2017-12-27 紐約時報中文網 NYT教育頻道
Taiwan is proof that a country can make a swift and huge change to its health care system, even in the modern day.
台灣證明，即便是在現代，一個國家也能迅速讓其醫療保健係統發生巨變。
The United States, in part because of political stalemate, in part because it has been hemmed in by its history, has been unable to be as bold.
美國一直做不到這麽大膽，這部分是因為政治僵局，部分是因為受製於曆史。
Singapore, which we wrote about in October, tinkers with its health care system all the time. Taiwan, in contrast, revamped its top to bottom.
我們10月寫過的新加坡，一直在對自己的醫療保健係統修修補補。相比之下，台灣是徹底改革。
Less than 25 years ago, Taiwan had a patchwork system that included insurance provided for those who worked privately or for the government, or for trade associations involving farmers or fishermen. Out-of-pocket payments were high, and physicians practiced independently. In March 1995, all that changed.
不到25年前，台灣的醫療保健係統係拚湊而成，包括為私營領域從業者，或為政府或涉及農民或漁民的行業協會工作的人提供的保險。自付費用高昂，醫生獨立行醫。1995年3月，一切都變了。
After talking to experts from all over the world, Taiwan chose William Hsiao, a professor of economics at the Harvard T.H. Chan School of Public Health, to lead a task force to design a new system. Uwe Reinhardt, a longtime Princeton professor, also contributed significantly to the effort. (Mr. Reinhardt, who died last month, was a panelist on an Upshot article comparing international health systems in a tournament format.) The task force studied countries like the United States, Britain, France, Canada, Germany and Japan.
在同來自世界各地的專家交流過後，台灣選擇讓哈佛大學陳曾熙公共衛生學院(Harvard T.H. Chan School of Public Health)的經濟學教授蕭慶倫(William Hsiao)帶領一個工作組設計新係統。長期在普林斯頓大學擔任教授的任赫德(Uwe Reinhardt)也做出了重要貢獻。（上月去世的任赫德是“結語”專欄[Upshot]中一篇用錦標賽的形式，比較國際醫療體係的文章的專家組成員。）這個工作組對美國、英國、法國、加拿大、德國和日本等國家進行了研究。
In the end, Taiwan chose to adopt a single-payer system like that found in Medicare or in Canada, not a government-run system like Britain’s. At first, things did not go as well as hoped. Although the country had been planning the change for years, it occurred quite quickly after democracy was established in the early 1990s. The system, including providers and hospitals, was caught somewhat off guard, and many felt that they had not been adequately prepared. The public, however, was much happier about the change.
最後，台灣選用了類似美國的聯邦醫療保險(Medicare)和加拿大的單一支付係統，而不是英國那種由政府運作的係統。起初，事情不像預想的那麽順利。盡管台灣為醫改籌備了很多年，但在90年代初民主製度確立後，變化發生得非常快。包括醫療服務提供者和醫院在內的醫療保健係統有些猝不及防，很多人覺得自己還沒有準備好。然而，公眾對這種變化的滿意程度要高得多。
Today, most hospitals in Taiwan remain privately owned, mostly nonprofit. Most physicians are still either salaried or self-employed in practices.
今天，台灣大部分醫院依然屬於私營，大多是非營利性質的。大部分醫生依然要麽是按月領工資，要麽是個體經營者。
The health insurance Taiwan provides is comprehensive. Both inpatient and outpatient care are covered, as well as dental care, over-the-counter drugs and traditional Chinese medicine. It’s much more thorough than Medicare is in the United States.
台灣提供的醫療保險頗為全麵。住院和門診治療，以及口腔治療、非處方藥和中藥都在保險範圍內。它比美國的聯邦醫療保險全麵得多。
Access is also quite impressive. Patients can choose from pretty much any provider or therapy. Wait times are short, and patients can go straight to specialty care without a referral.
就醫過程也令人印象相當深刻。患者幾乎可以從任何提供者或治療中選擇。等待時間短，患者無需轉診，便可直接接受專科治療。
Premiums are paid for by the government, employers and employees. The share paid by each depends on income, with the poor paying a much smaller percentage than the wealthy.
保險費由政府、雇主和雇員共同承擔。每個人支付的比例視收入而定，窮人支付的比例遠低於富人。
Taiwan’s cost of health care rose faster than inflation, as it has in other countries. In 2001, co-payments for care were increased, and in 2002, they went up again, along with premiums. In those years, the government also began to reduce reimbursement to providers after a “reasonable” number of patients was seen. It also began to pay less for drugs. Finally, it began to institute global budgets — caps on the total amount paid for all care — in the hope of squeezing providers into becoming more efficient.
和其他國家一樣，台灣的醫療保健成本漲幅超過了通貨膨脹。在2001年，醫療共同支付增加。2002年，共同支付費用繼續增加，保險費上漲。那兩年，政府在看到患者人數“合理”後，也開始減少對服務提供者的補償。政府還開始降低藥品支出。最後，政府開始製定總體預算，為各種醫療費用的總金額設定上限，希望服務提供者提高效率。
Relative to the United States and some other countries, Taiwan devotes less of its economy to health care. In the early 2000s, it was spending 5.4 percent of G.D.P., and by 2014 that number had risen to 6.2 percent. By comparison, countries in the Organization for Economic Cooperation and Development spend on average more than 9 percent of G.D.P. on health care, and the United States spends about twice that.
與美國等國相比，台灣在醫療保健方麵的投入占經濟總量的比重要小。在21世紀初，台灣在醫療保健方麵的花費占GDP的5.4%，到2014年，這個比例上升至6.2%。相比之下，經濟合作與發展組織(OECD)成員國的醫療投入平均占GDP9%以上，而美國的比例大約是這個數字的兩倍。
After the most recent premium increase in 2010 (only the second in Taiwan’s history), the system began to run surpluses.
在2010年的最近一次保險費上漲之後（這在台灣曆史上隻是第二次），該體係開始出現盈餘。
This is not to say the system is perfect. Taiwan has a growing physician shortage, and physicians complain about being paid too little to work too hard (although doctors in nearly every system complain about that). Taiwan has an aging population and a low birthrate, which will push the total costs of care upward with a smaller base from which to collect tax revenue.
這並不是說，這個體係是完美的。台灣的醫生短缺越來越嚴重，醫生們抱怨工資太低，工作太辛苦（盡管幾乎每個體係的醫生都有這樣的抱怨）。台灣正在經曆人口老齡化，人口出生率低，這將推動整體醫療費用的上升，而繳稅的人口基數在變小。
Taiwan has done a great job at treating many communicable diseases, but more chronic conditions are on the rise. These include cancer and cardiovascular and cerebrovascular disease, all of which are expensive to treat.
台灣在很多傳染性疾病的治療方麵做得很好，但慢性病數量在增多，包括癌症和心腦血管疾病，這些疾病的治療費用都很貴。
The health system’s quality could also be better. Although O.E.C.D. data aren’t available for the usual comparisons, Taiwan’s internal data show that it has a lot of room for improvement, especially relating to cancer and many aspects of primary care. Taiwan could, perhaps, fix some of this by spending more.
該衛生係統的質量還可以更好。雖然OECD的數據不能用於通常的比較，但台灣的內部數據顯示，它有很大的改善空間，尤其是在癌症以及初級保健的許多方麵。台灣也許可以通過增加投入來解決其中一些問題。
As we showed in our battle of the health care systems, though, complaints can be made about every system, and the one in the United States is certainly no exception. For a country that spends relatively little on health care, Taiwan is accomplishing quite a lot.
不過，正如我們在醫療保健係統之戰中看到的那樣，每個係統都會有抱怨，美國的自然也不例外。而台灣作為一個在醫療保健方麵花費相對較少的國家，已經取得了很大的成就。
Comparing Taiwan and the United States may appear to be like comparing apples and aardvarks. One is geographically small, with only 23 million citizens, while the other is vast and home to well above 300 million. But Taiwan is larger than most states, and a number of states — including Vermont, Colorado and California — have made pushes for single-payer systems in the last few years. These have not succeeded, however, perhaps because there is less tolerance for disruption in the United States than the Taiwanese were willing to accept.
拿台灣和美國作比較就像是拿蘋果和土豚作比較。一個領土麵積小，人口隻有2300萬，而另一個幅員遼闊，擁有3億多人口。不過，台灣比美國的大多數州都大。在過去幾年裏，包括佛蒙特州、科羅拉多州和加利福尼亞州在內的很多州已經在推動實行單一支付係統。然而，這些努力並沒有取得成功，也許是因為美國人不像台灣人那麽願意打破原來的體係。
Regardless of which health system you might prefer, Taiwan’s ambition showed what’s possible. It took five years of planning and two years of legislative efforts to accomplish its transformation. That’s less time than the United States has spent fighting over the Affordable Care Act, with much less to show for it.
無論你更喜歡哪種醫療體係，台灣的雄心展現出了可能性。台灣經過五年的規劃和兩年的立法才完成了這個轉變。這比美國在《合理醫療費用法案》(Affordable Care Act)上爭鬥的時間要少，盡管後者可以拿出手的遠不如前者。
作者：AARON E. CARROLL and AUSTIN FRAKT
Aaron E. Carroll是印第安納大學醫學院的兒科學教授。他在The Incidental Economist上撰寫有關健康研究與政策的博客文章，並在Healthcare Triage上製作視頻。他是《不良食物聖經：如何及為何要罪惡地吃東西》。歡迎在Twitter上關注他：@aaronecarroll。
Austin Frakt是波士頓保健係統合作循證政策資源中心的主管、波士頓大學公共衛生學院副教授以及哈佛大學曾熙公共衛生學院的兼任副教授。他在“The Incidental Economist”上撰寫博客，歡迎在Twitter上關注他：@afrakt。
翻譯：紐約時報中文網
