经济与社会科学2020thelancet.com
单一支付者医疗体系每年可节省 4500 亿美元并挽救 6.8 万生命
Single-payer healthcare would save $450B and 68k lives a year: study
进阶 · 约 75 分钟读完前置知识：美国医疗保险体系、卫生经济学基础、政策成本测算
导读
这项发表于《柳叶刀》的研究测算，美国若转向单一支付者医疗体系（single-payer），每年可节省约4500亿美元，并避免约6.8万例死亡。研究认为节省主要来自药品议价能力增强和行政开支降低。
HN 关注点：测算是否可信：节省是否主要依赖乐观的行政成本假设，以及转型的现实性和总成本。
HN 评论精选
这几条评论里：质疑 2 补充 1 亲历 1
质疑质疑研究把 Medicare 的低行政开销外推到全系统，认为其低开销可能源于缺乏控成本和反欺诈动力。
在这项研究中，几乎所有计算出的节省都来自两个来源。1. 由于更强议价能力带来的药品成本下降。2. 行政开销下降，这是通过把 Medicare 的行政开销外推到整个美国医疗经济来计算的。我对这两个估计都没有有根据的判断，但直觉上第1点似乎合理，而第2点似乎不太可能。他们给出的理由包括高管薪酬更低和欺诈减少。但据医疗专业人士告诉我，Medicare 更缺乏压低成本的动力，也更缺乏调查欺诈的动力，因此行政成本更低。
mgraczyk查看英文原文
In the study, nearly all the computed savings comes from two sources. 1. Decrease in pharmaceutical costs as a result of better bargaining power. 2. Decrease in administrative overhead, calculated by extrapolating the overhead in medicare to the entire US healthcare economy. I don't have an informed opinion on either of these estimates, but my intuition is that #1 seems reasonable while #2 seems unlikely. The justifications they give include lower executive salaries and decreased fraud. From what I have been told by healthcare professionals, medicare has less incentive to negotiate cost, less incentive to investigate fraud, and therefore lower administrative cost.
质疑认为节省数字虽准确但误导，忽略了巨额总成本和4年转型的不现实性。
净节省会是4500亿美元，但总成本仍将高达数十万亿美元（更正：10年30-50万亿），超过我们所有联邦支出总和。把它作为目标是一回事，作为实现路径是另一回事。他们引用的提案会让联邦医疗支出达到 GDP 的69%（更正：联邦总支出的69%）。在仅仅4年内把整个经济转成政府与医疗优先的系统根本不现实。这些计算还忽略了取消共付额和免赔额后消费者偏好变化的影响，而其他任何全民医疗体系都没有这样做过。
legitster查看英文原文
The net savings would be $450B, but the total cost would still be in the 10s of trillions of dollars (Edit: 30-50 over 10 years), bigger than all of our federal spending combined. It's one thing to have as an objective, and another as a plan for getting there. The proposal they cite would make federal healthcare expenditures 69%(!!!) of the GDP (Edit: total federal expenditures). It's simply not realistic to convert our entire economy into a government and healthcare first system within only 4 years. These calculations also ignore any affects of changed consumer preferences if you eliminate copays and deductibles, something no other universal healthcare system has done. This is one of those calculations that is entirely accurate, but also entirely misleading.
亲历以亲身经历说明美国私人保险费用高、理赔混乱，认为系统已彻底失灵。
我每年为保险支付近2万美元（父母加孩子），却没时间用（所幸没有严重需求）。有一次我儿子去看儿科医生，我们那家“私立”保险公司（名字就不提了）寄来500美元账单，只是体检。我们向保险公司申诉，他们同意下个月免掉这笔钱。下个月到了，猜怎么着？同样的信又来了。之后第三个月账单寄来时我们又申诉了一次又一次。这事已经持续6个月，我已经不再当真，没时间浪费。我意识到，即使你付了很多钱，这个系统仍在浪费大量金钱。它彻底坏了，令人反感。更糟的是，买处方药不用保险反而更划算。那我到底在为什么付钱？急诊？我每年付近2万美元就为了可能的急诊？事情复杂到无法理性分析，这是一个必须先用火烧再溺死在深水里的怪物。
onemoresoop查看英文原文
I'm paying nearly 20k (parents+child) on insurance I don't have time to use (and luckily no serious need) and once my son went to see his pediatrician and our 'private' insurance company (that i'm not going to name) sent us bill of $500, for a check-up. We disputed the charge with the insurance and they agreed to wave the payment next month. Next month comes and guess what? The same letter comes in mail. We disputed it again and again the month after when the bill was sent to us the third time. This is been happening for 6 months and don't take it seriously anymore, I don't have time to waste. I realize that a lot of money goes to waste on a system that is not working even if you're paying a lot. It is utterly broken. Downright revolting. And on top of it I get a better deal if I use no insurance at all for prescriptions. Then what am I paying for? Emergencies? I am paying nearly 20k a year for possible emergencies? It's become so complicated that nothing can be reasoned about it, this is a monster that has to be killed with fire then drowned in deep waters.
补充补充认为研究未计入单一支付者制释放的创业和职业选择等间接经济收益。
这还没有算上对经济的间接好处，例如许多人因为一旦离职就会失去福利，被困在不想要的工作里，无法创业（等等）。
markroseman查看英文原文
That also doesn't factor in the indirect benefits to the economy, like all the people who can't start a new business (etc.), being stuck in jobs they don't want because if they left they'd lose their benefits.
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从这篇论文所有 HN 讨论帖的全部评论里整理出来的链接。
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- 2020Hacker News 讨论帖353 分 · 390 评
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