<div><figcaption style="box-sizing: border-box; margin: 0.625rem 0.9375rem 0.25rem; line-height: 1em; padding: 0px; font-family: Helvetica, Arial, Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif; font-size: 16px;"><br /></figcaption></div><div><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">台湾证明，即便是在现代，一个国家也能迅速让其医疗保健系统发生巨变。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">美国一直<a rel="nofollow" target="_blank" href="https://www.npr.org/2017/03/02/517915510/americas-complacent-class-how-self-segregation-is-leading-to-stagnation" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">做不到这么大胆</a>，这部分是因为政治僵局，部分是因为<a rel="nofollow" target="_blank" href="https://www.nytimes.com/2017/09/05/upshot/the-real-reason-the-us-has-employer-sponsored-health-insurance.html" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">受制于历史</a>。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">我们10月写过的<a rel="nofollow" target="_blank" href="https://www.nytimes.com/2017/10/02/upshot/what-makes-singapores-health-care-so-cheap.html" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">新加坡</a>，一直在对自己的医疗保健系统修修补补。相比之下，台湾是彻底改革。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">不到25年前，台湾的医疗保健系统系<a rel="nofollow" target="_blank" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3960712/" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">拼凑而成</a>，包括为私营领域从业者，或为政府或涉及农民或渔民的行业协会工作的人提供的保险。自付费用高昂，医生独立行医。1995年3月，一切都变了。</p> <p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">在同来自世界各地的专家交流过后，台湾选择让哈佛大学陈曾熙公共卫生学院(Harvard T.H. Chan School of Public Health)的经济学教授萧庆伦(<a rel="nofollow" target="_blank" href="https://prescriptions.blogs.nytimes.com/2009/11/03/health-care-abroad-taiwan/" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">William Hsiao</a>)带领一个工作组设计新系统。长期在普林斯顿大学担任教授的任赫德(Uwe Reinhardt)也做出了<a rel="nofollow" target="_blank" href="https://www.nytimes.com/2017/11/15/obituaries/uwe-reinhardt-a-listened-to-voice-on-health-care-policy-dies-at-80.html" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">重要贡献</a>。（<a rel="nofollow" target="_blank" href="https://theincidentaleconomist.com/wordpress/uwe-reinhardt-giant-mensch-knife-twister/" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">上月去世</a>的任赫德是“结语”专栏[Upshot]中一篇用锦标赛的形式，比较国际医疗体系的<a rel="nofollow" target="_blank" href="https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">文章</a>的专家组成员。）这个工作组对美国、英国、法国、加拿大、德国和日本等国家进行了研究。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">最后，台湾选用了类似美国的联邦医疗保险(Medicare)和加拿大的单一支付系统，而不是英国那种由政府运作的系统。起初，事情<a rel="nofollow" target="_blank" href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.3.61" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">不像预想的那么顺利</a>。尽管台湾为医改筹备了很多年，但在90年代初民主制度确立后，变化发生得非常快。包括医疗服务提供者和医院在内的医疗保健系统有些猝不及防，很多人觉得自己还没有准备好。然而，公众对这种变化的满意程度要高得多。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">今天，台湾大部分医院依然属于私营，大多是非营利性质的。大部分医生依然要么是按月领工资，要么是个体经营者。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">台湾提供的医疗保险颇为全面。住院和门诊治疗，以及口腔治疗、非处方药和中药都在保险范围内。它比美国的联邦医疗保险<a rel="nofollow" target="_blank" href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.3.61" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">全面得多</a>。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">就医过程也令人印象相当深刻。患者几乎可以从任何提供者或治疗中选择。等待时间短，患者无需转诊，便可直接接受专科治疗。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">保险费由<a rel="nofollow" target="_blank" href="http://international.commonwealthfund.org/countries/taiwan/" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">政府、雇主和雇员</a>共同承担。每个人支付的比例视收入而定，穷人支付的比例远低于富人。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">和其他国家一样，台湾的医疗保健成本涨幅超过了通货膨胀。在2001年，医疗共同支付增加。2002年，共同支付费用继续增加，保险费上涨。那两年，政府在看到患者人数“合理”后，也开始减少对服务提供者的补偿。政府还开始降低药品支出。最后，政府开始制定总体预算，为各种医疗费用的总金额设定上限，希望服务提供者提高效率。</p></div><div> <p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">与美国等国相比，台湾在医疗保健方面的投入占经济总量的比重要小。在21世纪初，台湾在医疗保健方面的花费占GDP的5.4%，到2014年，<a rel="nofollow" target="_blank" href="http://international.commonwealthfund.org/countries/taiwan/" title="Link: http://international.commonwealthfund.org/countries/taiwan/" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">这个比例上升至6.2%</a>。相比之下，经济合作与发展组织(OECD)成员国的医疗投入平均<a rel="nofollow" target="_blank" href="https://www.brookings.edu/opinions/taiwans-health-care-system-the-next-20-years/" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">占GDP9%以上</a>，而美国的比例大约是这个数字的两倍。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">在2010年的最近一次保险费上涨之后（这在台湾历史上只是第二次），<a rel="nofollow" target="_blank" href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2014.1332" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">该体系开始出现盈余</a>。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">这并不是说，这个体系是完美的。台湾的医生短缺越来越严重，医生们抱怨工资太低，工作太辛苦（尽管几乎每个体系的医生都有这样的抱怨）。台湾正在经历人口老龄化，人口出生率低，这将推动整体医疗费用的上升，而缴税的人口基数在变小。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">台湾在很多传染性疾病的治疗方面做得很好，但慢性病数量在增多，包括癌症和心脑血管疾病，这些疾病的治疗费用都很贵。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">该卫生系统的质量还可以更好。虽然OECD的数据不能用于通常的比较，但台湾的内部数据显示，<a rel="nofollow" target="_blank" href="https://www.brookings.edu/opinions/taiwans-health-care-system-the-next-20-years/" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">它有很大的改善空间</a>，尤其是在癌症以及初级保健的许多方面。台湾也许可以通过增加投入来解决其中一些问题。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">不过，<a rel="nofollow" target="_blank" href="https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html" title="Link: https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html" style="box-sizing: border-box; color: #004276; text-decoration-line: none;">正如我们在医疗保健系统之战中看到的那样</a>，每个系统都会有抱怨，美国的自然也不例外。而台湾作为一个在医疗保健方面花费相对较少的国家，已经取得了很大的成就。</p><p style="box-sizing: border-box; font-size: 1.125rem; line-height: 1.875em; margin-bottom: 1.75rem; color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif;">拿台湾和美国作比较就像是拿苹果和土豚作比较。一个领土面积小，人口只有2300万，而另一个幅员辽阔，拥有3亿多人口。不过，台湾比美国的大多数州都大。在过去几年里，包括佛蒙特州、科罗拉多州和加利福尼亚州在内的很多州已经在推动实行单一支付系统。然而，这些努力并没有取得成功，也许是因为美国人不像台湾人那么愿意打破原来的体系。</p></div><div> <span style="color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif; font-size: 18px;">无论你更喜欢哪种医疗体系，台湾的雄心展现出了可能性。</span><a rel="nofollow" target="_blank" href="https://www.cambridge.org/core/journals/health-economics-policy-and-law/article/evolution-of-taiwans-health-care-system/CB581709237F318332B254BBE8978EA1" style="box-sizing: border-box; background: #cccccc; outline: 0px; color: #004276; text-decoration-line: none; border-radius: 0.25rem; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif; font-size: 18px;">台湾经过五年的规划和两年的立法</a><span style="color: #333333; font-family: Georgia, "PingFang SC", "Heiti SC", "Microsoft Yahei", simsun, sans-serif; font-size: 18px;">才完成了这个转变。这比美国在《合理医疗费用法案》(Affordable Care Act)上争斗的时间要少，尽管后者可以拿出手的远不如前者。</span></div>