怎么理解美国医保问题？牙疼一次就知道

这次“春假”，我和家人享受了一周天堂般的生活，所以非常确定一点，我真的很想彻底放松一个星期，没打算考虑医疗问题。

但老实说，想躲还是没躲过，到最后还是跟医生打上交道。这次在岛上度假期间，不管观赏鲸鱼、海底潜水、去瀑布探险，泡泳池玩滑水，还是在沙滩上闲逛，我的牙都疼得厉害。只要咬到比木瓜瓤硬的东西就会龇牙咧嘴，疼到从躺椅上跳起来，连喝混合椰汁的可拉达都只能像婴儿一样小口抿。我一拖再拖就是不愿看牙医，到最后是妻子帮我打了电话。（现在看来，比放假时赶上牙疼更糟糕的是，跟牙疼的配偶一起度假。）

妻子找到一位出色的牙医，我心怀感激。不过这段假期插曲主要还是说明，其实对医疗的需求无处不在。要改革医疗体制的人应该注意。

过去几周我们看到，共和党领袖先是推动特朗普的医保方案立法，后来又放弃了，因为有少数议员坚决不愿“修改”或者替代奥巴马医改法，宁可直接废除，然后建立一个纯粹自由的市场机制。理论上新体制下愿意买医疗服务（或者医保覆盖险种）的人在实际需要时购买，不想买或者无力负担医保的人不必购买。毕竟，从Froot Loops的早餐麦片、手机，到将万圣节期间女超人主题的宠物猫狗穿戴裙装，市场中很多商品都是这么运作的。

这种理念对经济自由派很有吸引力。四天前，我也曾是坚决的“自由派”，完全不能接受在夏威夷毛伊岛的宝贵假期忍受牙医电钻，浪费逛品牌折扣中心的时间。

但我放弃了原来的想法，这不是自由市场的问题，而是因为医保本身的特殊性质。以下是两个最重要原因：

无论是牙齿感染、胰腺手术，还是化疗、治疗枪伤，医疗需求之所以叫“需求”是有道理的。如果你买不起Froot Loops麦片，最新款iPhone或者给小宠物的裙子，问题不大，没有也能过下去。但不管买没买医保，需要急救的人必须得急救。到最后，人们会不计一切代价涌进急救室求医，很多没有医保的人逼急了就能做出来（然后由所有人均摊开销）。如果满足不了需求，很有可能就会死人。

在社会里生活，有很多机会例子可以解释这种需求的差异。比如邻居的房子着火了，你可能希望消防员立即赶到现场灭火，即便事后消防局不向邻居收费也没什么。我估计，你不会为此举着牌子到邻居家门前的草坪上高喊对方是“特权阶级”或者“寄生虫”。虽然倾向自由主义，但我们要把需求和愿望区别对待。

两者的区别部分在于分担风险的意识。邻居的屋子着火可能烧到你家。不过很多传染病也一样。

医疗市场上买方可能不计其数，卖方却受到法律严格监管。显然，没有哪部联邦政府和州政府的法律禁止人们在eBay网上卖掉西施犬穿的裙子，也没人禁止给狗狗穿裙子（但可能有人会觉得应该禁止）。但医疗系统面临全方位监管，除了法律法规，还有行业协会确立的行规，都跟法律的震慑力差不多。

先从容易理解的说起：社会中很多工种都具有准入门槛，就好比我们不会让某某邮差去开飞机，除非经过长年累月的训练拿到飞行执照。医疗市场也类似，所以本质上就有垄断因素，具体看提供医疗服务的类型。

在行业协会保护下医疗供应商对市场的掌控力堪称超乎想象。还没有收到账单以前，他们就已经定下费用（或者更通常情况下，知道你能通过医保支付多少费用）。所以，医疗市场的消费者在了解医疗成本之前，甚至在不知道服务质量以前就上了 “贼船”。事实上，需要住院的人几乎必须向院方承诺为所有服务付钱，有些服务可能都等不到用上，另一边医疗机构却可以狮子大开口。自由市场可不是这么运转的。

当然，如果沉浸在自由主义氛围里，喜欢事事亲力亲为，我是可以给自己拔牙，去沃尔玛买瓶漱口水对付了事。可即便能做到那一步，我还是没法给自己开抗生素（拔牙以后需要服用）。处方药可能看上去实现了自由市场，因为过去几年里商家已经证明可以随意叫价。不过，政府有上千条法规规定哪些药丸和药方可以卖给谁，谁来卖，具体用途以及发售时间。这些门槛对对有意开拓市场和推广新药的商家来说也是极高的，所以推升了价格。

坦白说，假如医疗市场真能像自由市场一样运作再好不过。目前有一些还不错的想法在推动医疗走向自由市场。比如美国科氏工业集团掌门人查尔斯•科赫与大卫•科赫两兄弟支持的非营利组织Freedom Partners最近发布了一份战略备忘录。其中建议，立法者改变当前的规定，允许个人和企业跨州购买保险项目，“鼓励培育”多年期保单甚至寿险保单市场，至少在某种程度上可以避免投保人因长年身缠重病陷入赤贫。同时，我们应该大幅提高税前健康储蓄账户的存款上限，拓宽账户资金的用途（最明显的例子，可以支付保费或者基础医疗团体计划的会员费）。重要的是，我们应该修改当前严重阻碍跨州远程医疗服务发展的法令。（点击此处了解相关背景。）

随着国会的领袖翻开医改新篇章（他们最近开玩笑似地表示会采取行动），可以考虑下我提的建议，众所周知医疗市场盘根错节，距自由市场机制还有漫漫征途。任何“改革”，如果想着仅仅改变谁为医保付钱以及如何支付就转为自由市场，在热爱自由的美国人心中，可能还不如眼下这个破绽百出的系统。（财富中文网）

译者：Pessy

审稿：夏林

I spent the week in paradise—on a “spring break” vacation with my family—and I can attest with the utmost certainty that it is better to spend a week not thinking about healthcare than thinking about it.

But truth be told, not thinking about healthcare got me thinking of it. And eventually in need of it. That’s because in the midst of a whale-watching, snorkeling, waterfall-exploring, pool-supersliding, beach-bumming island vacation, I had one heck of a toothache. I grimaced with each bite of anything harder than papaya, jumped from my chaise with the babiest baby-sip of colada—but still pushed off calling a dentist until…my wife called one for me. (The one thing worse than having a toothache on vacation, it appears, is vacationing with a spouse who has a toothache.)

She found an amazing dentist and I’m grateful for it. But the long and short of this episode was that the need for healthcare found me. And therein lies a lesson or two for anyone who hopes (in earnest) to reform it.

As we saw in the past few weeks, as Republican party leaders pushed for Trumpcare and then abandoned it, there is a small and determined group of lawmakers who don’t want to “fix” or replace Obamacare, but rather to repeal it outright and then institute a purely free market system in its place. That system, in theory, would let those so inclined buy healthcare (or insurance coverage for healthcare) when—and only when—they want it, and would leave those who don’t want it (or can’t afford it) alone. That’s, after all, how the market for Froot Loops works—and the one for mobile phones and for Supergirl-inspired Halloween tutus for your dog or cat.

There is a certain appeal to such economic liberty. And for four days or so, I myself was a Freedom Caucus’er—dead set against trading an afternoon of precious vacation for one in a Maui strip mall with a jawful of drill.

I lost that intellectual battle not because of the nature of free markets, but rather because of the nature of healthcare itself. Here are two fundamental reasons why:

A medical need—whether it be a tooth infection, pancreatic surgery, chemotherapy, or gunshot wound—is called a “need” for a reason. Dare the thought that you can’t afford a box of Froot Loops or a new iPhone or a tutu for your pet. It’s okay: You can probably live without it. But those who require urgent care will still have the same need for urgent care whether or not they have insurance. In the end, they might storm an emergency room to get it—which is what many without coverage still do (and which we still, collectively, pay for). And if they don’t address the need, they might well die.

As a society, we’re pretty good about recognizing that distinction in other contexts. When your neighbor’s house catches fire, chances are you’d want firefighters to race to the scene to put it out. You’ll probably even be okay with the fact that the fire department won’t send your neighbor a bill afterward—and I’m guessing you won’t post a sign on his front lawn saying, “Entitled!” or “Freeloader!” Freedom-loving folks though we are, we treat need differently than want.

Some of that distinction is due to the perception of shared risk, of course. A fire in your neighbor’s house could spread to yours. But then, the same can be said for many infectious diseases.

This market may have unlimited buyers, but sellers are strictly limited by law. There is, apparently, no federal or state law that prohibits a person from selling a tutu for your shih tzu on eBay, or for dressing your pet in one (though one might argue there should be). But our medical systems are thoroughly enveloped in laws and regulations, as well as practices so entrenched by guild or industry convention that they have the force of law.

Start with the obvious: We, as a society, don’t give everyone the keys to the operating room, any more than we let Joe from the mailroom fly a commercial jet—not without many moons of training and a license, that is. So the healthcare market has a bunch of built-in monopolies, depending on the particular service being offered.

Those guild-protected medical providers also have another uncanny market-controlling power: They can demand that you pay (or more commonly, have proof that you can pay through insurance) before they see you—and before you see the bill. So medical consumers are on the hook for payment long before they know what the total cost of the service is, or how well that service was provided. Indeed, those who require a stay in the hospital will almost certainly have to promise to pay for services from providers they may never see—and who can charge pretty much whatever they want. Not many free markets work like that.

Sure, in the euphoria of liberty-cherishing DYI-philia, I could have pulled my own tooth and gargled in Walmart peroxide. But even then, I couldn’t prescribe myself an antibiotic (which, it turns out, I needed). Our prescription drug trade may look like a free market—because sellers have proven over the past several years that they can charge whatever they want. But the government has thousands of rules about which pills and nostrums can be sold to whom, by whom, for what purpose, and when. The barriers to entry for those who want to create and market a new medicine are enormous—which drives up prices on its own.

It would be great, frankly, if healthcare did operate more like a free market. And there are some good ideas out there for how to push it in that direction. For example, Freedom Partners, a group supported by Charles and David Koch, suggested in a recent strategy memo that lawmakers change the current rules to let individuals and businesses purchase insurance plans across state lines, and “foster the creation of a market” for multiyear and even lifetime insurance contracts that would enable people to protect themselves, at least somewhat, from the financial ravages of a serious illness years down the line. At the same time, we should significantly raise the contribution caps on pre-tax health savings accounts and broaden the scope of what they can be used for (including, quite obviously, paying for insurance premiums or membership fees for primary care group plans). And importantly, we should rewrite the current statutes that largely prevent the expansion of telemedicine offerings across state lines. (Here’s some background reading on that.)

As leaders in Congress take up healthcare legislation anew (as they have recently teased they will), they might consider these options—along with the sobering fact that healthcare, as we know it, is a long way from a free-market system now. And any “reforms” that try to instill this ethos by simply changing who pays for insurance and how is likely to be even less embraced by freedom-loving Americans than the flawed system we have now.