本文是經濟學專業(yè)的Essay范例,題目是“A Single Payer Healthcare System in the US(價格機制在資本主義中的應用)”,各國采取了各種類型的健康保險制度,以保護其公民免受因醫(yī)療需求而產生的財務風險,并便利人們方便地獲得適當的醫(yī)療服務。大致上,醫(yī)療保險系統可分為單一支付者系統和多支付者系統。在單一支付者系統中,一個組織——通常是政府——為整個人口收集和集中收入并購買醫(yī)療服務,而在多支付者系統中,幾個組織為特定人群承擔這些角色。
Various countries have adopted a various types of health insurance systems to protect their citizens against the financial risks of medical needs and to facilitate easy access to appropriate medical care. Broadly health insurance systems are classified into: single-payer and multiple-payer systems. In single-payer systems, one organization-typically the government-collects and pools revenues and purchases health services for the entire population, while in multiple-payer systems several organizations carry out these roles for specific segments of the population.
Usually the term Single-Payer is used to describe a type of financing system. In the case of health care, a single-payer system would be an entity like a government run non-profit organization which would collect all health care fees, and pay out all health care costs. Health care delivery facilities like hospitals, doctors, nurses etc. remains in private hands and patients have guaranteed choice of care from providers. In U.S. Single Payer system is also known as Medicare for All. Single Payer system expands the cost-effectiveness and makes Medicare program more efficient to cover each and everyone in the United States. It creates a single-tiered system that covers all people equally regardless of age, income, employment, or diagnosis. This unified system would promote universal high quality healthcare, because quality of care would have to be kept high enough to be acceptable to all citizens.
U.S. has multi payer healthcare system. The collection of money for healthcare is done by government in the form of taxes from individuals and businesses; and the private insurance agencies in the form of premiums and other payments like co-payment and deductibles. In a similar fashion both agencies deliver the healthcare, private insurance agencies reimburses healthcare providers for the services used by privately insured individuals and government reimburses the healthcare service providers for the services used by publicly insured people like those enrolled in Medicare, Medicaid, SCHIP etc.
美國有多支付方醫(yī)療體系。政府以向個人和企業(yè)征稅的形式為醫(yī)療保健籌集資金;私人保險機構以保費和其他支付形式,如共同支付和免賠額。以類似的方式,兩個機構都提供醫(yī)療保健服務,私營保險機構向醫(yī)療保健提供者償還私人參保個人所使用的服務,而政府則向醫(yī)療保健服務提供者償還公共參保人所使用的服務,如參加醫(yī)療保險、醫(yī)療補助計劃、SCHIP等的人。
It is necessary to distinguish single payer from the ‘Socialized Medicine’ (as in United Kingdom), where the healthcare providing agencies are owned by the government. In single payer system government does not own the healthcare providing facilities. In socialized medicine the government owns the hospitals and the doctors and nurses are paid by the government. Single payer health system is a socialized health insurance system not a socialized medicine. In United States, Medicare can be viewed as a form of socialized health insurance, making it a kind of single payer system, where the doctors are in a private practice and are paid on a fee-for-service basis by the government, but it does not cover the whole population of United States. This kind of system has led to the rationing of healthcare in the country. If a person in capable to afford the care he gets it, and if he cannot afford, he doesn’t get it. According to Institute of Medicine, 18,000 Americans die because they don’t have health insurance. This is called rationing. The reason for this is that our system is not publicly accountable, no one in ultimately responsible for how the system works. In contrast, the Canadian health system in publically accountable so there’s no room for discrepancy, thus the single payer system in Canada is a success.
Currently U.S. healthcare system is expensive, inefficient and ineffective. U.S. spends nearly $8,160 per capita twice as much as other industrialized countries, but yet it is inadequate. Despite this, U.S. leaves 51 million uninsured and many other inadequately covered. U.S. spends more and gets less, reason being its patchwork system of for profit payers. U.S.’s private insures spend nearly one third of every dollar spent for healthcare on administrative costs and on those things that have nothing to do with it, for e.g. billing, marketing, overhead expenses, underwriting, huge profits and exorbitant executive pays. This make United States the most bureaucratic health care systemin the world. Single payer health insurance is the only way to recapture this wasted money. It would save around $400 billion annually, which is enough to provide comprehensive coverage to everyone without paying any extra. Also establishing a single payer health care system would provide a stimulus for the U.S. economy by creating 2.6 million new jobs and infusing $317 billion in new business and public revenues with another $100 billion in wages into the U.S. economy (source: Institute for Health & Socio-Economic Policy (IHSP) (2009). Single Payer/Medicare for All: An Economic Stimulus Plan for the Nation).
目前,美國的醫(yī)療體系是昂貴、低效和無效的。美國的人均支出接近8160美元,是其他工業(yè)化國家的兩倍,但這還不夠。盡管如此,美國仍有5100萬人沒有參保,還有許多人沒有得到充分的保障。美國花的更多,得到的更少,原因是它為利潤支付者拼湊的系統。美國的私人保險公司在醫(yī)療保健上花費的每一美元中,有近三分之一用于行政管理費用以及與醫(yī)療保健無關的其他費用,如帳單、營銷、管理費用、保險、巨額利潤和過高的高管薪酬。這使美國成為世界上最官僚的醫(yī)療保健系統。單一付款人的健康保險是回收這些浪費的錢的唯一方法。這將每年節(jié)省大約4000億美元,這足以在不支付額外費用的情況下為每個人提供全面的保險。也建立一個單一付款人醫(yī)療系統將提供一個刺激美國經濟創(chuàng)造260萬個新的工作崗位,并注入3170億美元的新商業(yè)和公共收入與另一個1000億美元的工資為美國經濟(來源:健康與社會經濟政策研究所(IHSP)(2009)。單一支付者/全民醫(yī)療保險:國家經濟刺激計劃)。
Peter Shumlin, newly elected governor of Vermont State, formally introduced the proposal of Single payer system in the state by 2014, which appears likely to be passed. If enacted, it will be first system of its kind in U.S. and Vermont will be the first state in U.S. to abolish most forms of private health insurance from the state and de-link health insurance from employment in the state.
However, the single-payer system also has some disadvantages that may make it unattractive to some. A single-payer system would lead to a wrenching change and create a huge, faceless bureaucracy. That prospect scares many physicians, even those who dread haggling with insurance companies over treatment for their patients. They also fear the power that would be conferred upon a single payer. The disadvantage that stands as the greatest obstacle to single payer is political in nature. At a time when many people feel that the private sector is better equipped to deliver high quality services to the population, it will be difficult to convince government agencies and politicians that government should take over the role of financing health care, especially when it would mean increased taxation. The government part of healthcare finance is inefficient because it fails to address key policy issues, fraud, and-for Medicaid- complex determination of eligibility. As health-care financing can become be a function of the federal government, it become sensitive to fluctuations in unexpected political climate. Budgetary adjustments in the healthcare system can have serious impacts on the quality of healthcare delivered.
然而,單一付款人系統也有一些缺點,可能使它對一些人沒有吸引力。單一支付者體系將導致一場痛苦的變革,并產生一個龐大的、面目不明的官僚機構。這一前景嚇壞了許多醫(yī)生,甚至包括那些害怕與保險公司就病人的治療討價還價的人。他們也害怕權力會被授予一個單一的付款人。單一支付方的最大障礙在于其政治性質。在許多人認為私營部門更有能力為民眾提供高質量服務的時候,很難說服政府機構和政客,讓他們相信政府應該接管為醫(yī)療保健提供資金的角色,特別是當這意味著增加稅收的時候。醫(yī)療保健金融的一部分是低效的,因為它不能解決關鍵的政策問題,欺詐,以及對醫(yī)療補助的復雜的資格認定。由于醫(yī)療保健融資可以成為聯邦政府的一項職能,它對意想不到的政治氣候的波動變得敏感。醫(yī)療保健系統的預算調整可能對提供的醫(yī)療保健質量產生嚴重影響。
Additionally, since this system virtually eliminates the private insurance companies, these wealthy and influential corporations would do everything in their power to prevent single payer from becoming a reality. The transition from the current health care system to a single payer would undoubtedly be very difficult. Thousands of people who work for private insurance companies would need to be shifted to other sectors of the economy. Though these individuals could be trained to work in the new system, they would still experience a significant change in their lives. More health care providers will be needed, and many insurance clerks can be retrained to enter these fields. Many people now working in the insurance industry are, in fact, already health professionals (e.g. nurses) who will be able to find work in the health care field again. But many insurance and health administrative workers will need a job retraining and placement program. Because of these considerations, most single payer advocates and policy analysts believe that any transition to a single payer system would necessarily be gradual, taking place over the course of many years.
此外,由于這個系統實際上消除了私人保險公司,這些富有和有影響力的公司將盡其所能阻止單一付款人成為現實。毫無疑問,從目前的醫(yī)療保健系統過渡到單一付款人將是非常困難的。成千上萬在私營保險公司工作的人將需要轉移到其他經濟部門。盡管這些人可以接受培訓,在新的系統中工作,他們的生活仍將經歷重大的變化。需要更多的醫(yī)療保健提供者,許多保險職員可以接受再培訓,進入這些領域?,F在在保險行業(yè)工作的許多人實際上已經是衛(wèi)生專業(yè)人員(如護士),他們將能夠再次在衛(wèi)生保健領域找到工作。但是許多保險和健康管理人員將需要一個工作再培訓和安置計劃。由于這些考慮,大多數單一付款人的支持者和政策分析人士認為,任何向單一付款人系統的過渡都必然是漸進的,需要經過多年的過程。
Profits of the pharmaceutical companies will drop because of government’s expanded role in purchasing prescription medication. Speaking for the entire population, the government would be able to negotiate lower prices for drugs, possibly by purchasing in bulk. Health care observers also fear that removing the profit motive from the health care system altogether would stifle investment and innovation in finding new treatments and drugs. If the federal government becomes the only payer, limiting potential profit, companies would be less likely to invest the huge sums necessary up front to develop new drugs and treatments. Reduction in profits margins for the pharmaceutical companies will lead to less money devoted to research and development and a minor slow down in technological advancement. It is said that money drives innovation, thus weakening or eliminating the profit-motive may cause technological slowdowns throughout the entire medical field.
由于政府在購買處方藥方面的作用擴大,制藥公司的利潤將會下降。就全體民眾而言,政府將能夠通過談判降低藥品價格,可能是通過批量購買。衛(wèi)生保健觀察人士還擔心,完全消除衛(wèi)生保健系統的利潤動機,將會抑制在尋找新治療方法和藥物方面的投資和創(chuàng)新。如果聯邦政府成為唯一的支付者,限制了潛在的利潤,公司就不太可能預先投資開發(fā)新藥和治療所需的巨額資金。制藥公司利潤空間的減少將導致用于研發(fā)的資金減少,技術進步也會略微放緩。據說,金錢驅動創(chuàng)新,因此削弱或消除利潤動機可能會導致整個醫(yī)療領域的技術放緩。
When the government lowers the price of health care and/or extends health insurance coverage for everyone, more people will want to use more health care services and the government has to find a way to ration care. Rather than rationing the healthcare by charging beneficiaries the full price of health care, they limit the budget of hospitals and physicians. Facing strict budgets that limit the amount of services they can provide, providers do not want anybody to take any of their budgeted dollars.
Another problem of a single-payer system is its reliance on rigid budgets. This will results in the demand for health care exceeding supply that, in turn, leads to rationing available care by forcing people to wait for long periods. That is a big cost and there are plenty of examples in which people in Canada have died while waiting on lists for 6 months to a year. Preventive care will not be promoted more because most of the available resources are allocated to acute or urgent care. In a single-payer system, however, there are limitations on budgets and prices which can limit the tasks performed by providers because no one is going to do additional tasks for which they will not be paid. Also there will be limitation to the ability of nurses to expand their practice in all settings. Under fixed and tight budgets, it will be difficult for the employers to increase wages in response to changing economic conditions. This could result in shortage of nurses, which will eventually negatively affect the willingness of many people to go into the nursing profession as alternative professions become more attractive financially. It is highly likely a single-payer system would lead to de-facto wage controls in the health care system, and the nursing profession would derive little benefit economically in addition to limited opportunities to advance professionally. Also the income disparity between medical specialties will shrink.
單一支付者體系的另一個問題是它對剛性預算的依賴。這將導致對保健的需求超過供應,進而迫使人們長時間等待,從而對現有的保健實行配給。這是一個很大的代價,在加拿大有很多人在等待名單6個月到1年的時候死亡的例子。預防性保健不會得到更多的推廣,因為大部分可用資源都分配給急癥或緊急護理。然而,在單一支付者系統中,預算和價格會受到限制,這可能會限制供應商完成的任務,因為沒有人會去做那些他們不會得到報酬的額外任務。此外,護士在所有環(huán)境中擴展實踐的能力也將受到限制。在固定和緊縮的預算下,雇主很難根據變化的經濟狀況提高工資。這可能會導致護士短缺,這最終會對許多人進入護理行業(yè)的意愿產生負面影響,因為替代職業(yè)在經濟上變得更有吸引力。單一付款人制度很有可能導致醫(yī)療保健系統的實際工資控制,而護理專業(yè)除了獲得有限的專業(yè)晉升機會外,在經濟上幾乎得不到什么好處。醫(yī)療專業(yè)之間的收入差距也將縮小。
Another argument against single payer is that if physicians are paid according to fee-for-service, there may be no incentive for doctors to try and control costs. Earlier, Managed Care became more prominent because physicians were unable to control their costs. Having the government reimburse physicians on a fee-for-service basis may encourage exploitation of the system. Lastly, it may not be easy to change some of the negative perceptions Americans have about a single-payer health care system, long lines, inefficient bureaucracy, restricted choice, and lack of quality care are some of the inaccurate complaints against single-payer systems. Government control of the health care system makes the rationing problem worse as governments attempt to slow the use of services by limiting access to modern medical technology. Under government management, both efficiency and quality of patient care steadily deteriorate.
This primer has endeavored to articulate the nature and advantages of a single payer system. Solutions that achieve universal health care through mechanisms that build on the current system of for-profit employer-based insurance, while potentially beneficial, do not achieve the philosophical purity, administrative simplification, or cost control potential that a single payer system achieves. Single payer, however, has significant potential disadvantages that must be addressed. Although many of the disadvantages can be avoided through proper management of the system (e.g. funding the system at a very high level and insuring adequate capacity), others represent true tradeoffs that the American public must debate in its mind. The time for such debates is now. In the current system, insurance companies have a financial incentive to avoid insuring the people who need it the most, which means that more and more Americans suffer every year. It is only a matter of time before some type of reform takes place, and single payer should be a reform option that should be seriously considered.
本入門已努力闡明的性質和優(yōu)勢的單一付款人系統。通過建立在當前以營利為目的的雇主保險體系基礎上的機制來實現全民醫(yī)保的解決方案,雖然可能是有益的,但無法實現單一支付系統所能實現的哲學純粹性、行政簡化或成本控制潛力。然而,單一付款人有重大的潛在缺點,必須加以解決。雖然許多缺點可以通過系統的適當管理來避免(例如,在一個非常高的水平上資助系統和確保足夠的容量),但其他一些缺點代表了美國公眾必須在頭腦中辯論的真正權衡。現在正是進行此類辯論的時候。在目前的體系中,保險公司出于經濟動機,不愿為最需要保險的人提供保險,這意味著每年有越來越多的美國人遭受損失。進行某種形式的改革只是時間問題,單一支付方應該是一個值得認真考慮的改革選項。
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