Sunday, September 21, 2014
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医疗改革勿要紧跟美国步伐

多伦多 ——美国最高法院开始考虑合理医疗费用法案(这一历史性的医疗改革方案被奥巴马的对手嘲笑为“奥巴马医改”),但是值得注意的是,虽然2010年颁布了医疗改革法律,但是当年没有享受医疗保险的美国人口却创下历史新高——大约50万美国居民(1/6的美国人口)无力支付巨额的医疗费用。

这一惊人数字产生的原因并不只是因为2008年爆发的经济衰退,长期的政治和政策选择也有难辞其咎。在全球范围内,特别是经济迅速增长的国家,这一教训很简单:避免美国的私人医疗保健模式

世界上大多数高收入国家都通过政府资助的预付系统为医疗保健买单,美国却是例外。富裕国家每年平均医疗支出约占国内生产总值的11%,其中80%以上来自公共资金,只有14%用于医疗服务。公共财政(在某些情况下,政府监管下的合作保险基金也等同于公共融资)为大多数医疗服务买单,私人保险只补充提供极少的额外服务。

多数富裕国家之所以选择公共融资方式来资助医疗保健,主要以下几个原因考虑。首先,自由市场运作的卫生保健体系通常不能保证公平且效率低下。个人需求差别很大,但是私人保险公司往往不愿投保那些最需要医疗服务的人群(例如那些已经生病的人,或可能会引发其他健康问题的糖尿病患者)。此外,那些购买医疗保险的人(承保人和病人)不可能获取必要信息以选择最安全、最有效的治疗方式。

与此同时,公共开支发挥着经济闸门的作用,可以控制国家整体开支,防止私人保险公司引发的成本快速上升。美国每年支出其国内生产总值的1%,仅仅是为了管理复杂低效的保险体系。如果最高法院当前没有通过改革计划,美国医疗保健支出总额将从现在GDP的16%上升到2025年GDP的25%。

现行制度产生的经济影响已经非常严重。去年美国人口普查显示,生活在贫困线以下的美国人口数量显著增加,这当然与缺乏健康保险密切相关,但同时也反映出美国过度依赖以雇主为基础的保险覆盖体系。

新兴市场经济体政府在制订卫生保健系统时应牢记以下五点。首先,医疗领域的投资会为“贫困陷阱”提供重要的社会保障安全网络,经济动荡时期尤为如此。例如,由于灾难性卫生支出(一般定义为医疗成本超过家庭总支出的10%),印度每年有37万人没有享受医疗保险而沦落至贫困线以下。

第二,公共医疗融资使穷人可以自由支配财富以满足其他需要。在低收入国家中,所有医疗保健支出中有一半(约占GDP的2.5%)属于非预算款项开支,而这一比重在中等收入国家仅为GDP的2%。这一巨大开支占据了贫困家庭总收入的很大部分,抑制了更富有成效的家庭投资,却几乎没有创造任何工作岗位,而且这些开支对于医生和医院往往是免税的,因为他们经常通过暗箱操作捞取油水。

第三,公开医疗融资可以提高整体就业率。加拿大各省从1961年到1975年就分阶段引入国民健康保险。一方面,推行该方案的地区在就业和工资方面均出现上涨,但平均工时却保持不变。另一方面,私人保险水平较高的省份,就业率较低,工资增长较慢。最近,加拿大击败了美国,获得了丰田汽车投资建立新厂的竞标,部分原因是因为美国昂贵的私人医疗保险成本会使汽车制造成本增加几千美元。

第四,较富裕国家现行的国家卫生保健系统可以作为选择采用类似系统的新兴市场经济体效仿的模型。公共融资需求并不意味着只有公共部门提供服务,私人医院和诊所有时也可以更有效地提供服务,这一点非常重要。1995年台湾推行了一种“单付费者制度”,极大地遏制了医疗费用上涨,改善了人口的生活质量。墨西哥的新全民健康保险制度首先在该国最贫穷的地区实施。

另一方面,中国的健康保险撤回政府投资,这一做法产生的严重后果发人深省。20世纪80年代初,中国推行的市场化改革使近100万农村居民几乎在一夜之间失去医疗保险。非预算款项开支暴涨,婴儿死亡率停止下降,疾病监测系统削弱,这可能在一定程度上导致了2002-2003年SARS疫情爆发,全球超过900人死亡,经济损失估计约60亿美元。中国政府已经公开承认改革失败,并承诺将支出几十亿美元用于公共融资的医疗保健。

最后,政府要遵循医疗保险“覆盖所有人而不覆盖一切”的原则,调查研究哪些服务最划算,哪些服务不应接受公开资助,因为这些服务不仅成本高而且效益低。保险服务的数量可以总是与增加居民收入和政府收入状况保持一致。提高烟草税尤其能产生双重效益:一方面可以减少吸烟(成年人死亡的首要原因),另一方面政府可以增加收入。

中国、印度和南非都致力于推行国民健康保险。哪个国家可以率先达到这一目标,不仅取决于该国的财政收入多少,而且也取决于是否有克服既得利益的政治意愿。这也将取决于医疗体系规整合理医疗保健方案、监控医疗服务状况、正确地评估新的治疗方法的能力。

美国医疗保健费用非常昂贵,效益低下,所以人们只能寄希望于“奥巴马医改”模型及美国未来的竞争对手实施的改革方案,希望这些方案会推动美国建立长期逾期而未曾兑现的政府资助的普遍卫生保健系统。

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  1. CommentedBJ Beard

    This opinion piece does not cite a single source for the claims used to support its arguments, while relying heavily on irrelevant coincidences. It doesn't mention the imploding of the British National Health System, nor the cash profits of Cuba's medical tourism that does not provide adequate minimal care to Cubans excluded from those facilities, nor its profits from renting out its doctors overseas. It doesn't address the long waits for tests and treatments in Canada that are non-existent in the USA. My dog got an MRI within 24 hours of her veterinarian ordering one within 4 miles of home. I can get a CAT scan within 2 miles of my house within one hour if I need it. I personally have met hundreds of "snowbirds' who purposely come to my state annually for world-class healthcare they can afford here but can't get in their home Province. Some facts about American healthcare that eviscerate the author's over-generalized unresearched premise and conclusion: 1. The decline in Americans carrying health insurance since the start of the Obama Recession correlates to unemployment reaching and sustaining Great Depression levels of 9% officially registered and 17-21% when self-employed ineligible for benefits, entry level young people who have not worked enough yet to get benefits and be countede cannot enter the workforce, those who have been unemployed so long they no longer receive benefits, and those who began collecting government disability income when unemployment benefits ran out are counted. 2. A percentage of low-risk Americans have always chosen to forego health insurance premiums - healthy young adults just out of school working in entry level jobs paying all their own living expenses for the first time, buying cars, taking vacations, retiring student loans, then saving for a first home. Upon marriage and family responsibilities they prudently begin to carry health and life insurance. It is a matter of personal priorities and choices. Many self-employed do not carry health insurance during the early years of building their business, and add it later when they have a few employees for whom they wish to offer the benefit with wages. At that point the small group coverage became an affordable business expense - which will disappear under the new healthcare law, forcing people into "pools." The ability to choose how to respond to a variety of life's risks, and to run one's own life is the essence of America, and seems to have served the country well over the long haul. 3. "Poor" people tend to be covered by Medicaid (state health insurance for the poor), also paid for through federal taxes, and almost exclusively provided at government facilities by government employees, are: the Armed Forces Health Services, caring for military and their dependents, Veterans Healthcare (federally funded The Obama Administration released its FY2011 budget on February 1, 2010. It requests $48.8 billion for VHA for FY2011, an increase of $3.7 billion over the enacted amount in FY2010. Furthermore, the Administration is requesting $50.6 billion in advance appropriations for FY2012 for the three medical care appropriations: medical services, medical support and compliance, and medical facilities. The majority of veterans who qualify for VA care prefer private healthcare service and can get it. Anyone like me who has considerable personal experience with both private and VA healthcare facilities and service can instantly see the glaring differences in favor of private and "would give their eye teeth" to avoid using the VA. Thank goodness the majority of us DO still have the CHOICE. Bureau of Indian Affairs Health System (federally funded Population Served: Members of 565 federally recognized Tribes
    2 million American Indians and Alaska Natives residing on or near reservations Annual Patient Services (Tribal and IHS facilities):Inpatient Admissions: 50,349
    Outpatient visits: 11,778,527 Dental Services: 3,568,201
    FY 2010 IHS budget appropriation: $4.05 billion Total IHS employees: 16,159 (70% are American Indian/Alaska Native) Includes about 900 Physicians, 2700 Nurses, 350 Physician Assistants/Nurse Practitioners, 300 Dentists, 650 Pharmacists, and 650 Engineers/Sanitarians. The remaining 10, 609 65.65% are bureaucrats.) Additionally, the FY 2009 budget included several proposals affecting the State Children's Health Insurance Program (SCHIP): Reauthorizes SCHIP through FY 2013 (at a cost of $19.7 billion over 5 years);
    Limits coverage to children at or below 200 percent of the Federal poverty level, which was, according to the budget materials, what the program "originally intended";
    Establishes outreach grants to support enrollment initiatives (a cost of $50 million in FY 2009 and $100 million in each of FYs 2010 - 2014; and Clarifies what counts as "income" when determining enrollment eligibility According to the budget materials, the SCHIP proposal would cover 5.6 million low-income children by FY 2013 and nearly nine million at some time during the year. Note that the US Health and Human Services definition of "poverty" is more generous than the Census Bureau's for determining eligibility, and does not include the value of other government subsidies for housing, aid to dependent children, food stamps, or disability benefits. For fiscal 2011 it is: 2011 HHS Poverty Guidelines Persons in Family 48 Contiguous
    States and D.C. Alaska Hawaii
    1 $10,890 $13,600 $12,540
    2 14,710 18,380 16,930
    3 18,530 23,160 21,320
    4 22,350 27,940 25,710
    So 200% for a family of 4 is an income of $44,700. The federal minimum wage is $7.25/hr or $15,080/yr - most states have enacted higher minimum wage laws.

    Those who aren't covered by a state or federal program simply haven't applied for it, despite the government spending millions annually to "recruit" them. The total number of people who do not have health insurance or government care is, by Health and Human Services' own calculation, 11 million out of 310 million people, a total population that includes 15 million non-citizen residents. 4. American hospitals have been legally required for 60 years to treat all regardless of ability to pay. Since 50% of those hospitals are non-profit charitably or religiously funded, most were doing so anyway. For example The Shriners Hospitals for Children are world-class and all treatment is free and funded by private donation. Everyone in the USA has access to quality healthcare. 5. The single largest driver of healthcare cost increases since 1960 has been Medicare - the artificially low-cost federal insurance program for seniors. Because it covers so much for our highest-cost users of the system, but pays so much below market price for services, providers must make up the difference by raising fees on the other patients, and thus their insurance - somebody has to pay. Health insurance premiums thus outpaced inflation in increases every single year. Further, the bureaucratic overhead, in paperwork to process claims, government reporting, and government employees required to administer federal healthcare (Medicare, Veterans, Indian, and State Medicaid) skyrocketed, due to lack of market accountability, efficiency, and patient interest in controlling expenses - the government workers and the recipients are all on an anonymous someone else's dime. Corruption and fraud to the tune of millions of dollars in claims in the government systems have been aided by the very ponderous bureacracy, which had no incentive to catch and stop it. In a suburb of my town, a fellow signing people up for motorized wheelchairs and "scooters" for the $6,000 apiece to be paid by Medicare filed thousands of fraudlent claims and pocketed over a million dollars before a whistleblower caused investigation in 2009. Public spending on healthcare is crippling state budgets. In my state: In order to cover Arizona’s large deficit, Gov. Jan Brewer and other Arizona lawmakers approved a budget earlier this year that cut Arizona’s Medicaid program, also known as the Arizona Health Care Cost Containment System or AHCCCS. The current AHCCCS program covers 1.3 million people in Arizona. That is 20 percent of the entire population as well as 20 percent of the patients treated by each private hospital system, and over 70 percent of the patients treated at county and state hospitals and university teaching hospitals.

    The first change to this program came on May 1 when enrollment for the AHCCCS “spend down” program was frozen. This program covers people who normally would not qualify for AHCCCS, but who have sustained medical expenses that reduced their income to below 40 percent of the federal poverty level. Without medical expenses, these people's income would not qualify as "poor." Taxpayers receive a tax deduction of 100% on annual medical expenses at or above 6% of their income.

    The next set of changes to the AHCCCS program will go into effect on July 1st. These changes include:

    •The elimination of enrollment for childless adults.
    •The elimination of enrollment for parents earning 100 percent of federal poverty level. (The children themselves are still covered 100% by the federal SCHIP program.)
    •The elimination of Federal Emergency Services (for non-qualified aliens, of which the poor economy has reduced our state's numbers from 500,000 to 360,000).
    •Current enrollees will be required to have eligibility redetermined in 6 months. (Thousands have been kept on the benefit rolls for years after no longer qualifying, enabling them to opt out of enrolling in coverage offered by their employers.)
    •There will be more mandatory co-payments. (More than 70% of services presently have no co-payment. Typical co-payments for privately insured citizens are $5 to $15 until a maximum annual figure is reached.)
    •And there will be new benefit limits, such as for emergency room visits and inpatient days. (The typical government-subsidized patient uses emergency services at a rate six times that of non-government subsidized patients.)
    Then on Oct. 1st, there is yet another change. AHCCCS will cut the payments to health care providers by five percent. This reduction of payment is in addition to the previous deduction of five percent that occurred on April 1st. ( Physicians estimate they will need to cut back on the number of AHCCS paid patients they see as a result. Due to government regulation and paperwork, in addition to their own insurance, equipment, and staff costs these patients cost more to treat than private payors or privately insured patients. One such additional expense, embedded in the 2008 "Stimulus" Bill to begin preparation for "Obamacare" was a requirement that all physicians report all treatment of all patients to the federal government electronically - not just any treatment for an infectious disease or condition the Center for Disease Control wants to study. That alone added $20 to the cost of every doctor visit. State aid healthcare patients also tend to sue service providers at a rate seven times higher than non-government subsidized patients. Law firms that specialize in this abound.)
    The statement "In particular, higher tobacco taxes yield a double benefit: they reduce smoking, a leading cause of adult death, and raise revenue." is a half-truth at best. Tobacco taxes pour millions into American healthcare and education systems annually, but is not spent on care for smokers. The leading cause of death in the US is not smoking (users are 20% more likely to develop cancer than non-users) but rather heart disease and other deadly ailments caused significantly by diabetes, obesity, and, golly, aging!
    This assertion by the authors would be right if turned on its head "At the same time, public spending acts as a brake on overall spending, and prevents the rapid cost escalation to which America’s private insurance companies contribute. The US spends 1% of its GDP annually simply to administer its complex, unwieldy insurance system. Without reform of the type now before the Supreme Court, total US health expenditures will rise from 16% of GDP today to 25% by 2025." It SHOULD READ "America's private system ENJOYS a 1% administrative cost, compared to a 25% administrative cost for its government healthcare, which does not have to account for costs of capital expenditures and numerous other line items ordinarily included in business budgets. This benefits research and development, and service delivery. For the last 50 years, public spending on healthcare has driven up costs at double or triple the inflation rate, whereas before public spending, health care cost increases remained in line, or were below general inflation, due to continued improvements in diagnostics, treatment, and private sector efficiencies responding to market needs. Also by the government's own estimates, DUE TO OBAMACARE, the percentage of the GDP that will be sucked up by healthcare instead of productive industry will rise from 16% to 25%, and its costs will be 400% higher in the first decade than what was claimed to the American taxpayer when it was rammed through Congress unread by the legislators. America is dedicated in its charter to personal liberty, which Obamacare violates with an unconstitutional tax requiring personal participation in public healthcare with a requirement to purchase it, despite heavy taxation for it already. To implement it, a majority need to be persuaded it trumps freedom enough to fundamentally change our national Constitution. The majority are not even remotely persuaded to forsake freedom for inferior medical care at a higher cost.
    The authors can prefer public healthcare on ideological grounds, but are disingenuous at best in their attempt to defend it on economic or quality terms when using America as their bogeyman.


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