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David Chan
Why is healthcare in the United States so expensive when compared to other countries which provide treatment of comparable or better quality?
There is a long list of reasons but here's a start.

美國的醫(yī)療費用為何遠高于其他國家，尤其是考慮到其他國家提供的醫(yī)療服務(wù)質(zhì)量相當(dāng)甚至更好？這里有很多原因，以下是一些主要的解釋：

1. Americans won't permit or accept healthcare rationing. America spends much more for care in the last 6 months of life than any other country. By a lot.
Walk through any ICU and you'll routinely see some people in vegetative conditions with virtually no chance of getting better. Yet they are receiving a full court press with anything and everything that can be done from the standpoint of medical technology.

美國人通常不接受醫(yī)療服務(wù)的配給制度。美國人在生命最后6個月的醫(yī)療費用比其他任何國家都要高,高出好多。
走過任何一個重癥監(jiān)護室，你都會經(jīng)常看到一些人處于植物人狀態(tài)，幾乎沒有好轉(zhuǎn)的機會，但他們?nèi)匀辉诮邮茚t(yī)療技術(shù)所允許的一切手段，進行全面而竭盡全力的治療。
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Some of the push for this care comes from families who are adamant against witholding or withdrawing care. But doctors are also guilty of over-treatment. We all know some crazy doctors who believe that miracles can happen daily in the ICU regardless of how hopeless the situation may be.

這種對治療的堅持部分源自那些堅決反對減少或停止治療的家庭成員。同時，醫(yī)生們也難辭其咎，他們有時會過度治療。我們都聽說過一些醫(yī)生，他們堅信在重癥監(jiān)護室里，不管情況多么絕望，總有奇跡發(fā)生。

The expense is enormous and American families are divorced from it. If the patient is uninsured, the costs are absorbed by the treating hospital and the doctors. If the patient is insured, the deductible has been met and the rest is paid for by insurance or via the taxpayers .

這筆開銷極為龐大，美國家庭卻往往與之脫節(jié)。若患者未投保，相關(guān)費用便由治療醫(yī)院和醫(yī)生承擔(dān)。若患者已投保，一旦滿足了免賠額，剩余費用便由保險公司承擔(dān)，或者通過納稅人資金支付。
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You won't see this in any other country with a national health service. Elderly patients don't get started on dialysis in the NHS in England. They die of kidney failure. You won't see 75 or 80 year olds getting quadruple bypass surgery either. Cancer patients in Canada and England routinely don't get $10,000 a month drugs for cancer treatment that prolongs life by several months (on average). The drugs either aren't available at all like in Canada (where some cancer drugs never get approved), or they are made virtually unavailable through a lottery in England.

在其他國家的國家衛(wèi)生服務(wù)體系中，你不會見到這樣的做法。例如，在英國的國家衛(wèi)生服務(wù)（NHS）中，老年患者通常不會開始接受透析治療，而是會因腎功能衰竭而去世。同樣，你也不會看到七八十歲的老人接受四重搭橋手術(shù)。在加拿大和英國，癌癥患者通常無法獲得每月高達1萬美元、平均只能延長幾個月生命的昂貴抗癌藥物。這些藥物在加拿大可能根本無從獲得（因為有些抗癌藥物從未獲得批準(zhǔn)），或者在英國，它們通過一種抽簽制度幾乎變得不可及。

2. Americans pay much more for pharmaceuticals than anyone else in the world. The American government, under pressure from the Big Pharma lobby, refuses to negotiate discount rates for Medicare. So Americans pay 30% to 300% more than Canadians for the identical drug made in New Jersey or California.

美國在藥品上的花費遠高于世界其他國家。在美國政府受到大型制藥業(yè)游說團體的影響下，拒絕為聯(lián)邦醫(yī)療保險（Medicare）提供折扣價格談判。因此，美國人為同樣的藥物支付的費用比加拿大人高出30%至300%——盡管這些藥物可能是在新澤西或加利福尼亞制造的。

3. There is gigantic waste and fraud in Medicaid and Medicare programs. Billing is electronic and payment is automatic. Auditing is very expensive and apparently very rarely occurs. It's so lucrative and easy to skim hundreds of millions of dollars per scheme that organized crime is now involved.

在美國聯(lián)邦醫(yī)療保險（Medicare）和聯(lián)邦醫(yī)療補助（Medicaid）項目中，存在著巨大的浪費和欺詐問題。賬單是電子化的，支付是自動完成的。審計過程不僅成本高昂，而且顯然很少執(zhí)行。由于通過欺詐手段從這些計劃中騙取數(shù)億美元的收益巨大且操作簡單，現(xiàn)在連有組織的犯罪集團也參與其中。

There are reasonable estimates that the fraud is $120-$180 billion a year. This are astronomic numbers.

據(jù)合理估算，每年的欺詐金額在1200億到1800億美元之間，這是一個天文數(shù)字。

Comments are frequently made about how efficient Medicare and Medicaid are because they have such low administrative costs compared to insurance companies. (It's pretty difficult to scam insurance companies for large amounts of money.) But the administration of Medicare/Medicaid includes the Department of HHS and also various law enforcement arms of the federal government. That's not cheap. And it's apparently not very effective either.

人們經(jīng)常稱贊聯(lián)邦醫(yī)療保險（Medicare）和聯(lián)邦醫(yī)療補助（Medicaid）的效率，因為與保險公司相比，它們的行政成本要低得多。（要從保險公司那里騙取大量資金相當(dāng)困難。）但是，Medicare/Medicare的行政管理不僅涉及衛(wèi)生及公共服務(wù)部（HHS），還包括聯(lián)邦政府的多個執(zhí)法機構(gòu)。這并不便宜，而且顯然效果也不盡人意。

4. Americans demand immediate access to technology. We want the ability to get an MRI tomorrow or that latest diagnostic test and treatment reported on CNN. That kind of access is incredibly expensive both in overhead — to build the facilities and purchase the machines — let alone the costs of the procedures.

美國民眾期望能夠即刻獲得技術(shù)資源。他們希望能夠迅速預(yù)約到磁共振成像，或者是在美國有線電視新聞網(wǎng)上看到的最新診斷測試和治療方法。這種即時獲取技術(shù)的能力，其代價極為昂貴，不僅包括建設(shè)醫(yī)療設(shè)施和購置昂貴設(shè)備的成本，還有執(zhí)行這些程序所需的費用。

We Americans want these tests sometimes, even when they are considered not necessary for good health. We ask our doctors to rule out the 1 in 10,000 event. It's human nature to want the latest and greatest of everything. But its never free and this kind of medical care costs a tremendous amount of money.

即使有時候這些檢查對于維持健康并非必要，美國人仍然希望進行這些檢查。我們請求醫(yī)生排除那些極小概率的事件。追求最新最好的一切是人類的本能。但它從來不是免費的，這種醫(yī)療服務(wù)需要花費大量的錢。

5. The wasteful practice of defensive medicine. In America there are enormous numbers of unnecessary tests and scans that are performed by a doctor to cover his/her ass just in case of a lawsuit. It's impossible to practice in America without facing the threat of litigation. I, and every doctor answering honestly, will admit to ordering defensive tests.
I've seen estimates of $600+ billion a year in unneeded tests and procedures done primarily to avoid litigation. That's a lot of money that could otherwise go to insuring the uninsured. Opponents to tort reform quote very small numbers because they only use the cost of defending lawsuits in their equation. But that's a drop in the bucket compared to what doctors in America waste so that no one will accuse them of "missing something."

美國存在一種防御性醫(yī)療的浪費做法。醫(yī)生們?yōu)榱吮苊饪赡艿脑V訟，會進行大量不必要的檢測和掃描，這種做法造成了巨大的資源浪費。在美國，醫(yī)生在執(zhí)業(yè)時無法忽視訴訟的威脅，我以及每一位坦率的醫(yī)生都會承認曾經(jīng)開具過出于防御目的的檢查單。
我見過估算顯示，每年因不必要的檢測和手術(shù)而浪費的金額超過6000億美元，這些檢測和手術(shù)主要是出于避免訴訟的考慮。這筆巨額資金本可以用于為未投保人群提供醫(yī)療保險。反對醫(yī)療事故改革的人在他們的論據(jù)中只提到了很小的數(shù)字，因為他們僅考慮了應(yīng)對訴訟的費用。然而，與美國醫(yī)生為了避免被控告“漏診”而浪費的資金相比，這僅僅是滄海一粟。
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6. Regulation and certification. The regulatory process in America has become so burdensome for hospitals, clinics and physicians that to meet compliance standards, a small army of administrators and attorneys are needed to go through them. After the ACA was implemented, many doctors had to join healthcare systems to navigate them. Over the past 10 years, our clinic administrative staff more than doubled. Similarly the hospital administrative staff have increased as well to meet regulatory requirements and pass the various inspections that accompany them. There are numerous fees and licenses involved in medical care today. There is a financial cost to this that gets passed on to insurance payers.

監(jiān)管和認證。
對于醫(yī)院、診所和醫(yī)生來說，美國的監(jiān)管程序已經(jīng)變得如此繁重，以至于為了達到合規(guī)標(biāo)準(zhǔn)，需要一小群管理人員和律師來通過這些程序?！镀絻r醫(yī)療法案》實施之后，為了適應(yīng)新的規(guī)章制度，許多醫(yī)生選擇加入了大型醫(yī)療系統(tǒng)。在過去十年里，我們診所的行政管理人員數(shù)量翻了不止一番。醫(yī)院同樣擴充了行政團隊，以確保符合各項規(guī)定并通過必要的各項檢查。醫(yī)療行業(yè)如今需要處理大量的費用和許可證問題。這些相關(guān)的財務(wù)開銷最終會轉(zhuǎn)嫁到保險公司，由它們支付。

Glyn Williams
I notice that you don't explain why for a given simple procedure, an American hospital might charge 10X more than the same procedure in the UK.

我注意到你沒有解釋為什么在美國，相同簡單的醫(yī)療程序，醫(yī)院的收費可能是英國的10倍。

Ben Levy
An American hospital, for a simple procedure, might charge 40x more than the same procedure done in another hospital in the US. 10X is nothing.
The costing and billing procedures used here are insane.
Data Reveal Hospital Charges Vary Widely for Same Procedure

在美國，即使是簡單的醫(yī)療程序，一個醫(yī)院的收費可能比美國國內(nèi)其他醫(yī)院高出40倍。相比之下，10倍根本不算什么。這里的成本計算和賬單程序簡直荒謬。數(shù)據(jù)顯示，即便是同一醫(yī)療程序，不同醫(yī)院的收費也存在巨大差異。

Chris Baer
I believe this is largely driven by using people who can pay to subsidize people who cannot pay.
In the US, hospitals are required to treat all patients in the emergency department regardless of whether the patient can pay. So, the hospital passes that charge along to the next guy who can pay.
Also hospitals typically have far more overhead than smaller ambulatory surgery centers and clinics. Simply being larger leads to more bureaucracy and complexity which needs staff. Example of complexity: academic medical center has PET scan, MRI, CT. Small community hospital only has CT. So staff at the academic center need to be either more competent or else have more staff to ensure all the systems are operated correctly.

我認為這主要是因為有能力支付的人在補貼那些無力支付的人。
在美國，醫(yī)院必須依法治療急診室的所有病人，不管他們是否有支付能力。因此，醫(yī)院將這些成本轉(zhuǎn)嫁給下一個有能力支付的病人身上。
此外，醫(yī)院通常比小型的門診手術(shù)中心和診所有更高的運營成本。規(guī)模的擴大導(dǎo)致了更多的官僚機構(gòu)和復(fù)雜性，這就需要更多的員工。例如，一個學(xué)術(shù)醫(yī)療中心可能擁有PET掃描、MRI、CT等設(shè)備，而小型社區(qū)醫(yī)院可能只有CT。因此，學(xué)術(shù)中心的工作人員要么需要更有能力，要么需要更多的工作人員來確保所有系統(tǒng)的正確運行。
這主要是因為有能力支付的人在補貼那些無力支付的人。這正是保險的作用，但有了（國家）保險，保費合理，貢獻者眾多，醫(yī)院和醫(yī)生不能隨意制定高得離譜的賬單。

In contrast, it sounds like in the UK:
1) there is more rationing which I read to mean more smaller community hospitals vs large academic centers
2) the hospitals aren't worried about patients not being able to pay, so costs are "true" per patient as opposed to including a subsidy for someone else.

相比之下，英國的情況似乎是：
實行了更多的配給制度，我理解為這指的是相比大型學(xué)術(shù)醫(yī)療中心，有更多小型的社區(qū)醫(yī)院。
醫(yī)院不必擔(dān)心病人無力支付醫(yī)療費用，因此每個病人的成本是“真實”的，并不包括對其他病人的補貼。

John Barber
I believe this is largely driven by using people who can pay to subsidize people who cannot pay. Well that’s exactly what insurance is, except with (national) insurance the premiums are reasonable, the pool of contributors is huge and the hospitals and doctors can’t just make up ridiculously high bills on an ad hoc basis.

我認為這種情況主要是由于有能力支付的人群在資助那些無力支付的人。這實際上就是保險的工作原理，但國民保險的特點是保費合理，參與的人數(shù)眾多，醫(yī)院和醫(yī)生不能隨意制定過高的醫(yī)療費用。

Hari Raghavan
As Glyn Williams indicates, the hospital system also deserves a big chunk of the blame: they are wildly lacking in price transparency (hospitals within a few miles of each other charge 5-10x the price of others), which doesn't introduce anything resembling competition or efficient pricing into the marketplace.
Additionally, I absolutely feel that doctors are underpaid relative to their time, effort and monetary investment; but the magnitude of investment in the first place is due to several runaway costs and poor incentive systems in place (rampant rise in tuition due to high demand for medical professionals, compounded by the number and amount of student loans administered). Someone has to pay for this and it's passed along from the doctors, then to the hospitals, then to the insurance companies and ultimately to the payers (whether consumers or government, and the latter then passes it on to the taxpayers anyway).

格倫·威廉姆斯指出，醫(yī)院體系本身也應(yīng)負有重要責(zé)任：它們在價格上缺乏透明度（彼此僅幾英里的醫(yī)院對相同服務(wù)的收費可能相差5到10倍），這并沒有在市場上形成任何競爭或有效定價的機制。
此外，我堅信，相較于醫(yī)生們的投入——包括時間、努力和經(jīng)濟投資——他們的收入是偏低的。這種高額投資的根源在于一些失控的成本和不良的激勵機制，比如由于對醫(yī)療專業(yè)人員的高需求導(dǎo)致的學(xué)費激增，以及學(xué)生貸款的數(shù)量和金額的增加。這些成本最終需要有人承擔(dān)，它們從醫(yī)生傳遞到醫(yī)院，再到保險公司，最后落到支付者身上——無論是消費者還是政府，而政府最終會將這些成本轉(zhuǎn)嫁給納稅人。

Andrew Gage
I would love to see the cost/expense breakdown that justifies a $13 per pill Tylenol bill levied by hospitals. Everything that is given you as treatment in a US hospital is a form of financial rape.

我很想知道，醫(yī)院如何解釋將泰諾林每粒藥片的價格定為13美元的成本和費用明細。在美國醫(yī)院接受的任何治療都感覺像是在被金融掠奪。

Wendy Barnes
Where do you think facilities get the money to pay for the uninsured?

你認為醫(yī)院從哪里獲得資金來支付未參與保險的病人的費用？

Michael Critelli
I would add one more comment to your thoughtful, complete and compelling answer. In many other countries, primary care physicians are more plentiful, they are paid better, and they are the gatekeepers to more expensive specialists. In America, we do a poor job controlling the way Americans access healthcare. Many patients go straight to specialists, who prescribe expensive and intensive treatments. Closely related to this is the fact that we have allowed health records to be kept in separate provider silos, which means that no physician has a complete record of the patient’s care elsewhere. We allow duplicative and dysfunctional care because of a poorly-designed health record system.

我對你的深入、全面且有說服力的回答還有一點補充。在許多其他國家，基層醫(yī)療的醫(yī)生數(shù)量更充足，收入也更高，他們充當(dāng)著通往更昂貴?？品?wù)的守門人角色。然而在美國，我們對民眾獲取醫(yī)療服務(wù)的方式控制不嚴(yán)。許多患者直接求助于?？漆t(yī)生，而這些醫(yī)生往往會推薦費用較高且復(fù)雜的治療方案。與此緊密相關(guān)的是，我們允許健康檔案分散在不同的醫(yī)療服務(wù)提供者手中，導(dǎo)致沒有一位醫(yī)生能夠全面掌握患者在其他地方接受的治療情況。由于健康檔案系統(tǒng)設(shè)計不佳，我們?nèi)萑塘酥貜?fù)和效果不佳的醫(yī)療服務(wù)。
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Matthew Milford
My PCP is essentially useless for all but the most basic of problems. One time he prescribed me an ointment, but otherwise, he has always directed me to a specialist. Skin problem? Dermatologist. Low libedo? Endocrinologist. Again and again. I hardly bother him anymore and if I have a problem with [body part] I just make an appointment with a [body part]ologist.

我的家庭醫(yī)生對于除了最基本問題之外的事情基本上沒什么用。有一次他給我開了一種藥膏，但除此之外，他總是把我轉(zhuǎn)給專科醫(yī)生。皮膚問題？看皮膚科醫(yī)生。性欲低下？看內(nèi)分泌科醫(yī)生。一次又一次。我現(xiàn)在很少麻煩他了，如果我身體的某個部位有問題，我就直接預(yù)約那個方面的?？漆t(yī)生。

Alan Higgins
That’s his job, weed out the bumps and bruises and direct to the appropriate specialist. Do you know weather you need and oncologist or a proctologist, no you don’t

他的職責(zé)是分辨出輕微的外傷，并將患者指引到合適的?？漆t(yī)生那里。你自己怎么能確定是需要腫瘤科醫(yī)生還是肛腸科醫(yī)生呢？你并不清楚。

Joyce Touche
I was discharged from a VA hospital the end of Feb. after a vicious bout with the flu, and on continuous oxygen. The tech told me to make an appointment with my PCP. I walked to her office and was told the first available appointment was June 21. I called back, and, well, May 15. I called the patient advocate and made it in April 20. I was discharged Feb 27. Had I not been a nurse, I may have ended up dead. They rolled me out to the door, no instructions, no emergency number and a lot of unanswered questions.

二月底，我在一場劇烈的流感后從退伍軍人醫(yī)院出院，需要持續(xù)使用氧氣治療。技術(shù)人員建議我預(yù)約我的家庭醫(yī)生。我走到她的診所，卻被告知最早的可預(yù)約時間是6月21日。我再次打電話，預(yù)約時間提前到了5月15日。通過聯(lián)系患者權(quán)益倡導(dǎo)者，我最終在4月20日得到了預(yù)約。我是2月27日出院的。如果我不是一名護士，我可能已經(jīng)不幸去世了。出院時，他們沒有給我任何具體指導(dǎo)，沒有緊急聯(lián)系電話，卻留下了許多未解答的問題。

Dani Rhian
I resonate with your comment so much, however, now it’s 2022 and I think this has started to improve right? I’m from Texas, and I’ve been in both corporate and on the end floor while being employed with more than one provider. This was the absolute most frustrating thing to me that EHR (at least) wasn’t accessible across the board using an NPN based system. Why are medical records still such a hassle when we transitioned from paper charting to electronic over a decade ago?

我非常理解你的評論，但現(xiàn)在已經(jīng)是2022年了，我想這種情況應(yīng)該有所改善了吧？我住在德克薩斯，曾在不止一家醫(yī)療機構(gòu)工作過，既有在公司層面，也有在臨床一線。最讓我感到沮喪的是，電子健康記錄（EHR）系統(tǒng)本應(yīng)提高醫(yī)療信息的可訪問性，但令我極其懊惱的是，這一系統(tǒng)并沒有實現(xiàn)全國性提供者編號（NPN）下的普遍接入。既然我們在十多年前就完成了從紙質(zhì)記錄到電子記錄的轉(zhuǎn)變，為何如今獲取醫(yī)療檔案依舊如此不便呢？

是什么讓美國的醫(yī)療體系如此昂貴?