Woolhandler Steffie, Himmelstein David U, Angell Marcia, Young Quentin D
Department of Medicine, Cambridge Hospital/Harvard Medical School, Cambridge, Mass 02139, USA.
JAMA. 2003 Aug 13;290(6):798-805. doi: 10.1001/jama.290.6.798.
The United States spends more than twice as much on health care as the average of other developed nations, all of which boast universal coverage. Yet more than 41 million Americans have no health insurance. Many more are underinsured. Confronted by the rising costs and capabilities of modern medicine, other nations have chosen national health insurance (NHI). The United States alone treats health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need. In this market-driven system, insurers and providers compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers. This creates the paradox of a health care system based on avoiding the sick. It generates huge administrative costs that, along with profits, divert resources from clinical care to the demands of business. In addition, burgeoning satellite businesses, such as consulting firms and marketing companies, consume an increasing fraction of the health care dollar. We endorse a fundamental change in US health care--the creation of an NHI program. Such a program, which in essence would be an expanded and improved version of traditional Medicare, would cover every American for all necessary medical care. An NHI program would save at least 200 billion dollars annually (more than enough to cover all of the uninsured) by eliminating the high overhead and profits of the private, investor-owned insurance industry and reducing spending for marketing and other satellite services. Physicians and hospitals would be freed from the concomitant burdens and expenses of paperwork created by having to deal with multiple insurers with different rules, often designed to avoid payment. National health insurance would make it possible to set and enforce overall spending limits for the health care system, slowing cost growth over the long run. An NHI program is the only affordable option for universal, comprehensive coverage.
美国在医疗保健方面的支出是其他发达国家平均水平的两倍多，而其他发达国家都宣称拥有全民医保。然而，超过4100万美国人没有医疗保险。还有更多人保险不足。面对现代医学不断上涨的成本和医疗能力，其他国家选择了国家医疗保险（NHI）。只有美国将医疗保健视为一种根据支付能力分配的商品，而不是一种根据医疗需求分配的社会服务。在这个市场驱动的体系中，保险公司和医疗服务提供者的竞争，与其说是通过提高质量或降低成本，不如说是通过避开无利可图的患者，并将成本转回到患者或其他支付方身上。这就造成了一个基于避开病人的医疗保健系统的悖论。它产生了巨额的管理成本，这些成本与利润一起，将资源从临床护理转移到了商业需求上。此外，如咨询公司和营销公司等新兴的附属企业，消耗了越来越多的医疗保健资金。我们支持美国医疗保健领域的一项根本性变革——创建一个国家医疗保险计划。这样一个计划，本质上是传统医疗保险扩大和改进后的版本，将为每个美国人提供所有必要的医疗护理。一个国家医疗保险计划每年至少可以节省2000亿美元（足以覆盖所有未参保者），方法是消除私营的、投资者所有的保险业的高额管理费用和利润，并减少营销及其他附属服务的开支。医生和医院将从因必须与规则各异、往往旨在避免支付的多家保险公司打交道而产生的文书工作的相关负担和费用中解脱出来。国家医疗保险将有可能设定并执行医疗保健系统的总体支出上限，从长远来看减缓成本增长。国家医疗保险计划是实现全民全面覆盖的唯一经济可行的选择。
