Medicare for All: Separating the slogan from the substance

People are fed up with the U.S. health care system, and rightfully so.

人们厌倦了美国的医疗保健系统，这是理所当然的。

Medical premiums and debt are rising, clinicians are burned out, and patients have less access to care.

医疗保费和债务不断上升，临床医生精疲力竭，患者获得护理的机会减少。

As another election approaches, these conditions are building up, just waiting to ignite change like wildfire.

随着另一次选举的临近，这些条件正在形成，等待着像野火一样点燃变革。

Is the solution Medicare for All?

解决方案是全民医疗保险吗？

It remains a bumper-sticker topic in several local congressional races.

它仍然是一些地方国会竞选中的热门话题。

This is somewhat unsurprising, given that many Democrats think it’s the answer and even some Republicans support it.

这有点不足为奇，因为许多民主党人认为这是答案，甚至一些共和党人也支持它。

But when it comes to politics, slogans tend to leave out nuances.

但当涉及到政治时，口号往往会忽略细微差别。

So I called Hayden Rooke-Ley, a professor of health policy and lawyer, to join me and weigh in on the practicalities of what could be the biggest change in health care since the passage of Medicare and Medicaid in 1965.

因此，我打电话给卫生政策教授兼律师海登·鲁克-莱伊 (Hayden Rooke-Ley)，让他和我一起探讨这可能是自 1965 年医疗保险和医疗补助法案通过以来医疗保健领域最大变革的实用性。

This is the first question everyone asks.

这是每个人都会问的第一个问题。

And the answer is yes.

答案是肯定的。

The U.S. currently spends more on health care than any other country, with private insurance driving the highest costs.

美国目前在医疗保健方面的支出比任何其他国家都多，其中私人保险的成本最高。

That’s why most experts think Medicare for All would lower overall healthcare spending .

这就是为什么大多数专家认为全民医疗保险会降低总体医疗保健支出。

But what society can afford differs from government financing.

但社会所能承担的费用与政府融资不同。

Fully funding this without going into debt requires significant new taxes.

在不负债的情况下充分资助这一项目需要大量新税收。

Convincing Americans to send more money to the IRS is a hard sell, even if the argument is that they’d stop sending money to insurance companies.

说服美国人向国税局汇更多钱是一件很难的事，即使他们的论点是他们会停止向保险公司汇钱。

That said, when you tally it all up, roughly 70% of the U.S. health care system is already financed by taxpayer money.

也就是说，当你把所有的钱都算起来时，你会发现美国医疗保健系统大约 70% 的资金已经是由纳税人的钱资助的。

So the real question is less about whether we want taxpayers financing the health care system.

因此，真正的问题不是我们是否希望纳税人为医疗保健系统提供资金。

We largely already do that.

我们基本上已经这样做了。

It’s more about how we want to do it.

更重要的是我们想如何去做。

Since the early 2000s, Medicare has been divided into the traditional government program (Original Medicare) and Medicare Advantage.

自2000年代初以来，Medicare分为传统政府计划（Original Medicare）和Medicare Advantage。

Advantage plans offer the same benefits as Original Medicare plus extras like drug, dental, or vision coverage, but this privatization is known to cost taxpayers an additional $100 billion (!) a year.

优势计划提供与原始医疗保险相同的福利以及药物、牙科或视力保险等额外费用，但众所周知，这种私有化每年会额外花费纳税人 1000 亿美元（！）。

Meanwhile, seniors on Original Medicare need to buy a separate private plan for any extra coverage.

与此同时，享受原始医疗保险的老年人需要购买单独的私人计划以获得额外的保险。

Medicare has other issues.

医疗保险还有其他问题。

It leads to overpaying specialists, subsidizing large corporate hospital systems, and leaving drug price negotiation to private plans and pharmacy benefit managers (PBMs).

它导致专家支付过高的费用，补贴大型企业医院系统，并将药品价格谈判留给私人计划和药品福利管理者（PBM）。

Medicare for All advocates envision a single, all-inclusive plan with no extra fees or private insurance.

全民医疗保险倡导者设想一个单一的、全包的计划，没有额外费用或私人保险。

This would replace all current programs and set new federal rules for taxes and coverage, making it a way bigger change than just expanding Medicare as it is now.

这将取代所有现有计划，并制定新的税收和保险联邦规则，使其成为比现在扩大医疗保险更大的改变。

U.S. health policy has long viewed high health care costs as the result of overutilization due to the fee-for-service model, where clinicians are paid per test or procedure.

长期以来，美国卫生政策一直将高昂的医疗保健成本视为按服务收费模式导致的过度使用的结果，在这种模式中，临床医生按每次检查或程序付费。

This has led to cost-containment measures that reduce use of services, like high deductibles, hospital and insurer consolidations, and prior authorization requirements.

这导致了减少服务使用的成本控制措施，例如高免赔额、医院和保险公司合并以及事先授权要求。

But Americans don’t generally use more health care than people in other wealthy countries.

但美国人通常不会比其他富裕国家的人使用更多的医疗保健。

In areas such as primary care, they may even use too little.

在初级保健等领域，他们甚至可能使用得太少。

The bigger reasons U.S. health care costs so much are higher prices for care, high billing and insurance overhead, and spending on costly drugs and treatments that offer little added benefit.

美国医疗保健费用如此之高的更大原因是医疗费用较高、账单和保险费用较高，以及花费在昂贵的药物和治疗上，但几乎没有什么额外的好处。

So rather than identifying the problem as fee-for-service and trying to manage utilization, Medicare for All would attack the core drivers of high costs head-on—mainly the prices and the administrative bloat.

因此，全民医疗保险不会将问题归咎于按服务收费并试图管理利用率，而是正面攻击高成本的核心驱动因素——主要是价格和管理臃肿。

It’s a very different approach to cost containment.

这是一种非常不同的成本控制方法。

This part doesn’t get talked about much.

这部分内容不多讲。

Big hospital chains and private equity rollups can charge insurers more than small medical practices can.

大型连锁医院和私募股权联合医院向保险公司收取的费用比小型医疗机构要高。

That’s due to their negotiating power, not the delivery of better care, which forces small clinics to sell to larger chains.

这是因为他们的谈判能力，而不是提供更好的护理，这迫使小型诊所向大型连锁诊所出售。

If everyone had the same government insurance with the same set prices, that advantage would disappear.

如果每个人都以相同的定价购买相同的政府保险，那么这种优势就会消失。

Small, independent clinics could survive without needing to merge into giant systems.

小型独立诊所无需合并到庞大的系统中即可生存。

Providers would compete instead on quality of care.

相反，提供者将在护理质量上进行竞争。

This doesn’t mean that corporate health care goes away overnight.

这并不意味着企业医疗保健会在一夜之间消失。

Some Medicare for All proposals ban for-profit facilities like hospitals, but many nonprofits have become corporate.

一些全民医疗保险提案禁止医院等营利性设施，但许多非营利组织已成为公司。

This means we need policies to regulate their governance and accountability, regardless of future reforms.

这意味着，无论未来的改革如何，我们都需要政策来规范其治理和问责制。

People often say, “if we get government health care, we’ll have to wait forever for treatment, like in other countries.”

人们常说，“如果我们得到政府的医疗保健，我们将不得不永远等待治疗，就像在其他国家一样。”

Is that true?

这是真的吗？

Not really.

并不真地。

U.S. wait times for primary care are longer than in peer countries, on average.

平均而言，美国初级保健的等待时间比其他国家要长。

While specialty care may take longer elsewhere, access also varies.

虽然其他地方的特殊护理可能需要更长的时间，但获得的机会也各不相同。

U.S. access to specialists is quicker than in Canada, but Germany and France have shorter wait times for elective surgery and specialty care.

美国获得专家治疗的速度比加拿大快，但德国和法国的择期手术和专科护理的等待时间较短。

Overall, Americans have the worst access to care among 10 peer nations.

总体而言，在 10 个同等国家中，美国人获得医疗服务的机会最差。

Medicare for All could improve access to care, depending on its goals.

全民医疗保险可以改善获得医疗服务的机会，具体取决于其目标。

Wait times are policy decisions.

等待时间是政策决定。

But more so, Medicare for All tries to address rationing of access that already exists within the system.

但更重要的是，全民医疗保险试图解决系统内已经存在的准入配给问题。

Medicaid pays providers much less than private insurance, so fewer doctors accept it, and 27 million Americans remain uninsured.

医疗补助支付给医疗服务提供者的费用远低于私人保险，因此接受该补助的医生越来越少，而且仍有 2700 万美国人没有保险。

In rural areas, sparse or spread-out populations can make hospitals and clinics financially difficult to sustain, leaving residents with fewer local care options.

在农村地区，人口稀少或分散可能会使医院和诊所在经济上难以维持，导致居民当地的护理选择较少。

High deductibles and copays can lead even insured people to skip unaffordable care.

高免赔额和共付额甚至可能导致受保人跳过负担不起的医疗服务。

This gets worse every time employer health care costs go up: rising premiums are a flat, regressive tax, eating disproportionately into the wages of lower-income workers.

每当雇主医疗保健成本上升时，情况就会变得更糟：不断上涨的保费是一种固定的累退税，不成比例地侵蚀低收入工人的工资。

Medicare for All tries to address these access problems by covering everyone, making care free (or very cheap), and making everyone “worth” the same to providers.

全民医疗保险试图通过覆盖所有人、提供免费医疗（或非常便宜）以及让每个人对医疗服务提供者“具有相同的价值”来解决这些获取问题。

Medicare for All would certainly be transformative, but changing insurance financing by itself won’t address many of the system’s issues, such as primary care shortages, medical school debt, financialization throughout the system, and much, much more.

全民医疗保险肯定会带来变革，但改变保险融资本身并不能解决该系统的许多问题，例如初级保健短缺、医学院债务、整个系统的金融化等等。

And those are just the concerns in the medical system.

这些只是医疗系统的担忧。

We know that most of what affects health actually occurs outside of the exam room.

我们知道，影响健康的大部分因素实际上发生在考场之外。

That gets into the realm of public health and how our society tackles issues like poverty, education, and access to resources.

这涉及公共卫生领域以及我们的社会如何解决贫困、教育和资源获取等问题。

But here, Medicare for All plays an underappreciated role because it provides a mechanism for weighing priorities democratically.

但在这里，全民医疗保险发挥的作用并未得到充分重视，因为它提供了一种民主权衡优先事项的机制。

It allows us to decide whether to allocate more funds to health care versus social programs, for example, and creates a unified budget that we can titrate accordingly.

例如，它使我们能够决定是否将更多资金分配给医疗保健而不是社会项目，并创建一个我们可以相应调整的统一预算。

The U.S. needs solutions to its ridiculous health care costs.

美国需要解决其荒谬的医疗保健费用。

No solution will be easy, and no solution will fix it all.

没有一个解决方案是容易的，也没有一个解决方案可以解决所有问题。

Whether the current health care landscape will reach a breaking point that makes Medicare for All a politically viable option at the federal level remains to be seen.

目前的医疗保健格局是否会达到一个临界点，使全民医疗保险成为联邦一级政治上可行的选择，还有待观察。

But it does feel like this country is at its tipping point.

但确实感觉这个国家正处于转折点。

About time.

时间到了。

Hayden Rooke-Ley , JD, is Assistant Professor at the Brown University School of Public Health.

Hayden Rooke-Ley 法学博士是布朗大学公共卫生学院助理教授。

His scholarship focuses on corporate consolidation in health care, Medicare and Medicaid financing, and labor and workforce issues in the health sector.

他的奖学金重点关注医疗保健领域的企业整合、医疗保险和医疗补助融资以及卫生部门的劳工和劳动力问题。

He has published in leading journals, including the New England Journal of Medicine and Journal of the American Medical Association (JAMA), and he advises state and federal policymakers, enforcement agencies, and other health care stakeholders.

他曾在《新英格兰医学杂志》和《美国医学会杂志》(JAMA) 等领先期刊上发表文章，并为州和联邦政策制定者、执法机构和其他医疗保健利益相关者提供建议。

He is a licensed attorney in Oregon and earned his JD from Stanford Law.

他是俄勒冈州的一名执业律师，并获得了斯坦福大学法学院的法学博士学位。

His work can be found on X and LinkedIn .

他的作品可以在 X 和 LinkedIn 上找到。

Your Local Epidemiologist (YLE) comprises a team of experts, ranging from physicians to immunologists to epidemiologists to nutritionists, working together with one goal: to “translate” ever-evolving public health science so that people are well-equipped to make evidence-based decisions.

您的当地流行病学家 (YLE) 由一个专家团队组成，其中包括医生、免疫学家、流行病学家和营养学家，他们共同努力实现一个目标：“转化”不断发展的公共卫生科学，以便人们有能力做出基于证据的决策。

The YLE suite of newsletters reaches over 475,000 people across more than 132 countries.

YLE 新闻通讯套件覆盖超过 132 个国家/地区的 475,000 多人。

This newsletter is free to everyone, thanks to the generous support of fellow YLE community members.

感谢 YLE 社区成员的慷慨支持，本通讯免费向所有人开放。

To support the effort, subscribe or upgrade below:

为了支持这项工作，请订阅或升级如下：

Our American insurance driven system is the worst if healthy outcomes are the goal.

如果以健康结果为目标，我们美国的保险驱动系统是最糟糕的。

Profit for insurance companies is currently the benchmark.

目前保险公司的利润是基准。

Good luck getting Americans to give up the old system that they complain about so often.

祝美国人好运，放弃他们经常抱怨的旧制度。

We can't even get Americans to get vaccinated against known pathogens.

我们甚至无法让美国人接种针对已知病原体的疫苗。

I would like to see a Medicare for all and send my insurance check to the government instead.

我希望为所有人提供医疗保险，并将我的保险支票寄给政府。

Sadly we have politicians that tell us, government is the problem, while they are in government office with benefits and pay from taxpayers.

可悲的是，有些政客告诉我们，政府才是问题所在，而他们在政府办公室里享受着纳税人的福利和工资。

.

。

I practiced for 40 years and studied health care systems while earning my MPH in health care services.

我从业了 40 年，研究了医疗保健系统，同时获得了医疗保健服务领域的公共卫生硕士学位。

Other counrtries have solved this problem.

其他国家已经解决了这个问题。

Providing basic, primary and preventive care and having optional riders for purchasing higher-end riders is workable.

提供基本、初级和预防性护理，并为购买高端附加险提供可选附加险是可行的。

As with any other insurance, even Medicare, you have the basic plan and more expensive options for those who choose that option.

与任何其他保险（甚至是 Medicare）一样，您可以选择基本计划，也可以为选择该选项的人提供更昂贵的选择。

At this point, many still think the Affordable Health Care option is Medicaid and many people still think Medicare and Medicaid are the same program.

在这一点上，许多人仍然认为平价医疗保健选项是医疗补助，并且许多人仍然认为医疗保险和医疗补助是同一个计划。

You cannot reform a system that you do not undertstand in the first place.

你无法改革一个你一开始就不理解的制度。

This is glaringly obvious in Congress.

这在国会中表现得非常明显。