因為和不言兄的討論，不知不覺扯到了醫保，正好重新炒一下“全民醫保”問題吧。
其實PBS早在08年就做了一個很好的紀錄片，探討英國、德國、日本等其他資本主義國家和台灣地區實現全民醫保的方法，可供借鑒。http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/
簡而言之，這些國家的“社會全民醫保”都有各自的優勢和問題。英國全免費，但看病免不了排長隊；德國規定保險公司必須“非贏利”，而且規定了醫生工資的標準，讓不少醫生覺得自己的工資太低，可是平均每個家庭每月$750的醫保費（premium），即使按照美國中產的標準，也是相當昂貴。去年美國每家平均實際的醫保費(premium)是每年$5,277，平均每月$440，比德國少了很多。瑞士的保費和德國相仿，co-pay更多。我個人是覺得，俺寧可在非全民醫保的美國呆著，也不想到德、瑞去享受“社會主義全民醫保”。相比之下，日本費用比較低，每家每月$280刀，但是有不少醫院在赤字運營，老人們三天兩頭到醫院做個測試什麽們的，醫護人員也很辛苦。真是家家有本難念的經。
美國是資本主義味道最濃的國家，也是她的曆史特色。采用什麽方式實現全民醫保，恐怕還真的不是10年20年能完全解決的問題呢。比如，如果要學習這些“社會主義”國家，那麽兩條共同經驗是：第一，醫保公司必須是非盈利企業；第二，必須設置醫生工資上限。哪一條在美國實行，都得假以時日，不是一個法令就可以馬上改得了的。是否有更好的方法？本來這是政治家和議員要思考的問題，但感覺他們也沒拿出什麽好辦法。美國醫保覆蓋率，08年以前是85%左右(90-08)。巴馬折騰了半天，隻暫時增加到了91%左右，而且還價格蹭蹭的張，不可持續。也就是說，最多6%的人在幾年內暫時獲益。但它拉動了整個保金價格上漲。那85%原來就有保險的人群（其中90%是工薪階層），要多付錢還要犧牲醫療服務質量。這樣的改革，無論如何不能說是成功。
再看全民醫保背後的稅率。德國稅率是25+5% surplus，醫保再加15%，總共40%的收入上繳；英國看病免費，但中產的稅率是40% （其實下限很低，6萬美元收入就進入這個範圍了），算起來和德國相仿。美國人能忍受40%的稅收用於免費醫療嗎？願意支付高稅收保絕對平安呢，還是願意少交稅擔點風險自己支配？個人主義和自由經濟色彩深厚的美國，恐怕多數人更喜歡後者，不願意像英國中產那樣交40%的稅吧。
自19世紀末以來，公共衛生設施的改善（飲用水、排汙係統等等），對延長人類壽命的貢獻比醫學本身的發展要大得多。也許在本世紀，推廣健康的生活和工作方式，和上個世紀改善衛生設施有著同等重要的意義，以便從根本上降低醫療成本，實現真正物美價廉的“全民醫保”。
UNITED KINGDOM
Percentage of Gross Domestic Product (GDP) spent on health care: 8.3
Average family premium: None; funded by taxation.
Co-payments: None for most services; some co-pays for dental care, eyeglasses and 5 percent of prescriptions. Young people and the elderly are exempt from all drug co-pays.
What is it? The British system is "socialized medicine" because the government both provides and pays for health care. Britons pay taxes for health care, and the government-run National Health Service (NHS) distributes those funds to health care providers. Hospital doctors are paid salaries. General practitioners (GPs), who run private practices, are paid based on the number of patients they see. A small number of specialists work outside the NHS and see private-pay patients.
How does it work? Because the system is funded through taxes, administrative costs are low; there are no bills to collect or claims to review. Patients have a "medical home" in their GP, who also serves as a gatekeeper to the rest of the system; patients must see their GP before going to a specialist. GPs, who are paid extra for keeping their patients healthy, are instrumental in preventive care, an area in which Britain is a world leader.
What are the concerns? The stereotype of socialized medicine -- long waits and limited choice -- still has some truth. In response, the British government has instituted reforms to help make care more competitive and give patients more choice. Hospitals now compete for NHS funds distributed by local Primary Care Trusts, and starting in April 2008 patients are able to choose where they want to be treated for many procedures.
JAPAN
Percentage of GDP spent on health care: 8
Average family premium: $280 per month, with employers paying more than half.
Co-payments: 30 percent of the cost of a procedure, but the total amount paid in a month is capped according to income.
What is it? Japan uses a "social insurance" system in which all citizens are required to have health insurance, either through their work or purchased from a nonprofit, community-based plan. Those who can't afford the premiums receive public assistance. Most health insurance is private; doctors and almost all hospitals are in the private sector.
How does it work? Japan boasts some of the best health statistics in the world, no doubt due in part to the Japanese diet and lifestyle. Unlike the U.K., there are no gatekeepers; the Japanese can go to any specialist when and as often as they like. Every two years the Ministry of Health negotiates with physicians to set the price for every procedure. This helps keeps costs down.
What are the concerns? In fact, Japan has been so successful at keeping costs down that Japan now spends too little on health care; half of the hospitals in Japan are operating in the red. Having no gatekeepers means there's no check on how often the Japanese use health care, and patients may lack a medical home.
GERMANY
Percentage of GDP spent on health care: 10.7
Average family premium: $750 per month; premiums are pegged to patients' income.
Co-payments: 10 euros ($15) every three months; some patients, like pregnant women, are exempt.
What is it? Germany, like Japan, uses a social insurance model. In fact, Germany is the birthplace of social insurance, which dates back to Chancellor Otto von Bismarck. But unlike the Japanese, who get insurance from work or are assigned to a community fund, Germans are free to buy their insurance from one of more than 200 private, nonprofit "sickness funds." As in Japan, the poor receive public assistance to pay their premiums.
How does it work? Sickness funds are nonprofit and cannot deny coverage based on preexisting conditions; they compete with each other for members, and fund managers are paid based on the size of their enrollments. Like Japan, Germany is a single-payment system, but instead of the government negotiating the prices, the sickness funds bargain with doctors as a group. Germans can go straight to a specialist without first seeing a gatekeeper doctor, but they may pay a higher co-pay if they do.
What are the concerns? The single-payment system leaves some German doctors feeling underpaid. A family doctor in Germany makes about two-thirds as much as he or she would in America. (Then again, German doctors pay much less for malpractice insurance, and many attend medical school for free.) Germany also lets the richest 10 percent opt out of the sickness funds in favor of U.S.-style for-profit insurance. These patients are generally seen more quickly by doctors, because the for-profit insurers pay doctors more than the sickness funds.
TAIWAN
Percentage GDP spent on health care: 6.3
Average family premium: $650 per year for a family for four.
Co-payments: 20 percent of the cost of drugs, up to $6.50; up to $7 for outpatient care; $1.80 for dental and traditional Chinese medicine. There are exemptions for major diseases, childbirth, preventive services, and for the poor, veterans, and children.
What is it? Taiwan adopted a "National Health Insurance" model in 1995 after studying other countries' systems. Like Japan and Germany, all citizens must have insurance, but there is only one, government-run insurer. Working people pay premiums split with their employers; others pay flat rates with government help; and some groups, like the poor and veterans, are fully subsidized. The resulting system is similar to Canada's -- and the U.S. Medicare program.
How does it work? Taiwan's new health system extended insurance to the 40 percent of the population that lacked it while actually decreasing the growth of health care spending. The Taiwanese can see any doctor without a referral. Every citizen has a smart card, which is used to store his or her medical history and bill the national insurer. The system also helps public health officials monitor standards and effect policy changes nationwide. Thanks to this use of technology and the country's single insurer, Taiwan's health care system has the lowest administrative costs in the world.
What are the concerns? Like Japan, Taiwan's system is not taking in enough money to cover the medical care it provides. The problem is compounded by politics, because it is up to Taiwan's parliament to approve an increase in insurance premiums, which it has only done once since the program was enacted.
SWITZERLAND
Percentage of GDP spent on health care: 11.6
Average monthly family premium: $750, paid entirely by consumers; there are government subsidies for low-income citizens.
Co-payments: 10 percent of the cost of services, up to $420 per year.
What is it? The Swiss system is social insurance like in Japan and Germany, voted in by a national referendum in 1994. Switzerland didn't have far to go to achieve universal coverage; 95 percent of the population already had voluntary insurance when the law was passed. All citizens are required to have coverage; those not covered were automatically assigned to a company. The government provides assistance to those who can't afford the premiums.
How does it work? The Swiss example shows that universal coverage is possible, even in a highly capitalist nation with powerful insurance and pharmaceutical industries. Insurance companies are not allowed to make a profit on basic care and are prohibited from cherry-picking only young and healthy applicants. They can make money on supplemental insurance, however. As in Germany, the insurers negotiate with providers to set standard prices for services, but drug prices are set by the government.
What are the concerns? The Swiss system is the second most expensive in the world -- but it's still far cheaper than U.S. health care. Drug prices are still slightly higher than in other European nations, and even then the discounts may be subsidized by the more expensive U.S. market, where some Swiss drug companies make one-third of their profits. In general, the Swiss do not have gatekeeper doctors, although some insurance plans require them or give a discount to consumers who use them.
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