As simple as Econ 101

给和需求决定资源的价格和产量是经济学中最简单,最有用的理论。今天我就把它应用到美国的医疗改革上一把。医疗保险作为一种稀缺资源,和其他产品一样,由市场供求决定了它的价格。而政府为了增加选民的支持,通常有很强的动机去abuse医疗保险系统。Washington Post的一篇文章(链接)简要回顾了一下美国政府MedicareMedicaid的历史:

“History is unambiguous. Originally, Medicare covered only the 65-and-over population. In 1972, Congress added the disabled, now about 15 percent of beneficiaries, notes Diane Rowland of the Kaiser Family Foundation. It also covered dialysis for kidney failure. In 2003, Congress created a drug benefit. Along the way, other services (hospice care, mammograms) were added.

Medicaid — the federal-state program for the poor — is the same story, says Rowland. Initially, it covered mainly people on welfare, as defined by states. Gradually, eligibility broadened. Now, children 6 to 18 in households under the poverty line ($22,050 for a family of four) get it. Congress also set higher limits (133 percent of the poverty line) for pregnant women and children under 6. In 1997, Congress created the Children’s Health Insurance Program (CHIP) to expand coverage further.

Meanwhile, open-ended reimbursement by government and private insurance has ballooned health spending despite repeated pledges to "contain" costs. For example, health payments for individuals rose from less than 1 percent of federal spending in 1965 to 23 percent in 2008.”

 对不停扩张的需求和相对稳定的供给,Econ101中再简单不过的一个结论就是:医疗保险的价格上涨。伴随价格的上升和更多人被纳入政府的医疗计划,医疗保险在政府总支出的比例越来越大。眼看就无法收拾了。巴马总统上场要改革。可惜没有政客会去告诉大家这个uncomfortable truth:我们要么减少支出(也就是降低政府医疗计划的coverage),要么增加政府收入(比如通过增加税收),不然目前的医疗计划玩儿不转了:政府快破产了。

上面任何一个方案都要得罪选民。没有政客会拿自己的政治生命冒险。政客最擅长的就是倒打一耙。明明是需求盲目扩张造成的问题,现在却完全赖给了供给方:巴马大哥声称医疗保险价格高的原因是因为保险公司搞垄断,效率低下。所以解决目前政府赤字问题的出路就是整治医疗保险供应商。为了能获得大众支持,这次和以前一样,再次扩大医保范围:搞个全民保险出来。

我也承认目前医疗保险系统中存在不少问题,比如医疗保险和工作挂钩降低了劳动力的流动性。私人买保险费用很高,提高了兴办小企业的成本。已经生病的人无法买到保险等等。有些现象是保险行业特有的问题,没什么好解决方法。但有些问题是可以通过一些市场机制解决的。John Cochrane提到了一些解决建议(链接)。比如如果某个人在健康时买了保险,他生病后也有权力继续购买同样的医疗保险。另外,我个人觉得医生门槛过高限制了医疗保险的供给也造成医疗成本高。政府可以指定政策鼓励行业内的竞争。

但在修补供给方问题的同时,更主要问题是如何解决政府干预市场造成的需求扩张过快。现在的医疗系统改革和这个方向完全背道而驰。现在医疗保险的供给和价格是由市场定,所以当政府行为引起需求持续上涨后,价格必然上涨。到现在政府没办法支付市场上的价格了,就建议把供给方也控制在自己手里。如果政府真把供给方也拿过来,价格是被政府控制住了,但需求大于供给的结果,根据econ101,在这种情况下只可能是资源短缺。

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