Evans R G
University of British Columbia.
J Health Polit Policy Law. 1990 Spring;15(1):101-28. doi: 10.1215/03616878-15-1-101.
"Control" of health care costs is often portrayed as a struggle between external, "natural" forces pushing costs up and individuals, groups, and societies trying to resist the inevitable. This picture is false. Control includes strenuous efforts by some to raise costs, and by others to resist those increases, and/or to transfer costs to someone else. But all such forces originate in the purposes and interests of individuals and groups. Health care cost control is a struggle among conflicting interests over the priorities of a society, and claims of "inevitability" are simply part of the political rhetoric of that struggle. International experience supports certain conclusions. First, there is no basis for the claim that limits on expenditure growth must threaten the health of (some members of) a society. Second, there is a substantial variety of experience with cost control. Failure in the United States is often presented as evidence of the impossibility of control, but most other countries have succeeded. Finally, control requires the direct confrontation of interests, with substantial build-up of stress. Advocates of expansion are more successful if they can transform compressive forces into efforts to shift the burden onto someone else. Pressures from providers in every country for "privatization" and/or payment by users reflect this recognition of economic interest.
医疗保健成本的“控制”常常被描绘成一种斗争，即外部“自然”力量推动成本上升，而个人、团体和社会试图抵制这种不可避免的趋势。这种描述是错误的。控制包括一些人竭力提高成本，以及另一些人抵制成本增加和/或将成本转嫁给他人。但所有这些力量都源于个人和团体的目的与利益。医疗保健成本控制是社会不同利益群体围绕社会优先事项展开的冲突，而所谓“不可避免”的说法不过是这场斗争中的政治言辞。国际经验支持某些结论。首先，认为支出增长限制必然会威胁到（部分）社会成员健康的说法毫无根据。其次，成本控制有多种不同的经验。美国的失败常被视为控制不可能实现的证据，但其他大多数国家都取得了成功。最后，控制需要直接面对利益冲突，并承受巨大压力。如果扩张的支持者能够将压缩性力量转化为将负担转嫁给他人的努力，他们就会更成功。各国医疗服务提供者对“私有化”和/或使用者付费的压力就反映了对经济利益的这种认识。
