Republicans Missed a Shot at Serious Medicaid Reform
共和黨錯失醫療補助改革良機

Every decade since the 1970s, Congress has tried and failed to reform Medicaid, the health entitlement for the poor. Republican lawmakers’ latest effort — as part of the One Big Beautiful Bill Act — appears to be no different. Instead of addressing the program’s core deficiencies, the party instead fixated on shrinking it. The likely result? Needless disruption and little in the way of serious savings or reform.
自 1970 年代以來，國會改革醫療補助計畫的嘗試屢屢失敗，共和黨最近的努力也不例外。他們未處理核心缺陷，反而執著於縮減規模，最終可能只會造成混亂，卻無助於節省開銷或實質改革。

All told, the bill seeks to cut about $1 trillion from federal Medicaid spending over a decade. This savings largely would be achieved through a series of technical changes that nonetheless would be costly and difficult to implement, and thus may not fully materialize.
該法案目標在十年內削減約一兆美元的聯邦醫療補助支出。這主要仰賴一系列技術性變更，但因執行成本高昂又困難，節省效果可能無法完全實現。

The most substantial amount in theory would come from adding “work requirements” for beneficiaries. Starting next December, Medicaid recipients under age 65 will need to work, seek employment, go to school or volunteer 80 hours a month, with exemptions for pregnant women, parents with children under 14, the “medically frail” and others. The goal is to save money by shrinking the pool of enrollees — without cutting benefits for those still eligible or dramatically increasing the uninsured rate.
理論上，最大筆的節省來自對受益人新增「工作要求」。明年 12 月起，65 歲以下的受益人每月需工作、求職或參與志工服務等達 80 小時，但孕婦、有 14 歲以下子女的父母及身體虛弱者等群體可豁免。此舉旨在透過減少投保人數來省錢，同時不影響合格者的福利或提高無保險率。

Accomplishing such a delicate task is, you might say, aspirational. States will need to update creaky IT systems and retrain staff. They’ll have to coordinate with the managed-care companies that administer Medicaid plans and communicate changes to a population that’s known to move and change jobs frequently. To show they’re working in good faith and not simply snatching benefits from the poor, officials ought to establish pathways to vocational and other programs that put recipients in compliance with the new rules. They likewise should work with local employers to help those who’ve lost coverage find alternatives.
完成這項艱鉅任務近乎空想。各州需更新資訊系統、訓練員工，並與保險公司協調，還得向流動性高的受益人傳達新規定。此外，官員應提供職業培訓等配套措施，並協助失去資格者尋找替代方案，以示善意。

Preparation of this sort is improbable, and not just because it’s laborious.
這類準備工作不太可能落實，而且不僅僅是因為過程繁瑣。

Thanks to Medicaid’s funding model, most states have little incentive to strictly comply with work requirements. Since its inception in 1965, Medicaid has offered a federal “match” for state spending on public aid, without a cap. For each dollar a state spends, it gets $1 to $9 from the federal government. By enforcing work rules — and thus lowering their Medicaid spending — states stand to cut off their biggest source of funding, at the risk of yanking away their residents’ health care. Far better to create workarounds.
由於醫療補助的資金模式，多數州缺乏嚴格執行工作要求的誘因。聯邦政府會無上限補助州的支出，州政府每花一元，就能得到聯邦一至九元的補助。若嚴格執法會減少州支出，反而切斷了主要的聯邦資金，並可能危及居民的醫療保障。因此，各州更傾向尋找變通辦法。

For these reasons, work requirements are unlikely to generate hoped-for savings. They’ll also hassle the poor while failing to address the perverse incentives of the open-ended federal match that has made Medicaid one of the fastest-growing federal programs, with expenditures soaring to more than $800 billion from about $40 billion in 1985.
基於此，工作要求難以節省預期開支，反而為難窮人，也未能處理核心問題：聯邦無上限配合款的不良誘因。此誘因已讓醫療補助計畫的支出從 1985 年的 400 億美元，飆升至超過 8000 億美元，成為增長最快的聯邦計畫之一。

Proposals that seek to eliminate the open-ended match have long been debated but remain unpopular. So-called block grants, for example, would allocate a fixed amount of money to states each year. Although that would curb runaway spending, it would be perilously inflexible in times of need — say, when enrollment rises during recessions, disease outbreaks or natural disasters.
取消「無上限補助」的提案爭議已久，卻不受歡迎。例如，「定額補助」是每年撥給各州一筆固定款項。此舉雖能抑制支出，但在經濟衰退、疫情或天災等緊急時期，將會過於僵化。

Get the Singapore Edition newsletter in your inbox.

Get the Singapore Edition newsletter in your inbox.

Get the Singapore Edition newsletter in your inbox.

Go beyond the headlines with insights into one of Asia's most dynamic economies. Delivered weekly.

Go beyond the headlines with insights into one of Asia's most dynamic economies. Delivered weekly.

Go beyond the headlines with insights into one of Asia's most dynamic economies. Delivered weekly.

*

Signed Up Sign Up Sign Up

By continuing, I agree to the Privacy Policy and Terms of Service.

One idea that deserves more attention is something of a hybrid. It involves maintaining the uncapped federal match for mandatory benefits and eligibility categories — that is, the core services and populations required by federal law — while setting limits on matching for states’ optional expansions. A split along these lines would make states, rather than federal taxpayers, responsible for spending they choose to incur.
一個值得考慮的混合方案是：維持聯邦對法定項目的補助無上限，但對各州自選的擴大項目設定補助上限。如此，各州便需為其選擇的額外支出負責，而非聯邦納稅人。

The good news is that the One Big Beautiful Bill has started a long-overdue conversation on Medicaid reform. The bad news is that, as things stand, the cuts the law has imposed are likely to result in disruptive yet ineffective change. Congress still has a chance to do the right thing.
好消息是，該法案開啟了遲來的醫療補助改革對話。壞消息是，法案的削減措施目前看來只會帶來破壞，卻無成效。國會仍有機會採取正確行動。

More From Bloomberg Opinion:
彭博觀點更多內容：

• Republicans Need to Show Work Requirements Can Work: Editorial
  社論：共和黨須證明工作要求可行
• Medicaid Cuts Will Hit Rural America Hard: Lisa Jarvis
  Lisa Jarvis：削減醫療補助將重創美國農村
• The Issue That Can Damage Republicans the Most: Matthew Yglesias
  Matthew Yglesias：共和黨的最大軟肋

Want more Bloomberg Opinion? OPIN <GO>. Web readers, click here. Or you can subscribe to our daily newsletter.
想看更多彭博觀點？歡迎訂閱我們的每日電子報。