Where is 医疗补助 Spending Headed? – Report
Where is 医疗补助 Spending Headed?
Prepared for: The Kaiser Commission on the Future of 医疗补助
编写者：城市研究所的John Holahan和David Liska
Much of the impetus behind the calls for major program restructuring came from the rapid growth in 医疗补助 expenditures that occurred between 1988 and 1992. 医疗补助 spending was argued to be “out of control”以及各州的主要财务负担。该程序还被视为“out of control” from the perspective of the federal government, as well as a major contributor to the federal deficit. In April 1996, the Congressional Budget Office (CBO) forecast that 医疗补助 spending would grow by about 10 percent per year through the year 2002, faster than the projected increases in inflation and in the US. population.
In this paper we first discuss reasons for the rapid growth in 医疗补助 spending between 1988 and 1992. We then show that 医疗补助 spending has, in fact, slowed considerably since 1992 and argue that this slowdown is likely to continue. 后 growing by an average annual rate of 22.4 percent between 1988 and 1992, 医疗补助 expenditures increased by an average of 9.5 percent each year between 1992 and 1995. Furthermore, although the data are preliminary, 1995-1996 spending growth for 医疗补助 appears to be about 3.2 percent.
The 医疗补助 Growth Explosion from 1988 to 1992
之间 1988 and 1992, 医疗补助 expenditures grew on average by 22.4 percent per year, increasing from $53.5 billion in 1988 to $119.9 billion in 1992. 如图所示 表格1，老年人和残疾人的支出每年平均分别增长14.7％和17.0％。成人和儿童的支出从131亿美元增长到309亿美元，年均增长23.9％。虽然成人和儿童的支出比老年人，盲人和残疾人的支出增长更快，但成人和儿童的人均成本降低了对总支出的影响。
表2 shows that 医疗补助 enrollment increased from 22.0 million to 29.8 million Americans from 1988 to 1992. Increases in the enrollment of the elderly were relatively slow, increasing from 3.1 to 3.5 million, or 3.2 percent per year. There was, however, substantial growth in coverage of the disabled, with enrollment increasing from 3.4 to 4.5 million, or by 6.7 percent per year. The high annual cost of covering the disabled means that this expansion has been extremely important to the cost of the program. The number of adults and children increased from 15.4 to 21.8 million, an average annual increase of 9.0 percent.
There are a large number of reasons for the growth in 医疗补助 expenditures during this period. Although precise contributions are difficult to quantify, the following factors seem to be particularly significant: DSH payments, enrollment, and costs per enrollee. 一个 earlier analysis conducted for the Kaiser Commission on the Future of 医疗补助 found that all of these factors were important contributors to spending growth in this period.1
第一, an important contributor to the large increase in 医疗补助 spending during this period was the aggressive use of provider taxes and donations and Disproportionate Share Hospital (DSH) payments.2 这些安排为各州带来了联邦资金，资金主要分配给了医院，为低收入人群提供了不成比例的护理。典型的做法是各州要求提供者缴纳费用或对提供者征税-医疗补助计划会通过DSH付款增加向同一提供者的支付。这些DSH付款将返回很多（如果不是全部）医院'捐赠或纳税；然后，州政府可以要求联邦配套资金向医院支付DSH。在许多情况下，这些资金被用于协助医院为低收入人群提供贫困护理。在另一些国家中，用联邦资金代替各州的支出，而卫生保健的总卫生支出则相对相同。但是，使用了这些资金，对这段时期的医疗补助支出增长产生了重大影响。 DSH付款在1988年约为4亿美元，到1992年增长到超过170亿美元。
第二个主要因素与入学人数增加有关。一系列立法授权将医疗补助范围扩大到孕妇和儿童以及老年人和残疾人。在1980年代后期 's，Medicaid终止了参与对有抚养子女的家庭援助（AFDC）计划与获得Medicaid承保范围之间的独家联系。到1990年，联邦法律要求所有收入低于联邦贫困线133％的六岁以下孕妇，婴儿和儿童，无论AFDC的接受程度如何。各州可以选择通过联邦补助金将覆盖范围扩大到贫困线的185％的孕妇和婴儿，而33个州已经这样做。现在要求各州覆盖6至12岁的儿童，直至联邦贫困线。计划在2002年逐步淘汰13至18岁的贫困儿童。 之间 1988年和1992年，这些任务涵盖了450万孕妇和儿童。3这些 新的符合条件的团体约占总入学人数增长的50％，尽管它们在总支出增长中所占的比例明显较低。4
Congress also extended 医疗补助 eligibility to elderly and disabled 医疗保险 beneficiaries. The 医疗保险 Catastrophic Coverage Act of 1988 and the Omnibus Budget Reconciliation Act of 1990 required 医疗补助 programs to cover 医疗保险 costs for low-income persons not eligible for cash assistance-Qualified 医疗保险 Beneficiaries (QMBs). States are required to cover 医疗保险 premiums and cost sharing for all 医疗保险 eligible persons with incomes below the federal poverty line. By 1995, this was extended to premium assistance for 医疗保险 eligibles with incomes between 100 percent and 120 percent of poverty. 因为 of data limitations, it is difficult to know how many enrollees have been covered by these provisions; one estimate is that there are 1.3 million low-income elderly and disabled in 1995 who received premium assistance through the QMB 立法 and would not have otherwise qualified for 医疗补助 .5
医疗补助 also expanded during these years because of the recession and in concert with other related programs. For example, between 1988 and 1991, AFDC enrollment increased by 15.6 percent and food stamp enrollment by about 20 percent. States also took a number of steps to simplify the eligibility and enrollment processes during this period.
Third, increased in health care prices are an important contributor to 医疗补助 expenditure growth and yet are largely outside the control of the program. 医疗类 price inflation accounted for about one third of 医疗补助 spending growth between 1988 and 1992.6 While states did not strictly have to increase provider payment rates with inflation, it has proven difficult over the long term to allow these rates to continue to diverge widely from private and 医疗保险 rates without eroding provider participation in 医疗补助 . Furthermore, the Boren Amendment requires states to pay the cost of efficiently and economically operated facilities such as hospitals and nursing homes; the costs of such facilities have clearly increased with inflation as a direct result of wage costs, among other factors.
医疗补助 's financial role in nursing home care also expanded during this time. While the number of nursing home beneficiaries grew only modestly, the role of 医疗补助 financing increased because of newly enacted protections against spousal impoverishment that reduced the cost for nursing home residents whose spouses continued to live in the community. 医疗补助 expenditures during this period also grew in many states because of greater availability of 医疗补助 -financed long term care in the community and at home and reportedly because of more widespread divestiture of assets to become eligible for nursing home benefits.
最后, states became increasingly aggressive during this period in shifting services to 医疗补助 that had previously been financed by other state and federal programs.7 这种做法，称为“医疗补助最大化，” results in the shift of services that have formerly been paid for by state only dollars on to 医疗补助 where they receive federal matching payments. 这些 services include state-funded institutional services for the developmentally disabled and mentally ill, and home and community-based services for the disabled funded under Title XX.
The Slowdown in 医疗补助 Expenditure Growth, 1992 to 1995
Following four years of rapid expansion, 医疗补助 program growth slowed precipitously after 1992. 后 four years with an average annual growth rate of 22.4 percent, 医疗补助 spending grew on average by 9.5 percent per year between 1992 and 1995 (表格1）。支出从1992年的1199亿美元增加到1995年的157.3美元。家庭（12.1％）的年均增长率继续高于残疾人（11.3％）和老年人（7.9％）。初步数据表明，1996年医疗补助支出增长了约3.2％。1996年的低增长率可能至少部分反映了1995年国家支出的加速增长，因为拟议的重组医疗补助的立法将以1995年的数据为基础进行分配整笔拨款。然而，纵观1994年和1996年，年均支出增长约为6％。
There are several reasons for the decline in 医疗补助 spending growth. 一个 important reason the growth in 医疗补助 expenditures have declined is because of 1991 and 1993 立法 影响不成比例的股份支付的使用。8 如图所示 表格1在经历了几年的爆炸性增长之后，1992年至1995年间，不成比例的股票支付每年仅增长2％。 1991年，立法禁止使用提供者捐赠，并严格限制了州可以采用的提供者税收的种类。实际上，各州不能再保证医院可以“made whole”通过相互的DSH付款进行捐赠或纳税。 1991年的法律还规定，DSH的付款不得超过计划支出的12％。任何DSH支付超过12％的州都将冻结在1993年的水平，直到DSH支付占医疗补助支出的12％为止。 DSH支付低于12％的州被允许以与计划支出相同的速度增长。由于计划支出已放缓，因此DSH付款的允许增长率也已放缓。 1993年的立法限制了向医院支付DSH的水平。由于医疗补助报销率低或通过提供无偿护理，各州所支付的医院费用不再超过该设施的损失。这种严格限制的状态'能够向特定医院支付大量费用，并减少了其中一些州的医疗补助支出。