University of California, Los Angeles.
University of Texas-Houston.
Health Syst Transit. 2020 Dec;22(4):1-441.
This analysis of the US health system reviews the developments in organization and governance, health financing, healthcare provision, health reforms and health system performance. The US health system has both considerable strengths and notable weaknesses. It has a large and well-trained health workforce and a wide range of high-quality medical specialists, as well as secondary and tertiary institutions, a robust health sector research programme and, for selected services, among the best medical outcomes in the world. But it also suffers from incomplete coverage of its citizenry, health expenditure levels per person far exceeding all other countries, poor measures on many objective and subjective measures of quality and outcomes, and an unequal distribution of resources and outcomes across the country and among different population groups. It is difficult to determine the extent to which deficiencies are health-system related, though it is clear that at least some of the problems are a result of poor access to care. The adoption of the Affordable Care Act in 2010 resulted in greatly improved coverage through subsidies for the uninsured to purchase private insurance, expanded eligibility for Medicaid (in some states), and greater protection for insured persons. Furthermore, primary care and public health received increased funding, and quality and expenditures were addressed through a range of measures such as financial rewards for providing higher-value care. At the same time, a change in political administration resulted in subsequent efforts to scale back the legislation. Many key issues remain, including further reducing the number of uninsured people, alleviating some of the burdensome patient cost-sharing requirements, and considering some new cost-containment methods such as allowing the government to negotiate drug prices with pharmaceutical manufacturers. The direction of future health policy will almost certainly depend on which political party is in power.
本报告对美国卫生系统进行了分析，回顾了其组织和治理结构、卫生筹资、医疗服务提供、卫生改革以及卫生系统绩效等方面的发展情况。美国卫生系统既有显著优势，也有明显劣势。其拥有数量庞大且训练有素的卫生人力队伍、广泛的高质量医学专家以及二级和三级医疗机构，还有强大的卫生部门研究计划，在某些服务领域，其医疗效果位居世界前列。但美国也存在覆盖面不完整、人均卫生支出远高于其他所有国家、在许多客观和主观的质量和结果指标上表现不佳、资源和结果在全国以及不同人群之间分配不均等问题。虽然难以确定这些缺陷在多大程度上与卫生系统有关，但显然，至少有一些问题是由于获得医疗服务的机会有限造成的。2010 年《平价医疗法案》（Affordable Care Act）的通过，通过补贴无保险者购买私人保险、扩大医疗补助（Medicaid）的资格（在某些州）以及对参保人提供更大保护，极大地提高了覆盖率。此外，初级保健和公共卫生获得了更多的资金，通过一系列措施解决了质量和支出问题，例如为提供更高价值的护理提供经济奖励。与此同时，政治行政部门的更迭导致随后对该立法进行了缩减。许多关键问题仍然存在，包括进一步减少无保险人数、减轻一些繁重的患者自付费用要求，并考虑一些新的成本控制方法，例如允许政府与制药商就药品价格进行谈判。未来卫生政策的方向几乎肯定取决于哪个政党掌权。
