国外医疗救助政策比较

通过分析国家医疗保险、社会医疗保险、商业医疗保险、储蓄医疗保险四种筹资体系下英国、德国、美国、新加坡四个发达国家医疗救助的具体政策，总结出各国医疗救助政策在强调政府责任、聚焦弱势人群、定位低层次、严格管理程序等政策制定、执行上的共同特点，以期为我国医疗救助的更好开展提供借鉴。     

Is German long-term care insurance a model for the United States?

German long-term care insurance, implemented in 1995, significantly extends the coverage of care-related risks. Given the similarities of German and U.S. institutional features, the German social insurance approach has been put forward as a possible model for long-term care in the United States. Using a political economy framework, the authors conducted a policy analysis that compares the main shortfalls of long-term care (LTC) provision in the United States and Germany, examines the responses provided by LTC insurance in Germany, and relates them to broader trends and proposals for change in welfare policy in both countries. German LTC insurance includes a high degree of consumer direction and compensation and protection for informal caregivers; it supports the extension of community-based services. Its shortfalls include the continued split between health and LTC insurance. In both countries, decentralization and institutional and financial fragmentation are some of the characteristics responsible for the failure to promote egalitarian social policy and substantially expand social protection to family- and care-related risks. The German LTC program is a good model for the United States. With a social insurance approach to LTC, costs are spread across the largest possible risk pool. Major goals that can be reached with such a program include establishment of universal entitlements to LTC benefits, consumer choice, and equitability and uniformity.     

美国医疗保险改革演进及对中国的启示

美国在医疗保险方面独具特色,它以商业医疗保险为主体,以政府的医疗照顾和医疗救助为补充。美国曾因是唯一未能实现全民医疗保险的发达国家而饱受诟病。从1912年起,美国联邦政府就开始了全民医疗保险立法之路。但受到党派斗争、利益集团、价值理念等因素的影响,立法进程缓慢。直到2012年,在历经整整一个世纪之后才在奥巴马总统执政期间促成医保法案的最终通过,从而为美国迈向全民医保之路奠定了制度基础。考察美国医保演进之路对中国医保改革具有重要的启示,特别是其强调立法先行、民主参与和私营医疗保险的发展经验对当前中国医保覆盖面扩大后如何提升质量具有重要的借鉴意义。     

Governing through lifestyle—Lalonde and the biopolitical management of public health in Canada

In 1974, the Liberal government of Pierre Trudeau released a “green paper” known as the Lalonde Report, after the health minister at that time. The report formulated perspectives on health and the main concepts and ideas developed in it, particularly the concept of “lifestyle,” which became the foundation of public health policies in many different European countries and the United States. The concept of “lifestyle” connected personal behaviour and habits to the individual health condition; people were not dying due to a lack of access to medical care but because they lived a life prone to personal risk taking. Furthermore, what is seldom discussed is that this report not only propagated the (neo)liberal view of citizens as autonomous rational actors (homo oeconomicus), with personal responsibility for their health, but it was a first step in the transformation of Medicare and went far beyond the question of health promotion. Health was no longer something that happened to a person but was created through personal choice and, therefore, one had to assume responsibility for one's behaviour. Using Foucault's definition of government as the “conduct of conduct,” we will demonstrate that the Lalonde report must be understood as a specific “technology of government” and contributed to a neoliberal transformation of health care despite the fact that the Canadian system of Medicare was based on the idea of universality, meaning citizens had equal access to health care independent of their socio‐economic situation. As we will demonstrate, the Lalonde report undermined this foundation and initiated a profound reorientation, not only of the healthcare system, but even more importantly, it radically changed the way we think about our behaviour around health‐related issues. We will also discuss how the making of the report contributed to the redefinition of politics and demonstrated a lack of concern with liberal‐democratic decision‐making processes.     

Canada Deserves a National Health System

A defining — some would say peculiar — feature about Canada and Canadians is the strong position that we give social programs within our national identity. FORUM presents an essay by Dr. Thomas Noseworthy based on an address to the annual meeting of the Association of Canadian Medical Colleges in April 1996. In it, Dr. Noseworthy calls for a national health system. He sees the federal government retaining an important role in preserving medicare and, in fact, strengthening its powers in maintaining national consistency and standards. Dr. Noseworthy's views are contrary to the governmental decentralization and devolution of powers occurring across the country. In a “point/counterpoint” exchange on this issue, we have invited commentaries from three experts. Raisa Deber leads off by noting that while a national health system may be desirable, constitutional provisions would be an obstacle. Governments, says Deber, have an inherent conflict of interest between their responsibility for maintaining the health care system and their desire to shift costs. Michael Rachlis reminds us that medicare fulfills important economic as well as social objectives. It helps to support Canada's business competitiveness among other nations. The problem, says Rachlis, is that public financing of health care does not ensure an efficient delivery system. Michael Walker offers some reality orientation. He observes that Canada's health care system is based upon ten public insurance schemes with widely different attributes. While he supports a minimum standard of health care across the country, citizens should be able to purchase private medical insurance and have access to a parallel private health care delivery system. Ultimately, this debate is about who should control social programs: the provinces or the federal government?We'll let you, the readers, decide. — RRS     

Attitudes of Washington State primary care physicians toward capitation-based insurance plans

Recent years have brought many changes in health care financing, including health care insurance plans based on capitation allowances to physicians. This study describes a survey examining physician attitudes toward such plans. The survey was distributed to a random sample of 30% of the family physicians, general practitioners, general internists, and general pediatricians in the Washington State Medical Association in 1986. Responses from 322 physicians (71%) indicated that most primary care physicians had a negative attitude toward such plans. Participants in capitation-based plans (48% of total respondents) had a nearly neutral attitude, which was significantly different from the attitude of nonparticipants. Respondents identified the main disadvantages of such plans as confusion about benefits, increased administrative demands, liability risks, altered professional relationships, and loss of autonomy. The main advantages perceived were increased physician awareness of cost, increased importance of the primary care role, and reduction of unnecessary health care utilization. Attitudes were significantly more negative among solo practitioners and physicians with more years in practice. Respondents rated selection of consultants, favorable economic arrangements, and benefits information as the features most likely to influence them to participate in capitation-based plans.     

Elderly care: similarities and solutions in Denmark and the United States

Denmark, like the United States and other developed countries, is experiencing an increase in the percentage of dependent elderly in its population. They consume a disproportionate share of health and social services at a time when government is attempting to contain costs. Both countries face similar problems in caring for the elderly--problems of escalating hospital costs, dramatically increased nursing home costs, and insufficient public revenues to cover their entire care. Denmark has developed a wide range of services for the elderly--home help, home nursing, adult day care centers, day nursing homes, and sheltered housing. The response in the United States has taken somewhat different directions, although in both countries home and community services have been expanded as a substitute for expensive institutional care. The possible relevance of the U.S. experience in these areas to Denmark and lessons that the United States might learn from the Scandinavian country are discussed.     

我国卫生保健服务不公平性的主要表现及对策

通过对我国卫生保健服务不公平的提供和筹资进行剖析,就如何改变现状和不断提高我国卫生保健的公平性提出如下建议;强化政府责任,建立合理的医疗保障和卫生服务体系;加强基层卫生机构能力建设;改变现有的医疗保险支付模式,合理吸引社会资金用于医疗保健投资。     

Public opinion on global distribution of COVID-19 vaccines: Evidence from two nationally representative surveys in Germany and the United States

Despite ongoing calls for a more even global distribution of COVID-19 vaccines, there remains a great disparity between high- and low-income countries. We conducted representative surveys among the adult populations in the United States (N = 1,000) and Germany (N = 1,003) in June 2021 to assess public opinion in these countries on the distributive justice of COVID-19 vaccines. We conducted two instances of analytic hierarchy processes (AHP) to elicit how the public weighs different principles and criteria for vaccine allocation. In further discrete choice experiments, respondents were asked to split a limited supply of vaccine doses between a hypothetical high-income and a hypothetical low-income country. AHP weights in the United States and Germany were 37.4% (37.2–37.5) and 49.4% (49.2–49.5) for “medical urgency”, 32.7% (32.6–32.8) and 25.4% (25.2–25.5) for “equal access for all”, 13.7% (13.6–13.8) and 13.3% (13.2–13.4) for “production contribution”, and 16.3% (16.2–16.4) and 12.0% (11.9–12.1) for “free market rules”, respectively, with 95% CI shown in parentheses. In the discrete choice experiment, respondents in the United States and Germany split available vaccine doses such that the low-income country, which was three times more populous than the high-income country, on average received 53.9% (95% CI: 52.6–55.1) and 57.5% (95% CI: 56.3–58.7) of available doses, respectively. When faced with a dilemma where a vulnerable family member was waiting for a vaccine, 20.7% (95% CI: 18.2–23.3) of respondents in the United States and 18.2% (95% CI: 15.8–20.6) in Germany reduced the amount they allocated to the low-income country sufficiently to secure a vaccine for their family member. Our results indicate that the public in the United States and Germany favours utilitarian and egalitarian distribution principles of vaccines for COVID-19 over libertarian or meritocratic principles. This implies that political decisions favouring higher levels of redistribution would be supported by public opinion in these two countries.     

Physicians' Plan for a healthy Minnesota. The MMA proposal for health care reform. The report of the Minnesota Medical Association Health Care Reform Task Force

The health care system in the United States, according to some, is on the verge of imploding. The rapidly rising cost of services is causing more and more Minnesotans to forego needed care. At the same time, the increasing costs are placing additional pressure on families, businesses, and state and local government budgets. The Minnesota Medical Association's (MMA) Health Care Reform Task Force has proposed a bold new approach that seeks to ensure affordable health care for all Minnesotans. The proposal is a roadmap to provide all Minnesotans with affordable insurance for essential health care services. In creating this plan, the task force strove to achieve three common reform goals: expand access to care, improve quality, and control costs. To achieve those ends, it has proposed a model built on four key features: (1) A strong public health system, (2) A reformed insurance market that delivers universal coverage, (3) A reformed health care delivery market that creates incentives for increasing value, (4) Systems that fully support the delivery of high-quality care. The task force believes that these elements will provide the foundation for a system that serves everyone and allows Minnesotans to purchase better health care at a relatively lower price. Why health care reform again? The average annual cost of health care for an average Minnesota household is about 11,000 dollars--an amount that's projected to double by 2010, if current trends continue. Real wages are not growing fast enough to absorb such cost increases. If unabated, these trends portend a reduction in access to and quality of care, and a heavier economic burden on individuals, employers, and the government. Furthermore, Minnesota and the United States are not getting the best value for their health care dollars. The United States spends 50 percent more per capita than any other country on health care but lags far behind other countries in the health measures of its population.     

Managed care in Latin America: transnationalization of the health sector in the context of reform

This article presents the results of the comparative research project "Managed Care in Latin America: Its Role in Health Reform". The project was conducted by teams in Argentina, Brazil, Chile, Ecuador, and the United States. The study's objective was to analyze the process by which managed care is exported, especially from the United States, and how managed care is adopted in Latin American countries. Our research methods included qualitative and quantitative techniques. Adoption of managed care reflects transnationalization of the health sector. Our findings demonstrate the entrance of large multinational financial capital into the private insurance and health services sectors and their intention of participating in the administration of government institutions and medical/social security funds. We conclude that this basic change involving the slow adoption of managed care is facilitated by ideological changes with discourses accepting the inexorable nature of public sector reform.     

The German health care system: a model for hospital reform in the United States?

Experience in Germany illustrates that the United States could potentially achieve universal access, comprehensive and high-quality services, and value for the money expended with what is often referred to as a "quasi-private and quasi-public" health care system. The German hospital system is analyzed from a number of perspectives, and it is concluded that this approach has some advantages over a single-payer, monolithic-type national health insurance model. This is primarily because of its pluralistic prepayment system and because the commencement of reimbursement negotiations are without direct governmental intervention. The adoption of the German design in the United States, it is concluded, would result in a sharp change in policy direction from a conceptually procompetitive, market-driven hospital environment to a highly federally regulated, state-administered one. The implementation of the German approach in this country would also require a shift from managed care plans and other third party payers having to micromanage the use of health care services for individual patients to tightly centralized national and state fiscal controls (e.g., institutional global capital and operating budgets) targeted at providers.     

Self care: Japan and the U.S. compared.

Experience of common symptoms and subsequent self care behaviors among older adults are compared between Japan and the United States, two industrial countries with different cultural backgrounds and health insurance systems. Based on a modification of the Health Belief Model, perceived susceptibility to illness and belief in the efficacy of physician care were selected as major explanatory concepts for the decision to use self care for a complaint. Among 900 respondents in Japan and 728 in the United States, in three communities of varying size, self evaluations of good health, an indicator of low susceptibility, were very similar. Although Japanese respondents claimed fewer experiences of physician error, they still expressed lower preference for physician care than did those in the U.S. In addition, the Japanese reported far fewer symptoms than their U.S. counterparts during a three month period, and were more likely to use self care, even for symptoms they considered more serious. Disparate effects of such variables as good health behaviors, presence of a chronic condition and desire for autonomy are discussed in terms of cultural differences in the two countries.     

Health care needs of Hispanic Americans and the responsiveness of the health care system

The Hispanic population in the United States is growing rapidly but this population has many health care needs that are not being met. The findings from recent research on the current health status of Hispanic people who live in the United States are presented. An assessment of how accessible and available medical care services are to Hispanic people is made. Serious gaps exist in the delivery of medical care services to this group. Human service providers, particularly social workers, can help make the current health care system more responsive to the needs of this group by helping Hispanic individuals who have no health insurance coverage to find employment that includes health insurance benefits or some other form of insurance, by establishing community-based health care centers in Hispanic communities, by developing counseling programs tailored to the alcohol and drug abuse problems of the Hispanic population, and by advocating for government agencies to improve existing sources of data on the health of this group.     

Observations on "Cost containment and new priorities in the European community" by Brian Abel-Smith.

A commentary on the article by Brian Abel-Smith briefly explores why the United States lags behind Europe in controlling health care costs. Three important factors are, first, that until recently the real cost of health insurance was not apparent to U.S. workers and political leaders; second, Americans prefer to try competition before resorting to other strategies; and third, responsibility for financing health care is divided among a large number of independent entities, while government regulation is split between the state and federal levels. At the same time, governments and private insurers in the United States have developed new health delivery structures and reimbursement mechanisms that the Europeans may find useful. A convergence of the two systems would be to the benefit of both.     

英、美、德国家医疗卫生监管体系介绍及启示

对英国、美国、德国3个典型国家的医疗卫生监管体系进行分析,总结医疗卫生监管主体、监管内容及监管模式的特点和经验。英国监管主体独立,具有健全的协调合作机制及信息共享机制;美国监管主体分散,社会 第三方监管机构发达;德国行业组织健全,其具有较强的监管能力,同时社会和公民自我管理意识强。启示我国应强化政府主导;发展多元化的监管主体,调动第三方评估、社会组织监管作用;利用信息化手段创新监管方式 ,争取做到医疗卫生领域监管全覆盖。     

Health spending in OECD countries: obtaining value per dollar

In 2005 the United States spent $6,401 per capita on health care-more than double the per capita spending in the median Organization for Economic Cooperation and Development (OECD) country. Between 1970 and 2005, the United States had the largest increase (8.3 percent) in the percentage of gross domestic product (GDP) devoted to health care among all OECD countries. Despite having the third-highest level of spending from public sources, public insurance covered only 26.2 percent of the U.S. population in 2005. The United States was equally likely to be in the top and bottom halves for sixteen quality measures compiled by the OECD.     

Long-term care insurance in Germany: analyzing its progress from the perspective of economic indicators

Germany enabled public long-term care insurance (LTCI), a social insurance system, in 1995. This study focuses on the LTCI program in Germany, analyzes progress of LTCI in view of economic indicators in the inland 16 states (“Länder” in Germany), categorizes 16 states, and describes problems concerning the LTCI program. Statistical analysis was conducted using 24 variables of LTCI and the economic index. The 16 states were categorized in five clusters. The results revealed gaps in adoption rates of LTCI care services among 16 states, suggesting that each of the states developed its own service system of LTCI dependent on regional variables such as economic power and size of population. All former East German states tended to have lower economic resources of care. States with many requests for cash benefits tended to offer lower amounts of care services. The characteristics of these 16 states provide useful information for developing LTCI policies in Germany and offer an informative guide to other countries.     

Sharing in the financing of health care: government,insurance and the patient

The health care systems of all countries have faced the problems of rising expenditures. In those countries with well developed social security health insurance financing, cost issues have been tackled without the threat of a major decrease in revenues. In Israel, revenues have declined dramatically in recent years. The major cause was the steep decrease in government participation, linked first to political and currently to economic factors. Since the level of government participation in the health insurance budget was not guaranteed by statute, the present system is confronted with a large and growing deficit, and by uncertainty to the point of threatening the viability of public health services in Israel.To understand the scope and issues in the sharing of financing between government, insurance contributions and the patient in other countries, this paper describes the situation in France, West Germany, Belgium, Luxembourg and the Netherlands as compared to Israel. In summary, the decline and instability in government support in Israel differentiates that country from the others and raises questions as to the recognition by government of the role of social security financed health care.