The real reason American health care is so expensive

I cannot tell you how obsessed I am with this chart. 
我不知該如何向你說明，我對這個圖表著迷的程度。

It shows exactly what is wrong with America's conversation about health care.
它完全顯示了美國在健保上面所面臨的大問題。

On one level,  you've seen this chart before.
在某個層面上，你應該看過這個圖表。

It shows health care spending as a share of the economy of a bunch of countries. 
它指出健保在各個不同國家經濟上的佔比。

There's Germany and France and Japan and Canada and oh! There's America.
這是德國、法國、日本、加拿大，然後，喔！還有美國。

But now I want to add something you haven't seen to this chart.
不過現在，我想要加入一些你們沒有看過的元素到這個圖表裡面。

This is how much of that spending in each country is private and how much is public.
這是健保佔比在各國當中，有多少為私人花費、有多少為公共花費。

Here's what's amazing: America's government spending on health care on programs like Medicaid and Medicare and the VA,
驚人的部分是：美國政府花費在健保項目上，比如：醫療補助、醫療保險還有退伍軍人照護，

Our versions of socialized medicine, it's about the same size as these other countries. 
我們國家的公費醫療制度佔比，已經幾乎同等於其他國家的全體佔比。

These countries where the government runs the whole health care system!
這些國家的政府負責維持整個健保制度的運作！

And then there's our private spending.
然後這塊是我們私人花費在健保的部分。

It's the private insurance system that makes health care in America so expensive. 
美國健保的價格之所以會如此高不可攀，全託那些非官方保險公司的制度所賜。

Conventional wisdom says the government is more expensive than the private sector.
傳統觀念上，大眾會認為政府提供的保險比私人公司所提供的還昂貴。

“It can't say no. It's corrupt, it’s inefficient, it's slow.”
“你們無法拒絕。這個制度腐敗、毫無效率，而且還非常緩慢。”

“If you want something done right, you give it to the private sector.”
“如果你們希望事情可以處理好，那就交由私人的保險公司來著手。”

That is what we hear in America all the time.
這些是我們在美國各地到處都可以聽到的流言。

And yet here we are with the biggest private sector spending the most.
不過事實上，我們卻讓私人保險公司坐擁最大占比的保險額，然後花費最多的錢。

Why is a free market so bad at controlling the cost of healthcare in the United States?
為何美國身在一個自由貿易市場，卻在控制健保成本上如此拙劣呢？

If you look at the data on physician visits and hospital discharges, you can get rid of one theory.
如果你觀察一下門診病患和出院病患的數據，或許可以暫且刪除掉一個理論。

Americans don't consume more health care than people in these other countries.
美國人與其他國家的國民比起來，消耗掉的醫療資源其實差不多。

We don't go to the doctor more than the Germans or the Japanese.
我們不比德國人或日本人還常去醫院報到。

In fact, we go to the doctor less.
事實上，我們比很多國家的國民都還少去醫院。

The difference between us and them is that we pay more. 
我們與其他國家的唯一差別就是我們花費更高。

Every time we go to the doctor for everything from an angioplasty to a hip replacement, from a c-section to a pain reliever,
每次我們就醫，從血管修復手術到寬關節置換術，從孕婦剖腹手術到止痛藥，

In America, the price for the same procedure at the same hospital, it varies enormously depending on who is footing the bill.
在美國，某醫院同樣療程的價格可能天差地別，而一切都取決於誰要負擔此筆費用。

The price for someone with public insurance like Medicare or Medicaid is often the lowest price.
如果這位病患享有保政府提供的公眾保險，比如：醫療保險、醫療補助，通常就能得到最優惠的價格。

These groups it covers so many people that the government can demand lower prices from hospitals and doctors and they get those lower prices.
這樣的群體因為涵蓋了太多人民，所以政府可以向醫院和醫生爭取更低廉的價格，因此這群人才能享受到最優惠的低價。

If the doctors and hospitals say “No,” they lose a ton of business.
如果院方不願意接受則將會損失一大筆交易。

They lose all those people on Medicare all those people on Medicaid.
他們會失去保醫療保險和領取醫療補助的病患所帶來的商機。

But there are hundreds of private insurance companies.
不過這裡也有數以百計的私人保險公司。

And they each cover far fewer people than a Medicare or a Medicaid.
它們各自涵蓋著遠低於投保公共保險的人數。

And each one has to negotiate prices with hospitals and doctors on their own. 
這些私人保險公司需要各自向醫院和醫生協商療程或藥物的價格。

And if you're uninsured, you have been less leverage.
而你若根本未投保，那麼你在這塊可以說是毫無影響力。

Nobody is negotiating on your behalf.
沒有人會替你協商醫療支出的價格。

So you end up paying the highest price. 
所以最後，你將成為在醫療體系中付出最高價格的肥羊。

One study found that most hospitals charge uninsured patients four times as much as Medicare patients for an ER visit.
有一個研究甚至指出，未投保任何醫療險的病患若到急診室就診，大部分的醫院將對其索討高於有投保病患四倍的天價。

Other countries, they don't have this problem.
在其他的國家，他們並不會面臨這樣的問題。

Instead of every private insurance company negotiating with every healthcare provider.
取而代之的是，每個私人保險公司將會與提供醫療保險的機構一一協商。

There's just this big list.
有一個列舉所有醫療項目的巨大名錄。

The country, the central government, they go and they say, “if you want to sell to us, to all of our people,
各個國家和他們的中央政府會告訴供應商，“如果你想要將這些項目賣給我們、賣給我們所有的人民，

then here's what you can charge for a checkup, here is what you can charge for an MRI or a prescription for Lipitor. 
那合理的健檢價格大概會落在這裡、合理的核磁共振檢查或降膽固醇藥物價格大概會落在這裡。’’

And so then whether that bill goes to the heavily regulated private insurance companies in Germany or directly to the government like in the UK,
因此，即便這筆帳單落在私人保險公司被嚴格監管的國家中，比如德國；或直接被政府接管，像是英國，

each country is telling the doctor or hospital or drug company how much that bill will be.
這些國家都將告訴醫生、醫院或藥商合理的價格區間。

And because the government controls access to all of the customers,
並且由於政府掌控所有病患的資訊，

it's an offer that hospitals and doctors and pharmaceutical companies typically can't refuse.
通常這些國家的醫院、醫生和藥廠不會拒絕政府的開價。

“I’m going to make him an offer he can’t refuse.”
“我要提出一個他無法輕易拒絕的價格。”

In America, the idea is that you'll be a consumer,
在美國，這樣的概念大概好比你身為一個顧客，

and you'll do what you do when you go to Best Buy and buy a television.
你會直覺性的到Best Buy購買你要的電視。（Best Buy：美國一家電子零售商。）

But that just doesn't work in healthcare.
但這樣的概念卻無法適用於健保制度。

It doesn't work in healthcare because you often come and get health care when you're unconscious, in an ambulance, when you're scared, when it's for your spouse or your child.
不適用的原因是，通常你需要用到健保時，你早已不省人事、在救護車上、感到害怕、或當它發生在你的配偶或小孩身上。

It is a time when you have the least bargaining power.
通常會發生在你最脆弱且沒有談判能力的情況下。

You are not usually capable of saying, “No.” 
基本上你沒有辦法拒絕。

You're not knowledgeable enough to do it, you're not comfortable doing it, or you're not conscious enough to do it.
因為你並未如此博學、這麼做使你感到不自在，或是意識不清晰。

That's why in other countries the government is a person who can say “No” for you.
這就是為何在其他的國家，政府握有替人民說“不”的權力。

You can say, “No, that's too expensive, you're going to have to lower your price.” because they do have that power. 
你可以說：“不，這樣的開價太貴了，你們需要調低價格。”因為政府的確握有這樣的權利。

A new push for single-payer health care right here in the US.
新的健保單一保險人制度正在美國被推動著。

What do we want?
我們的訴求為何？

Single-payer!
單一保險人制度！

When do we want it?
我們何時需要它被落實？

Now!
現在！

California and others are saying maybe we should adopt the European model.
加州和一些其他州表示，或許我們該承襲歐洲的榜樣。

If we decided to create a single-payer system with one of these huge prices lists in the US, there’d be nothing to stop lobbying from hospitals from doctors from drug companies.
如果我們最終決定在美國價格過高的醫療項目基礎下引進單一保險人制度，將會導致無法遊說醫院、醫生和藥廠的狀況。

And those prices would get influenced.
而這種情況下，這些醫療項目的價格將會產生波動。

So we could end up with a single-payer system that is expensive.
我們可能會淪落成擁有昂貴單一保險人體制的下場。

Even as expensive as our current system.
即使這樣的體制與我們當今的情況一樣。

It all depends on how much you negotiate down the prices.
這一切都取決於我們如何靠協商來降低醫療項目的價格。

And now in America these groups have so much power because they are so rich.
而當今在美國，這些團體因富有程度而掌握了極大的權力。

That it's really hard to get them to bring down the prices. 
因此很難指望他們來降低這些醫療項目的價格。

This is the irony of American healthcare: it's so expensive that it's become hard to make it cheaper.
這是美國健保體系最諷刺的地方：它的價格已經高到一定的程度，使降價成為不可能的任務。

All that money they make, that becomes political power. 
他們靠這樣的體系賺來的錢，全成為在政治上談判的籌碼。

And years and years and years of overpaying, those are huge industries now.
年復一年的鉅款，如滾雪球般地成為一個龐大的行業。

And they have a lot of influence in Congress.
他們在議會也坐擁巨大的影響力。

Under a single-payer system if we did drive prices down, doctors and hospitals
they would be paid less than they are right now.
如果我們在健保單一保險人制度落實下，將各種醫療項目的價格調降，那麼醫生和醫院所得則會減少。

That might mean some of them closed or some go out of business or some move.
這代表在醫療體系的族群可能會面臨歇業、出走或是遷移。

It would be really painful. 
這將會是非常惱人的問題。

One person's waste is another person's essential service or local hospital or their income.
個人的浪費或許等同於他人基本需求、當地醫院資產亦或他們的收入。

But then single payer it's not an all-or-nothing choice.
但單一保險人制度非一個不全則無的選項。

For instance, there's a really interesting section of Bernie Sanders Medicare-for-all bill.
例如，在Bernie Sanders撰寫的文章“給大眾的健保’’中，有一個很有趣的段落。

Where he lays out this interim plan.
他在此展示出一份過渡期計畫。

It's a plan he wants while he’s setting up his new single-payer system.
他想要在佈局新的單一保險人制度前，先執行這份計畫。

And in that plan, he expands Medicare to cover vision and dental.
在這份計畫當中，他將醫療健保的範疇擴張到眼科和牙科。

And he opens it to nearly everyone.
並且幾乎對所有國民開放。

Not just people 65 and older.
不受限於65歲以上的國民才能參加。

All kids go on Medicare automatically and most adults can buy in. 
所有的孩童自動入保，且大部分的成人也可以投保。

That plan, on its own, it wouldn't get American health care spending far down overnight. 
這樣單一的計畫，不太可能一夕之間將美國人的醫療開銷比率大幅降低。

But it would at least begin to recognize what we already know and what most of other countries already do.
但至少這會讓我們開始意識到眾所皆知的事實，且悉知其他的國家所達到的成就。

That health care is one of those things the government can do cheaper and better than the private sector.
這樣的健保制度，是政府可以做的比非官方保險公司還好且更便宜的事情之一。

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