一個健保,多方表述

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2012 / 9月

文‧滕淑芬



父親過世前的幾年,常進出急診室和加護病房。

有一次他的心臟病發作,救護車送到醫院時已經臉色發青,又因肺部感染,在加護病房和一般病房住了快一個月;鼻子插管太久、臥床太久,喉嚨破了,腿部肌肉萎縮,轉到一般病房時,還需進行呼吸治療和復建。在加護病房時,他不能說話、只能灌流質食品,情緒一來,他會賭氣掙脫管線,為了怕他傷到自己,有幾天我們必須綁住他的手腳;他的病況數度危急,但在醫生與護士的細心照料下,他總是躺著進去、走著出來。

出院時,我拿到帳單,竟然只要一萬多元,不可思議的金額。像我父親這樣高齡又具有榮民身分的患者,確實「耗費」了不少醫療資源,但真的感謝台灣有健保。

爸爸的一位同僚住在基隆,為了到台北榮總看病,必須搭車3、4小時,加上等待看病,用了一整天時間,只為了拿一個月的高血壓藥,而掛號、檢驗、部分負擔、藥品負擔等加起來,三百多元。然而,對他來說,這可不是筆小錢,因為他的月退俸只有八、九千元。

台灣健保的好處,全民受惠;相較於自由市場的美國,更是顯而易見。基本上,美國並沒有一套適用於所有人的醫療保險制度,政府提供的醫療服務,僅限於老人的「聯邦醫療保險」,以及低收入者的「醫療補助」,兩者共占22%的人口;一般受薪階級的醫療保費則多由雇主負擔(約占61%)。

有人形容,美國的醫療保險制度就是「日頭赤炎炎,隨人顧性命」;也就是說,有錢人可以向保險公司購買高檔的醫療險,但窮人若生病,家屬可能即因需要支付昂貴的醫療費用被拖累。至今美國仍約有15%(約四千多萬人)的民眾沒有任何醫療保險。

2010年美國花了2.6兆美金(約78兆台幣)在醫療保健上(占GDP17.9%),這簡直就是天文數字(台灣約是八千億台幣,占GDP6%),也是全世界最昂貴的醫療健保支出。

健保改革是歐巴馬總統競選時的政見核心,他堅決改革,來自親身體會。他的母親當年病重之際,還在擔心無力支付醫藥費,讓他深感低收入民眾無力購買醫療保險及支付醫藥費的辛酸。歐巴馬因而認為,由政府經營的健保制度將更能照顧欠缺醫療保險的民眾,同時也可以藉由競爭促使民營保險業者降低費率,以減輕民眾及企業的負擔。

他的改革方案2010年在國會過關後,卻遭到二十多個州提起訴訟;州政府認為,該法案中授權聯邦政府可「強制個人」購買醫療保險乃違憲;經過一番辯論,6月美國聯邦最高法院才做出「合憲」的宣示。改革終於可以上路了。

透過改革,歐巴馬希望能增加健保覆蓋率、失業人口與兒童的健保,以及實施電子病歷等,而台灣在這方面可說是遙遙領先。台灣健保的主要問題是財務不穩定,但方向與架構絕對正確。我們很早就擁有令世界各國稱羨的健保制度,讓健保永續經營應是共識。

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[Editor’s Note]One System, Many Interpretations

Teng Sue-feng /tr. by Scott Williams


My father was constantly in and out of emergency rooms and critical care units in the few years before he passed away.

After one of his heart attacks, he was blue by the time the ambulance got him to the ER. Then a lung infection kept him in the hospital for nearly a month, first in the critical care unit, then an ordinary room. Bedbound and hooked up to oxygen tubes, his throat became raw and the muscles of his legs atrophied. Unable to speak and limited to a fluid diet while in the CCU, he occasionally became so distraught that he would pull out all his tubes and IVs. Afraid that he would seriously injure himself, we had to secure his hands for a time. He continued to need respiratory treatment and rehabilitation even after his transfer to the general ward. Though his condition turned critical several times, the conscientious care of his doctors and nurses enabled him to leave the hospital on his feet.

I got the bill after he was discharged. It was an unbelievably low NT$10,000 or so. Taking into account my father’s advanced years, the hospital had “wasted” enormous amounts of medical resources on his care, and I couldn’t help but feel grateful for our National Health Insurance (NHI) system.

My father had a colleague who lived in Kee­lung who used to have to spend three to four hours traveling to Tai­pei Veterans General Hospital for care. When you add the time actually spent on the appointment, getting his monthly blood-pressure medication took all day. All told, the registration, examination, copayment, and medication cost him something over NT$300. But given that his monthly pension was only NT$8–9,000, the figure was more than just pocket change to him.

The greatest attribute of Taiwan’s NHI system is that it benefits everyone. This is especially apparent when it is compared to the free-market system of the US, which lacks universal coverage. The US’s government-administered health insurance programs consist of only Medicare for the elderly and Medi­caid for the poor, and together cover just 22% of the population. Most salaried workers (about 61%) receive health insurance via their employers.

Some have described the US health insurance system as being an “every man for himself” kind of system. That is, the rich can purchase high-quality medical insurance, while poor people who become sick are likely to find themselves further impoverished by exorbitant medical expenses. At present, roughly 15% of the US population (more than 40 million people) have no medical insurance.

In 2010, the US spent an astronomical US$2.6 trillion (nearly NT$78 trillion) on medical care (about 17.9% of US GDP), the highest level of such spending in the world. By comparison, Taiwan spent roughly NT$800 billion, or 6% of its GDP.

During the 2008 US presidential campaign, then-candidate Obama made health insurance reform a core policy position. Obama’s determination to change the system was informed by memories of his seriously ill mother worrying about being unable to pay for treatment. The experience made him painfully aware of the hardships confronting low-income individuals unable to afford health insurance or healthcare. He concluded that a hybrid public-private health insurance system would provide broader coverage at lower cost.

Following the 2010 passage of his reform program, 20-some US states sued to block its implementation. The state governments argued that the law’s requirement for individuals to purchase health insurance was unconstitutional. In June, the US Supreme Court ruled that the mandate was constitutional, and that the reforms could move forward.

Among Obama’s reforms are measures to extend coverage to a larger percentage of the population and introduce the use of electronic medical records. Taiwan is far ahead of the US in both these areas. While our system has some problems with its finances, it is built atop a solid foundation and is moving in the right direction. We should be proud. We have created an NHI system that is the envy of the world, and all agree that we should work to ensure it remains sustainable over the long haul.

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