欧洲的社会主义“全民医保”真的那么诱人吗？

因为和不言兄的讨论，不知不觉扯到了医保，正好重新炒一下“全民医保”问题吧。

其实PBS早在08年就做了一个很好的纪录片，探讨英国、德国、日本等其他资本主义国家和台湾地区实现全民医保的方法，可供借鉴。http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/ 

简而言之，这些国家的“社会全民医保”都有各自的优势和问题。英国全免费，但看病免不了排长队；德国规定保险公司必须“非赢利”，而且规定了医生工资的标准，让不少医生觉得自己的工资太低，可是平均每个家庭每月$750的医保费（premium），即使按照美国中产的标准，也是相当昂贵。去年美国每家平均实际的医保费(premium)是每年$5,277，平均每月$440，比德国少了很多。瑞士的保费和德国相仿，co-pay更多。我个人是觉得，俺宁可在非全民医保的美国呆着，也不想到德、瑞去享受“社会主义全民医保”。相比之下，日本费用比较低，每家每月$280刀，但是有不少医院在赤字运营，老人们三天两头到医院做个测试什么们的，医护人员也很辛苦。真是家家有本难念的经。

美国是资本主义味道最浓的国家，也是她的历史特色。采用什么方式实现全民医保，恐怕还真的不是10年20年能完全解决的问题呢。比如，如果要学习这些“社会主义”国家，那么两条共同经验是：第一，医保公司必须是非盈利企业；第二，必须设置医生工资上限。哪一条在美国实行，都得假以时日，不是一个法令就可以马上改得了的。是否有更好的方法？本来这是政治家和议员要思考的问题，但感觉他们也没拿出什么好办法。美国医保覆盖率，08年以前是85%左右(90-08)。巴马折腾了半天，只暂时增加到了91%左右，而且还价格蹭蹭的张，不可持续。也就是说，最多6%的人在几年内暂时获益。但它拉动了整个保金价格上涨。那85%原来就有保险的人群（其中90%是工薪阶层），要多付钱还要牺牲医疗服务质量。这样的改革，无论如何不能说是成功。 

再看全民医保背后的税率。德国税率是25+5% surplus，医保再加15%，总共40%的收入上缴；英国看病免费，但中产的税率是40% （其实下限很低，6万美元收入就进入这个范围了），算起来和德国相仿。美国人能忍受40%的税收用于免费医疗吗？愿意支付高税收保绝对平安呢，还是愿意少交税担点风险自己支配？个人主义和自由经济色彩深厚的美国，恐怕多数人更喜欢后者，不愿意像英国中产那样交40%的税吧。 

自19世纪末以来，公共卫生设施的改善（饮用水、排污系统等等），对延长人类寿命的贡献比医学本身的发展要大得多。也许在本世纪，推广健康的生活和工作方式，和上个世纪改善卫生设施有着同等重要的意义，以便从根本上降低医疗成本，实现真正物美价廉的“全民医保”。

 

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.