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导读
中国的基本医疗保险现状
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音乐| 精读 | 翻译 | 词组
Medicine
医学
本文英文部分选自经济学人Leaders版块
Universal health care, worldwide, is within reach
全民医疗保险触手可及
The case for it is a powerful one—including in poor countries
这在贫穷国家亦有极强可行性
BY MANY measures the world has never been in better health. Since 2000 the number of children who die before they are five has fallen by almost half, to 5.6m. Life expectancy has reached 71, a gain of five years. More children than ever are vaccinated. Malaria, TB and HIV/AIDS are in retreat.
从许多方面看，世界从未像现在这样健康过。自2000年以来，五岁前儿童夭折数量下降了一半，至560万。人类预期寿命提高5年，达到71岁。接种疫苗的儿童比以往任何时期都多，疟疾、结核病和艾滋病正在消退。
Yet the gap between this progress and the still greater potential that medicine offers has perhaps never been wider. At least half the world is without access to what the World Health Organisation deems essential, including antenatal care, insecticide-treated bednets, screening for cervical cancer and vaccinations against diphtheria, tetanus and whooping cough. Safe, basic surgery is out of reach for 5bn people.
然而，相较于医学的更大潜力，眼下这些进步也许仍差之千里。世界上至少一半的国家无法获得世界卫生组织认定的最基础的医疗服务，包括产前保健、经杀虫剂处理的蚊帐、宫颈癌筛查以及预防白喉、破伤风、百日咳的疫苗接种。有50亿人得不到安全的基本外科手术治疗。
Those who can get to see a doctor often pay a crippling price. More than 800m people spend over 10% of their annual household income on medical expenses; nearly 180m spend over 25%. The quality of what they get in return is often woeful. In studies of consultations in rural Indian and Chinese clinics, just 12-26% of patients received a correct diagnosis.
那些能去看医生的人往往花钱不菲。超过8亿人每年家庭收入的10%用于医疗，更有将近1.8亿家庭超过25%，而他们得到的服务却是槽糕的。在对印度和中国农村诊所进行的咨询研究中，只有12%-26%的患者得到了正确的诊断。
That is a terrible waste. As this week’s special report shows, the goal of universal basic health care is sensible, affordable and practical, even in poor countries. Without it, the potential of modern medicine will be squandered.
这是一种严重的浪费。正如这周特别报导所表明的，实现全民基本医疗保健这一目标合理、可负担，也实际，即使在贫穷国家也是如此。没有全民基本医疗，现代医学的潜力会被浪费。
How the other half dies
另一半人是如何死去的
Universal basic health care is sensible in the way that, say, universal basic education is sensible—because it yields benefits to society as well as to individuals. In some quarters the very idea leads to a dangerous elevation of the blood pressure, because it suggests paternalism, coercion or worse. There is no hiding that public health-insurance schemes require the rich to subsidise the poor, the young to subsidise the old and the healthy to underwrite the sick. And universal schemes must have a way of forcing people to pay, through taxes, say, or by mandating that they buy insurance.
如果说，全民基础教育是合理的，那依据同样的道理，全民基本医疗也是合理的——因为它对个人和社会都有好处。然而这个想法对于某些人群来说，会让他们血压飙升，因为这意味着家长式管理、强迫或更糟的事。直言不讳，公共医疗保险计划需要富人补贴穷人，年轻人补贴老人，健康的人补贴病人。全民医疗计划必须采取办法强迫人们缴费，通过收税，或强制他们买保险。
But there is a principled, liberal case for universal health care. Good health is something everyone can reasonably be assumed to want in order to realise their full individual potential. Universal care is a way of providing it that is pro-growth. The costs of inaccessible, expensive and abject treatment are enormous. The sick struggle to get an education or to be productive at work. Land cannot be developed if it is full of disease-carrying parasites. According to several studies, confidence about health makes people more likely to set up their own businesses.
但是，全民医疗保险也具有其原则性和自由度。我们可以合理地认为每个人都想得到一副好身体，从而全面发挥自己的潜在能力。而全民医疗保险便是能够赋予大家好身体的其中一种方法，并且还能够促进经济的增长。看病难、看病贵、治疗差所造成的损失是巨大的。病患为了能够上学、正常工作而苦苦挣扎。像是一块土地如果长满寄生虫，而且这些寄生虫还能够传播疾病，那么这块土地将无法得以开发。多项研究表明，对健康有自信的人更愿意创业。
Universal basic health care is also affordable. A country need not wait to be rich before it can have comprehensive, if rudimentary, treatment. Health care is a labour-intensive industry, and community health workers, paid relatively little compared with doctors and nurses, can make a big difference in poor countries. There is also already a lot of spending on health in poor countries, but it is often inefficient. In India and Nigeria, for example, more than 60% of health spending is through out-of-pocket payments. More services could be provided if that money—and the risk of falling ill—were pooled.
全民基本医疗保险也并非难以负担。一个国家无需待到富庶之时才能实现全面且基本的卫生治疗。卫生保健产业是劳动密集型产业。跟医生和护士相比，向辖区卫生工作者所支付的酬劳也相对较低。因此，在贫穷国家中，辖区卫生工作者的意义重大。贫穷国家的卫生花费已经相当大，但其所带来的效益却常常不如人意。在印度以及尼日利亚，百分之六十以上的卫生费用都是患者直接自付的。如果这些钱可以筹集在一起，并且患病风险可以集中管控，那么这将能够为大家提供更多服务。
The evidence for the feasibility of universal health care goes beyond theories jotted on the back of prescription pads. It is supported by several pioneering examples. Chile and Costa Rica spend about an eighth of what America does per person on health and have similar life expectancies. Thailand spends $220 per person a year on health, and yet has outcomes nearly as good as in the OECD. Its rate of deaths related to pregnancy, for example, is just over half that of African-American mothers. Rwanda has introduced ultrabasic health insurance for more than 90% of its people; infant mortality has fallen from 120 per 1,000 live births in 2000 to under 30 last year.
全民医疗保险可行性的证明并非是纸上谈兵，开拓性的实例已有证实。智利和哥斯达黎加只花费了美国个人健康保险费用的1/8，但有着相似的预期寿命。泰国每人每年在医保上花费220美元，但却取得了和经合组织国家一样好的效果，举个例子，与妊娠有关的死亡率，仅仅只有非裔美国妈妈的一半多一点。卢万达为其90%以上的人民引入了非常基础的医疗保险，婴儿死亡率从2000年的千分之一百二十降低至去年的千分之三十不到。
And universal health care is practical. It is a way to prevent free-riders from passing on the costs of not being covered to others, for example by clogging up emergency rooms or by spreading contagious diseases. It does not have to mean big government. Private insurers and providers can still play an important role.
全民医疗保险是实用的，它能避免“占便宜”的不参保人群把成本转嫁给参保的人，比如占用急诊室或者扩散传染病。而这也并不意味着全靠政府大包大揽，私有保险公司和供应商也仍将发挥着重要的作用。
Indeed such a practical approach is just what the low-cost revolution needs. Take, for instance, the design of health-insurance schemes. Many countries start by making a small group of people eligible for a large number of benefits, in the expectation that other groups will be added later. (Civil servants are, mysteriously, common beneficiaries.) This is not only unfair and inefficient, but also risks creating a constituency opposed to extending insurance to others. The better option is to cover as many people as possible, even if the services available are sparse, as under Mexico‘s Seguro Popular scheme.
实际上，这种务实的做法正是低成本改革所需要的。例如，医疗保险计划的设计。许多国家的开始是让一小部分人有资格获得大量的福利，期望以后会增加其他群体。（神奇的是，公务员总是受益者。）这不仅是不公平和低效的，而且也有可能造成反对向他人提供保险保障的选民。更好的选择是尽可能多地覆盖尽可能多的人，即便现有的服务很少，就像墨西哥的“大众医疗保险”那样。
Small amounts of spending can go a long way. Research led by Dean Jamison, a health economist, has identified over 200 effective interventions, including immunisations and neglected procedures such as basic surgery. In total, these would cost poor countries about an extra $1 per week per person and cut the number of premature deaths there by more than a quarter. Around half that funding would go to primary health centres, not city hospitals, which today receive more than their fair share of the money.
少量的支出任重道远。由健康经济学家迪恩贾米森领导的研究已经确定了超过200种有效的干预措施，包括免疫接种和基本手术等被忽视的手段。总的来说，这些措施将使贫穷国家每人每周多出1美元，但这能将过早死亡人数减少逾四分之一。大约一半的资金将用于初级卫生中心，而不是城市医院，这些医院如今获得的资金超过了它们应得的份额。
The health of nations
世界各国的医疗
Consider, too, the $37bn spent each year on health aid. Since 2000, this has helped save millions from infectious diseases. But international health organisations can distort domestic institutions, for example by setting up parallel programmes or by diverting health workers into pet projects. A better approach, seen in Rwanda, is when programmes targeting a particular disease bring broader benefits. One example is the way that the Global Fund to Fight AIDS, Tuberculosis and Malaria finances community health workers who treat patients with HIV but also those with other diseases.
我们看一下每年花在世界医疗救助上的370亿美元。自2000年来，这些投资挽救了数百万的传染病病人。但是，各种世界卫生组织可能会歪曲各国国内卫生组织的工作方向，比如要求国内卫生组织设立类似平行项目或者将卫生工作者分配到宠物项目。卢旺达找到了一个好方法，就是某一疾病的专项基金并不局限于单一项目。。例如，针对艾滋病、肺结核和疟疾的全球卫生基金，补助给辖区卫生工作者，让他们既能治疗艾滋病人，也能帮助其他病患。
Europeans have long wondered why the United States shuns the efficiencies and health gains from universal care, but its potential in developing countries is less understood. So long as half the world goes without essential treatment, the fruits of centuries of medical science will be wasted. Universal basic health care can help realise its promise.
欧洲人一直搞不懂，为何美国不接受全球卫生项目所带来的效率和健康收益，却少有人了解这一机制在发展中国家的巨大潜力。为了不让医学进步的硕果成为一纸空谈，就得让全世界半数的人群得到必要保障。全民基本医疗保险将让这个目标成为现实。
翻译组：
Cece，女，消防工作者，CATTI三笔
Neil, 男，外贸民工，经济学人铁粉
Cyrus，男， 口译民工，经济学人爱好者
Alieen，女，大四数学狗，经济学人爱好者
Doris，女，法律学习者，经济学人爱好者
校核组：
Samantha，女，外企低管，邓伦未婚妻
Eva , 女，经贸翻译学生，经济学人爱好者
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观点 |评论|思考
本次观点由Xiaofeng独家奉献
Xiaofeng, 女，好奇心重的医疗民工，经济学人爱好者
一、卫生保健的提供常见5大缺陷（根据2008年世界卫生报告，即使10年后的今天依旧存在）：
颠倒的保健：富人往往需求较小，却享受最多保健服务；反之，最贫穷、存在健康问题最多的穷人，享受的保健服务最少
致贫的保健：任何国家，缺乏社保和保健支付能力的人群，绝大多数接收保健服务时就已经身无分文。
已经和正在支离破碎的保健：医疗提供者过度专业化和对许多疾病控制项目的狭义关注，使得穷人和边缘人群获得的医疗通常是支离破碎并且资源不足的
不安全的保健：有缺陷的卫生医疗系统设计无法保证卫生安全和符合卫生标准。由此可导致医院获得性感染的高发生率，用药失误以及其他一些可避免的、被低估的可致死和致病的不良反应
被误导的保健：资源配置集中于高额的治疗服务费用，却忽略了初级预防及健康教育可预防高达70%的疾病负担
二、世界卫生组织的《2019–2023 年第十三个工作总规划》
近年来，全球健康状况明显改善：世界许多地区人民预期寿命增加，2016年五岁以下儿童死亡人数比1990年减少600万人，脊灰即将被消灭，目前共有2100万艾滋病毒感染者正接受治疗。随着经济发展和社会发展，千百万人摆脱了极端贫困，许多国家增强了能力，能够为全球议程作出贡献。
尽管取得了这些成就，各地人民的健康和福祉仍面临各种各样威胁。这些威胁相互关联，形式多样，从贫困和不平等到冲突和气候变化等，不一而足。人们仍深受传染病影响，与此同时，非传染性疾病负担日益沉重。需要采取果断行动处理妊娠和分娩并发症、精神健康障碍、物质滥用以及损伤等问题。全球仍有一半以上人口在获得卫生服务时遇到经济困难。世界目前面临严重突发卫生事件（流行病、大流行病、冲突、自然灾害和技术灾难）以及新出现的抗微生物药物耐药性问题威胁。超过2.44亿人（占世界人口3%以上）离开原籍国，其中6500万人被迫逃离本国。全球共有2100多万难民，300万寻求庇护者，估计有4000多万人在本国流离失所。其中许多健康危害源自社会、政治、经济和两性不平等现象以及其他因素。
针对这些现状 ，《第十三个工作总规划》强烈呼吁全世界采取必要行动，推进实现以下三项可持续发展的“十亿人目标”，确保健康的生活方式，促进各年龄段所有人的福祉：
推进全民健康覆盖——全民健康覆盖受益人口新增 10 亿人 。
突发卫生事件——面对突发卫生事件受到更好保护的人口新增 10 亿人。
促进人群健康——健康和福祉得到改善的人口新增 10 亿人。
三、个人评论
健康是一项基本人权。今年2月份一篇《流感下的北京中年》让大家看到，面对疾病，在北京的中产阶级中年人尚且要考虑卖房付医疗费；而对于那些底层老百姓来讲，一生病，或者倾家荡产，或者放弃抵抗，听天由命。如果是家庭收入的主要来源者，将会是雪上加霜。这其中的无奈与辛酸，恐怕只有挣扎在底层的人，才能真正的体会到。
健康保险全民覆盖是一种可能实现保障这一基本人权的措施。而根据《中国-—世卫组织国家合作战略(2016-2020）》，中国的基本医疗保险几乎实现全民覆盖（已覆盖95%的人口），这是一项可喜的成就。同时，本人从事医疗行业工作，也会看到中国医疗环境目前还处于非常不成熟的状态：
医疗机构众多，但是病人感觉看病贵、看病难、医护人员态度恶劣。原因：一、其实中国的医疗机构是非常多的，不应该像我们感受到的那么短缺。原因是病人集中往大型医院跑，县级医院、社区医院病人不断流失。解决方案：国家已经开始实行医疗分级诊疗制度（小病去社区医院，大病去三甲医院、专科医院）、推动医疗规范诊疗、提高县级及社区医院设备配置、省级医院和县级医院等合作、医生下乡等。
二、每1000人配备的医护人员数量过少，医护人员工作量过大，耐心恐怕也不会那么多。解决方案：提高全民学医的积极性（目前中国的环境下，由于医护人员工作环境相对恶劣，医学专业已经逐渐变成了不那么热门的专业）、增加护工等工作人员、提高医护人员收入、改善医护人员工作环境（比如对恶劣医闹的情况，保障医护人员人生安全，严格惩处恶劣医闹问题）；
三、病人对医生带着非常高的期望，与医学本身尚不能治愈一切的现实的冲突。如一句名言：有时去治愈，常常去帮助，总是去安慰（To Cure Sometimes, To Relieve Often, To Comfort Always）。医学不能治愈一切疾病。解决方案：增加社会对医学的了解，帮助大家对医学有一个正确的期望，增加医患沟通和换位思考。同时，也需要推动医疗规范化诊治、医生技能提高
医保资金短缺与人口老龄化、老百姓医疗需求增加的冲突。体现在医保控费、药品及耗材追求低价中标、医务工作者收入较低导致医务工作人员短缺。解决方案，经济发展、增加医保投保范围和金额、增加医疗投入、引进商业医疗保险。
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