美国医疗体系趣闻（二）

Dominic Connor
Why does American healthcare cost so high?
An honest answer annoys everyone every side of the issue, not just people on the left and right but people who watch TV
Basic Economics
First up, Americans have amongst the highest wages in the world in one of the most efficient labour markets and of course labour efficiency is one reason for that high average.
Smart, highly educated hardworking people in the US earn more than their equals in most other countries and healthcare is very labour intensive. Not just doctors, but nurses and technicians have talent and training more than most people, so in a efficient rich country, their time will cost a lot.

为什么美国的医疗费用这么高？
一个诚实的答案会惹恼所有人，不仅是左翼和右翼派人士，还有看电视的人
基础经济学
首先，美国是世界上工资最高的国家之一，也是最有效的劳动力市场之一，当然，劳动效率是平均工资高的原因之一。
美国聪明、受过高等教育、勤奋工作的人比大多数其他国家的同龄人赚得更多，医疗保健是劳动密集型的行业。不仅是医生，护士和技术人员也比大多数人更有才能和接受过更多的训练，所以在一个高效的富裕国家，他们的时间会值很多钱的。

The next thing is marginal benefit. The most cost/effective thing any health system does is vaccination. Very cheap, saves millions of lives and many expensive hospital admissions. However, once it is done, it’s done, so you move to the next most cost/effective, which is obviously less cost/effective, so the more we do, the less cost/effective each additional thing is. The US does a lot, which means that it’s well into the zone of low cost/effectiveness. Kidney transplants costs thousands for each year of quality life they give.
Ironically the more intelligently you allocate resources, the more quickly you use up the highly cost/effective allocations.
I didn’t buy the best car in the world, not even the best in the showroom, I picked a lesser car because even though I could afford a much better car it just wasn’t worth it to me.
Healthcare ain’t like that, if I’m ill I want the best and Americans are on average richer than most other people so the quality/price trade off is in a different place.

下一个是边际效益。任何卫生系统所做的最具成本效益的事情就是接种疫苗。非常便宜，挽救了无数人的生命和节省了许多高昂的住院费用。然而，一旦它完成了，它就完成了，所以你会转向下一个最具成本/效益的领域，这显然是成本/效益较低的领域，所以我们做得越多，每一件额外的事情的成本/效益就越低。美国做了很多，这意味着它已经进入了低成本/低效率的区域。肾脏移植每年要花费数千美元来改善生活质量。
具有讽刺意味的是，你越是明智地分配资源，你就会越快地耗尽高成本/高效的分配。
我没有买世界上最好的车，甚至没有买展厅里最好的车，我选了一辆中档点的车，因为即使我买得起更好的车，但对我来说也不值得。
医疗保健不是这样的，如果我生病了，我想要最好的，而美国人平均比大多数其他人更富有，所以质量/价格的权衡就不一样了。

Possibly the best thing President Obama did for the cost of American healthcare was open up relations with Cuba, which has a lot of well qualified cheap healthcare professionals and is near enough to ship mildly sick people.
Also we need to be sophisticated about what we mean by expensive. Because the US as a whole pays for it’s healthcare through insurance, directly or through government it necessarily follows that as a whole it can afford what it has.
However, the bureaucratic mess and hard work by insurers to avoid paying claims means that the variability of healthcare costs is huge which means for many it is unaffordable at the point it is actually needed.

奥巴马总统为降低美国医疗成本所做的最好的一件事，可能就是开放与古巴的关系。古巴有很多合格的廉价医疗专业人员，而且离美国很近，近到可以运送轻度病人过去。
此外，我们需要对我们所说的“昂贵”的含义有所了解。因为美国作为一个整体，通过保险，病人直接付或通过政府来支付医疗费用，这必然意味着作为一个整体，它可以负担得起这些费用的。
然而，在美国，官僚制度的混乱和保险公司为避免支付索赔而付出的辛勤工作意味着医疗成本的可变性是巨大的，这意味着对许多人来说，在实际需要的时候，它是负担不起的。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处

Greys Anatomy, ER, Chicago Hope and other medical soaps
Every long term drama series needs a pool of villains and although people end up in hospital because of bad things done to them often it is found that the person who caused the misery is themselves a victim of some illness or social situation that caused them to be bad. That’s comforting, but to run for hundreds of episodes you need bad people who are just bad. 90% of the truly bad people are cost cutters. The evil accountants, managers, etc who try to make healthcare cheaper. Invariably they make things much worse, we’re currently binge watching Grey’s Anatomy and without wanting to give you spoilers some of the most engaging and attractive main characters are actually killed by the cost cutters and several suffer long term effects due to cost cutting. Oh yes and some patients die as well.

《实习医生格蕾》(Grey’s Anatomy)、《急诊室》、《杏林先锋》和其他医疗行业的肥皂剧
每一部长篇电视剧都需要一批反派角色，尽管人们最终会因为他们做的坏事而住院，但人们发现，造成痛苦的人本身就是某种疾病或社会环境的受害者，这很令人欣慰，但要想播出数百集，你需要的是坏人。90%的真正的坏人都是削减成本者。邪恶的会计师、经理等试图降低医疗成本。它们总是会让事情变得更糟，我们目前正在狂刷《实习医生格蕾》，不想剧透，一些最吸引人、最吸引人的主角实际上被削减成本的人杀死了，还有一些人因为削减成本而受到长期影响。哦，是的，有些病人也会死。

So you dear reader are part of the problem. You watch medical drams and read news articles about where cost cutting or shortcuts caused misery and death and associate cost-cutting with tragedy. That’s because news about a process change that makes operations 5% cheaper never makes it to the mass media and makes for boring dramas. So you don’t want cost cutting so it doesn’t happen.
Another way it’s your fault
Americans eat badly, really badly. When I first visited America rather jet lagged I caught sight of things that looked like a bit like people but weren’t. Initially I parsed them not as people but as some sort of actor or clown dressed up in padding perhaps from a kids TV show or as a marketing stunt, after a second look it clicked that they were people, just astonishingly fat. In huge numbers. Diabetes is a horribly expensive illness, few people die of it quickly and the treatment together with the many things that go wrong (loss of bits of your body, heart issues, cognitive impairment, kidneys, etc) add up to large lifetime costs adding to insurance and other costs. Also of course there is heart and liver disease from gross overeating as well as the issues caused by the physical stress on the bodiy.

所以亲爱的读者，你是问题的一部分。你看医疗剧，读新闻报道削减成本或走捷径导致痛苦和死亡，并将削减成本与悲剧联系在一起。这是因为，有关流程变化使手术成本降低5%的新闻从来没有出现在大众媒体上，而是变成了无聊的电视剧。所以你不想削减成本，所以它不会发生。
换句话说就是你的错
美国人吃得很差，真的很差。当我第一次去美国的时候，时差还没倒过来，我看到了一些看起来有点像人，但不是。起初，我并没有把他们当成人，而是把他们当成某种演员或穿着衬垫的小丑——可能来自儿童电视节目或作为营销噱头再看一眼，我才明白他们是人，只是胖得惊人，而且这个群体数量巨大。糖尿病是一种“富贵病”，很少有人会很快死于这种疾病，而且治疗过程中会出现很多问题(身体部分功能丧失、心脏问题、认知障碍、肾脏等)，加上保险和其他费用，加起来是一笔巨大的开支。当然，过度饮食也会导致心脏和肝脏疾病，以及身体压力引起的问题。

The West in general has this issue, but less of it and it’s most expensive in America.
Then there’s drugs a lot of drugs, opioid addiction and because of faith based government policy of both parties almost no effort to get addicts to stop being addicts because they’re bad people . That is an expensive faith morality to choose.
Illegal immigration is also an issue. People that can make across the border and then work in a hard job are going to be on average healthier than both the populaton they join and the one they leave. But having no access to preventive care and appalling working conditions means higher costs.
I doubt any of the above is contentious, so let’s look at things that will annoy more people.
The politics are toxic and is so often the case on Quora we compare the US to the UK, being both democratic capitalist free market English speaking countries.

其余西方国家普遍存在这个问题，但没这么严重，而且美国费用最为高昂。
还有毒品，很多毒品，阿片类药物成瘾，由于两党基于信仰的政府政策，几乎没有努力让成瘾者停止成瘾，因为他们是坏人。这是一种代价高昂的信仰道德选择事宜。
非法移民也是一个问题。那些能够跨越边境，然后从事艰苦工作的人，平均而言将比他们加入的人口和离开的人口都更健康。但是，无法获得预防性护理和恶劣的工作条件意味着这方面要付出更高的成本。
我怀疑上面的任何一个都是有争议的，所以让我们看看会惹恼更多人的事情。
政治是令人极不愉快的，在Quora上我们经常把美国和英国比较，这两个国家都是民主资本主义自由市场的说英语的国家。
原创翻译：龙腾网 https://www.ltaaa.cn 转载请注明出处

Bullying
In the UK, a key role of the National Health Service is to bully healthcare providers. Although not 100% a monopoly, any anti-trust regulator would see a firm with 93% of the market as one. That means it plays hardball with drug companies, equipment makers and the staff who even allowing for lower UK average pay, British healthcare workers are paid rather less.
This is a better deal than it sounds, the debts incurred by British medical students are vastly lower than in America and until relatively recently Britsh medical students didn’t have to pay anything.
We see from this why insurers and other healthcare business are prepared to spend any amount of money in bribes and propaganda to stop European style healthcare. Ironically the bribes to both Democrat and Republicans add to the cost of healthcare.

欺凌
在英国，国家医疗服务体系的一个关键作用是欺负医疗保健提供者。尽管不是100%的垄断，但任何反垄断监管机构都会将拥有93%市场份额的公司视为垄断。这意味着它对制药公司、设备制造商和员工采取强硬态度，即使考虑到英国平均工资较低，英国医疗工作者的工资也要低得多。
这是一个比听起来更好的交易，英国医学生的债务比美国的要低得多，直到最近，英国医学生才需要支付费用。
我们由此看出，为什么保险公司和其他医疗保健企业愿意不惜一切代价进行贿赂和宣传，以阻止欧洲式医疗保健。具有讽刺意味的是，对民主党和共和党的贿赂增加了医疗成本。

Insurance
I happen to know the guy who is in charge of all National Insurance money in Britain, I live in a nicer house and drive a better car. Be clear that he’s not poor (we both live in what is called by people selling houses and the media as “the golden triangle” for its density of celebs, but he’s not rich either.
His job is important but one reason he’s paid less than the fatcats in US insurance is that the the NHS funding is run off the tax system, Look at the colossal scale of American health insurance firms, so many staff “adjusting claims” (ie not paying them), selling, marketing, lawyering, devising new insurance products, complying with regulations, reporting, managing payments to hospitals etc. There are more HR professionals just managing the staff in the US health insurance system than everyone collecting NI in Britain put together.

保险
我碰巧认识一个人，他掌管着英国所有的国民保险资金，我住的房子更好，开的车更好。要清楚，他并不穷(我们都住在卖房子的人和媒体所说的“金三角”里，因为那里名人密集，但他并不富有。
他的工作很重要，但他的薪水比美国保险业的有钱人少的一个原因是，英国国家医疗服务体系的资金来自税收系统，看看美国健康保险公司的庞大规模，如此多的员工“调整索赔”（即不支付索赔）、销售、营销、律师、设计新的保险产品、遵守法规、报告、管理对医院的付款等。美国医疗保险系统中管理员工的人力资源专业人士比英国所有领取医疗保险的人加起来还要多。

To get someone to run these complex and important organisation means you have to pay millions. I happen to know what my guy earns, some health insurance CEOs earn more in a year than he has earned in his whole life.
If you’re not wheeled in feet first hospitals demand a credit card or details of your insurer because debt collection is a significant activity at US hospitals. If you don’t have insurance,US hospitals apparently to simply make up a large number with no breakdown at all.

要找个人来管理这些复杂而重要的组织，意味着你必须支付无数钱。我碰巧知道我认识的那人挣多少钱，一些医疗保险公司的CEO一年挣的钱比他一生挣的钱还多。
如果你无法走路的话，医院首先会要求你提供信用卡或保险公司的详细信息，因为催收债务是美国医院的一项重要活动。如果你没有保险，美国医院显然会编造一笔很大的数字，而且根本不会给出明细。

In Britain that whole huge, expensive operation of insurers, debt collection , etc simply does not exist at all, what passes for private health insurance in the UK is an optional top up that most people never use since it is in addition to state healthcare.
I mentioned regulation, which I first learned about from The West Wing which although fiction(sadly) contains some truly mad things, like the New Hampshire Board of Medicine, which as a Brit I found to be quite funny as well as stupid.

在英国，保险公司、债务催收等庞大而昂贵的运作组织根本不存在，在英国，所谓的私人医疗保险是一种可选择的补充选项，大多数人从未买过它，因为它是国家医疗保险的补充。
我提到了监管，这是我第一次从《白宫西翼》(The West Wing)中学到的，尽管这个虚构的事(很遗憾)包含了一些真正疯狂的东西，比如新罕布什尔医学委员会(New Hampshire Board of Medicine)，作为一个英国人，我觉得它既有趣又愚蠢。

That is symptomatic of the political issues that drive health costs. Some level of the US government gets lobbied (or as we say in Britain “bribed”) and creates a group of well paid regulators who now have a budget to pay their own bribes and if threatened with removal go to the media with horror stories. Politicians get patronage (and thus bribes) by appointing senior regulators and don’t want ot lose that patronage/income stream. In the UK the politicians couldn’t even tell you their names.
This menas compliance with regulation is jaw droppingly expensive in America because it has so many sets of regulations, registrations, laws etc
This is not just a private sector thing. The UK has no equivalent of the Veterans Administration, it doesn’t need one because British solders already have access to free healthcare when they leave. It follows that not only is much money saved from bureaucracy, but you don’t get the common situation where veterans are denied healthcare because of the staggering incompetence of the VA in keeping records. The UK does have a few specialist medical units to deal with the injuries veterans get, but that’s it.

这是推动医疗成本的政治问题的症状。美国政府的某些层面受到游说(或者像我们在英国所说的“贿赂”)，并创造了一群高薪的监管机构，他们现在有预算来支付自己的贿赂，如果受到撤职的威胁，他们就会向媒体讲述恐怖故事。政客们通过任命高级监管者(以及贿赂)来获得庇护，他们不想失去这种庇护/收入来源。在英国，政客们甚至不能告诉你他们的名字。
这意味着在美国遵守法规的成本高得惊人，因为它有非常多的法规、注册（要求）、法律等。
这不仅仅是私营部门的事情。英国没有类似的退伍军人管理局，也不需要，因为英国士兵离开时已经可以享受免费医疗。由此可见，不仅从官僚制度中节省了很多钱，而且你也不会看到而且由于退伍军人事务部在记录方面的惊人无能，退伍军人无法获得医疗保健的情况。英国确实有一些专门的医疗单位来处理退伍军人受伤的问题，但仅此而已。

In rough numbers the bureaucratic overhead of the US healthcare system (insurance, cost shifting, government involvement) is comparable to the entire healthcare budget for Britain, a country of 63 million people.
In the UK, the corrupt anti-vaxxer doctors have been banned from ever practicing medicine.

粗略计算，美国医疗体系的官僚开销(保险、成本转移、政府参与)与拥有6300万人口的英国的整个医疗预算相当。
在英国，腐败的反疫苗医生被禁止行医。

Prevention
In Britain, a regular news item is of the form “X will save the NHS Y million per year”. This can be anything from getting people to sit up straight to having some test. Because the NHS is paid for by every single person who happens to be in Britain (we have a VAT sales tax of 20%, you can’t escape), measures to reduce demand are seen as unqualified good and so have political and bureaucratic support and more importantly, funding.
In Britain, Japan, Russia, Canada and Europe healthcare is far more aimed at children, seeing this as more humane, but it is vastly more economically efficient since if you treat earlier then costs are lower. In the US healthcare is aimed at older people because they have insurance, votes and powerful faith groups are so obsessed with abortion and contraception that they simply ignore children dying for lack of healthcare.
Hence America has one of the worst child mortality rates in the world, not just worse than developed countries but overlapping with what President Trump describes as “shithole countries”, but at the same time spends more than any of them because American children are often only treated after something has gone terribly wrong, which aside from the suffering and far more frequent deaths, is much more expensive.

预防
在英国，一条常规新闻的形式是“X将每年为英国国家医疗服务体系节省Y万英镑”。这可以是任何事情，从让人们坐直到进行一些测试。因为英国国家医疗服务体系是由碰巧在英国的所有人支付的（我们增值税销售税是20%的，这是你无法逃避的），减少需求的措施被视为不合格的商品，因此有政治和官僚制度支持，更重要的是有资金支持。
在英国、日本、俄罗斯、加拿大和欧洲，医疗保健更多地针对儿童，认为这更人性化，但它在经济上更有效，因为如果你早点治疗，成本就会更低。在美国，医疗保健针对的是老年人，因为他们有保险、投票权，而且是非常痴迷于堕胎和避孕的坚定的信仰团体，以至于他们完全忽视了因缺乏医疗而死亡的儿童。
因此，美国是世界上儿童死亡率最高的国家之一，不仅在发达国家中是最高的，而且这个死亡率与特朗普总统所说的“粪坑国家”的儿童死亡率重叠，但同时花费的费用比任何一个国家都多，因为美国的儿童通常只有在出现严重问题后才会得到治疗，这种治疗除了会带来痛苦和更频繁的死亡之外，费用也要高得多。