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Question

美国是所有工业化国家中惟一不给其全体国民直接提供基本医疗服务的国家，但其有较为完善的商业保险，政府为老年人和低收入人群提供了医疗保障。本文试图通过考察分析美国医疗保险制度，结合我国基本国情和医疗保障体系现状，得出建立健全医疗保障体系需要充分考虑基本国情、需要体现社会公平和效率、需要与医药卫生体制改革同步、需要多管齐下多途径保障的启示，提出构建适合国情的医疗保障体系构想。

笔者在美国学习考察期间，重点考察了美国医疗保险制度，试图以此为鉴，得以启示，结合我国基本国情和医疗保障体系现状，提出构建适合国情的医疗保障体系的构想。

一、美国的医疗保险制度概况

美国的医疗保险制度由私人医疗保险和社会医疗保险构成。美国是所有工业化国家中惟一不给其全体国民直接提供基本医疗服务的国家，对一定贫困线以下的人口却有专门的免费公共医疗服务，但是如果一个家庭收入超过这一贫困线，就没有权利享受这种免费的医疗服务。美国的医疗保险制度大致如下：

（一）私人医疗保险

美国私人保险的一大特点是雇主为雇员支付保险金(Employer-Provided Insurance)，这种情况约占90%。这是二战期间政府实行工资和价格管制的一种意外结果。由于医疗保险保健属于非工资福利，当时不受政府管制，雇主便用它来吸引工人。当然，这种情况也有美国所得税税法中某些条款上的原因。

80年代以前，多数私人保险公司支付保险金的办法都是实报实销 (Cost-Based Reimbursement)，但是这种机制不利于鼓励人们节约，面临急剧高涨的医疗费用，保险公司便设法改用其它办法，其中最主要的便是"按人收费"(Capitation-Based Reimbursement)方法。按这种方法，医疗单位每年按人收取一定的医疗费用。"医疗保障组织"(HMOS)是一个规模较大的医疗保险组织，就以这种方法为主。但是，这种方法也有弊端，主要是选择性较差。

(二)社会医疗保险

美国政府的医疗保险是一种特指的社会保险制度属于政府资助的社会保险项目。它起始于1965年，是为了向65岁以上的老年人提供医疗保险，是仅次于社会保障项目的第二大政府财政支出项目。医疗保险项目由联邦政府负责管理，各州间政策统一。

政府建立了三类主要医疗保险项目：医疗保险(Medicare)，医疗补贴(Medicaid)和通过联邦所得税税制对私人保险的隐含补贴。政府医疗补贴(Medicaid)项目，在很大程度上带有财政转移支付的功能。医疗补贴项目与医疗保险项目的区别是，前者是为贫困者而设，医疗补贴大约包括了低收入者住院治疗费用的80%，不足部份通过医院对私人投保者提高收费来解决。后者是为老年人而设，二者之间没有直接联系。由于私人保险公司自身不可能胜任规模如此庞大、涉及面如此广的医疗保险，政府介入老年人医疗保险市场。医疗保险中隐含的政府补贴按照联邦税法，个人的工资收入需要同时交纳社会保险工薪税和个人所得税。由雇主交纳的医疗保险费不必交税。自我雇用的私人业主，医疗保险费用的25%是免税的。

Answer 1

The United States is in all industrialized countries not only to direct all its nationals to provide basic medical services, but there are better commercial insurance, the elderly and low-income people to provide medical protection. In this paper, the United States of trying to study medical insurance system, the combination of China's basic national conditions and medical security system status quo, that establish a sound medical security system need to give full consideration to the basic national conditions and needs of social equity and efficiency, need to synchronize with the medical and health system reform, needs more Under the multi-pronged way to protect the Enlightenment, the proposal of building a suitable conditions in the medical security system concept.

I study in the United States During the inspection, mainly inspected the U.S. medical insurance system, trying to draw a lesson from this, to enlightenment, with China's basic national conditions and medical security system status, conditions for the proposal of building a medical security system concept.

First, the U.S. medical insurance system Overview

U.S. medical insurance system by private medical insurance and social medical insurance posed. The United States is in all industrialized countries not only to direct all its nationals to provide basic medical services, some of the population below the poverty line there are special free public medical services, but if a family income over the poverty line, there is no right Enjoy this free medical services. U.S. medical insurance system is as follows:

(A) private medical insurance

U.S. private insurance is a major feature of the employer to pay insurance premiums for employees (Employer-Provided Insurance), such cases accounted for about 90 percent. This is the practice during World War II wage and price controls as a result of the accident. As medical insurance health of the non-wage benefits, was not subject to government regulation, employers will use it to attract workers. Of course, this situation has the United States income tax on certain provisions in the tax laws of reason.

Before the 1980s, most private insurance companies to pay for insurance are accountable (Cost-Based Reimbursement), but this mechanism is not conducive to encourage people to save, facing rapidly rising medical costs, insurance companies would try to switch to other methods, The most important is "the charges were" (Capitation-Based Reimbursement) method. According to this method, medical units a year by collecting a certain medical expenses. "Health care organizations" (HMOS) is a large-scale medical insurance organizations, based on in this way. However, this method has drawbacks, is less selective.

(B) social health insurance

The U.S. government's medical insurance is a specifically the social insurance system of government-funded social insurance item. It started in 1965, to the elderly over the age of 65 to provide medical insurance, social security is second only to the Government's fiscal second-largest expenditure item. Medical insurance coverage from the federal government responsible for the management, policy coherence among the states.

The Government had established three categories of major medical insurance coverage: health insurance (Medicare), medical subsidies (Medicaid) and the tax system through the federal income tax on private insurance, the implied subsidies. Government medical subsidies (Medicaid), to a large extent with the financial transfer payment functions. Medical subsidies and medical insurance project is the difference between a project, which is designed for the poor, about health care subsidies to low-income, including the cost of hospital treatment of 80 percent, less than most private insurance through the hospital to raise fees to resolve. The latter is designed for the elderly, there is no direct link between the two. As private insurance companies can not own such a large scale of competence, such a wide scope of medical insurance, government intervention in the elderly health insurance market. Medical insurance implied in the federal tax laws in accordance with government subsidies, individual wages need to pay social insurance payroll taxes and personal income tax. By the employer to pay medical insurance premiums do not have to pay tax. Self-employed by private owners, and medical insurance costs of 25 percent is tax-free.

Answer 2

U.S.A. all industrialized country only to give all people their offer basic medical treatment service country directly, but it has comparatively complete business insurance, the government has offered the medical guarantee to the elderly and low income crowd. This text attempt, through investigate, analyze system, medical insurance of U.S.A., combine of our country fundamental realities of the country and medical security system current situation, obtaining and setting up and amplifying the medical security system needs fully considering the fundamental realities of the country, need, reflect society fair and efficiency, need, in pace with system reform of medical and health, need multicell to lay many route ensure enlightenment together, put forward and construct the medical security system idea suitable for the national conditions.

I have investigated U.S.A.'s medical insurance system especially during learning to investigate in U.S.A., attempt to use this as a guide and mirror, must use enlightenment, combine the fundamental realities of the country of our country and medical security system current situation, put forward the idea of constructing the medical security system suitable for the national conditions.

First, medical insurance system overview of U.S.A.

The system of medical insurance of U.S.A. is formed by private medical insurance and social medical insurance. U.S.A. all industrialized country only to give all people their offer basic medical treatment service country directly, but have special public medical care of charge free to the population under certain poverty line, but if a family income exceeds this poverty line, have no right to enjoy such free medical care. The medical insurance system of U.S.A. is roughly as follows:

(1) private medical insurance

A big characteristic of U.S.A.'s private insurance is that an employer pays the insurance premium (Employer-Provided Insurance) for employees, this kind of situation accounts for 90%. This is a kind of accident result implementing salary and price control of government during World War II. It is not the salary welfare because of health care of medical insurance, not controlled by the government at that time, the employer attracts workers with it. Certainly, this kind of situation has a reason on some clauses in American income tax tax law too.

Before the eighties, most private methods of paying insurance premium of insurance company were all to reimburse the cost (Cost-Based Reimbursement), but this kind of mechanism is unfavorable to encouraging people to save, face the sharply surging hospitalization cost, the insurance company tries to use other methods instead, among them the main one " charges the method according to people " (Capitation-Based Reimbursement). In this way, the medical unit collects certain hospitalization cost according to people every year. It is organized, take this kind of method as the core by a larger medical insurance that " medical treatment ensures organizing " (HMOS). However, this kind of method has a drawback, is mainly that an alternative is relatively bad.

(2) social medical insurance

The medical insurance of the U.S. government is that a kind of social insurance system referred in particular to belongs to the social insurance project of government's subsidy. It originates in 1965, offers the medical insurance to the elderly to 65, second only to the second major government finance expenditure in the social security project. The medical insurance project is managed by federal government, the policy is unified among every state.

The government has set up three kinds of main medical insurance projects: The medical insurance (Medicare), replenish (Medicaid) in medical treatment and through implying and replenishing to private insurance of tax system of federal income tax. Government medical treatment replenish project, function with financial transfer payment to a great extent. The difference of replenishing the project and medical insurance project of medical treatment is, the former is designed for poverty person, it is probably including hospital treatment expenses of the low income person 80% for medical treatment not to replenish, insufficient component improve, charge, solve through hospital to person who insures individual. The latter is designed for the elderly, has not got in touch directly between the two. Because private insurance company oneself competent at scale to be so huge involving surfacing so wide medical insurance while being impossible, the government gets involved on market of the elderly's medical insurance. The implicit government replenishes according to the federal tax law in the medical insurance, the personal salary income needs to pay social insurance salary tax and Individual Income Tax at the same time. The medical insurance premium paid by the employer needn't be paid duty on. The private owner employed oneself, 25% of the medical insurance premium are duty-free.