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REFORMINGHEALTHCARESYSTEMANDDELIVERY改革医疗体系和服务LeiyuShi（石磊玉）,Dr.PH,MBA,MPAProfessorofHealthPolicy&ManagementDirectorofJohnsHopkinsPrimaryCarePolicyCenter约翰霍普金斯大学公共卫生学院卫生政策与管理系教授约翰霍普金斯大学基本医疗政策研究中心主任2017年6月(2017Copyrighted)Background背景•Reforminghealthcareisakeychallengeforalmosteverynation.几乎每个国家都面临医疗改革的挑战。•Low-incomecountries:providebasichealthcareacrossasmuchofthepopulationaspossible,forlittlemoneyandlimitedresources.低收入国家：以有限的资金和资源为尽可能多的人提供基本医疗服务。•Emergingeconomies:deliverhigh-qualitycareatapriceaffordabletotheirnewmiddleclassesunderavailableresources.新兴经济体：以可负担的价格和可用资源为中产阶级提供高质量的医疗服务。•Developednations:maintainequitableaccesstocareandqualitywhilecontrollingcosts(efficiency)andbalancingresources(distribution).发达国家：控制成本和平衡资源的同时保持获得医疗服务的公平和医疗质量。•Despitedifferencesinpriorities,containingcostandmaximizinglimitedresourcesarecommonchallengesforallnations.尽管优先级不同，控制成本和最大化利用有限资源是所有国家的共同挑战。HealthcareReformIsParticularlyChallengingforUSandChina医疗改革对美国和中国尤其具有挑战性TheUnevenDevelopmentWithinChina中国发展不均衡AdaptingtoChina’sSituation适应中国的情况•Mostpopulous(1.3billion),increasingagingpopulationandchronicallyill人口最多（13亿）老龄化、慢性病•Rankedasthe2ndlargesteconomy,but93rdinGDPpercapita第二大经济体，但人均GDP仅第93名Increasingdisparities(rich&poor,urban&rural,regional)日益严重的不均等（贫富、城市&农村、区域）•Healthcare:expensiveanddifficulttoaccess看病难，看病贵3HighCost,AverageOutcome,andLowEquityWithinUSA美国医疗成本高，效果一般、公平性低•Mostcostlyhealthcaresystemintheworld(specialization,medicaltechnology,multi-stakeholders,andinefficiency)世界上最昂贵的医疗体系（专业化，医疗技术，多方利益相关者和低效率）•Largeelderlypopulationandchronicallyill老龄化、慢性病•Disparitiesinaccess,quality,andoutcomeacrossracial/income/insurancegroups:anincreasingsocialproblem不同种族/收入/保险群体间在医疗可及性、质量和结果方面存在差距：越来越严重的社会问题EvolutionofU.S.HealthcareReform美国医疗改革的演变StrategiestoImproveUSHealthcareDelivery提升美国医疗服务的策略3.Discussion:ImplicationsforChina讨论：对中国之借鉴Roadmap1.EvolutionofUSHealthcareReform美国医疗改革的演变5EvolutionofUSHealthcareReform美国医疗改革的演变•Healthcarereformvs.healthinsuranceexpansion医疗改革与医疗保险扩张•ForcesbehindhealthinsuranceintheUS:美国医疗保险背后的力量-Technology(advancedtreatmentsbecameavailable,buttheywereexpensive)技术（先进的治疗方法成为可能，但是昂贵）-Social(desirabilityofmedicaltreatments)社会（医疗的可取性）-Economic(unpredictabilityofmedicalneedsandcostsoftreatment)经济（医疗需求和治疗费用的不可预测性）•Riseofprivateinsurance私人保险的崛起-1929–Modernhealthinsurancewasborn(BaylorPlanforschoolteachers,atBaylorUniversityhospitalTexas,aprepaidplan,themodelforBlueCross1929年-现代医疗保险诞生了（在得克萨斯州贝勒大学医院的贝勒保险计划为学校教师提供，一个预付费制保险，是蓝十字保险的模型）-1939–TheCaliforniaMedicalAssociationstartedtheBlueShieldplantocoverphysicianservices1939年-加州医学协会启动了蓝盾保险计划，覆盖医师服务•Privatehealthinsurancebecameemploymentbased私人医疗保险变为基于雇用-1948SupremeCourtdecisionlegitimizedhealthinsuranceasanegotiableiteminunion-managementbargaining1948年基于最高法院的决定，医疗保险合法成为工会管理谈判中可交涉的项目-1954taxruling:employercontributionsforhealthinsurancebecameexemptfromtaxableincomefortheemployee1954年税收裁定：雇主对医疗保险的缴款可作为该雇员的应纳税收入的免税额度EvolutionofUSHealthcareReform(Cont.)美国医疗改革的演变•Riseofpublicinsurance公共保险的崛起-Politiciansbelievedtherewouldbelessoppositionforprogramstargetedattheunderprivileged政治家认为针对弱势群体的方案将会得到较少反对-SocialSecurityAmendments,1965createdMedicarefortheelderlyandMedicaidforthepoor1965年的社会保障修正案建立了老年人医疗保险和穷人医疗补助保险-The1997StateChildren„sHealthInsuranceProgram(SCHIP)forchildren1997年建立儿童医疗保险计划•Failedactionsonnationalhealthinsurance未成功的全国医疗保险法案-1935-1940sF.Roosevelt‟snewdealandfailednationalhealthinsurancebills1935-40年代罗斯福的新协议和失败的国家医疗保险法案-1940s:HarryTruman:FirstUSPresidenttoproposenationalhealthinsurance20世纪40年代：哈里·杜鲁门：在美国由总统提出的第一个全国医疗保险-1990s:ClintonandBushproposals1990年代：克林顿和布什的提案-ReasonsforDefeatedNHIProposalsintheUnitedStates:PoliticalInexpediency(nothreattopoliticalstability),StakeholdersOpposition(medical,insurance,pharmaceutical,hospital),IdeologicalDifferences(individualismanddistrustofgovernment),TaxAversion(middleclassnotwillingtopayincreasedtaxestopayforthepoor)美国全国医疗保险建议失败的原因：政治失策（不威胁政治稳定），利益相关者反对（医疗、保险、药厂、医院），意识差异（个人主义和不信任政府），避税（中产阶级不愿意增加缴税、为穷人付钱）EvolutionofUSHealthcareReform(Cont.)美国医疗改革的演变•TheACAorObamaCare奥巴马医改-PatientProtectionandAffordableCareAct,2010患者保护与平价医疗法案2010-NotasingleRepublicanvotedinfavor,PresidentObamaunitedhisownpartybehindthelegislation;Backroomdealsweremadewithwafflingmembersandinterestgroups;TheAMAreverseditshistoricstanceinsupportingthelegislation没有一个共和党投票赞成，奥巴马总统团结民主党促成立法；与摇摆成员和利益团体达成幕后交易；美国医学会改变一贯立场支持立法-TheAmericanpublicwaskeptinthedarkaboutthedetails美国公众对细节并不了解-LegalchallengespushedthelegislationbeforetheSupremeCourt法律挑战将立法推向最高法院-ThemajorityofACAprovisionswereruledconstitutionalundertheCongress‟powertotax(theindividualmandate)大部分条款通过议会对于税收的权利被宪法裁定（个人强制）•KeyDifferencesbetweenACA(ObamaCare)andAHCA(TrumpCare)奥巴马医改与特朗普医改的主要区别-IndividualMandate(ACA:individualsarerequiredtoobtainACA-complianthealthinsuranceorfaceanannualtaxpenalty;AHCA:Taxpenaltywillbedropped.Instead,individualswhogoformorethantwomonthswithouthealthinsurancewillfacea“continuouscoverage”surchargeof30%whentheybuyanewinsuranceplan)个人强制（ACA：个人需要获得符合标准的医疗保险或面临年度税款罚款;AHCA：税款罚款条款被取消，取而代之的是对两个月以上没有保险的个人购买新保险计划