippi spurning
Obamacare hits trouble in the states
Jul 13th 2013| JACKSON, MISSISSIPPI |From the print edition Economist
BARACK OBAMA’S health reform was supposed to bring universal health coverage to America on January 1st, 2014. It won’t. To understand why, consider states such as Mississippi.
Terry Brown, a Republican state senator there, stood before his colleagues on June 28th, as they lounged in summer poplin and seersucker. They had assembled to decide whether Mississippi would expand Medicaid, the public health programme for the poor, as Obamacare urges. That day Mississippi said it would not. “I don’t want Mississippi to be a part of that train wreck,” said Mr Brown.
Health care
Obamacare aims to extend insurance to the poor in two main ways, both starting in 2014. First, it required states to offer Medicaid to all those with incomes of up to 138% of the federal poverty level, or $15,856 for an individual. (At present Medicaid must cover only some poor people, such as pregnant women.) The federal government and the states usually share the cost of Medicaid. But Obamacare would pay for the expansion through 2016, with the feds’ share falling to 90% in 2020.
Second, individuals would be able to shop for insurance on new state-based markets, called health exchanges. Those with incomes between 100% and 400% of the federal poverty level would qualify for federal subsidies.
Neither provision is going as planned. Last year the Supreme Court made the Medicaid expansion optional. At least 21 states say they will opt out. Even more are refusing to set up their own exchanges, leaving the task to federal bureaucrats.
Mississippi would seem the ideal place to cover more poor people. It is America’s poorest state and has the shortest life expectancy. Its current Medicaid programme is among America’s least generous. Mississippians devote an unusually large share of their income to health care (see chart). One resident in five is uninsured.
But Obamacare’s main provisions have gone nowhere in the Magnolia State. The fight over the Medicaid expansion involved hair-raising brinkmanship. Had lawmakers not voted before July 1st, the state’s entire Medicaid programme would have stopped functioning. Republicans insisted an expansion was unaffordable. State Medicaid costs would have increased by 7% from 2013 to 2022, estimates the Urban Institute, a think-tank. That is much less than the expected 30% increase in Medicaid subsidies from the central government. But the 7% rise would have been bigger than in any other state, mostly because Mississippi’s current Medicaid programme is so skimpy.
The fight over the state’s exchanges was equally bareknuckle. Mississippi’s elected insurance commissioner wanted a state-based exchange. The Republican governor, Phil Bryant, wanted nothing to do with Obamacare. After a messy spat, plans for a state exchange dissolved. By default, Mississippi will have a “federally facilitated exchange”, managed by the health secretary’s deputies. So far only two insurers have made bids to sell health plans on it. Residents of 42 counties will have a choice of only one subsidised plan; 36 counties will have none. And many poor Mississippians will be ineligible for Medicaid.
Stansel Harvey is the boss of the Delta Regional Medical Centre, in the heart of old cotton country. The Mississippi Delta contains some of America’s poorest counties. About 10% of Mr Harvey’s patients fail to pay their bills. The insurance expansion would have made many of them paying customers. Crucially, that new revenue would have helped offset another Obamacare change: lower payment rates to hospitals. Without new insurance revenue, Mr Harvey reckons that he may need to cut services. If other hospitals follow suit, Mississippians will have a problem. In the age of Obamacare, they may have less access to health care, not more.
From the print edition: United States
