本帖最后由 单眼皮vs肿眼皮 于 2009-10-23 00:04 编辑
The doubters have a better case than the defenders. Granted（的确）, medical inventions are readily embraced by American doctors and patients. In specific instances—technology to save babies born prematurely and statin drugs to reduce cholesterol, to take two—the benefits of spending greatly outweigh the costs. But if the system in general were providing value for money, America’s vast expenditure would at least be reflected in a healthier population than in more frugal countries.
Alas（（表示悲伤或遗憾）哎呀，唉）, it is not. Comparisons with other rich countries and within the United States show that America’s health-care system is not only growing at an unsustainable（不能持续的；无法维持的） pace, but also provides questionable value for money and dubious medical care. Three troubling symptoms stand out: uneven quality of care, inadequate coverage and soaring costs. 提出论点
Start with quality.论证一 Evidence is mounting that spending more does not necessarily buy better health. On the contrary, it appears that many Americans are getting mixed（喜忧参半的） or even downright dreadful health care. In a recent study economists at the OECD found that America does indeed do well on some measures, such as breast-cancer survival rates and cervical-cancer screening, compared with other rich countries. However, it does worse in other areas. American infant mortality（婴儿死亡率） was 6.7 per 1,000 births in 2007, against an OECD average (excluding Mexico and Turkey) of 4.0. The death rate after haemorrhagic strokes（脑溢血中风）was 25.5% in American hospitals but only 19.8% in OECD countries as a group.
Jonathan Skinner, an economist at Dartmouth College, cautions that factors other than health-care systems—attitudes to teenage pregnancy, say, or smoking—may influence the numbers. Even so, he thinks the system is wasteful. In a paper in the Journal of Economic Perspectives last year he and Alan Garber, of Stanford University, argued that America’s health system was “uniquely inefficient”, producing too little per unit of input and consuming far too much of the country’s resources.
Mr Skinner is involved with another worrying line of research. The Dartmouth Atlas project has scrutinised variations in health outcomes and spending involving Medicare. It has found wide differences in costs across the country—less than $5,000 per person in Salem, Oregon, in 2006; a bit more than $8,000 in San Francisco, in line with the national average; more than $16,000, and rising fast, in Miami—but no connection between higher spending and better outcomes. In fact, the evidence points in the other direction: outcomes tend to be better where costs are lower. Mr Orszag points to the Dartmouth work to argue that up to 30% of America’s health-care spending is sheer waste.
The second symptom is coverage.论证二 Uniquely among rich countries, America’s system of health insurance is not universal. Around 49m people have no health insurance. On current trends, within a decade 60m will be without cover. Studies have shown that not all these people are indigent: a quarter or more can afford insurance, but choose not to buy it.
They know they are unlikely to be left to die in the streets. With the truly poor, the free-riders turn up at emergency rooms. This is hugely inefficient, because pricey late interventions and operations could very often have been avoided with a much smaller investment in preventive care保健医学. Insured people and taxpayers are forced to cross-subsidise such “uncompensated” and wasteful treatments to the tune of（总额达，总数为）tens of billions of dollars per year.
Other rich countries cover almost all their citizens in one of two ways. Some, such as Britain, Canada and Sweden, have “single payer” systems, in which taxes support a public service. Others, notably the Netherlands and Switzerland, oblige individuals to buy insurance. France has a mixed public-private system.
After decades of failed attempts at reform, a consensus appears to be emerging in America around the principles needed for universal coverage. One likely change means a restructuring of America’s failed health-insurance markets. Firms are today allowed to pick the safest patients and reject the sickest. In future they will have to take all comers. Because this imposes unfair burdens on firms that attract lots of older or sicker people, reform is likely to include government-funded mechanisms for risk pooling or reinsurance. The Netherlands, in particular, uses such an approach.
American health insurers, having long opposed this idea, have performed a startling U-turn in recent weeks. America’s Health Insurance Plans, their chief lobbying group, now says it is willing to accept such heavy-handed reforms—if they are accompanied by a requirement that all Americans purchase coverage. This may seem a cynical ploy to expand their business, but some compulsion is needed to get around the selection problem. Any legislation is likely to include subsidies to help the poorest pay for cover.
If done properly, this will in time move America towards the Swiss and Dutch models of universal private insurance. These are not perfect, to be sure. Regina Herzlinger of Harvard Business School observes that the Dutch reforms have led to rapid consolidation of insurers and hospitals, fuelling resented price increases. She favours the decentralised Swiss model, which preserves individual choice and competition. Others note that Swiss health-care costs are high by European standards. But they are a third less, as a share of GDP, than America’s, and the country’s excellent health outcomes should be the envy of（羡慕（或忌妒）的对象；羡慕（或忌妒）的东西）American reformers. Our poll suggests that an individual mandate would be unpopular, with only 21% in favour and 53% opposed. Respondents did favour having the option to buy from the government, by 56% to 23%.
Such reforms would expand coverage, but could exacerbate the third symptom, cost, as the experience of Massachusetts, a trailblazing state that has already implemented a plan for universal coverage, suggests. The state faces possible bankruptcy unless it finds a way to rein in costs. 论证三
Your money or your life
Indeed, tackling inflation in American health care remains the most important and difficult part of the treatment. According to our poll, cost is a tender nerve: 61% thought the high cost of care and insurance was a bigger problem than the number of uninsured, against 31% who believed the reverse. Only 21% would be willing to support a reform plan if they had to pay more in insurance or tax; 62% would not.
Some common diagnoses are wide of the mark. One is price gouging by drug companies. In fact, pills account for（占据，总计）
barely a tenth of health-care spending in America and similarly small shares elsewhere. But aren’t costs lower in Europe because of price controls? Europe does indeed spend less on new branded drugs, but also uses fewer generic drugs and pays much more for them. And Switzerland actually has higher drug prices than America (as does Canada). Greedy drugmakers are not the main cause of America’s runaway costs.
Nor are baby-boomers, though they are often blamed for health-care inflation because there are a lot of them and they are getting old. Ageing will clearly push up costs in time (see our special report in this issue), but it is not the main culprit yet. The CBO estimates that ageing accounts for only a quarter of the health-care inflation to come in the next few decades, and the share in other rich countries is similar.
Doctors’ generous pay is another popular culprit. But doctors in several European countries are well paid too. The OECD estimates that general practitioners in America earn 3.7 times the average wage. Their British counterparts earn 4.2 times their national average. American specialists earn 5.6 times the average wage, against 7.6 times for their Dutch colleagues. Yet health-care costs in Britain and the Netherlands remain lower than America’s. The real problem is not how much American doctors are paid, but how. The system of medical reimbursement warps incentives for doctors, insurers and patients that lead Americans to consume more and more medical services.作者的观点 There is strong evidence that Americans use pills, procedures, scans and other expensive forms of health care more often than do patients in other rich countries, and not always to good effect.
America’s insurance system encourages overuse in several ways. One is the tax break（赋税优惠，减税）that favours health insurance provided by employers, which leads to excessively generous coverage and hence over-consumption. Another is the fact that American health insurers earn a lot of revenue from administering the health plans provided to employees by big corporations which, in effect, insure themselves. This leaves insurers with no incentive to curb costs, because more spending means fatter management fees.
The incentives facing doctors are even more perverse. Most doctors are not paid a fixed salary, still less rewarded for better health outcomes. Integrated American systems such as Kaiser Permanente and the Mayo Clinic are exceptions to this rule, and Britain’s National Health Service (NHS) is trying to adopt a similar approach. But most doctors and hospitals are paid more if they provide more services, regardless of the results. Predictably（果不出所料的）, this leads to far higher rates of doctors’ visits, specialist referrals, scans and so on.
For instance, the OECD countries have an average of 11 magnetic-resonance imaging machines per 1m people. America has 25.9. America uses them more often, too: 91.2 times per 1,000 people per year, compared with the OECD average of 39.1. Similar tales can be told about other pricey kit. | 
GO
楼主: 单眼皮vs肿眼皮
发表于 2009-10-20 16:23:01
1
转发
