2012年7月18日 星期三

好險,有健保:美國健保制度簡介

在二○一○年三月,美國國會以七票之差通過健保改革法案,歐巴馬總統獨排眾議強度關山,雖然可預見必定會困難重重,但至少也突顯他要修補美國這個資本主義社會,長久以來貧富裂縫深長的決心。


很多人一定很好奇,像美國這樣的先進國家,怎麼會沒有一套完整的健保制度呢?其實嚴格說來也並不是完全沒有,只是並非「全民」的。美國從一九六五年來開始實行一種由政府透過保險公司以私人契約制訂的健康保險,目標是針對沒有能力負擔或是沒有工作收入來支付其他昂貴保險費的族群,主要可分成下兩種:老人醫療照護險(Medicare)與政府醫療補助(Medicaid)。


Medicare/Medicaid申請資格大不同


一般來說,老人醫療照護險Medicare的申請資格為一、年滿六十五歲,二、未滿六十五歲的殘障者,三、長期腎病患者,四、永久居民(綠卡持有人,需要在美國至少住滿五年)。

此醫療保險又細分為四部分;

A部分為住院醫療險(Hospital Insurance),為強制性的,可讓被保者享有每年九十天的住院治療及一百天的技術護理;而如果兩者在同一年發生,則被保人要自行負擔部份費用。

B部分為補充性醫療保險(Supplemental Medical Insurance),主要用於院外醫師診察費、醫師指定用藥等其他院外醫療服務,為自願性的,幾乎九十九%的老年人都有繳月費另參加此保險;二○一一年已參加者的月費約九四˙六美元,新參加者則漲至一一○˙五美元。

C部分稱為Medicare Advantage(MA),除了透過私人醫療公司提供兼具A、B部分的醫療服務外,還包含牙齒及視力的給付項目。

D部分為購藥方案,由業者提供幾種不同的購藥組合。但由於政府補助金額逐年減少,有些健保公司最後只剩下「基本」與「進階」兩種購藥選擇,投保者必須多加注意。

另一方面,政府醫療補助Medicaid是為了照顧低收入戶所訂的醫療計畫,申請對象為一、合法的美國低收入者(由每州政府自行核定標準),二、孩童、孕婦、老年人,三、殘障者及其父母。這個醫療補助計畫就不算是應有的福利,是需要經過申請及資格審核,而在大部分的州內,Medicaid也是預算的主要撥款項目。在二○一○年通過健保改革法案後,除了強制美國民眾加入健保,也會擴大Medicaid的內容。

兒童醫療保險(CHIP)的催生

其實有許多家庭雖然不達州政府訂的申請Medicaid低收入戶標準,但因家中有孩童要扶養,在收入不高不低的情況下,醫療保險仍是沉重的負擔;因此在一九九七年,美國平衡預算法(The Balanced Budget Act of 1997)便建立了兒童健康保險(CHIP),主要適用於:一、家中有十八歲以下且未有任何醫療保險的兒童(兒童本人必須是美國公民或合法永久居民),則可由監護人申請補助;二、現年十九歲或獨立生活的青少年可自行申請,三、家庭年收入在四萬五千美元以下,其他條件則依各州政府規定。

至於收費標準以德州(Texas)為例,申請加入的費用是依照家庭的年收入而有所不同,最多約五十美元。而每次就醫及開藥的部分負擔費用約五至二十五美元不等,確實降低了不少。

另外,歐巴馬總統更在就職後就緊接簽署的兒童健康保險再授權法(Children's Health Insurance Program Reauthorization Act)以及平價照顧法(Affordable Care Act)共提供了一億兩千萬美元,希望能幫助更多資格符合者加入兒童醫療保險。

Medicaid,民眾反應兩極

那麼,單就一般低收入的民眾較可申請的政府醫療補助計畫來說,是不是真的有幫助到呢?美國經濟分析局(National Bureau of Economic Research)在二○一一年七月發表的一篇研究顯示:有參與政府Medicaid者,相較於沒有的人,提升了三分之一的滿足感與快樂。

研究人員之一的Amy Finkelstein表示,如果你具有醫療補助身分的話,將提高三十五%的機率可掛到門診,並高達七十%的機率會得到優先的門診照護,除此之外,也提高了五十五%可固定看某一醫生的機會。

當然,也有批評的聲浪出現,美國《華爾街日報》在二○一一年三月刊登了一篇標題為「有醫療補助計畫倒不如沒有」(Medicaid Is Worse Than No Coverage)的社論,批評Medicaid使國民越來越貧窮,並降低醫療品質;原因在於政府給付給醫生和醫療照護者的太少了,以致於資源、人力不足。比起一般能夠付起現金的病人,醫生自然較不願意接受身份為政府醫療補助者,甚至也有病患找了二十位醫生都還無法找到一個願意替他看病的。

除此之外,也因政府不斷的將Medicaid的申請條件放寬,或是另外建立許多醫療補助方案,導致申請人數持續增加,預算也年年往上提升,以致各州政府財務嚴重超支,被認為是財政極大的負擔,也為美國目前亟需解決的最大問題之一。

儘管正反兩面聲音不斷,但不可否認的,在美國看病原是一件多麼昂貴的開銷,不管這個政府補助計畫是好是壞,相信也多少幫助到一些弱勢的人。

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