编辑部密歇根州民主党参议员候选人阿卜杜勒·埃尔-赛义德（Abdul El-Sayed）向选民提出了一个简单的方案。他说，试想一下，如果有一种医疗保险计划“没有保费、没有共付额、没有免赔额——当你需要时，就能获得医疗服务”。埃尔-赛义德和其他支持者将这一理念称为“全民医保”（Medicare for All）。
By The Editors Abdul El-Sayed, the Democratic candidate for Senate in Michigan, has a simple pitch to voters. Imagine, he says, a health-insurance plan with “no premium, no copay, no deductible — just healthcare when you need it.”El-Sayed and other proponents call the idea Medicare for All.
为每个人提供免费、随需应变的医疗服务听起来确实不错。目前，在美国众议院已有超过100位共同提案人支持建立全国性“全民医保”的立法，许多进步派人士也在今年秋季的竞选中以此为口号。
Free, on-demand care for everyone sure sounds good. Legislation to establish Medicare for All nationwide has more than 100 cosponsors in the House, with many progressives campaigning on the idea this fall.
但这里有一个问题：该提案与现行的联邦医疗保险（Medicare）实际运作方式几乎毫无相似之处。即使在乐观的假设下，它也会将数万亿美元的医疗支出转嫁到联邦预算上，同时可能导致医疗质量下降并限制医疗服务的获取。
There’s just one wrinkle: The proposal bears little resemblance to how Medicare actually works. Even under generous assumptions, it would shift trillions of dollars in healthcare spending onto the federal budget while potentially slashing quality and restricting access to care.
毫无疑问，当前的医疗体系充斥着成本飙升、企业不当行为、定价不透明和激励机制扭曲等问题，亟需改革。然而，一套更务实的改革议程不仅能让民主党在期中选举中获益，从长远来看，也更符合美国民众的利益。
No doubt, the current system — beset by soaring costs, corporate misconduct, opaque pricing and perverse incentives — needs fixing. Yet a more pragmatic reform agenda would serve Democrats better in the midterms and serve Americans better over the long term.
不难理解“全民医保”为何具有吸引力。传统的联邦医疗保险覆盖了几乎所有65岁及以上的美国人，以及数百万残障人士。大多数服务不受限制，且超过95%的医生参与其中。该项目广受欢迎并不令人意外。
It isn’t hard to see why Medicare for All has appeal. Traditional Medicare covers nearly all Americans 65 and over, along with millions of people with disabilities. Most services are offered without restriction, and more than 95% of physicians participate. The program’s immense popularity should come as little surprise.
然而，即便仅限于这一相对特定的群体，联邦医疗保险的运作也极其复杂且昂贵。据估计，十年内它将占政府借款的一半以上。该项目有时还会让老年人背负沉重的账单，包括保费和服务费在内的平均自付费用每年超过6000美元。就目前情况而言，照顾日益老龄化和多病的人群需要更多的财政收入；将联邦医疗保险扩展到全部3.43亿美国人，将极大地增加这些需求。若在没有保费、共付额或免赔额的情况下实施，意味着支出将出现前所未有的激增。
And yet, even when limited to this relatively targeted population, Medicare is fiendishly complex and costly. By one estimate, it will comprise more than half of government borrowing in a decade. The program also can leave seniors with hefty bills, with average out-of-pocket costs, including premiums and services, exceeding $6,000 annually. As things stand, more revenue will be needed to care for an older, sicker population; extending Medicare to all 343 million Americans will hugely increase those demands. Doing so without premiums, copays or deductibles implies an unprecedented surge in spending.
还必须强调，医院就诊往往也由赔付慷慨的商业保险计划交叉补贴。任何取消这类付款方的制度，要么需要投入多得多的资金来维持现有标准，要么就得大幅削减福利。政府主导的制度虽然可能减少寻租行为，但也会消除支持者所期待的创新动力——从最新癌症疗法到减重药物，无一例外。
It also bears emphasizing that hospital visits are often cross-subsidized by generous commercial plans. A system that eliminates such payers either will need to spend vastly more to maintain current standards or significantly reduce benefits. And while a government-run system might reduce rent-seeking, it would also remove incentives for the very innovations proponents want — from the latest cancer treatments to weight-loss drugs.
因此，实际上，埃尔-赛义德的提案很可能更接近医疗补助计划（Medicaid）。这项面向贫困人群的健康计划报销费率较低，历来不受医生欢迎。“有需要时就能获得医疗服务”因此更准确地说，可能意味着医疗资源配给和更长的等待时间。想把这个方案卖给选民，可没那么容易，因为大多数选民都希望继续保留雇主提供的保险。
In practice, then, El-Sayed’s proposal is likely to look more like Medicaid. The health program for the poor, with its low reimbursement rates, is notoriously unpopular among doctors. “Healthcare when you need it” might thus more accurately be described as rationing and longer wait times. Good luck selling that to voters, most of whom want to keep their employer coverage.
明确目标会有益。过去，全民医保的倡导者强调实现全民覆盖。如今，支持者似乎转而追求一种普惠的财务安全感——也就是让已参保者能够应对意外的高额医疗账单，以及保障范围和医疗网络的突然变化。这些问题要狭窄得多，可以通过更直接、更务实的方案来解决。
Clearer goals would be salutary. In the past, champions of Medicare for All emphasized universal coverage. Proponents now appear to be seeking a universal sense of financial security — that is, protection against shock medical bills or abrupt changes to coverage and networks among the insured. These are much narrower problems, and they can be addressed with more direct and practical solutions.
其中，《无意外费用法案》在很大程度上终结了医疗紧急情况下保险网络外医生开具意外账单的现象，但它仍未解决私人保险保障不透明的问题。让员工有更大的灵活性，可以选择医疗网络较窄但更稳定的保险计划，这些网络往往更能反映患者对医疗服务的实际需求。（大多数劳动者受制于雇主的选择。）事实上，这类计划已经开始受到 increasingly widespread 的欢迎。
The No Surprises Act, for one, largely ended unexpected bills from out-of-network doctors during medical emergencies. It nonetheless falls short of addressing the opacity of private coverage. Giving employees more flexibility to choose a plan with narrower but steadier networks — which often better reflect patients’ demand for services — would make sense. (Most workers are bound by their employers’ choices.) Already, such plans are gaining traction.
另一种思路是提供全面保障，确保消费者在承担与收入挂钩的免赔额后，不会因灾难性医疗支出而遭受巨额损失。这类保险可以保护消费者免于因医疗费用而倾家荡产，同时缩减日常医疗服务的保险覆盖范围，以建立一个真正有助于降低成本的市场。在这一理念的某些版本中，预防性医疗及其他服务则由税前账户支付。
Another approach involves a universal guarantee against catastrophic financial losses after an income-based deductible. Such coverage would protect consumers from financial ruin while scaling back insurance for routine care — with the goal of creating a genuine market to lower costs. In some versions of the idea, preventative care and other services are funded by pretax accounts.
这两种想法都并非毫无阻力，但都旨在让消费者安心，同时现实地权衡各种取舍。这个目标没有“全民医保”那么宏大，但也更有可能奏效。
Neither idea is free of opposition, but both seek to give consumers peace of mind while realistically balancing trade-offs. That’s a less extravagant ambition than Medicare for All. It’s also far more likely to help.
如需联系负责彭博社评论版社论的资深编辑，请联系 Timothy L. O'Brien，邮箱为 tlobrien@bloomberg.net。
To contact the senior editor responsible for Bloomberg Opinion’s editorials: Timothy L. O'Brien at tlobrien@bloomberg.net