Custer W
Employee Benefit Research Institute.
EBRI Issue Brief. 1993 Mar(135):1-33.
Since the election, the health care reform debate has focused on three broad features: implementation of managed competition, changes in the tax treatment of health insurance, and the imposition of budget caps or targets. The basic element of managed competition is the creation of sponsors who act as collective purchasing agents for large groups of individuals. One of the potentially most politically difficult issues in implementing any health care reform proposal is likely to be defining the minimum standard benefit package. It will determine the costs society bears, the income of providers, the health of many individuals, and the attributes of a workable health care reform package. Managed competition is intended to foster competition among health plans on the basis of cost and quality. The measures of quality actually employed in the health care system will determine in large part the incentives faced by insurers, providers, and consumers. The problem of adverse selection is potentially the most important issue in reforming the health insurance market. If individuals can opt not to purchase health benefits, poorer risks will be more likely to purchase health insurance than good risks, and at minimum the price of these benefits will be higher than would otherwise be the case. Managed competition requires that individuals share at least some of the financial consequences of their choices among health plans. As a result, most managed competition proposals change the tax code by limiting the exclusion of employer contributions to health insurance from worker's taxable income. Changing the health insurance market, mandating employer health benefits, and changing the tax code may have significant effects on the health care delivery system, but they are unlikely to reduce health care cost inflation in the near term. One of the proposals for restraining the growth in health care costs is the imposition of a budget on the amount spent on health care services. The combination of the constraints placed on federal governmental action by the budget and the significant political problems involved in reaching a consensus on the important elements of health care reform may limit the ability of the federal government to implement national health care reform in the near term. As a result, individual states may be encouraged by the federal government to continue to experiment with their own health reform programs.
自选举以来，医疗保健改革辩论主要集中在三个广泛的特征上：管理竞争的实施、医疗保险税收待遇的变化以及预算上限或目标的设定。管理竞争的基本要素是创建作为大群体个人集体采购代理的赞助者。在实施任何医疗保健改革提案时，潜在的最具政治难度的问题之一可能是界定最低标准福利套餐。它将决定社会承担的成本、提供者的收入、许多人的健康状况以及可行的医疗保健改革方案的属性。管理竞争旨在促进健康计划在成本和质量基础上的竞争。医疗保健系统实际采用的质量衡量标准将在很大程度上决定保险公司、提供者和消费者所面临的激励措施。逆向选择问题可能是改革医疗保险市场中最重要的问题。如果个人可以选择不购买健康福利，那么健康风险较差的人比健康风险良好的人更有可能购买医疗保险，而且至少这些福利的价格会比其他情况更高。管理竞争要求个人至少分担他们在健康计划选择中的部分财务后果。因此，大多数管理竞争提案通过限制将雇主对医疗保险的缴款从工人应纳税所得中排除来改变税法。改变医疗保险市场、强制要求雇主提供健康福利以及改变税法可能会对医疗保健提供系统产生重大影响，但短期内它们不太可能降低医疗保健成本的通胀。抑制医疗保健成本增长的提案之一是对医疗保健服务支出设定预算。预算对联邦政府行动的限制以及就医疗保健改革的重要要素达成共识所涉及的重大政治问题，可能会限制联邦政府近期实施全国性医疗保健改革的能力。结果，联邦政府可能会鼓励各个州继续试验它们自己的医疗改革计划。
