[資訊] 如何改革美國醫療體系

[kwei (光影)]

How to Fix American Health Care
如何改革美國醫療體系

原文：Foreign Affairs https://tinyurl.com/qp7bdk8
譯文：法意讀書 https://wemp.app/posts/1fc5bed6-83e3-45d6-a743-a6fbc89d9c9c
作者： William C. Hsiao
譯者：岳虹

[法意導言]蕭慶倫（William C. Hsiao）是美國科學院院士、哈佛大學公共衛生學院衛生
政策管理系和全球衛生與人口學系衛生經濟學教授、中國國務院醫改領導小組專家委員會
外籍顧問，是醫療改革和社會保險領域的傑出專家，曾出任美國尼克森、卡特、柯林頓三
屆總統醫療體制改革政策的衛生經濟顧問。《外交事務》雜誌2020年第一期（1月/ 2月刊
）中，他發表了《目前美國醫療保障體系改革的出口是德國模式》（How to Fix
American Health Care: What Other Countries Can—and Can’t—Teach the United
States）一文。與建立了全民醫療保險體系的加拿大、日本等發達國家不同，美國的醫療
保險體系是由醫療保險（Medicare）和醫療補助（Medicaid）等公共保險項目和商業保險
組成的多人支付（Multiple-payer）系統。這種制度帶來的費用高昂、效率低下、資源浪
費等問題一直為人詬病，而醫保改革也是美國政治領域的焦點話題。近年來，建立由政府
為單一支付人（Single-payer）的全民醫療保障體係獲得了較多的呼聲，但與此同時，相
關利益集團的反對、稅收增加的壓力等因素也使得這一目標在政治上舉步維艱。本文作者
探討了加拿大、台灣和德國的醫療保障模式，認為美國目前醫療保障體系改革最切實際的
選擇是德國模式。

There are many statistics that illustrate the flaws of the U.S. health-care
system. One in particular stands out. In 2017, Americans spent an average of
$10,224 per person on health care, according to a Kaiser Family Foundation
study. The equivalent figure across similarly wealthy countries that year was
just $5,280. Yet despite spending almost twice as much as Australians,
Canadians, Japanese, and many Europeans, Americans suffer from lower life
expectancy, higher infant mortality rates, and a higher prevalence of heart
disease, lung disease, and sexually transmitted infections.

美國醫療體系的缺陷體現在許多統計數據中，其中之一尤為突出。根據凱撒家庭基金會（
Kaiser Family Foundation）的一項研究，2017年，美國人均醫療保健花費為10,224美元
。同年，在與美國類似的發達國家中，人均醫療花費僅為5,280美元。儘管美國的人均醫
療花費幾乎是澳大利亞、加拿大、日本和許多歐洲國家的兩倍，美國的人均壽命卻更低，
嬰兒死亡率更高，心臟病、肺病和性傳播疾病的患病率更高。

This reflects the deep dysfunction in the U.S. health-care system. Experts
estimate that around 30 percent of the money spent on health care in the
United States--around $1 trillion a year--is wasted on inefficiencies,
excessive administrative expenses, the duplication of services, and fraud and
abuse in insurance claims. Meanwhile, huge numbers of Americans remain
uninsured or underinsured. The 2010 Affordable Care Act (ACA) attempted to
address such problems but has proved insufficient for many reasons--including
the Trump administration's efforts to hollow out the legislation.

這反映了美國醫療保障體系中的嚴重功能障礙。專家估計，每年約有30％（約1兆美元）
的醫療保障資金被浪費在低效率、過度的行政開支、重複的服務以及醫療保險詐騙和濫用
上。同時，大量美國人仍未投保或投保不足。2010年的《平價醫療法案》（Affordable
Care Act）試圖解決此類問題，但許多因素導致其發揮的作用有限，其中包括特朗普政府
為架空這部法案所做的努力。

It is true that some Americans have better access to advanced technologies
and drugs than do most Canadians and Europeans. And in certain fields, such
as cancer diagnostics and treatment, the United States offers unsurpassed
care. What is more, on average, Americans experience shorter wait times for
certain specialty services, such as orthopedic surgery. But the fact remains
that when it comes to health care, Americans pay more and get less.

的確，部分美國人比大多數加拿大人和歐洲人更容易獲得先進技術和藥品。在某些領域，
例如癌症診斷和治療，美國提供了首屈一指的醫療服務。並且，平均而言，在某些特殊醫
療服務（例如整形外科）方面，美國人的等待時間較短。但事實仍然是，美國人在醫療上
花費更多，得到的卻更少。

Establishing truly effective and affordable universal health care will
require a dramatic overhaul. Just what sort of change will be necessary is
the subject of fierce debate right now, especially within the Democratic
Party. One alternative would be to shift to a single-payer system along the
lines of the Medicare for All proposals introduced by Senator Bernie Sanders
of Vermont and Senator Elizabeth Warren of Massachusetts, who are running for
the Democratic presidential nomination. If properly carried out, such a plan
would be cost-effective and would bring about major improvements in U.S.
health care. But it is far from certain that it would prove politically
possible, since it would require raising taxes and, even more controversial,
abolishing most forms of private health insurance.

建立真正有效和可負擔的全民醫療保障體系需要進行重大改革。目前，尤其是在民主黨內
部，激烈爭論的主題是需要進行什麼樣的改革。第一種方案由正在競選民主黨總統候選人
的佛蒙特州參議員伯尼·桑德斯（Bernie Sanders）和馬薩諸塞州參議員伊麗莎白·沃倫
（Elizabeth Warren）提出。他們主張建立“全民醫療保險”，將醫療保險由多支付人機
制轉向單一支付人機制。若執行得當，此政策將具有成本效益，並使美國醫療保障體系得
到重大改善。但是，這在政治上是幾乎不可能的，因為這需要提高稅收，更具爭議的是，
還需要取消大多數形式的私人醫療保險。

A less far-reaching, less cost-effective, but perhaps more politically
achievable option would be a gradual transition that would maintain the
multiple-payer model for two to three decades while steadily increasing the
role and authority of government at the federal and state levels. The
ultimate result would be a hybrid system in which a number of insurers,
including private ones, would continue to exist but a single payer--a
partnership between the federal and state governments--would predominate.

另一個影響較小、成本較高但也許在政治上更可行的選擇是逐步過渡，維持多支付人機制
二十到三十年，同時穩步提高聯邦和州政府在醫療保障體系中的作用和權力。最終將形成
一種混合系統，由單一支付人（聯邦政府和州政府形成的合夥關係）主導，包括私人保險
公司在內的多種保險公司將繼續存在。

Proponents of major reform often point to the disparity between health-care
costs and outcomes in the United States and those in other developed
economies and argue that Washington should look abroad to fix what is broken
at home. This is indeed a good idea--but only if U.S. policymakers choose the
right foreign models. For examples of highly successful single-payer systems,
they should look to Canada and Taiwan. For inspiration on a hybrid system
that would not require scrapping private insurance right away, they should
consider the German model. The governments and societies of those places
differ in important ways from those of the United States, of course; in
considering foreign healthcare systems, U.S. policymakers should adapt rather
than adopt. But any reform effort that ignores these successes would deprive
Americans of solutions that would allow them to live longer, healthier lives.

支持重大改革的人常常指出，美國與其他發達經濟體的醫療保障成本和結果之間存在差距
，並主張聯邦政府應將目光投向國外，以解決國內的問題。這確實是一個好主意，但前提
是美國決策者選擇正確的外國模式。例如提到成功的單一支付人體制，應該關注加拿大和
台灣。若要建立一個無需立即取消私人保險的混合體制，應該借鑑德國模式。當然，這些
地方的政府和社會與美國在許多重要方面存在不同。在借鑑外國醫療保障體系時，美國決
策者應該因地制宜而不是全盤照搬。但是，若忽略這些成功例子，美國將無法拿出提高人
民壽命、促進人民健康的解決方案。


A DIFFERENT KIND OF AMERICAN EXCEPTIONALISM
另一種形式的美國例外主義

The United States is the only advanced economy that does not offer universal
health-care coverage. For the past five decades, Washington has moved in fits
and starts toward that goal but has never quite arrived. In 1965, major
reforms to expand insurance coverage led to the establishment of Medicare (to
cover the elderly and the disabled) and Medicaid (to cover the poor). That
expansion was extended in 2010 by the ACA, or Obamacare, which made coverage
accessible to the "near poor" (those making an income between the poverty
line and 25 percent above it) and others without health insurance. Today,
however, 28 million Americans remain uninsured, and 44 million are
underinsured, meaning they spend more than ten percent of their incomes on
out-of-pocket health-care expenses.

美國是唯一不提供全民醫療保險的發達經濟體。在過去的五十年中，聯邦政府步入正軌並
朝著這一目標邁進，但從未完全實現。1965年，為擴大保險範圍而進行的重大改革建立了
醫療保險（Medicare，覆蓋老年人和殘疾人）和醫療補助（Medicaid，覆蓋窮人）計畫。
歐巴馬的平價醫療法案於2010年擴大了其覆蓋範圍，使“近乎貧困的人”（收入在貧困線
至貧困線之間25％的人）以及其他沒有醫療保險的人也可以享受該保險。但是，今天，仍
有2800萬美國人沒有醫療保險，而4400萬美國人的醫療保險不足，這意味著他們收入的10
％以上用於自付費用的醫療。

This has a profound effect on American society. The news media often focus on
the more than half a million household bankruptcies that medical bills induce
every year, but other substantial harms are less well recognized. The
uninsured and the underinsured delay or even forgo treatment when they are
ill, and their children often do not receive critical immunizations. This
contributes to a pernicious form of inequality: on average, the top quarter
of American earners live ten years longer than those in the bottom quarter.

這對美國社會產生了深遠的影響。新聞媒體經常關注每年因醫療費用引起的五十多萬戶家
庭破產，但其他重大危害卻鮮為人知。未投保和投保不足的病人會延誤甚至放棄治療，他
們的孩子往往得不到重要的免疫接種。這導致了一種危險的不平等現象：美國收入最高的
四分之一的人的平均壽命比收入最低的四分之一的人長十年。

Making matters worse, the system is terribly inefficient. The amount spent in
the United States on administrative expenses related to health care is three
times as high as that in other advanced economies. That is because in a
multiple-payer system, insurers offer many different policies, each one
featuring distinct benefits packages, premium rates, and claim procedures. At
the same time, insurers negotiate separately with hospitals and clinics,
which means they pay different prices for the same services. So to file
claims, health-care providers have to employ vast administrative staffs to
sort out the various plans, rules, and prices.

更糟的是，這種體系效率極低。在美國，與醫療保障有關的行政費用支出是其他發達經濟
體的三倍。這是因為在多支付人體系中，保險公司提供許多不同的保險計畫，每種計畫都
有不同的保險金、保費率和索賠程序。同時，保險公司與醫院和診所分別進行談判，這意
味著他們為相同的服務支付不同的價格。因此，要提出索賠，醫療保險公司必須僱用大量
的管理人員來整理各種方案、規則和價格。

Fraud and abuse also drive up the price of care, accounting for around $150
billion in unnecessary spending every year, according to the best estimates
available. A cottage industry has sprung up to advise hospitals and
physicians on how to game the claims system by fragmenting bills and
"upcoding" services--exaggerating their complexity--in order to maximize
payments. Large providers now employ workers whose main task is to find ways
to pad charges. Some hospitals and clinics take a blunter approach: they
simply file claims for services they have not actually performed.

詐騙和濫用保險也推高了醫療保險的價格，根據現有的最佳估計，這每年造成約1500億美
元的不必要支出。一個向醫院和醫生提供諮詢的行業迅速出現，它幫助醫院和醫生利用醫
保制度，通過拆分賬單和“升級”服務（誇大其複雜性）以最大程度地增加收費。大型醫
療機構現在僱用專門人員，其主要任務是尋找支付醫療費用的方法。一些醫院和診所採取
了更笨拙的方法：他們甚至要求醫保支付尚未實際執行的服務費用。

The structure of the U.S. system also plays a role in driving up prices.
Multiple payers lack the market power to negotiate effectively with
pharmaceutical companies and providers for reasonable prices. When one
insurance plan is able to negotiate a lower price, a company or a provider
can adapt by simply charging other insurance plans higher prices. Indeed, the
exact same service or medical procedure can vary in price by more than 300
percent. Meanwhile, in some places in the United States, hospitals enjoy a
monopoly on most forms of medical care, which allows them to charge high
prices. And even in places where competition exists, patients often
mistakenly believe that higher prices indicate a higher quality of care.

美國醫療保障體系的結構也是推動醫療價格上漲的重要因素。多支付人機制缺乏市場力量
，無法以合理的價格與製藥公司和醫療機構進行有效談判。當一種保險計畫內的醫療價格
被協商至較低的價格時，製藥公司或醫療機構可以簡單地通過向其他保險計畫收取更高的
價格來確保其收益。實際上，完全相同的服務或手術的價格可相差300％以上。同時，在
美國的某些地方，醫院對大多數形式的醫療服務享有壟斷權，這使得它們可以收取高昂的
價格。即使在存在競爭的地方，患者也常常錯誤地認為較高的價格代表了較高的服務質量
。

The root of these problems is that as the United States became a prosperous,
industrialized society in the early twentieth century, it chose to treat
health care as a commercial product rather than as a social good, such as
education. As a result, whereas government-mandated universal schooling had
become the norm by the 1920s, health care still remains primarily a
private-sector activity driven by the profit motive.

這些問題的根源在於，隨著美國在20世紀初成為一個繁榮的工業化社會，它選擇將醫療保
健視為一種商業產品，而不是類似教育的社會產品。結果，在上世紀20年代美國政府普及
了教育，而醫療保健仍主要是由利潤驅動的私營部門運作。

But the markets for health insurance and health care have failed in a number
of serious ways. Consider, for example, the effects of the asymmetry of
information between buyers and sellers of health insurance, what economists
call "adverse selection." Unhealthy people are much more likely to buy
insurance than healthy people, which drives up premiums to unaffordable
levels. Insurers, meanwhile, optimize profits by trying to sell coverage only
to those they consider "good risks," such as relatively young and healthy
people, and by avoiding the unhealthy, the disabled, and the elderly. A
similar asymmetry distorts the health-care market, because physicians (the
sellers) have far superior medical knowledge compared with patients (the
buyers), which puts the former in a dominant position in any transaction.

醫療保險和醫療服務市場已經在許多方面存在嚴重問題。例如，醫療保險買賣雙方之間信
息不對稱的影響，經濟學家稱之為“逆向選擇”。不健康的人比健康的人更有可能購買保
險，這將保費推高至無法承受的水平。同時，保險公司僅向那些 “風險較低”的人（例
如相對年輕和健康的人）出售保險，並避免向不健康的人、殘疾人和老人出售保險，以獲
取最大利潤。類似的不對稱現象扭曲了醫療保險市場，因為與患者（買方）相比，醫生（
賣方）擁有遠超於患者的醫學知識，這使醫生在任何交易中均處於主導地位。

The system of employer-based health insurance that defines the current U.S.
system blossomed during World War II. At that time, wages were largely
frozen, and employers found that offering health insurance was one way to
compete for scarce workers. After the war, the United States did not follow
European countries in establishing universal health insurance programs owing
in part to institutional opposition from powerful special interests that took
advantage of the politics of the early Cold War period. In the late 1940s,
President Harry Truman made a concerted effort to introduce national health
insurance. But the deep-pocketed American Medical Association opposed the
program, hoping to protect physicians' superior market power and professional
autonomy. The AMA mobilized its nationwide network of county medical
societies to stir up fear that the plan would lead to "socialized medicine."
The AMA went so far as to call the plan "un-American" and deride the Truman
administration as following "the Moscow party line." Opponents of universal
coverage have relied on variations of the same playbook ever since.

當前美國以僱主為主要支付人的醫療保險制度成長於第二次世界大戰期間。當時，政府採
取了工資管制，僱主發現提供醫療保險是競爭稀缺工人的一種方法。戰後，美國沒有跟隨
歐洲國家建立全民醫療保險制度，部分原因是強大的特殊利益集團利用冷戰初期的政治反
對全民醫療保險。在上世紀40年代後期，總統哈里·杜魯門（Harry Truman）努力引進全
民醫療保險。但是財力雄厚的美國醫學會（American Medical Association）反對該計畫
，希望保護醫生的強大市場力量和專業自主權。美國醫學會動員了其全國各縣的醫學會網
絡，以激起人們對該計畫可能導致“公費醫療”的擔憂。美國醫學會甚至稱該計畫為“非
美國化的”，並嘲笑杜魯門政府，稱其奉行的是“莫斯科政黨路線”。從那以後，全民醫
療保險的反對者就一直依賴這同一理論的變體。

Slowly but steadily, however, public sentiment has shifted, resulting first
in the advent of Medicare and Medicaid and later in the passage of the ACA.
According to public opinion polls conducted by the Kaiser Family Foundation,
between 2000 and 2019, the proportion of Americans with a favorable opinion
of a single-payer, government-run health insurance system rose from 40
percent to 53 percent. The question, it seems, is no longer whether the
United States will establish a single-payer system, or at the very least a
hybrid system radically different from the one it has now. The question,
instead, is how that change will take place and what kind of system it will
produce. To help find answers, Americans should look to three places: Canada,
Taiwan, and Germany.

但是，公眾的態度卻漸漸發生了變化，這首先導致了聯邦醫療保險和醫療補助計畫的問世
，然後是《平價醫療法案》的通過。根據凱撒家庭基金會進行的民意調查，在2000年至
2019年之間，贊成單一支付人，即由政府運營的醫療保險體系的美國人比例從40％上升至
53％。看來，問題不再是美國應當建立單一支付人體系，還是至少建立與現在體系完全不
同的混合體系。相反，問題是這種變化將如何發生以及它將產生什麼樣的體系。為了找到
答案，美國人應該把目光投向三個地方：加拿大，台灣和德國。


HEALTHY, WEALTHY, AND WISE
健康、富有、智慧

Canada established single-payer universal health insurance in 1968. The
Canadians opted for a one-tiered system built on the principle that coverage
should be not just universal but also equal. Canada thus forbids private
insurers from duplicating the benefits offered by the government and
prohibits physicians and hospitals from serving both publicly insured
patients and those with private insurance. Providers must choose to serve one
group or the other.

加拿大於1968年建立了由政府為單一支付人的全民醫療保險。加拿大人基於全民覆蓋且平
等的原則選擇了一種單層體系。因此，加拿大禁止私人保險公司提供類似的保險，並禁止
醫師和醫院同時為加入公共保險的患者和加入私人保險的患者提供服務。他們必須在這兩
種群體之間擇其一，提供服務。

In the Canadian system, the federal government sets national standards and
funds 50 percent of the cost. The country's 13 provinces fund the other half
and run their own programs, acting as the single payer for their residents,
determining payment rates to providers, and negotiating with pharmaceutical
companies. This arrangement vastly reduces the potential for fraud and waste
because the single payers maintain uniform records of each medical
transaction and closely monitor every provider's behavior. In 2018, Canada
spent $4,974 per person on health care. Administrative expenses related to
insurance accounted for just six to eight percent of overall spending because
there is only one set of rules and procedures for filing claims. Likewise,
hardly any fraud or abuse occurs because a comprehensive data-collection
system allows authorities to monitor the performance of all providers. And
the system is highly effective: life expectancy in Canada is 82 years, and
the infant mortality rate is 4.5 deaths per 1,000 births--better on both
counts than in the United States, where life expectancy is 79 years and the
infant mortality rate is 5.8 deaths per 1,000 births.

在加拿大模式中，聯邦政府制定了國家標準，並承擔了50％的費用。該國的13個省提供另
一半提供資金並實行自己的政策，充當居民的唯一支付人，核定向醫療機構支付的費用，
並與製藥公司進行談判。這種安排極大地減少了欺詐和資源浪費的可能性，因為單一支付
人會對每筆醫療交易進行統一記錄並密切監視每個服務提供商的行為。2018年，加拿大人
均在醫療保健上的支出為4,974加元。與保險相關的行政費用僅佔總支出的6％至8％，因
為保險理賠只有一套規則和程序。同樣，幾乎沒有任何欺詐或濫用，因為全面的數據收集
系統允許政府監控所有醫療機構的行為。該體系非常有效：加拿大的人均預期壽命為82歲
，嬰兒死亡率為每1000名嬰兒4.5例死亡，這兩項指標均優於美國，美國的人均預期壽命
為79歲，嬰兒死亡率為每1000名5.8例死亡。

Canada served as the most important model for Taiwan, which established
universal health insurance in 1995. Like the Canadians, the Taiwanese set up
a single-payer system in which people freely choose their providers, which
encourages clinics and hospitals to compete on quality and efficiency. But
there are some significant differences between the two approaches. As a
small, densely populated island, Taiwan opted to centrally administer its
program. Patients also have modest copayments to deter the overuse of
services and drugs. In Canada, government budgets finance the program, which
means that the level of support fluctuates, depending on the agenda of the
political party in power at any given time. Taiwan, in contrast, adopted a
more stable financing arrangement that relies on earmarked taxes, insulating
the system from changes in the political landscape. Taiwan also took
inspiration from the actuarial methods used by the U.S. Medicare program to
assure its long-term sustainability.

加拿大模式是台灣最重要的參考，台灣在1995年建立了全民醫療保險。台灣人與加拿大人
一樣，建立了單一支付人系統，人們可以自由選擇醫療機構，從而鼓勵診所和醫院在質量
和效率上進行競爭。但是，這兩種模式之間存在一些重大差異。台灣是一個人口稠密的小
島，因此選擇集中管理。病人也有適度的自付費用，以防止其過度使用醫療服務和藥物。
在加拿大，政府預算為醫保提供資金，這意味著資金支持水平會隨時間變化，取決於在特
定時間內執政黨的議程。相比之下，台灣的資金安排更穩定，資金來源於專項稅收收入，
從而使該體系免受政治形勢變化的影響。台灣還借鑑了美國醫療補助計畫使用的精算方法
，以確保其制度的長期可持續性。

Taiwan leapfrogged other countries with single-payer systems by developing
innovative data technology to monitor patients' care and to detect and deter
fraud and abuse. For example, in the initial years of its program, Taiwan
found that several physicians were submitting suspicious bills that, had they
been accurate, would have required them to work 24 hours a day, seven days a
week. Administrators turn over such suspect claims to a local committee of
practicing physicians, which deals with fraudsters by applying
sanctions--including, in serious cases, stripping them of their licenses to
practice. During the first year in which this process was followed, the
overall amount that physicians and hospitals charged the system fell by eight
percent.

台灣開發了新的數據技術來監控患者的醫療記錄並檢測和制止欺詐和濫用行為，這一點超
越了其他國家。例如，在該制度實行的最初幾年，台灣發現幾名醫生正在提交可疑的賬單
，若屬實，產生這些賬單需要他們每週7天、每天24小時工作。管理者將此類可疑案例移
交給當地執業醫師委員會，該委員會對欺詐者實施制裁，包括在嚴重情況下吊銷他們的執
業資格證。在此制度執行的第一年，醫生和醫院向醫保基金支取費用的總金額下降了8％
。

The Taiwanese system is remarkably cost-effective: in 2016, Taiwan spent
$1,430 per person on health care, and only between five and six percent of
that spending related to the administrative costs of the single-payer system.
As in Canada, there is hardly any fraud or abuse. And as in Canada, life
expectancy (81 years) is better than in the United States, as is the infant
mortality rate (3.9 deaths per 1,000 births).

台灣模式具有明顯的成本優勢：2016年，台灣在人均醫療保健上的支出為1,430美元，而
該支出中只有5％至6％與單一支付人制度的行政成本有關。與加拿大一樣，幾乎沒有欺詐
或濫用行為，人均預期壽命（81歲）比美國長，嬰兒死亡率（每1000例死亡3.9例）也低
於美國。

Germany offers a different model--not least because its system has evolved
over a long period of time. In 1883, German Chancellor Otto von Bismarck
declared that industries, occupational guilds, and agricultural cooperatives
would have to form nonprofit health insurance programs, called "sickness
funds," for their members. Numerous funds were established, each one offering
distinct benefits packages, premium rates, payment rates to providers, and
claim procedures. People could enroll in the fund of their choice. But many
opted out and remained uninsured. Eventually, in 1914, Germany passed
legislation compelling all workers in selected industries earning less than a
certain amount to obtain coverage; those who earned more could voluntarily
enroll or purchase private insurance. After World War II, West Germany
continued that system, which was extended to the former East Germany after
reunification.

德國採取了不同的模式，並已發展了很長時間。1883年，德國總理奧托·馮·俾斯麥（
Otto von Bismarck）宣佈，工業界、職業協會和農業合作社必須為其成員購買名為“疾
病基金”的非營利醫療保險。德國建立了大量基金，每個基金有不同的福利待遇、保費率
、報銷率以及索賠程序。人們自願選擇加入的基金。但是許多人仍選擇不投保。最終，在
1914年，德國通過了一項法律，強迫所有收入低於一定水平的特定行業的工人加入保險；
收入更高的人可以自願參加醫療保險或購買私人保險。第二次世界大戰後，西德延續了這
一制度，統一後又擴展到了前東德。

Germany's multiple-payer system, however, suffered from inefficiency and
waste because separate groups of people were pooling their health risks,
which led to highly variable premium rates. So in the 1990s, Germany's
legislature began requiring all funds to offer a standard benefits plan. The
various funds pool the premiums they receive, which the central government
then allocates to the funds based on the health risks of the people enrolled
in them. Meanwhile, associations of sickness funds in each state negotiate
with that state's medical association to design a single set of claim
procedures and a uniform payment rate for physician services. Likewise, all
hospitals in a given state negotiate one uniform set of rules, procedures,
and rates with that state's hospital association. One result of these reforms
has been a vast reduction in the number of sickness funds, from around 1,200
in 1993 to just 115 today.

但是，德國的多支付人體系效率低下、浪費嚴重，因為不同人群所集中的疾病風險差異大
，從而導致不同基金的保費率差異也很大。因此，在上世紀90年代，德國立法機關開始要
求所有基金提供標準的福利計畫。各基金將收到的保費彙總，然後由中央政府根據投保者
的疾病風險分配給這些基金。同時，每個州的疾病基金協會與該州的醫學會進行協商，以
設計一套統一的索賠程序和統一的醫療服務報銷率。同樣，各州的所有醫院都與該州的醫
院協會協商一套統一的規則、程序和費率。這些改革的結果是大大減少了疾病基金的數量
，從1993年的約1200個減少到今天的115個。

Germany's hybrid system now relies on doctors in private practice for
physician services and a mixture of public and private hospitals for hospital
care. Patients can freely choose their providers. The federal government sets
the rules and negotiates with pharmaceutical companies, allowing Germany to
keep drug prices relatively low. In 2017, Germany spent $5,728 per person on
health care. Some fraud and abuse exist, but at far lower levels than in the
United States. Life expectancy is better than that in the United States (81
years), and the infant mortality rate (3.4 deaths per 1,000 births) is lower.

德國的混合體系現在依靠私人執業的醫生提供醫師服務，並依靠公立和私立醫院來提供住
院治療服務。病人可以自由選擇服務提供者。聯邦政府制定規則並與製藥公司進行談判，
從而使藥品價格保持在較低水平。2017年，德國人均醫療保健支出為5728美元。儘管仍存
在一些欺詐和濫用行為，但其水平遠低於美國。人均預期壽命比美國（81歲）長，嬰兒死
亡率（每千名新生兒中有3.4例死亡）較美國低。


THE PERFECT AND THE GOOD
完美制度與公共福祉

A number of clear lessons for the United States emerge from these three
places. Perhaps the most basic one is the need for a broad public consensus
about the values that should shape any reform. Should the United States
continue to treat health insurance primarily as a commercial product shaped
by market forces and one that everyone can choose to either acquire or do
without? Or should health insurance be understood more as a social good akin
to primary and secondary education: guaranteed by the state, paid for
primarily by taxation, and mandatory for everyone?

這三種模式給美國提供了許多可借鑑的經驗。也許最基本的是公眾需要就影響改革的價值
觀達成廣泛的共識。美國是否應該繼續將醫療保險視為由市場力量塑造、人們可自由選擇
購買與否的商業產品？還是應該將醫療保險更多地理解為類似於初等和中等教育的社會福
利：由國家擔保，主要由稅收支付，全民強制購買？

If Americans do decide to shift away from a market-based system, the cases of
Canada, Taiwan, and Germany show that Washington would need to mandate that
every citizen and permanent resident enroll in a health insurance plan that
offers a standard benefits package. Otherwise, health risks would not be
pooled across the healthy and the unhealthy, the rich and the poor. The U.S.
federal government could fund universal coverage through a payroll tax on
both employers and employees; the poor and the near poor would receive
subsidies to offset the tax burden. A better method, however, would be taxes
on income and wealth, which would be more progressive and therefore fairer.
Moreover, payroll taxation is less effective than in the past because in
contemporary economies formal employment has become less common as companies
increasingly hire independent contractors rather than staffers. It's for
these reasons that Taiwan and Germany gradually shifted away from payroll
taxes to fund their systems and adopted ear-marked income taxes instead.

如果美國決定放棄市場導向的制度，加拿大、台灣和德國的經驗表明，聯邦政府需要要求
每個公民和永久居民加入提供統一福利待遇的醫療保險。否則，疾病風險將無法在健康者
和不健康者、富人和窮人之間分攤。美國聯邦政府可以通過向僱主和僱員徵收工資稅為全
民保險提供資金；貧困和近乎貧困的人將獲得補貼以抵消稅收負擔。但是，更好的方法是
對收入和財產徵稅，這更加漸進，因此更加公平。此外，工資稅的方式沒有過去有效，因
為在現代經濟中，隨著公司越來越多地僱用獨立承包商而非職員，正式的勞動關係變得不
那麼普遍了。正是由於這些因素，台灣和德國逐漸放棄了通過工資稅徵收醫保資金，而採
用了專項所得稅。

Would Americans have to pay more for health care under a single-payer system
similar to those in Canada and Taiwan? A definitive study published in 2018
by a team of researchers led by the economist Robert Pollin has determined
that they would not. In fact, Americans would see a net reduction in overall
health expenditures. According to the report, the United States could save
more than $250 billion each year by establishing a single-payer system.

在類似加拿大和台灣的單一支付人模式下，美國人是否需要為醫療支付更多費用？由經濟
學家羅伯特·波林（Robert Pollin）領導、於2018年發表的一項權威研究表明，美國人
的醫療開支不會增長。實際上，整體醫療支出將呈淨減少趨勢。根據該報告，通過建立單
一支付人機制，美國每年可以節省2500多億美元。

The plans put forward by Sanders and Warren incorporate many features of the
Canadian and Taiwanese approaches: a single payer with one comprehensive
standard benefits package for all, free choice of providers, uniform payment
rules, and procedures that would vastly reduce administrative expenses and
limit fraud and abuse. The savings would be great enough to pay for covering
uninsured and underinsured Americans while still giving most Americans a
reduction in their health expenses. The plans would raise taxes: some
payroll, income, and wealth taxes would have to increase. But those increases
would be offset by reductions in other taxes and by a vast drop in premiums.

桑德斯和沃倫提出的方案融合了加拿大和台灣模式的許多特徵：單一支付人、為全民提供
一套全面的福利標準、自由選擇醫療機構的權利和統一的支付規則。這種規則可大大減少
行政費用並限制欺詐和保險濫用。節餘資金足夠支付未投保和投保不足的美國人的保險費
用，同時仍然減少了大多數美國人的醫療費用。該方案將增加稅收：一些工資稅、所得稅
和財產稅將不得不增加。但是這些增加的稅收將被其他減少的稅收和大幅下降的保費所抵
消。

Medicare for All, or a plan similar to it, would encounter strong opposition.
People's fear of a major change would be a paramount obstacle. Americans who
are currently insured might worry that their benefits would be reduced.
Physicians, nurses, and hospitals might see a threat to their incomes. The
public would resist higher taxes, even though they would be paying less for
health care overall. And insurance companies, pharmaceutical firms, and
powerful interest groups such as the AMA and the American Hospital
Association would lobby hard against a shift to genuine universal coverage.
Although Americans have begun to take a more favorable view of single-payer
systems in recent years, it's far from clear that the idea has enough popular
support to clear such hurdles.

全民醫療保險或類似的方案將遭到強烈反對。人們對這種重大變化的擔憂是最大的障礙。
當前有保險的美國人可能擔心他們的利益會受影響。醫生、護士和醫院可能認為這對其收
入構成威脅。公眾將抵制更高的稅收，即使他們為醫療保健支付的整體費用更少。保險公
司、製藥公司以及諸如美國醫學會和美國醫院協會這樣的強大利益集團將進行遊說，強烈
反對真正的全民醫療保險。儘管近年來美國人開始對單一支付人體系持更積極的態度，但
尚不清楚民眾支持是否足以消除此類障礙。

Perhaps a more practical approach would be for the United States to follow
Germany's lead and to undertake reforms that would allow for multiple
insurers but create a uniform system of payments and electronic records to
help control waste and fraud. Such a system would also let insurers
collectively bargain with major pharmaceutical companies for reasonable drug
prices. These measures alone could save somewhere between $200 billion and
$300 billion each year--savings that, along with modest tax increases, could
be used to expand existing public coverage for the uninsured.

也許更實際的方法是讓美國跟隨德國的腳步並進行改革，允許多家保險公司同時建立統一
的支付和電子記錄系統，以控制浪費和欺詐。保險公司還可以集體與大型製藥公司就合理
的藥品價格進行討價還價。僅這些措施每年就可以節省約2000億至3000億美元，這些節餘
加上適度增加的稅收，可用於擴大現有的公共保險覆蓋範圍。

Over time, the United States could go further, as Germany did, and pool the
enrollees of various private insurers into a state-level or federal-level
risk pool and then introduce regional health budgets to control costs. This
gradual approach might take two to three decades and would likely require
additional taxes along the way, since the savings available under this hybrid
system would not be sufficient to cover the uninsured and the underinsured.
But the German alternative would not require the abolition of private
insurance in the near term, thus sidestepping one of the most politically
problematic aspects of Medicare for All.

隨著時間的流逝，美國可能會走上與德國一樣的道路，將各種私人保險公司的投保者集中
到州或聯邦一級的風險池中，然後引入地區醫療衛生預算來控制成本。這種漸進的方式可
能要花兩到三十年的時間，並且可能會一直需要額外的稅收，因為在這種混合系統下可獲
得的節餘資金不足以覆蓋未投保和投保不足的人。但是德國模式並不需要在短期內廢除私
人保險，從而避開了全民醫療保險最具政治難題性的方面之一。

It's possible that public sentiment will continue to shift and that support
for a straightforward single-payer system will gain enough momentum to
overcome the institutional and political obstacles that stand in its way
today. In the meantime, however, proponents of Medicare for All and other
sweeping reforms should take a careful look at the German model. It may not
achieve all their goals as quickly as they would like. But the perfect should
not be the enemy of the good, and such an approach would put the United
States on the road to an equitable, sustainable, and affordable system of
health care for all Americans.

公眾的態度可能會繼續發生變化，簡單的單一支付人機制可能會獲得足夠的支持，並克服
目前阻礙其發展的體制和政治障礙。然而，與此同時，全民醫療保險和其他全面改革的支
持者應仔細研究德國模式。德國模式可能無法達到他們想要的所有目標。但是，追求完美
不應該阻止公共福利的增長，而德國模式將使美國走上通往全民平等、可持續、可負擔的
醫療保障體系的道路。

--
論述謬誤：1 轉移議題 change of subject、2 偷換概念 concept swap、3 虛假目標
strawman argument、4 人身攻擊 ad hominem、5 感性辯護 appeal to emotion、
6 關聯替代因果 correlation as causation、7 不當類比 false analogy、8 不當引申
slippery slope、9 同義反覆 circular reasoning、10 無知辯護 argument from
ignorance、11 引用權威 appeal to authority、12 黨同伐異 appeal to faction 

--
※ 發信站: 批踢踢實業坊(ptt.cc), 來自: 129.110.242.26 (美國)
※ 文章網址: https://www.ptt.cc/bbs/IA/M.1582313676.A.999.html
→ kwei: 改善醫療體系應學台灣和德國，不應學美國。
※ 編輯: kwei (129.110.242.26 美國), 02/22/2020 03:39:52
→ skyhawkptt: 怪了！那還長住美國，還是翻出去另有目的???
→ skyhawkptt: 沒事對岸一切好 有病回台用健保
推 kpier2:  不愧是高級黑...
→ kpier2: 話說低級紅 YusaAoi 去哪了?  隔離了嘛?