Himmelstein D U, Woolhandler S
Center for National Health Program Studies, Cambridge Hospital-Harvard Medical School, Cambridge, MA 02139.
N Engl J Med. 1989 Jan 12;320(2):102-8. doi: 10.1056/NEJM198901123200206.
Our health care system is failing. Tens of millions of people are uninsured, costs are skyrocketing, and the bureaucracy is expanding. Patchwork reforms succeed only in exchanging old problems for new ones. It is time for basic change in American medicine. We propose a national health program that would (1) fully cover everyone under a single, comprehensive public insurance program; (2) pay hospitals and nursing homes a total (global) annual amount to cover all operating expenses; (3) fund capital costs through separate appropriations; (4) pay for physicians' services and ambulatory services in any of three ways: through fee-for-service payments with a simplified fee schedule and mandatory acceptance of the national health program payment as the total payment for a service or procedure (assignment), through global budgets for hospitals and clinics employing salaried physicians, or on a per capita basis (capitation); (5) be funded, at least initially, from the same sources as at present, but with all payments disbursed from a single pool; and (6) contain costs through savings on billing and bureaucracy, improved health planning, and the ability of the national health program, as the single payer for services, to establish overall spending limits. Through this proposal, we hope to provide a pragmatic framework for public debate of fundamental health-policy reform.
我们的医疗保健系统正在失灵。数千万人没有医保，成本飞涨，官僚机构不断膨胀。修修补补的改革只是用老问题换了新问题。美国医疗领域进行根本性变革的时候到了。我们提议实施一项全国性医疗计划，该计划将：（1）通过单一、全面的公共保险计划为每个人提供全面覆盖；（2）每年向医院和疗养院支付一笔总计（整体）金额，以涵盖所有运营费用；（3）通过单独拨款为资本成本提供资金；（4）通过以下三种方式之一支付医生服务和门诊服务费用：采用简化收费表的按服务收费，并强制接受全国性医疗计划付款作为某项服务或程序的全额付款（指派），通过为聘用受薪医生的医院和诊所制定整体预算，或按人均（人头）计算；（5）至少在初期，从与目前相同的来源获得资金，但所有付款都从一个资金池中支出；（6）通过节省计费和官僚机构成本、改进医疗规划以及全国性医疗计划作为服务的单一付款人设定总体支出限额的能力来控制成本。通过这一提议，我们希望为根本性医疗政策改革的公开辩论提供一个务实的框架。
