In March 9, 2020, novel coronavirus pneumonia affected some of the drug stores in San Francisco Bay area. China News Agency
The United States is one of the highest drug prices in the world. According to statistics, nearly 28 million people in the United States do not have medical insurance, and at least 19 million adults have chosen to buy drugs in Canada or Mexico and other countries because of the high price of domestic drugs.
The strong demand for medical care has even spawned a set of medical industry chain with medical tourism as the core, attracting nearly 2 million Americans to seek medical treatment across the border every year.
The U.S. governments annual health care expenditure accounts for nearly 20% of GDP. Obviously, this huge amount of money has not benefited the American people.
Why is it so difficult for Americans to see a doctor?
Before the 20th century, health care in the United States was neglected for a long time.
At the beginning, American colonies relied on the assistance of private and local communities to establish a number of hospitals to provide medical services for the poor, mainly relying on religious organizations and government assistance to maintain operation, and medical care remained at the workshop level for a long time.
The government has done little in this field. Before and after the civil war, American States set up Health Council, but their functions were limited to strengthening health management and controlling infectious diseases. Public health and private health care are strictly separated, and public health officials are not even allowed to practice medicine.
In the 19th century, more and more doctors set up private medical schools to train doctors, treat patients and collect fees. The mode of private practice and charging service gradually formed, and private medical organizations also achieved great development. One of the most remarkable is the rise of the American Medical Association (AMA).
At the beginning of the 20th century, in order to eliminate low-level medical schools and increase the homogeneity and cohesion of the medical industry, American medical schools raised the banner of medical education reform; by 1915, the number of American medical schools decreased from 131 to 95, and the number of medical school graduates decreased from 5440 to 3536. The American Medical Association has become a national medical college accreditation institution, which has established its strong position in the American medical community.
At this time, after the industrial revolution and the baptism of the bourgeois revolution, most European countries had established the medical insurance system.
With the rapid development of social economy, only a small amount of public assistance can not meet the needs of the public health care, and the voice of health care reform in the United States is increasing.
In the early 20th century, the U.S. government repeatedly proposed the medical insurance bill to let government welfare intervene in the field of health care, but it was opposed by the doctors, and most of them were not passed.
In 1929, the Great Depression swept through the United States, and the unemployment rate soared. Under the promotion of President Roosevelt, the Social Security Act was passed smoothly in 1935, which gave the federal government the right to provide funds for maternal and child care and treatment of disabled children.
In the 1930s, the federal government established a private health insurance system represented by the third-party payment through the Blue Cross and Blue Shield programs.
The United States Blue Cross and Blue Shield medical insurance organization is composed of the double blue Federation and 39 independent Blue Cross and Blue Shield regional medical insurance companies.
Since then, the federal government continued to encourage the development of private medical insurance. During World War II, it provided financial support for insurance benefits not subject to wartime wage freeze. After the war, it provided tax incentives for it, which greatly stimulated the development of private medical insurance in the United States. From 1940 to 1955, the number of insured increased from 13 million to 100 million.
The National Hospital Construction Act of 1946 provided funds for the construction of hospitals in the United States. The medical industry is expanding rapidly. From 1947 to 1966, the number of hospitals in China increased from 4445 to 5736, and the admission rate also increased significantly. By the end of the 1950s, one out of every eight Americans could stay in the hospital once a year.
However, the U.S. government has been unable to really intervene in the field of health care.
The reason is very simple. If the government intervenes too much, it will squeeze the limited interest space, which is unacceptable to the private medical insurance which is used to the policy dividend.
In 1935, under the pressure of the American Medical Association, President Roosevelt deleted the content of medical insurance in the social security act;
The United States has failed to establish a universal health insurance system.
2. Medical insurance has been developed into a monster to eat money
The failure of health care reform in the first 50 years of the 20th century made reformers realize that the implementation of universal health insurance in the United States is facing strong resistance. If the government wants to intervene, it should target the most needy people and embark on the road of gradual reform.
The elderly have become the breakthrough point of health care reform in the United States.
In 1961, California representative Cecil king and New Mexico Senator Clinton Anderson jointly submitted the medical care bill to Congress, which was supported by President Kennedy. Under the bill, the government provides 90 days of hospitalization and 180 days of care for 17 million people over the age of 65 each year.
In 1965, the U.S. Congress passed the 18th amendment to the social security act of 1935. The medical care plan and medical assistance plan were incorporated into the social security system, and the U.S. government began to fully intervene in the field of health care. Since then, government subsidies have gradually concentrated in public medical institutions.
However, the dream of universal health insurance has not been realized, and the phenomenon of excessive consumption of medical resources in the United States is becoming increasingly serious. From 1960 to 1970, the cost of health care in the United States increased from 26.9 billion US dollars to 74.2 billion US dollars; during the same period, the federal governments health care related expenditure increased from 2.9 billion US dollars to 17.8 billion US dollars, an increase of more than five times, faster than the rate of inflation.
After the 1970s, in the face of the multiple pressures of the rapid rise of medical and health costs and stagflation, the medical insurance in the United States began to shrink in an all-round way. In the 1980s, in order to reduce the budget deficit, the Reagan administration significantly reduced health expenditure and funding for medical care and medical assistance, temporarily relieving the governments financial pressure.
Universal health insurance has been shelved again, while the endogenous problems of the American health care system have been ignored.
First, the coverage is narrow.
The United States is the only developed country that has not achieved universal health insurance. By 1991, more than 30 million Americans still had no health insurance.
Second, the cost is high.
Since the 1960s, the medical and health expenditure in the United States has been increasing continuously, with the annual growth rate higher than that of GDP for a long time, reaching 699.4 billion US dollars in 1990, 25 times higher than that 30 years ago.
In 1960, the national health care cost accounted for less than 6% of GDP. By 1993, the index had grown to 14%, which had become an important factor affecting the macro-economic situation of the United States.
Third, the distribution is unbalanced.
On the one hand, this imbalance is reflected in investment. The United States has always paid more attention to injury and experimental medical services, and the investment in preventive and health care services is insufficient, resulting in uneven quality of medical services.
By the end of the last century, the health care system in the United States had become sickly.
3. Can we solve the problem by changing it again and again?
Since the 1990s, the U.S. government has embarked on a long and tortuous road to reform.
In 1993, in his speech to Congress, Clinton proposed a grand plan to comprehensively reform the medical insurance system in the United States, namely, the medical (Health) Security Act
*We will implement a unified national health insurance system, implement the one person health card plan, and force employers to provide subsidies for employees to purchase private medical insurance;
*Relying on the expansion of insurance coverage, the governments medical and health expenditure will be reduced;
In order to raise funds, Clinton chose to cut the expenditure of existing health insurance programs, increase the tax revenue of tobacco beverage industry and private insurance companies, and increase the proportion of out of pocket personal medical services. As a result, it was boycotted by many parties and the effect of the policy was greatly reduced.
In 1998, the cost of health care in the United States was $1149.1 billion, or $4270 per capita, more than double the average of OECD member countries. In the same year, the proportion of health care expenditure in the United States accounted for 14% of GDP, 6% higher than the OECD average.
In 2003, George W. Bush signed the medical insurance Modernization Act, which increased the types of medical insurance and prescription drugs provided to the elderly, and initiated the personal medical savings account to promote the incentive mechanism focusing on medical quality.
Unlike Clinton, Republican George W. Bush is not eager to expand health care coverage, but focuses on minor repairs to existing mechanisms.
As a result, the pressure on the U.S. health care system has not eased. By the end of 2008, 46.34 million people were uninsured in the United States, accounting for 15.4% of the total population. From 1999 to 2009, the average wage in the United States increased by 33%, while the total cost of health care increased by 131%.
The per capita growth rate of health care expenditure in the United States and its percentage in GDP.
*We will continue to expand the coverage of medical insurance, force citizens to participate in insurance, and employers of enterprises to provide medical insurance for employees, standardize the business of insurance companies, and increase the coverage rate of medical insurance to 95%;
*To strengthen the role of the government, the federal government should take the responsibility of supervising private insurance companies, and establish medical insurance exchanges in each state to reduce the premium through joint bargaining;
*The federal government allocated 940 billion US dollars for medical insurance subsidies, provided tax incentives to enterprises that insured employees, raised income tax rates for high-income earners, and raised consumption tax standards for high-income medical insurance policies to raise funds for healthcare reform.
In 2010, the affordable health care bill, which was promoted by Obama, was passed. According to a report released by the U.S. Department of health and human services in 2016, the bill will bring health care benefits to 20 million people at the bottom.
In March 2010, Obama signed the health insurance reform bill.
In 2016, the proportion of health care expenditure in GDP in the United States has risen to 17.9%, and the fiscal situation is in short supply. Trump launched the American Medical Act to abolish compulsory medical insurance and reduce medical expenses, trying to correct the mistakes of Obamas health care reform.
According to the CBO, Trumps new health care law will reduce the federal governments deficit by $337 billion in the next 10 years.
4. Open the black box of medical service market
At present, the medical insurance system in the United States presents a fixed mode with private medical insurance as the main part and public medical insurance as the supplement.
Proportion of population covered by medical insurance in the United States over the years
As of February 2015, 21 million people have been covered by Medicaid in the United States, and 14 million people have been covered by other public health insurance plans; in the same period, in the field of private medical insurance, the employers subsidy scheme has covered 120 million people, and other forms of private medical insurance have covered 18 million people.
At that time, the total population of the United States was 321 million. It can be seen that only a few people can enjoy public health care.
[Note: private health insurance in the United States is mainly composed of two parts: employer sponsored group health insurance and individual purchased personal health insurance.
After decades of operation, the private health care system in the United States has not achieved the Pareto optimal expected by economists. Instead, it has been suffering from the dilemma of narrow coverage and soaring costs for a long time.
The reason is not complicated. Medical services are quasi public goods in essence, and can not completely rely on market mechanism to realize the effective allocation of resources and benefit most people.
The attribute comparison between medical service market and general commodity market.
In order to avoid risks and ensure profits, insurance companies usually refuse to provide insurance to low-income people or those with past medical history; moreover, they provide more unnecessary medical services to the insured, resulting in the waste of medical resources and the rise of medical costs, which promotes the rise of medical insurance costs.
The rise of medical insurance costs will lead to the decrease of the actual income level and the consumption ability of the insured, forcing the low-income groups to give up the insurance.
There is no special medical service pricing institution in the United States, and the pricing system is not open. Most of them are based on the hospital related service pricing and adopt negotiation pricing.
Generally speaking, every clinic and hospital in the United States has signed price discount agreements with several commercial insurance companies. The medical expenses of the insured patients are settled by the insurance company according to the discount price, and the patients without insurance can only pay out of their own pocket.
Moreover, the pharmaceutical industry in the United States is relatively concentrated. It is very common for a pharmaceutical factory to monopolize the production of certain drugs. This makes pharmaceutical companies have more chips when negotiating prices with insurance companies, forcing expensive drugs into the insurance catalog, resulting in higher premiums.
The soaring premium was eventually shared among the people, and some hospitals in the United States charged patients 10 times more than the actual cost of treatment. Seeing a doctor is more and more expensive and difficult.
In 2019, 25% of Americans said that in the past year, they or their families delayed treatment of serious injuries due to high medical costs.