Buck J A, Kamlet M S
Carnegie Mellon University.
J Health Polit Policy Law. 1993 Spring;18(1):1-25. doi: 10.1215/03616878-18-1-1.
Many proposals for financing health care for the uninsured recommend expanding the Medicaid program. They often advocate extending Medicaid to all those under the poverty level and standardizing program benefits. However, the proposals have ignored important problems that must be resolved if the plans are to be successfully implemented, the most serious being the fiscal impacts that such proposals would have on states. The current Medicaid matching formula fails to reflect either the size of a state's Medicaid program or its ability to pay for it. As a result, the proportional fiscal effort that expansion proposals would require of states would greatly exceed that required of the federal government. Additionally, the fiscal impact would vary widely and have little relationship to a state's current Medicaid program generosity. Besides fiscal problems, significant differences exist between Medicaid and private plans in the areas of benefits, cost sharing, managed care, cost containment, and provider payment. Under a national system of health care, these differences would limit program economies, and create problems with perceived equity, continuity of care, and migration effects.
许多为未参保者提供医疗保健融资的提议都建议扩大医疗补助计划。这些提议通常主张将医疗补助扩大到所有贫困线以下的人群，并使计划福利标准化。然而，这些提议忽略了一些重要问题，如果要成功实施这些计划，就必须解决这些问题，其中最严重的是此类提议对各州造成的财政影响。当前的医疗补助匹配公式既没有反映出一个州医疗补助计划的规模，也没有反映出该州支付该计划的能力。因此，扩大计划对各州所需的按比例财政努力将大大超过对联邦政府的要求。此外，财政影响差异很大，与一个州当前医疗补助计划的慷慨程度关系不大。除了财政问题，医疗补助与私人保险计划在福利、成本分担、管理式医疗、成本控制和提供者支付等方面存在重大差异。在全国性的医疗保健体系下，这些差异将限制计划的经济性，并在公平感、医疗连续性和迁移效应方面产生问题。
