因为和不言兄的讨论，不知不觉扯到了医保，正好重新炒一下“全民医保”问题吧。
其实PBS早在08年就做了一个很好的纪录片，探讨英国、德国、日本等其他资本主义国家和台湾地区实现全民医保的方法，可供借鉴。http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/
简而言之，这些国家的“社会全民医保”都有各自的优势和问题。英国全免费，但看病免不了排长队；德国规定保险公司必须“非赢利”，而且规定了医生工资的标准，让不少医生觉得自己的工资太低，可是平均每个家庭每月$750的医保费（premium），即使按照美国中产的标准，也是相当昂贵。去年美国每家平均实际的医保费(premium)是每年$5,277，平均每月$440，比德国少了很多。瑞士的保费和德国相仿，co-pay更多。我个人是觉得，俺宁可在非全民医保的美国呆着，也不想到德、瑞去享受“社会主义全民医保”。相比之下，日本费用比较低，每家每月$280刀，但是有不少医院在赤字运营，老人们三天两头到医院做个测试什么们的，医护人员也很辛苦。真是家家有本难念的经。
美国是资本主义味道最浓的国家，也是她的历史特色。采用什么方式实现全民医保，恐怕还真的不是10年20年能完全解决的问题呢。比如，如果要学习这些“社会主义”国家，那么两条共同经验是：第一，医保公司必须是非盈利企业；第二，必须设置医生工资上限。哪一条在美国实行，都得假以时日，不是一个法令就可以马上改得了的。是否有更好的方法？本来这是政治家和议员要思考的问题，但感觉他们也没拿出什么好办法。美国医保覆盖率，08年以前是85%左右(90-08)。巴马折腾了半天，只暂时增加到了91%左右，而且还价格蹭蹭的张，不可持续。也就是说，最多6%的人在几年内暂时获益。但它拉动了整个保金价格上涨。那85%原来就有保险的人群（其中90%是工薪阶层），要多付钱还要牺牲医疗服务质量。这样的改革，无论如何不能说是成功。
再看全民医保背后的税率。德国税率是25+5% surplus，医保再加15%，总共40%的收入上缴；英国看病免费，但中产的税率是40% （其实下限很低，6万美元收入就进入这个范围了），算起来和德国相仿。美国人能忍受40%的税收用于免费医疗吗？愿意支付高税收保绝对平安呢，还是愿意少交税担点风险自己支配？个人主义和自由经济色彩深厚的美国，恐怕多数人更喜欢后者，不愿意像英国中产那样交40%的税吧。
自19世纪末以来，公共卫生设施的改善（饮用水、排污系统等等），对延长人类寿命的贡献比医学本身的发展要大得多。也许在本世纪，推广健康的生活和工作方式，和上个世纪改善卫生设施有着同等重要的意义，以便从根本上降低医疗成本，实现真正物美价廉的“全民医保”。
UNITED KINGDOM
Percentage of Gross Domestic Product (GDP) spent on health care: 8.3
Average family premium: None; funded by taxation.
Co-payments: None for most services; some co-pays for dental care, eyeglasses and 5 percent of prescriptions. Young people and the elderly are exempt from all drug co-pays.
What is it? The British system is "socialized medicine" because the government both provides and pays for health care. Britons pay taxes for health care, and the government-run National Health Service (NHS) distributes those funds to health care providers. Hospital doctors are paid salaries. General practitioners (GPs), who run private practices, are paid based on the number of patients they see. A small number of specialists work outside the NHS and see private-pay patients.
How does it work? Because the system is funded through taxes, administrative costs are low; there are no bills to collect or claims to review. Patients have a "medical home" in their GP, who also serves as a gatekeeper to the rest of the system; patients must see their GP before going to a specialist. GPs, who are paid extra for keeping their patients healthy, are instrumental in preventive care, an area in which Britain is a world leader.
What are the concerns? The stereotype of socialized medicine -- long waits and limited choice -- still has some truth. In response, the British government has instituted reforms to help make care more competitive and give patients more choice. Hospitals now compete for NHS funds distributed by local Primary Care Trusts, and starting in April 2008 patients are able to choose where they want to be treated for many procedures.
JAPAN
Percentage of GDP spent on health care: 8
Average family premium: $280 per month, with employers paying more than half.
Co-payments: 30 percent of the cost of a procedure, but the total amount paid in a month is capped according to income.
What is it? Japan uses a "social insurance" system in which all citizens are required to have health insurance, either through their work or purchased from a nonprofit, community-based plan. Those who can't afford the premiums receive public assistance. Most health insurance is private; doctors and almost all hospitals are in the private sector.
How does it work? Japan boasts some of the best health statistics in the world, no doubt due in part to the Japanese diet and lifestyle. Unlike the U.K., there are no gatekeepers; the Japanese can go to any specialist when and as often as they like. Every two years the Ministry of Health negotiates with physicians to set the price for every procedure. This helps keeps costs down.
What are the concerns? In fact, Japan has been so successful at keeping costs down that Japan now spends too little on health care; half of the hospitals in Japan are operating in the red. Having no gatekeepers means there's no check on how often the Japanese use health care, and patients may lack a medical home.
GERMANY
Percentage of GDP spent on health care: 10.7
Average family premium: $750 per month; premiums are pegged to patients' income.
Co-payments: 10 euros ($15) every three months; some patients, like pregnant women, are exempt.
What is it? Germany, like Japan, uses a social insurance model. In fact, Germany is the birthplace of social insurance, which dates back to Chancellor Otto von Bismarck. But unlike the Japanese, who get insurance from work or are assigned to a community fund, Germans are free to buy their insurance from one of more than 200 private, nonprofit "sickness funds." As in Japan, the poor receive public assistance to pay their premiums.
How does it work? Sickness funds are nonprofit and cannot deny coverage based on preexisting conditions; they compete with each other for members, and fund managers are paid based on the size of their enrollments. Like Japan, Germany is a single-payment system, but instead of the government negotiating the prices, the sickness funds bargain with doctors as a group. Germans can go straight to a specialist without first seeing a gatekeeper doctor, but they may pay a higher co-pay if they do.
What are the concerns? The single-payment system leaves some German doctors feeling underpaid. A family doctor in Germany makes about two-thirds as much as he or she would in America. (Then again, German doctors pay much less for malpractice insurance, and many attend medical school for free.) Germany also lets the richest 10 percent opt out of the sickness funds in favor of U.S.-style for-profit insurance. These patients are generally seen more quickly by doctors, because the for-profit insurers pay doctors more than the sickness funds.
TAIWAN
Percentage GDP spent on health care: 6.3
Average family premium: $650 per year for a family for four.
Co-payments: 20 percent of the cost of drugs, up to $6.50; up to $7 for outpatient care; $1.80 for dental and traditional Chinese medicine. There are exemptions for major diseases, childbirth, preventive services, and for the poor, veterans, and children.
What is it? Taiwan adopted a "National Health Insurance" model in 1995 after studying other countries' systems. Like Japan and Germany, all citizens must have insurance, but there is only one, government-run insurer. Working people pay premiums split with their employers; others pay flat rates with government help; and some groups, like the poor and veterans, are fully subsidized. The resulting system is similar to Canada's -- and the U.S. Medicare program.
How does it work? Taiwan's new health system extended insurance to the 40 percent of the population that lacked it while actually decreasing the growth of health care spending. The Taiwanese can see any doctor without a referral. Every citizen has a smart card, which is used to store his or her medical history and bill the national insurer. The system also helps public health officials monitor standards and effect policy changes nationwide. Thanks to this use of technology and the country's single insurer, Taiwan's health care system has the lowest administrative costs in the world.
What are the concerns? Like Japan, Taiwan's system is not taking in enough money to cover the medical care it provides. The problem is compounded by politics, because it is up to Taiwan's parliament to approve an increase in insurance premiums, which it has only done once since the program was enacted.
SWITZERLAND
Percentage of GDP spent on health care: 11.6
Average monthly family premium: $750, paid entirely by consumers; there are government subsidies for low-income citizens.
Co-payments: 10 percent of the cost of services, up to $420 per year.
What is it? The Swiss system is social insurance like in Japan and Germany, voted in by a national referendum in 1994. Switzerland didn't have far to go to achieve universal coverage; 95 percent of the population already had voluntary insurance when the law was passed. All citizens are required to have coverage; those not covered were automatically assigned to a company. The government provides assistance to those who can't afford the premiums.
How does it work? The Swiss example shows that universal coverage is possible, even in a highly capitalist nation with powerful insurance and pharmaceutical industries. Insurance companies are not allowed to make a profit on basic care and are prohibited from cherry-picking only young and healthy applicants. They can make money on supplemental insurance, however. As in Germany, the insurers negotiate with providers to set standard prices for services, but drug prices are set by the government.
What are the concerns? The Swiss system is the second most expensive in the world -- but it's still far cheaper than U.S. health care. Drug prices are still slightly higher than in other European nations, and even then the discounts may be subsidized by the more expensive U.S. market, where some Swiss drug companies make one-third of their profits. In general, the Swiss do not have gatekeeper doctors, although some insurance plans require them or give a discount to consumers who use them.
多谢雅临点评，讲得非常好！
Rank Race Median household income (2015 US$)
1 Asian 74,245[1]
2 White 59,698[1]
3 Native Hawaiian and Other Pacific Islander 55,607[1]
4 Some other race 42,461[1]
5 American Indian and Alaska Native 38,530[1]
6 Black or African American 36,544[1]
西裔大约45，000，远低于白人，但活得更长。
所言很中肯。和各个族裔的生活方式也很有关系，美国的亚裔平均寿命是86.7岁，比日本人还长寿(83.8岁）；西班牙裔平均83岁，和西班牙人相仿，远高于墨西哥（77岁）。印第安人，平均寿命81岁。相对而言普通白人和黑人倒是最可怜，分别是79和75.5岁。
http://www.worldlifeexpectancy.com/usa/life-expectancy-african-american
No free lunch。：）多谢您雅临点评！现代人活得越来越长，我觉得恐怕推迟退休也是必须的。如果60岁退休活到100岁，那40年岂不是太无聊了，医保负担也太重了。
久不见侃兄，先问个大安！
所言一如既往地客观中肯，老龄化尤其切中要害。医保，说白了，是靠年轻人养着老人的。老龄人口增加，必然加大年轻人的负担。加上给新来的移民/难民提供几乎免费的医保，以后欧洲的全民医保还能不能再持续50年，其实还是有风险的。
所以我觉得，需要提倡健康的生活方式和加大预防性治疗的力度。当然美国的医保也许太市场化，考虑一下怎样提高医保资金利用效率是应该的。
周末愉快！
全民医保的国家人均寿命比号称世界一流的美国寿命高4-6年。
好不好很明朗的。
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人均寿命高低与医保制度不一定有很强的相关性。看看各国的饮食结构，美国的食品是最不健康的。当人口规模过大时，工业化大规模生产就巨大的利润空间，从而使低价低质食品充斥市场
不过即使是对于同一组数据，不同网友也会有不同解释，不容易“统一思想”。这无关紧要啦！
用俺们普通人的俗语讲，甘蔗没有两头甜。
日本文化环境、饮食习惯跟天朝接近，医保系统也很不错。可是地方小点，工作辛苦点，每当大陆抗日情绪高涨时，华人在彼处难免觉得不自在。
欧洲历史悠久、人文荟萃，假日丰裕，医疗“公费”。可是生活费钱，税率不低，也有短处。
加新澳也属发达国家，各个方面与欧日也不遑多让。可惜都有不足，或偏冷、或偏远、或偏小。赚大钱也不容易。
无怪乎，美国是众多华人趋之若鹜的理想之地。
有Urban Legend说：“美国之所以最发达、最有活力、最富有，是因为它不像欧日加新澳等给国民提供那么多的额外保障，而是用努力就能发大财的哲学，驱动美国人努力奋斗，创造财富。”难说是对是错。
不过呢，所谓全面福利、全民医保的不少国家有不少都面临入不敷出的困难。生活条件改善了，奋斗精神削弱了，平均创造的价值减少了；人的寿命延长了，老弱阶段增加了，平均消耗提高了。现实的问题，不是简单能解决的。
多谢您的点评。这个跟工作节奏和人种也有关系。
好不好很明朗的。
多谢您点评，不过我在网上看只要年收入超过4万5千英镑，或6万美元，就是40%的税收了。这个收入真的是不高啊，恐怕连中产都算不上。
周末愉快。
今天的西方发达国家，不是丛林。能否照顾弱势人群，是区分现代文明社会和丛林社会的标志之一。”
毫无意外，你根本在回避问题。问题不在于要不要照顾弱势人群，而是怎样做。你主张政府用暴力来做，我主张用别的途径。请回答：凭什么说你对“文明社会”的见解要高于我?
从老百姓生活看，自己可支配的收入vs支出是主要的标准。所以加税不是办法，但提高医保系统的效率是应该做的。公司不给你交保，那钱也不会增加到您的工资里，您说是不是？美国实际上是把这部分变成了公司间的交易。
今天的西方发达国家，不是丛林。能否照顾弱势人群，是区分现代文明社会和丛林社会的标志之一。
spending不等于premium,后者是我们支付的，见正文。
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教授啊，我想这就是你我所说的差别所在。譬如你在大学工作，大部分Premium是大学给付了，自己付很少一部分。但这不等于说，你的医保费用就低。你的雇主帮你付了大部分Premium。羊毛出在羊身上。你雇主付出的钱还是要从你身上赚回来的。所以，spending 才是指标，而不是Premium。
多谢您雅临点评。美国的spending，并不是个人的保金，而直接影响老百姓的是自己到底出了多少钱。另一方面，这确实反映出美国医保资金利用的效率低下，这里是可以改进的，但不能照搬欧洲增税的方法。
2015 Canada, France, Germany, U.K., U.S,
a 4609, 4407, 5267, 4003, 9451;
b 4.1, 3.1, 2.8, 2.6, 2.5;
c 8.2, 6.2, 2.9, 2.7, 2.7;
d 0, 0.1, 0.2, 0, 9.1;
a:Health spending per person($):
b:Number of primary care doctors per 1000 people:
c:Hospital beds per 1000 people:
d:Percentage of people without medical insurance(%):
美国人平均医疗花销约是另三国二倍，虽然少交税，但交医保许多。其他三国多交税，但医保不用花钱（大约吧）。
假定这些数字是真的，那你说顶端1%应该占有百分之几的社会财富？为什么？怎么算出来？
如果反过来说：“美国顶端1%的人只占有了40%的财富，接下来的顶端19%的人仅仅占了50%的财富，这社会太合理了” 是不是同样没有道理？
凭什么伦理道义你有权通过政府暴力强迫他人为你的信仰买单？
这实际上是社会主义（包括全民医保）的本质。你同情穷人可以捐献，干嘛要强迫他人拿出百分之多少？
相对来说，看病等候时间有一定灵活性。有的家庭医生病人多，预约要等挺久的。有的家庭医生不是那么忙，当天可以看。急诊就要看严重情况，我妈妈有两次是被救护车送进去的，基本上15分钟护士就来了，各种测试都做1遍也不到1个小时。检查下来没有啥问题，你就可能等很久。专科就看运气了，我自己的妇科专家预约了一年，但是父母（可能因为是老人），几个星期就约到了。反正家里有老人的，体质不好，病多的，肯定是加拿大好。
这也是我去年写的chicken or beef的问题，两党制搞了200多年，很难撼动啊。我问过不少美国同事，他们说历史上尝试过种种办法，都不大奏效。也许应该往议会制靠靠？还有英国同行跟我开玩笑说，英国本来有3个党，现在也变成两党制了。不过他们好歹还有个真正的左翼政党。
--------------------
同意。我以前也讨伐过美国的这个两党独大的政治体制。为什么玩来玩去，就只有两党？我的看法是选举人团制度的赢者通吃法则，保证了美国不会出现新的党。结果这两党就是半斤八两，只为大财主大财团服务。美国顶端1%的人占有了40%的财富，接下来的顶端19%的人占了50%的财富，而余下的80%的民众只占有10%的财富。这社会太畸形了。
也许有道理。也希望加拿大的网友分享一下经历。
不言兄，我看问题的关键在于，美国的两党其实都是大财主资助的，谁也不想彻底借用社会主义的方法解决问题，谁也不敢去约束医保市场，跟那些大医药公司说不。和英国德国法国不同，美国历史上从来就没有一个真正的左翼政党。没有这个平衡，事情就不大好搞。
“深厚”，不是“身后”。typo,抱歉。
多谢园姐讨论！回复枪兄的时候顺手查了一下英国的税率，确实高得惊人，没赚多少钱就得交40%了。各种取舍吧。
其实要说同样的钱产生的医保效力（用预期寿命衡量），这些国家都赶不上古巴。：）大概人们本来就应该玩着过一生，哈哈。
多谢您雅临点评。这里面是个trade-off，愿意支付高税收保绝对平安呢，还是愿意少交税担点风险自己支配。个人主义和自由经济色彩身后的美国，恐怕多数人更喜欢后者，不愿意像英国人中产那样交40%的税吧。
Band Taxable income Tax rate
Personal Allowance Up to ?11,500 0%
Basic rate ?11,501 to ?45,000 20%
Higher rate ?45,001 to ?150,000 40%
Additional rate over ?150,000 45%
谢谢阿留的宽容，容忍，纵容！其实世界上哪里有病人不花钱的事？羊毛出在羊身上，英国的税赋吓死人。听着挣得不少，其实到手所剩无几，单位的会计在把工资打入各个员工的账户前，已经把相关的税都收走了。（这点也和美国不一样，交税不劳烦自己动手，有点像中国哈。）此外，百物腾贵，消费税非常高昂。离开英国多年，具体说不上来了，只记得汽油价格节节攀高。每年政府制定预算，不太敢狂加个人所得税，就把税加在各种各样的消费品上，比如，被称为有碍环境的汽油和有害健康的香烟。在老百姓背负沉重税负但可以生病的同时，英国象牙塔尖上有钱有权的人也无可奈何，他们无法推翻英国二战后工党政府建立起来并深受老百姓喜爱的全民医疗制度，只得跟着交税，均财富了。
假定美国家庭收入20万，联邦税经各种免税后实际税率约15%，交三万的税。如果实行全民医保，税率铁定升到45%以上。等于每年交6万的医疗保险。你会觉得合算吗？
华人主张全民医保属于把自己卖了还帮人数钱。
俺也搞不懂是怎么算的，感觉有必要透明一下哈。
美国医院是可以侃价的，如果超过支付能力，可以argue和negotiate。这个有点太市场了。
多谢雅临点评！问安！
"in public insurance, they are based on your income. Both you and your employer have to each pay 15.5% of your gross income every month. The maximum premium amounts to circa 630 Euro."
也就是雇主和个人各付收入的15.5%，总共大约等于工资的30%，作为医疗保险。如果年收入5万7千美元以上（按现在的汇率折算），则每月交cap大约750刀。也就是说总保金大致和美国相仿，但在美国平均个人付的要少很多，公司付的部分比德国公司要多。
BTW， 清漪园姐，我是你的粉，你的留言都说到我心里去
非常赞同。多谢雅临点评！
多谢您雅临分享！看来大家对英国的医疗体制是比较满意的，现在的问题是能否或如何推广到美国？
多谢您雅临点评。您在哪个国家？北欧？
多谢梅子姐分享经验。转回去有什么障碍么？
多谢园姐比较切身体会，老熟人了，砖随便拍，冷水随便泼，大夏天的凉快，哈哈。：）
其实我一直有一个疑问，也许您有些insight：英国的病人不花钱的医保制度，为什么德国学不来呢？美国不想学或学不来我可以理解，但感觉德国和英国应该差不多啊。
不言兄，去年美国每家平均实际的支出是每年$5,277，这个数字和俺们这个的情况差不多，不论学校或公司。也许您那边是因为self employeed所以只能自己cover全部？这一点确实需要改革，俺赞同。
"The increased cost of health insurance is a central fact in any discussion of health policy and health delivery. Annual premiums reached $18,142 in 2016 for an average family, up 3 percent from 2015, with workers on average paying $5,277 towards the cost of their coverage."
我在英国，美国都生过病，住过院。在英国当然一分钱不花，但要住大病房，选择医生的范围很小，可以说要碰运气,遇到哪位医生就是哪位。在美国生病住院，除了看到医生的速度快，手术时间安排速度快，单人病房等硬件比较好之外，其他乏善可陈。回家后看到要自负的费用吓了我一跳，连用一条热毛巾都要我自负。特别是美国医院对病人需求的关注、护理要差得很远。我猜，也许美国人动不动打医疗官司，把医护人员都吓坏了吧，不敢跟病人多说一句话，见了面能少呆一分钟就少呆一分钟，能少说一句话就少说一句话，干完他们的活，有时还没干完，就溜走了，与英国医护人员对病人的态度差得不是一点半点。也许是人口素质问题吧，也许在英国学医的孩子不是为了挣大钱的目的去的吧。总之，美国人的医保系统sucks，对普通民众来说，它就是一个为赚钱而运转的生意系统，无他。