特 集 :アメリカの 社 会 保 障 アメリカの 医 療 保 障 システム 雇 用 主 提 供 医 療 保 険 の 空 洞 化 とオバマ 医 療 保 険 改 革 長 谷 川 千 春 1980 20 1 2 2009 2010 2 Employer- Sponsored Health Insurance I 65 16
fringe benefit 6565 1 FEHB Federal Employees Health Benefits States Employee Health Benefits Medicare 1965 TitleX VIII of the Social Security Act1966 7 A Medicare social security tax 65 65 1 Medicaid2 2 3 3 85 A65 6565 8 2008 65 93.4 98.3 4 65 82.6 18 2471.4 25 34 73.5 5 1 2006 61 6000 1670 17
Summer 2010 No. 171 1 65 1987-2008 1987 1990 1993 1996 1997 1998 1999 2000 214.4 220.6 228.0 234.1 236.2 238.6 242.6 244.8 150.3 149.6 146.7 151.7 156.9 160.4 164.7 167.5 73.5 74.1 76.0 78.0 78.5 80.2 82.2 84.6 76.8 75.5 70.7 73.7 78.4 80.2 82.4 82.9 15.0 15.1 17.5 16.8 17.1 16.5 16.4 16.0 28.8 32.2 38.5 37.8 35.3 34.6 34.8 35.8 3.1 3.5 3.7 4.6 4.7 4.8 4.9 5.4 18.6 22.7 29.4 28.6 26.4 25.2 25.5 26.2 Tricare/CHAMPVA 8.6 7.9 7.5 6.9 6.6 6.9 6.6 6.8 29.5 32.9 36.4 38.3 39.9 39.4 38.5 38.2 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 70.1 67.8 64.3 64.8 66.4 67.2 67.9 68.4 34.3 33.6 33.3 33.3 33.2 33.6 33.9 34.6 35.8 34.2 31.0 31.5 33.2 33.6 34.0 33.8 7.0 6.8 7.7 7.2 7.2 6.9 6.8 6.5 13.4 14.6 16.9 16.2 15.0 14.5 14.3 14.6 1.5 1.6 1.6 2.0 2.0 2.0 2.0 2.2 8.7 10.3 12.9 12.2 11.2 10.6 10.5 10.7 Tricare/CHAMPVA 4.0 3.6 3.3 2.9 2.8 2.9 2.7 2.8 13.7 14.9 16.0 16.4 16.5 16.5 15.9 15.6 2001 2002 2003 2004 2005 2006 2007 2008 247.5 250.8 252.7 255.1 257.4 260.0 261.4 262.8 166.1 164.9 162.9 161.0 161.3 161.7 162.5 160.6 84.1 82.5 81.5 81.6 82.3 82.9 83.9 82.5 82.0 82.4 81.5 79.4 79.0 78.8 78.5 78.1 16.0 16.6 16.7 18.0 17.9 17.7 17.1 16.7 37.9 40.0 42.5 45.1 45.5 45.5 47.7 51.0 5.6 5.8 6.2 6.3 6.4 6.5 7.1 7.7 28.3 29.9 32.4 34.2 34.7 34.9 36.3 39.2 Tricare/CHAMPVA 6.6 6.9 6.9 7.4 7.7 7.1 7.5 7.8 39.5 41.8 43.1 43.0 44.4 46.5 45.0 45.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 67.1 65.7 64.5 63.1 62.7 62.2 62.2 61.1 34.0 32.9 32.2 32.0 32.0 31.9 32.1 31.4 33.1 32.8 32.2 31.1 30.7 30.3 30.0 29.7 6.5 6.6 6.6 7.1 7.0 6.8 6.5 6.3 15.3 15.9 16.8 17.7 17.7 17.5 18.2 19.4 2.3 2.3 2.5 2.5 2.5 2.5 2.7 2.9 11.4 11.9 12.8 13.6 13.5 13.4 13.9 14.9 Tricare/CHAMPVA 2.7 2.8 2.7 2.9 3.0 2.7 2.9 3.0 16.0 16.6 17.1 16.9 17.2 17.9 17.2 17.4 TRICARE CHAMPUS CHAMPVA the Civilian Health and Medical Program for the Department of Veterans Affairs Fronstin 2003, 2009 18
1960 1970 1980 1990 1993 1997 1998 GDP YY 1999 2000 2001 2002 2003 2004 2005 2006 2007 U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (2010) 1 GDP1960 2008 2008 6.7 17.55100 457017.9 III 1965 1 1980 GDP GDP1980 199012.0 1995 13.4 1990 13.2 13.3 200816.2 1997 1999 GDP 4555 2 2007 7710 19
Summer 2010 No. 171 2 1987 1992 1997 2000 2001 2002 2003 2004 2005 2006 2007 $149.0 $274.6 $359.0 $454.7 $497.6 $551.1 $603.7 $645.9 $690.0 $727.5 $771.0 136.6 252.5 335.0 426.2 467.6 517.2 566.4 608.4 653.9 688.0 730.0 105.0 191.0 246.7 321.2 350.9 384.1 421.0 450.7 484.8 502.9 532.4 84.2 147.9 191.4 250.9 271.7 293.4 319.2 338.5 362.1 375.4 398.4 4.9 10.7 11.4 14.3 15.8 17.7 19.7 21.6 23.1 24.3 25.5 16.0 32.4 43.9 55.9 63.3 73.1 82.1 90.6 99.5 103.3 108.5 31.5 61.6 88.4 105.0 116.8 133.1 145.4 157.7 169.1 185.1 197.7 24.9 49.5 71.8 85.1 94.4 107.9 118.2 128.4 136.8 150.3 160.3 2.4 3.5 4.1 5.3 5.9 6.6 7.3 8.0 8.4 9.2 10.0 4.2 8.5 12.4 14.7 16.4 18.6 19.8 21.4 23.9 25.7 27.4 12.4 22.1 24.0 28.5 30.0 33.9 37.3 37.5 36.1 39.4 40.9 U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (2008) 1997 2 7300 20075324 3984255 1085 1977 1603100 274 II 4 6 1 7 2 3 4 HI Trust Fund Workers Compensation and Temporary Disability Insurance 21980 453 1980 199019901123 10001990 2007 3984 1980 20
1965 1970 1975 1980 1985 1987 1988 1989 1990 1991 1992 1993 1994 19965 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 1965-19851994 1987-20072007 Cowan et al (1996); U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (2008) 2 2007 20 General Motors GM GM 1980 GM 200 1980 GM GM 1983 430 GM 1983 22 1970 6 8 GDP 2.51970 20042003 21
Summer 2010 No. 171 20 18 16 14 12 10 8 6 4 2 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 U.S. Bureau of Labor Statistics (1988-2008), Current Employment Statistics Survey 3 (1988 2008 ) 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 1500 9 GM 10 10 2004 GM 1954 272005 1946 103 2004 522005 53 11 GM 12 21 Wal Mart WM 2000 2001 3 200119801990 1990 2001 1990 22
2006 16 2005 30.242601995 300 WM 20094056 2009134 1402009 8 13 WM 2007 14 15 WM2007 1 WM 47.2 50 3.1 4 19.6 16 III 1990 17 1990 FPL: Federal Poverty Guideline 18 200 19 1999 2000 19902001 1987 295019973990 10 1040 4 20 20002008 7502008 23
Summer 2010 No. 171 Fronstin (2003, 2009) 4(1987-2008 ) 4570 198713.7 1990 16 2000 200817.4 1990 1980 2000/2001 5 198070 200861.1 1994 2000 64-68 1980 61990 2001 2000 74.9 200870.3 200818.8 1990 1993 83.1 200089.4 2000 1 24
25 Fronstin 2003, 2009 5 (1987-2008 ) Fronstin (2009) 61994-2008
Summer 2010 No. 171 2 19902000 20 1990 2001 2008 IV 1 2009 1 2 3 21 Energy & Commerce; Ways & Means; Education & Labor Affordable Health Care for America Act (H.R. 3962)2009 11 7 Fi nance; Health, Education, Labor and Pen sions Patient Pro tection and Affordable Care Act (H.R. 3590) 2009 12 24 2010 2 2010 2 22 2 22 51 2 3 Exchange 4 53 1 18 18 23 24 26
32009 12 Exchange H.R. 3962) H.R. 3590) filing threshold 9350 1 87002.5% 750 ( 2250 ) 2 qualified health benefits plan) 5 Exchange 72.5 65 Exchange 8 Exchange 75 8 75 50 30 )50 750 3000 750 200 Commissioner) Health and Human Services) 2015 Exchange Exchange SHOP exchange) Exchange 2013 25 2015 2014 502015 100 50 100 Exchange 2016 100 2017 Exchange 72.5 ) 65 ) 27
Summer 2010 No. 171 400% Exchange 12% (2014 Commissioner 400% Exchange 9.8% 6 (2014 3 2 Exchange ) FPL133 1.5 FPL150 FPL133 3 FPL300 10 FPL400 2 FPL150 4.6 12 FPL300 4009.8 2013 FPL150 500 FPL151 200 1000 FPL251 300 4000 FPL351 400 5000 ) FPL150 97 FPL151 200 93 FPL251 300 78 FPL351 400 70 Exchange Exchange HHS 20 HSA) 2009 5800 11600 2014 FPL200 3 2 FPL201 300 2 1 FPL301 400 3 1 ) FPL150 90 FPL151 200 80 FPL200 400 70 FPL150% FPL133% Congressional Research Service (2009); Congressional Research Service (2010); H. R. 3962 an ACT (http://www.gpo. gov/fdsys/pkg/bills-111hr3962eh/pdf/bills-111hr3962eh.pdf); H.R. 3590 AMENDMENTS (http://www.gpo.gov/ fdsys/pkg/bills-111hr3590eas/pdf/bills-111hr3590eas.pdf); Kaiser Family Foundation (2010) 28
filing threshold 2.5 750 2 50 50 72.5 65 Exchange 8 50 752 6 30 50 Exchange 75062.50 3000 250 750 200 10 2 3 Health Insurance Exchange Exchange Health Choices Com missionercommissioner Exchange Commissioner Commonwealth Health Insurance Connector Authority (Connector) Con nector 25 Exchange 29
Summer 2010 No. 171 Exchange 4 FPL400 FPL400 Exchange Exchange 2 2 FPL133 9.8 FPL300 400 97 FPL133 150 70 FPL350 40090 FPL100 150 70 FPL200.1 5 Exchange 20 3 2010 2 22 26 20 30
1980 2010 3 21 3 23 1 20052010 2 State Children s Health Insurance Program: SCHIP2009 Children's Health Insurance Program CHIP 3 Fronstin 2003, 2009 4 U.S. Census Bureau (2009). 5 U.S. Census Bureau (2009). 6 EBRI Notes, March 2002. 7 O Brien (2003). 8 American Demographics, May 1987. 9 General Motors Corporation (2004). 10 General Motors Corporation (2006). 11 2005UAW UAW 2006 48 General Motors Corporation 2006, Annual Report 12 1985 GM 2010a 2 13 Wal-Mart State by State Information. 14 Wal-Mart 2010a) 3 15 2006 2 24 2004 4 18 16 Wal-Mart (2007); Washington Post, January 11, 2007. 17 20083 1 32.5 21 34.9 1 2 32.57 5000 6.8 Fronstin (2009) 18 U.S. Department of Health and Human Services 2009 4 18222050FPL100 Federal Register, Vol. 74, No. 14, January 23, 2009 19 1980 2000 20 1990 2000 2010a 4 20 2010a 4 21 White House (2009). 22 Congressional Research Service (2009); Congres sional Research Service (2010); H. R. 3962 an ACT (http:// www.gpo.gov/fdsys/pkg/bills-111hr3962eh/ p d f / B I L L S - 1 1 1 h r 3 9 6 2 E H. p d f ) ; H. R. 3 5 9 0 AMENDMENTS(http://www.gpo.gov/fdsys/pkg/ BILLS-111hr3590EAS/pdf/BILLS-111hr3590EAS.pdf); Kaiser Family Foundation (2010). 23 2010b 24 financial hardship 25Connector 2010b 31
Summer 2010 No. 171 26 White House, THE PRESIDENT S PROPOSAL, February 22, 2010. Congressional Research Service (2009), Private Health Insurance Provisions of H.R.3962, CRS Report, R40885. Congressional Research Service (2010), A Comparative Analysis of Private Health Insurance Provisions of H.R. 3962 and Senate-Passed H.R. 3590, CRS Report, R40981. Cowan, C.A., B.R. Braden, P.A. McDonnell and L. Sivarajan (1996), Business, households, and government: health spending, 1994, Health Care Financing Review, 17(4), pp.157-178. Fronstin, P. (2003), Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2003 Current Population Survey, EBRI Issue Brief, 264. Fronstin, P. (2009), Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2009 Current Population Survey, EBRI Issue Brief, 334. General Motors Corporation (2004-2006), General Motors Corporation Annual Report. Kaiser Family Foundation (2010), Side-by-Side Comparison of Major Health Care Reform Proposals, Focus on Health Reform, updated January 13. O Brien, E. (2003), Employers Benefits from Workers Health Insurance, Milbank Quarterly, 81(1). U.S. Bureau of Labor Statistics (1988-2008), Current Employment Statistics Survey. U.S. Census Bureau (2009), Income, Poverty, and Health Insurance Coverage in the United States: 2008. U.S. Department of Health and Human Services, Center for Medicare & Medicaid Services (2008), Sponsors of Health Care Costs: Businesses, Households, and Governments, 1987-2007. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (2010), National Health Expenditure Data. Wal-Mart (2007), Open Enrollment Survey Report. White House (2009), The OBAMA Plan Stability & Security for All Americans. 2005 20 3 2010 2010a 2010b - 170 32