Social Policy の視点から：So-netブログ

Obama Health Care の最近の動向をまとめておきます．

下記の引用原文は，主な動きを伝えていますが，最近の重要な動きとして，アメリカのカソリック教会のBishop　が女性の避妊，妊娠中絶に関わって，Obamaを宗教の自由を保障したアメリカ連邦憲法に違反すると厳しく批判したことが報じられています．
Obamaは，２００８年選挙では，カソリック教徒の過半数をかなり上回る得票に支持されていましたから，軽視できない問題です．

下記の引用に見るように，保険の完全実施は2014年からですが，既に，連邦政府の事前準備が，一部の法律反対の州を除いて，徐々に進んでおり，医療界でも，中小病院が大規模病院に吸収される動きが強まっています．また，
法律がすべてのアメリカ人に民間保険の購入を義務づけ，違反者からは罰金を取るという形ですから，保険会社で従来は既往症，特にガンなど死亡率の高い既往症歴のある者は「お断り」だったモノが，その拒否項目を外す動きが早まっています．それは，日本に進出しているアメリカ保険会社のTVコマーシャルを見ていても分かる通りです．

日本の「税と社会保障の一体改革」という曖昧模糊とした政治宣伝にも影響を持つモノとしては，アメリカ政府が，せっかく難産の末に成立したHealth Care Act から，あっさりとLong-Term Care　Insurance（ほぼ日本の介護保険に相当）を，財政的負担が大きく，かつ実際に機能させるのはきわめて困難だとして削除してしまったことがあげられます．

日本の介護保険も，来年度から，保険料が6,000円を超えるのではと報じられていますが，それは年金受給者にとっては実質的な年金給付引き下げというべきです．
介護保険を巡っては，日本の介護保険料支払者は40歳以上ですから未だ徴収率が良い方ですが，本来の社会保険が危険を広く分担するモノという概念からすれば，当然，若年者からも徴収すべきモノです．
それが，実態として，国民年金の保険料徴収率が６０％を下回るほど低迷していますから，給与から天引きできるサラーリーマンに期待して４０歳以上に押さえた経緯があり，政府が社会保障改革の内容を公表したがらない，ないしは，できない，ひとつの要因となっています

私は，初めから，介護保険を医療保険と別立てにすることには反対してきており，その立場には変わりはありませんから，アメリカが昨年年10月になってLong-Term Care　Insurance をカットしたのは適切な判断だったと思います．
ドイツの制度は，各州の負担である公的扶助から介護保険制度を分離独立させたモノでしたから，Medicare, Medicaid のあるアメリカや既に国民皆保険制度があり，生活保護から独立した老人福祉法も制度化していた日本にとって，さらに横割り縦割りに屋上屋を重ねる「介護保険制度」の必要性があったとはまったく考え難いのです．
 
政府が年金制度を一元化するといい，序でに，最低保障年金を制度化するといっていることには，その内容が未だ不明で，私が主著「選別的普遍主義の可能性」で論じたモノにどれだけ近いかを計りがたいので，その点を見極めてから論じたいと考えていますが，せっかく年金制度の一元化を図るなら，介護保険を医療保険に一本化して，医療保険制度も一元化すべきでしょう，

もう一点，アメリカのAffordable　Health Care Act についてですが，下記の記事以外に，アメリカ連邦最高裁の判事９人のうち２人について，この法律の違憲性の判断に触れるような発言を過去にした人として，自主的に判決に加わるべきでないという政治的プレッシャーが高まっていたのですが，最高裁長官が，連邦地裁や連邦高裁と違って，そうした適否を判断する上級裁判所がない最高裁の判事に対して，そうした政治的プレッシャーは認めがたいとして，拒否していましたから，３月下旬に３日間行われるヒアリング，そして６月というアメリカ大統領選挙に重大な影響を及ぼすであろう時期に行われる判決には，９人の判事の全員参加が予想されています．

あとは，原文を，ご自由に，ご渉猟下さい．

 

 

 

Regulatory Steps

In the first 18 months after the law's passage, some important provisions were put in place, including tougher oversight of health insurers, the expansion of coverage to one million young adults and more protections for workers with pre-existing conditions.

More broadly, a combination of the law and economic pressures has forced major institutions to wrestle with the relentless rise in health care costs.

From Colorado to Maryland, hospitals are scrambling to buy hospitals. Doctors are leaving small private practices. Large insurance companies are becoming more dominant as smaller ones disappear because they cannot stay competitive. States are simplifying decades of Medicaid rules and planning new ways for poor and rich alike to buy policies more easily.

Even though critics say the law does little to reduce the costs of care, its passage touched off myriad efforts to pare widespread waste.

And by November 2011, Federal officials had awarded nearly $516 million to states to help build new insurance exchanges, although some states whose officials are opposed to the law, like Florida and Alaska, have either refused the money or postponed any plans in hopes of getting the legislation overturned.

Even without a significant expansion of Medicaid for the exchanges, state programs will soon be transformed through a provision that tries to standardize some of the byzantine eligibility and other rules. It requires states to offer a single, simple Internet application for not only Medicaid recipients but everyone seeking care on health exchanges.

But an inspector general's report from the Treasury Department indicated that fewer small businesses than expected had taken advantage of a tax credit under the law that encourages providing coverage for employees.

Republican Attempts to Repeal

In the November 2010 elections, Republicans took back control of the House and cut the Democratic majority in the Senate. After a delay caused by the shooting of Representative Gabrielle Giffords in Tucson, Ariz., the House voted on January 19, 2011 to repeal the health care overhaul, marking what the new Republican majority in the chamber hailed as the fulfillment of a campaign promise and the start of an all-out effort to dismantle President Obama's signature domestic policy achievement.

The House vote was the first stage of a Republican plan to use the party's momentum coming out of the midterm elections to keep the White House on the defensive, and will be followed by a push to scale back federal spending. In response, the administration struck a more aggressive posture than it had during the campaign to sell the health care law to the public. With many House Democrats from swing districts having lost their seats in November, the remaining Democrats held overwhelmingly together in opposition to the repeal.

Knowing that a full-scale repeal would be blocked by the Senate and Mr. Obama, Republicans say they will try to withhold money that federal officials need to administer and enforce the law.

Republicans also intend to go after specific provisions, including requirements that many employers to offer insurance to employees or pay a tax penalty and that most Americans obtain health insurance. Alternatively, Republicans say, they will try to prevent aggressive enforcement of the requirements by limiting money available to the Internal Revenue Service, which would collect the tax penalties.

The repeal effort is part of a multipronged systematic strategy that House Republican leaders say will include trying to cut off money for the law, summoning Obama administration officials to testify at investigative hearings and encouraging state officials to attack the law in court as unconstitutional. For House Republicans, a repeal vote would also be an important, if largely symbolic, opening salvo against the president, his party and his policy agenda.

Republicans denounced the law as an intrusion by the government that would prompt employers to eliminate jobs, create an unsustainable entitlement program, saddle states and the federal government with unmanageable costs, and interfere with the doctor-patient relationship. Republicans also said the law would exacerbate the steep rise in the cost of medical services.

For their part, the Obama administration and Democrats, who largely lost the health care message war in the raucous legislative process, see the renewed debate as a chance to show that the law will be a boon to millions of Americans and hope to turn "Obamacare" from a pejorative into a tag for one of the president's proudest achievements. Democrats argue that repeal would increase the number of uninsured; put insurers back in control of health insurance, allowing them to increase premiums at will; and lead to explosive growth in the federal budget deficit.

Republicans said their package would probably include proposals to allow sales of health insurance across state lines; to help small businesses band together and buy insurance; to limit damages in medical malpractice suits; and to promote the use of health savings accounts, in combination with high-deductible insurance policies.

Republicans also want to help states expand insurance pools for people with serious illnesses. The new law includes such pools, as an interim step until broader insurance coverage provisions take effect in 2014, but enrollment has fallen short of expectations. They have also proposed allowing people to buy insurance across state lines and to join together in "association health plans," sponsored by trade and professional groups.

But state insurance officials have resisted such proposals, on the ground that they would weaken state authority to regulate insurance and to enforce consumer protections — a concern shared by Congressional Democrats.

Mr. Obama has responded to criticism by saying he would be willing to amend portions of the law. On Feb. 28, 2011, he endorsed bipartisan legislation that would allow states to opt out earlier from a range of requirements, including the mandate, if they could demonstrate that other methods would allow them to cover as many people, with insurance that is as comprehensive and affordable, as provided by the new law. The changes must also not increase the federal deficit.

If states can meet those standards, they can ask to circumvent minimum benefit levels, structural requirements for insurance exchanges and the mandates that most individuals obtain coverage and that employers provide it. Washington would then help finance a state's individualized health care system with federal money that would otherwise be spent there on insurance subsidies and tax credits.

Prospects for the proposal appear dim. Congress would have to approve the change through legislation, and House Republican leaders said that they were committed to repealing the law, not amending it. Even if the change were approved, it could be difficult for states to meet the federal requirements for the waivers.

Scrapping Long-Term Care Coverage

In October 2011, the Obama administration announced that it was scrapping a long-term care insurance program created by the new law because it was too costly and would not work.

The program, known as Community Living Assistance Services and Supports, or Class, was intended for people with chronic illnesses or severe disabilities who wanted to live in the community, though benefits could also have been used to help pay for nursing home care or assisted living.The program would have been financed with premiums paid by workers, through voluntary payroll deductions, with no federal subsidy. Premiums were supposed to have ensured the solvency of the program over 75 years.

But Kathleen Sibelius, secretary of health and human services, said she had concluded that premiums for the program would be so high that few healthy people would sign up.

She said she agreed with actuaries who feared that "not enough young, healthy people" would enroll. "This could have led to a vicious cycle where premiums would have to be set higher and higher to cover the likely costs of benefits, leading fewer and fewer healthier people to sign up for the program," she said.

Court Challenges

Immediately after Mr. Obama signed the bill, states began filing challenges to it in federal court. Twenty states, led by Attorney General Bill McCollum of Florida, a Republican who is running for governor, banded together to file suit in federal district court in Pensacola, Fla. The first challenge to make it to a hearing was the one filed by the attorney general of Virginia.

In October, a federal judge in Detroit became the first to rule on the lawsuits, upholding the government's position. The next month, a federal judge in Lynchburg, Va., did the same.

Then in December, a federal judge in Richmond issued the first ruling against the law, calling the individual mandate unconstitutional. The judge, Henry E. Hudson, who was appointed by President George W. Bush, wrote that his survey of case law "yielded no reported decisions from any federal appellate courts extending the Commerce Clause or General Welfare Clause to encompass regulation of a person's decision not to purchase a product, not withstanding its effect on interstate commerce or role in a global regulatory scheme."

The case centered on whether Congress has authority under the Commerce Clause to compel citizens to buy a commercial product — namely health insurance — in the name of regulating an interstate economic market. Plaintiffs in the lawsuits argue there effectively would be no limits on federal power, and that the government could force people to buy American cars or, as Judge Hudson remarked at one hearing, "to eat asparagus."

The Supreme Court's position on the Commerce Clause has evolved through four signature cases over the last 68 years, with three decided since 1995. Two of the opinions established broad powers to regulate even personal commercial decisions that may influence a broader economic scheme. But other cases have limited regulation to "activities that have a substantial effect on interstate commerce."

A major question, therefore, has been whether the income tax penalties levied against those who do not obtain health insurance are designed to regulate "activity" or, as Virginia's solicitor general, E. Duncan Getchell Jr., has argued, "inactivity" that is beyond Congress' reach.

Justice Department lawyers responded that individuals cannot opt out of the medical market, and that the act of not obtaining insurance is an active decision to pay for health care out of pocket. They say that such decisions, taken in the aggregate, shift billions of dollars in uncompensated care costs to governments, hospitals and the privately insured.

In January 2011, Judge Roger Vinson of Federal District Court in Pensalcola, Fla., became the second to rule against the health care law. His ruling came in the most prominent of the more than 20 legal challenges mounted against some aspect of the sweeping health law.

Only Judge Vinson has declared the entire act void, including provisions that have already taken effect, like requirements that insurers cover children regardless of pre-existing conditions. Three other federal judges, meanwhile, have upheld the law.

In June 2011, a two-judge panel of the appeals court for the Sixth Circuit upheld the law, in what was the first of three appellate decisions.

As they look ahead to the Supreme Court, the law's defenders can take encouragement from the concurring opinion written by Judge Jeffrey S. Sutton, an appointee of President George W. Bush, a Republican. Judge Sutton is typically considered conservative on questions of constitutional reach.

After acknowledging the difficulty of pinpointing the limits on Congress's power to regulate interstate commerce, Judge Sutton wrote, "In my opinion, the government has the better of the arguments." He added, "Not every intrusive law is an unconstitutionally intrusive law."

Concerning the mandate, Judge Sutton added, "Inaction is action, sometimes for better, sometimes for worse, when it comes to financial risk." Whether an individual buys an insurance policy or not, the judge wrote, "each requires affirmative choices; one is no less active than the other; and both affect commerce."

In August 2011, a divided three-judge panel of the 11th Circuit Court of Appeals struck down the so-called individual mandate, which is considered the centerpiece of the law, ruling that Congress exceeded its powers to regulate commerce when it decided to require people to buy health insurance. But the court held that while that provision was unconstitutional, the rest of the wide-ranging law could stand.

In September 2011, a federal appellate court in Richmond, Va., threw out a pair of cases challenging the constitutionality of the Affordable Care Act, ruling for varying reasons that the plaintiffs did not have legal standing to sue. In the process, two of the three judges on the panel volunteered that they would have upheld the law if they had been able to rule on the substance of the cases.

The Supreme Court Steps In

On Sept. 28, the Justice Department asked the Supreme Court to review the decision from the 11th Circuit invalidating the mandate.

On Nov. 14, the court agreed to hear a challenge to the law. The development set the stage for oral arguments by March and a decision in late June, in the midst of the 2012 presidential campaign. The development set the stage for oral arguments by March and a decision in late June, in the midst of the 2012 presidential campaign.

The court's decision to step in had been expected, but the order answered many questions about just how the case would proceed. The court scheduled five and half hours of argument instead of the usual one, a testament to the importance of the case, which has as its center an epic clash between the federal government and the 26 states that together filed a challenge to the law.

The justices will hear two hours of argument on whether Congress overstepped its constitutional authority, 90 minutes on whether the mandate may be severed from the balance of the law if Congress did go too far, and an hour each on the Medicaid and Anti-Injunction Act questions.

The court will hear three appeals, two from challengers to the law and a third from the Obama administration. The appeals involving the 26 states is Florida v. Department of Health and Human Services, No. 11-400. A second challenge, from a business group and two individuals, is National Federation of Independent Business v. Sebelius, No. 11-393.

The federal government's appeal is Department of Health and Human Services v. Florida, No. 11-398.