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 $420 per year.
What is it? The Swiss system is social insurance like in Japan and Germany, voted in by a national referendum in 1994. Switzerland didn't have far to go to achieve universal coverage; 95 percent of the population already had voluntary insurance when the law was passed. All citizens are required to have coverage; those not covered were automatically assigned to a company. The government provides assistance to those who can't afford the premiums.
How does it work? The Swiss example shows that universal coverage is possible, even in a highly capitalist nation with powerful insurance and pharmaceutical industries. Insurance companies are not allowed to make a profit on basic care and are prohibited from cherry-picking only young and healthy applicants. They can make money on supplemental insurance, however. As in Germany, the insurers negotiate with providers to set standard prices for services, but drug prices are set by the government.
What are the concerns? The Swiss system is the second most expensive in the world -- but it's still far cheaper than U.S. health care. Drug prices are still slightly higher than in other European nations, and even then the discounts may be subsidized by the more expensive U.S. market, where some Swiss drug companies make one-third of their profits. In general, the Swiss do not have gatekeeper doctors, although some insurance plans require them or give a discount to consumers who use them.
多謝雅臨點評，講得非常好！
Rank Race Median household income (2015 US$)
1 Asian 74,245[1]
2 White 59,698[1]
3 Native Hawaiian and Other Pacific Islander 55,607[1]
4 Some other race 42,461[1]
5 American Indian and Alaska Native 38,530[1]
6 Black or African American 36,544[1]
西裔大約45，000，遠低於白人，但活得更長。
所言很中肯。和各個族裔的生活方式也很有關係，美國的亞裔平均壽命是86.7歲，比日本人還長壽(83.8歲）；西班牙裔平均83歲，和西班牙人相仿，遠高於墨西哥（77歲）。印第安人，平均壽命81歲。相對而言普通白人和黑人倒是最可憐，分別是79和75.5歲。
http://www.worldlifeexpectancy.com/usa/life-expectancy-african-american
No free lunch。：）多謝您雅臨點評！現代人活得越來越長，我覺得恐怕推遲退休也是必須的。如果60歲退休活到100歲，那40年豈不是太無聊了，醫保負擔也太重了。
久不見侃兄，先問個大安！
所言一如既往地客觀中肯，老齡化尤其切中要害。醫保，說白了，是靠年輕人養著老人的。老齡人口增加，必然加大年輕人的負擔。加上給新來的移民/難民提供幾乎免費的醫保，以後歐洲的全民醫保還能不能再持續50年，其實還是有風險的。
所以我覺得，需要提倡健康的生活方式和加大預防性治療的力度。當然美國的醫保也許太市場化，考慮一下怎樣提高醫保資金利用效率是應該的。
周末愉快！
全民醫保的國家人均壽命比號稱世界一流的美國壽命高4-6年。
好不好很明朗的。
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人均壽命高低與醫保製度不一定有很強的相關性。看看各國的飲食結構，美國的食品是最不健康的。當人口規模過大時，工業化大規模生產就巨大的利潤空間，從而使低價低質食品充斥市場
不過即使是對於同一組數據，不同網友也會有不同解釋，不容易“統一思想”。這無關緊要啦！
用俺們普通人的俗語講，甘蔗沒有兩頭甜。
日本文化環境、飲食習慣跟天朝接近，醫保係統也很不錯。可是地方小點，工作辛苦點，每當大陸抗日情緒高漲時，華人在彼處難免覺得不自在。
歐洲曆史悠久、人文薈萃，假日豐裕，醫療“公費”。可是生活費錢，稅率不低，也有短處。
加新澳也屬發達國家，各個方麵與歐日也不遑多讓。可惜都有不足，或偏冷、或偏遠、或偏小。賺大錢也不容易。
無怪乎，美國是眾多華人趨之若鶩的理想之地。
有Urban Legend說：“美國之所以最發達、最有活力、最富有，是因為它不像歐日加新澳等給國民提供那麽多的額外保障，而是用努力就能發大財的哲學，驅動美國人努力奮鬥，創造財富。”難說是對是錯。
不過呢，所謂全麵福利、全民醫保的不少國家有不少都麵臨入不敷出的困難。生活條件改善了，奮鬥精神削弱了，平均創造的價值減少了；人的壽命延長了，老弱階段增加了，平均消耗提高了。現實的問題，不是簡單能解決的。
多謝您的點評。這個跟工作節奏和人種也有關係。
好不好很明朗的。
多謝您點評，不過我在網上看隻要年收入超過4萬5千英鎊，或6萬美元，就是40%的稅收了。這個收入真的是不高啊，恐怕連中產都算不上。
周末愉快。
今天的西方發達國家，不是叢林。能否照顧弱勢人群，是區分現代文明社會和叢林社會的標誌之一。”
毫無意外，你根本在回避問題。問題不在於要不要照顧弱勢人群，而是怎樣做。你主張政府用暴力來做，我主張用別的途徑。請回答：憑什麽說你對“文明社會”的見解要高於我?
從老百姓生活看，自己可支配的收入vs支出是主要的標準。所以加稅不是辦法，但提高醫保係統的效率是應該做的。公司不給你交保，那錢也不會增加到您的工資裏，您說是不是？美國實際上是把這部分變成了公司間的交易。
今天的西方發達國家，不是叢林。能否照顧弱勢人群，是區分現代文明社會和叢林社會的標誌之一。
spending不等於premium,後者是我們支付的，見正文。
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教授啊，我想這就是你我所說的差別所在。譬如你在大學工作，大部分Premium是大學給付了，自己付很少一部分。但這不等於說，你的醫保費用就低。你的雇主幫你付了大部分Premium。羊毛出在羊身上。你雇主付出的錢還是要從你身上賺回來的。所以，spending 才是指標，而不是Premium。
多謝您雅臨點評。美國的spending，並不是個人的保金，而直接影響老百姓的是自己到底出了多少錢。另一方麵，這確實反映出美國醫保資金利用的效率低下，這裏是可以改進的，但不能照搬歐洲增稅的方法。
2015 Canada, France, Germany, U.K., U.S,
a 4609, 4407, 5267, 4003, 9451;
b 4.1, 3.1, 2.8, 2.6, 2.5;
c 8.2, 6.2, 2.9, 2.7, 2.7;
d 0, 0.1, 0.2, 0, 9.1;
a:Health spending per person($):
b:Number of primary care doctors per 1000 people:
c:Hospital beds per 1000 people:
d:Percentage of people without medical insurance(%):
美國人平均醫療花銷約是另三國二倍，雖然少交稅，但交醫保許多。其他三國多交稅，但醫保不用花錢（大約吧）。
假定這些數字是真的，那你說頂端1%應該占有百分之幾的社會財富？為什麽？怎麽算出來？
如果反過來說：“美國頂端1%的人隻占有了40%的財富，接下來的頂端19%的人僅僅占了50%的財富，這社會太合理了” 是不是同樣沒有道理？
憑什麽倫理道義你有權通過政府暴力強迫他人為你的信仰買單？
這實際上是社會主義（包括全民醫保）的本質。你同情窮人可以捐獻，幹嘛要強迫他人拿出百分之多少？
相對來說，看病等候時間有一定靈活性。有的家庭醫生病人多，預約要等挺久的。有的家庭醫生不是那麽忙，當天可以看。急診就要看嚴重情況，我媽媽有兩次是被救護車送進去的，基本上15分鍾護士就來了，各種測試都做1遍也不到1個小時。檢查下來沒有啥問題，你就可能等很久。專科就看運氣了，我自己的婦科專家預約了一年，但是父母（可能因為是老人），幾個星期就約到了。反正家裏有老人的，體質不好，病多的，肯定是加拿大好。
這也是我去年寫的chicken or beef的問題，兩黨製搞了200多年，很難撼動啊。我問過不少美國同事，他們說曆史上嚐試過種種辦法，都不大奏效。也許應該往議會製靠靠？還有英國同行跟我開玩笑說，英國本來有3個黨，現在也變成兩黨製了。不過他們好歹還有個真正的左翼政黨。
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同意。我以前也討伐過美國的這個兩黨獨大的政治體製。為什麽玩來玩去，就隻有兩黨？我的看法是選舉人團製度的贏者通吃法則，保證了美國不會出現新的黨。結果這兩黨就是半斤八兩，隻為大財主大財團服務。美國頂端1%的人占有了40%的財富，接下來的頂端19%的人占了50%的財富，而餘下的80%的民眾隻占有10%的財富。這社會太畸形了。
也許有道理。也希望加拿大的網友分享一下經曆。
不言兄，我看問題的關鍵在於，美國的兩黨其實都是大財主資助的，誰也不想徹底借用社會主義的方法解決問題，誰也不敢去約束醫保市場，跟那些大醫藥公司說不。和英國德國法國不同，美國曆史上從來就沒有一個真正的左翼政黨。沒有這個平衡，事情就不大好搞。
“深厚”，不是“身後”。typo,抱歉。
多謝園姐討論！回複槍兄的時候順手查了一下英國的稅率，確實高得驚人，沒賺多少錢就得交40%了。各種取舍吧。
其實要說同樣的錢產生的醫保效力（用預期壽命衡量），這些國家都趕不上古巴。：）大概人們本來就應該玩著過一生，哈哈。
多謝您雅臨點評。這裏麵是個trade-off，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身後的美國，恐怕多數人更喜歡後者，不願意像英國人中產那樣交40%的稅吧。
Band Taxable income Tax rate
Personal Allowance Up to ?11,500 0%
Basic rate ?11,501 to ?45,000 20%
Higher rate ?45,001 to ?150,000 40%
Additional rate over ?150,000 45%
謝謝阿留的寬容，容忍，縱容！其實世界上哪裏有病人不花錢的事？羊毛出在羊身上，英國的稅賦嚇死人。聽著掙得不少，其實到手所剩無幾，單位的會計在把工資打入各個員工的賬戶前，已經把相關的稅都收走了。（這點也和美國不一樣，交稅不勞煩自己動手，有點像中國哈。）此外，百物騰貴，消費稅非常高昂。離開英國多年，具體說不上來了，隻記得汽油價格節節攀高。每年政府製定預算，不太敢狂加個人所得稅，就把稅加在各種各樣的消費品上，比如，被稱為有礙環境的汽油和有害健康的香煙。在老百姓背負沉重稅負但可以生病的同時，英國象牙塔尖上有錢有權的人也無可奈何，他們無法推翻英國二戰後工黨政府建立起來並深受老百姓喜愛的全民醫療製度，隻得跟著交稅，均財富了。
假定美國家庭收入20萬，聯邦稅經各種免稅後實際稅率約15%，交三萬的稅。如果實行全民醫保，稅率鐵定升到45%以上。等於每年交6萬的醫療保險。你會覺得合算嗎？
華人主張全民醫保屬於把自己賣了還幫人數錢。
俺也搞不懂是怎麽算的，感覺有必要透明一下哈。
美國醫院是可以侃價的，如果超過支付能力，可以argue和negotiate。這個有點太市場了。
多謝雅臨點評！問安！
"in public insurance, they are based on your income. Both you and your employer have to each pay 15.5% of your gross income every month. The maximum premium amounts to circa 630 Euro."
也就是雇主和個人各付收入的15.5%，總共大約等於工資的30%，作為醫療保險。如果年收入5萬7千美元以上（按現在的匯率折算），則每月交cap大約750刀。也就是說總保金大致和美國相仿，但在美國平均個人付的要少很多，公司付的部分比德國公司要多。
BTW， 清漪園姐，我是你的粉，你的留言都說到我心裏去
非常讚同。多謝雅臨點評！
多謝您雅臨分享！看來大家對英國的醫療體製是比較滿意的，現在的問題是能否或如何推廣到美國？
多謝您雅臨點評。您在哪個國家？北歐？
多謝梅子姐分享經驗。轉回去有什麽障礙麽？
多謝園姐比較切身體會，老熟人了，磚隨便拍，冷水隨便潑，大夏天的涼快，哈哈。：）
其實我一直有一個疑問，也許您有些insight：英國的病人不花錢的醫保製度，為什麽德國學不來呢？美國不想學或學不來我可以理解，但感覺德國和英國應該差不多啊。
不言兄，去年美國每家平均實際的支出是每年$5,277，這個數字和俺們這個的情況差不多，不論學校或公司。也許您那邊是因為self employeed所以隻能自己cover全部？這一點確實需要改革，俺讚同。
"The increased cost of health insurance is a central fact in any discussion of health policy and health delivery. Annual premiums reached $18,142 in 2016 for an average family, up 3 percent from 2015, with workers on average paying $5,277 towards the cost of their coverage."
我在英國，美國都生過病，住過院。在英國當然一分錢不花，但要住大病房，選擇醫生的範圍很小，可以說要碰運氣,遇到哪位醫生就是哪位。在美國生病住院，除了看到醫生的速度快，手術時間安排速度快，單人病房等硬件比較好之外，其他乏善可陳。回家後看到要自負的費用嚇了我一跳，連用一條熱毛巾都要我自負。特別是美國醫院對病人需求的關注、護理要差得很遠。我猜，也許美國人動不動打醫療官司，把醫護人員都嚇壞了吧，不敢跟病人多說一句話，見了麵能少呆一分鍾就少呆一分鍾，能少說一句話就少說一句話，幹完他們的活，有時還沒幹完，就溜走了，與英國醫護人員對病人的態度差得不是一點半點。也許是人口素質問題吧，也許在英國學醫的孩子不是為了掙大錢的目的去的吧。總之，美國人的醫保係統sucks，對普通民眾來說，它就是一個為賺錢而運轉的生意係統，無他。