【社会】美国的医疗体系趣闻_风闻

【来源龙腾网】

评论原创翻译：

Andrew M. Baer

What’s wrong with the US healthcare system?

I am hungry. Let’s go shopping. Let’s buy chicken. (I am sort of vegetarian, but let’s keep it simple.) At local store X, chicken is $1.50 per lb. Next door, at local store Y, it is 1.58 per lb. About a mile away, local store Z is selling it for $1.48 per lb. All things being equal, that is to say, chicken is chicken, I suspect most of us would go to store Z.

Why don’t we try something different. Not everyone eats chicken…at least not daily or even once a week. I have a lot of money and I am going to do something interesting. Why not sell food insurance. Tell you what, for a family of 4, I will charge $1,500 per month. (For arguments sake, let’s say a family of 4 spends $1,000 per month on food.) Additionally, you will use your insurance at the store, unless you buy particular items or more of a particular item than your insurance plan allows, then you have to pay a deductible.

As my insurance business grows along with the monopoly on food it has created, the price of chicken is now $24.00 per lb.

美国的医疗体系出了什么问题？

我饿了，我们去购物吧，我们买鸡肉哈。（我是素食主义者，不过还是简单点吧。）在当地的X商店，鸡肉每磅1.5美元。隔壁的Y商店，每磅1.58美元。大约一英里外，当地的Z商店以每磅1.48美元的价格出售。在所有条件相同的情况下，也就是说，鸡肉就是鸡肉，我怀疑我们大多数人都会去Z商店的。

我们为什么不尝试一些不同的东西呢。不是每个人都吃鸡肉……至少不是每天或每周吃一次。我有很多钱，我要做一些有趣的事情。为什么不出售食品保险呢。告诉你吧，对于一个四口之家，我将收取每月1500美元的费用。（为了论证起见，假设一个四口之家每月在食物上花费1000美元。）此外，你将在商店使用你的保险，除非你购买了特定的物品或超过你的保险计划允许的特定物品，那么你就必须支付免赔额。

随着我的保险业务的发展以及它对食品的垄断，现在鸡肉的价格是每磅24美元。

As you enter the store to buy less food than you could prior to my food insurance industry, you can see me in front of the store making extra money at a three card Monte table…or maybe a shell game…kind of a metaphor for what this is all about.

Are you beginning to get the idea? Yes, the analogy is off the wall, but so is the medical insurance business.

I am not going to go into the entire history of health insurance but I will touch on some points along the time line. At the beginning of the 20th century, with the industrial revolution in full swing, what we now know as workman’s compensation insurance began in 1910 when states began enacting laws to protect workers. Initially, an injured worker would see his own physician and the bill would be covered by the workers compensation fund. Subsequently, some companies hired their own physicians to provide care. Both of these models would evolve over time into models that we see today.

Interestingly, even prior to this, since around the time of the civil war, some employers took a portion of their employees pay to put into a sickness fund that would be used to pay employees something during times they did not work due to illness. However, for the most part, absent workman’s compensation paid visits, the majority of physician and hospital visits were paid out of pocket by the patient.

随着你在商店买的食物比推行食品保险行业之前买的要少，你可以看到我在店门口的三张赌桌上赚外快，也许是个骗局……这是对这一切的隐喻。

你开始有这个认知了吗？是的，这种类比很离谱，但医疗保险业务就是如此。

我不打算详细介绍医疗保险的整个历史，但我将沿着时间线谈谈一些要点。20世纪初，随着工业革命的全面展开，我们现在所说的工伤保险始于1910年，当时各州开始颁布法律保护工人。最初，受伤的工人会自己去看医生，费用将由工人赔偿基金支付。随后，一些公司聘请了自己的医生来提供护理。随着时间的推移，这两种模型都会演变成我们今天看到的模型。

有趣的是，甚至在这之前，因为大约在内战期间，一些雇主从员工工资中拿出一部分投入疾病基金，用于支付员工因病不工作时的工资。然而，在大多数情况下，在没有工伤保险的情况下，找医生和医院就诊都是由患者自掏腰包支付的。

One must also take into consideration the fact that medicine as we know it today had quite a revolution since the first colonists came to America. At that time, all American physicians were trained in Europe. There were no CT scans, MRIs, blood work, or antibiotics. Jenner’s work on smallpox would not come until the end of the 19th century.

Blood letting was a popular treatment of the time. The “physician” doing the procedure might likely be your barber. The medicines of the day were predominantly botanical. Surgery as we no it today was non-existent.

我们还必须考虑到这样一个事实，即自第一批殖民者来到美国以来，我们今天所知的医学已经发生了相当大的革命。当时，所有的美国医生都在欧洲接受培训。没有CT扫描、核磁共振成像、血液检查或抗生素。詹纳（Jenner）关于天花的研究直到19世纪末才问世。

放血是当时流行的治疗方法。做手术的“医生”可能是你的理发师。当时的药物主要是植物药，我们今天所说的手术是不存在的。

Interestingly, while the age of enlightenment would bring science or what we today call evidence based medicine into being. American physicians kept many of the traditional non-evidence based procedures in their armamentarium. Today, a patient going into cardiac arrest brings to mind the image of a crash cart, defibrillator, and CPR. Back in the 1700s a shortage of such equipment necessitated the use of other means. So, what did they do. The answer lies in a common expression uttered by an individual who believes he is being duped or lied to. “blowing smoke.” For those that do not know the full expression, it is, “he is blowing smoke up my ass, or more properly put in doctor speak, rectum. Ever wonder where the expression came from? You guessed it. A method of revival was to give a rectal smoke enema. It started in 1774 in London by two doctors, William Hawes and Thom-as Cogan who administered the procedure at a cost of 4 guineas, about $756 in today’s dollars. (To be sure, the unconscious patient’s wallet would be examined to see if it contained a Blue Cross/Blue Shield card, or American Express.)

有趣的是，启蒙时代带来了科学，也就是我们今天所说的循证医学。美国医生在他们的医疗设备中保留了许多传统的非循证程序。今天，一个心脏骤停的病人会让人想起急救车、除颤器和心肺复苏术。早在18世纪，这种设备是短缺的，于是就需要使用其他手段。那么，他们做了什么呢？答案在于一个认为自己被欺骗或被欺骗的人说出的一个常见表达方式——“吹烟”。对于那些不知道如何完整表达的人来说，是“他把烟插到屁股上，或者更确切地说，插进直肠。有没有想过这个表达是怎么来的？你猜对了。”：一种恢复的方法是从直肠处烟雾灌肠。1774年，两位医生（William Hawes和Thom as Cogan）在伦敦执行这项业务流程，他们的手术费用为4几尼，换算成今天的美元约为756美元。（可以肯定的是，昏迷患者的钱包会被检查，看看里面是否有蓝十字/蓝盾卡或美国运通卡）

In America both before and after the revolution, doctors could be paid in cash and if they could not afford the bill, they would likely pay in goods. At this juncture, an important point needs to be made. In the 1700s and 1800s, most notably in Europe, physicians in particular, and surgeons were highly respected members of society despite the fact that in reality, there was very little they could do for many of the common afflictions of mankind. While they may have been highly respected, what they were not was what we would call wealthy by today’s standards. One did not enter into medicine to become wealthy

在美国，无论是革命前还是革命后，看医生都可以用现金支付，如果他们付不起医药费，他们可能会用商品支付。在这个节骨眼上，有一点很重要。在18世纪和19世纪，尤其是在欧洲，医生和外科医生是社会中备受尊敬的成员——尽管事实上，他们对人类的许多常见疾病无能为力。虽然他们可能受到了高度尊重，但以今天的标准来看，他们并不是我们所说的富人，毕竟行医不是为了致富。

We should look at this further by noting changes in language. The traditional definition of a profession is that it is a “calling.” It is something one does not for monetary gain or social status, but rather for the benefit of mankind. Historically, there were only three professions, the clergy, law, and medicine…nothing else. Physicians in the 1700s and 1800s were financially in what today we would call the middle class. One did not undertake medical training in the hope of attaining great wealth.

Unfortunately, the concept of medicine as a calling has been lost. Approaching medicine as a personal calling is not a requirement for entrance into medical school although, perhaps it should be because in my opinion the practice of medicine requires a certain selflessness that I think is necessary to be a good physician. Of importance with respect to healthcare finance this plays an important role in understanding the economics of physician salaries today and differences in how the different specialties are compensated. If all physicians have answered a calling, then they would be paid equally. however, they are not as will be discussed subsequently.

我们应该通过注意语言的变化来进一步了解这一点。职业（ profession）的传统定义是“使命感（calling）”。它不是为了获得金钱利益或社会地位，而是为了人类的利益。历史上，只有三种职业，神职人员、法律和医学，没有其他职业。18世纪和19世纪的医生在经济上属于今天我们所说的中产阶级。人们接受医学训练不是为了获得巨大的财富。

不幸的是，医学作为一种“使命感（calling）”的概念已经消失了。将医学视为一种个人使命并不是进入医学院的必要条件，尽管也许应该这样做，因为在我看来，医学实践需要一定的无私精神，我认为这是成为一名好医生所必需的。重要的是尊重，对于医疗保健金融来说，这在理解当今医生工资的经济学和不同专业如何补偿的差异方面发挥着重要作用如果所有的医生都响应了“使命感（calling）”那么他们就会得到同样的报酬。然而，它们不像后面将要讨论的那样。

Getting back to the history of insurance, the depression hit hospitals very hard. Justin Kimble, an administrator at Baylor Hospital devised a plan that would pay hospitals and can be considered a forerunner of Blue Cross. He enrolled 1250 Dallas, TX teachers in to the plan. For 50 cents a month they would be provided 21 days of hospital care. The AMA was opposed to this so only the hospital and not the physicians were covered. In 1932 in Sacramento a plan was created not for one hospital but for all of those in a particular community. These plans were all non-profit. It should be noted, especially because it is the crux of my position, the states did not view these plans as insurance. The looked at them as pre-paid plans. However, in 1933, the NY state insurance commissioner deemed these plans as insurance. His reasoning was that these plans were collecting money for services to be rendered in the future. In a sense, he likened them to life or casualty insurance both of which are paid out at a future time. As will be subsequently discussed I beleive this was a mistake that has had serious consequences in terms of its impact causing the healthcare problems we have tody.

回到保险业的历史，大萧条对医院的打击非常严重。贝勒医院（Baylor Hospital）的行政人员贾斯汀·金布尔（Justin Kimble）设计了一项向医院支付费用的计划，可以被视为蓝十字的先驱。他招募了德克萨斯州达拉斯市的1250名教师加入该计划。每月支付50美分，他们将获得21天的医院护理。美国医学协会反对这样做，所以只有医院而不是医生被覆盖。1932年，萨克拉门托制定了一项计划，不是针对一家医院，而是针对某一特定社区的所有人，这些计划都是非营利性的。应该注意的是，特别是因为这是我立场的关键，各州并没将这些计划视为保险。他们将其视为预付费计划。然而，1933年，纽约州保险专员将这些计划视为保险。他的理由是，这些计划是在为未来提供的服务筹集资金。从某种意义上说，他把它们比作人寿保险或意外伤害保险，两者都是在未来的某个时候支付的。正如随后将要讨论的那样，我认为这是一个错误，造成了严重的后果，导致了我们今天的医疗问题。