這次“春假”,，我和家人享受了一周天堂般的生活,，所以非常確定一點(diǎn),，我真的很想徹底放松一個(gè)星期，沒打算考慮醫(yī)療問(wèn)題,。

但老實(shí)說(shuō),，想躲還是沒躲過(guò)，到最后還是跟醫(yī)生打上交道,。這次在島上度假期間,，不管觀賞鯨魚、海底潛水,、去瀑布探險(xiǎn),，泡泳池玩滑水，還是在沙灘上閑逛,，我的牙都疼得厲害,。只要咬到比木瓜瓤硬的東西就會(huì)齜牙咧嘴，疼到從躺椅上跳起來(lái)，連喝混合椰汁的可拉達(dá)都只能像嬰兒一樣小口抿,。我一拖再拖就是不愿看牙醫(yī),，到最后是妻子幫我打了電話。（現(xiàn)在看來(lái),，比放假時(shí)趕上牙疼更糟糕的是,，跟牙疼的配偶一起度假。）

妻子找到一位出色的牙醫(yī),，我心懷感激,。不過(guò)這段假期插曲主要還是說(shuō)明，其實(shí)對(duì)醫(yī)療的需求無(wú)處不在,。要改革醫(yī)療體制的人應(yīng)該注意,。

過(guò)去幾周我們看到，共和黨領(lǐng)袖先是推動(dòng)特朗普的醫(yī)保方案立法,，后來(lái)又放棄了,，因?yàn)橛猩贁?shù)議員堅(jiān)決不愿“修改”或者替代奧巴馬醫(yī)改法，寧可直接廢除,，然后建立一個(gè)純粹自由的市場(chǎng)機(jī)制,。理論上新體制下愿意買醫(yī)療服務(wù)（或者醫(yī)保覆蓋險(xiǎn)種）的人在實(shí)際需要時(shí)購(gòu)買，不想買或者無(wú)力負(fù)擔(dān)醫(yī)保的人不必購(gòu)買,。畢竟,，從Froot Loops的早餐麥片、手機(jī),，到將萬(wàn)圣節(jié)期間女超人主題的寵物貓狗穿戴裙裝,，市場(chǎng)中很多商品都是這么運(yùn)作的。

這種理念對(duì)經(jīng)濟(jì)自由派很有吸引力,。四天前,，我也曾是堅(jiān)決的“自由派”，完全不能接受在夏威夷毛伊島的寶貴假期忍受牙醫(yī)電鉆,，浪費(fèi)逛品牌折扣中心的時(shí)間,。

但我放棄了原來(lái)的想法，這不是自由市場(chǎng)的問(wèn)題,，而是因?yàn)獒t(yī)保本身的特殊性質(zhì),。以下是兩個(gè)最重要原因：

無(wú)論是牙齒感染、胰腺手術(shù),，還是化療,、治療槍傷，醫(yī)療需求之所以叫“需求”是有道理的,。如果你買不起Froot Loops麥片,，最新款iPhone或者給小寵物的裙子,，問(wèn)題不大，沒有也能過(guò)下去,。但不管買沒買醫(yī)保,，需要急救的人必須得急救。到最后,，人們會(huì)不計(jì)一切代價(jià)涌進(jìn)急救室求醫(yī),，很多沒有醫(yī)保的人逼急了就能做出來(lái)（然后由所有人均攤開銷）。如果滿足不了需求,，很有可能就會(huì)死人,。

在社會(huì)里生活，有很多機(jī)會(huì)例子可以解釋這種需求的差異,。比如鄰居的房子著火了,，你可能希望消防員立即趕到現(xiàn)場(chǎng)滅火，即便事后消防局不向鄰居收費(fèi)也沒什么,。我估計(jì),，你不會(huì)為此舉著牌子到鄰居家門前的草坪上高喊對(duì)方是“特權(quán)階級(jí)”或者“寄生蟲”。雖然傾向自由主義,，但我們要把需求和愿望區(qū)別對(duì)待,。

兩者的區(qū)別部分在于分擔(dān)風(fēng)險(xiǎn)的意識(shí)。鄰居的屋子著火可能燒到你家,。不過(guò)很多傳染病也一樣,。

醫(yī)療市場(chǎng)上買方可能不計(jì)其數(shù)，賣方卻受到法律嚴(yán)格監(jiān)管,。顯然,，沒有哪部聯(lián)邦政府和州政府的法律禁止人們?cè)趀Bay網(wǎng)上賣掉西施犬穿的裙子，也沒人禁止給狗狗穿裙子（但可能有人會(huì)覺得應(yīng)該禁止）,。但醫(yī)療系統(tǒng)面臨全方位監(jiān)管,，除了法律法規(guī)，還有行業(yè)協(xié)會(huì)確立的行規(guī),，都跟法律的震懾力差不多,。

先從容易理解的說(shuō)起：社會(huì)中很多工種都具有準(zhǔn)入門檻，就好比我們不會(huì)讓某某郵差去開飛機(jī),，除非經(jīng)過(guò)長(zhǎng)年累月的訓(xùn)練拿到飛行執(zhí)照。醫(yī)療市場(chǎng)也類似,，所以本質(zhì)上就有壟斷因素,，具體看提供醫(yī)療服務(wù)的類型。

在行業(yè)協(xié)會(huì)保護(hù)下醫(yī)療供應(yīng)商對(duì)市場(chǎng)的掌控力堪稱超乎想象,。還沒有收到賬單以前,，他們就已經(jīng)定下費(fèi)用（或者更通常情況下,，知道你能通過(guò)醫(yī)保支付多少費(fèi)用）。所以,，醫(yī)療市場(chǎng)的消費(fèi)者在了解醫(yī)療成本之前,，甚至在不知道服務(wù)質(zhì)量以前就上了 “賊船”。事實(shí)上,，需要住院的人幾乎必須向院方承諾為所有服務(wù)付錢,，有些服務(wù)可能都等不到用上，另一邊醫(yī)療機(jī)構(gòu)卻可以獅子大開口,。自由市場(chǎng)可不是這么運(yùn)轉(zhuǎn)的,。

當(dāng)然，如果沉浸在自由主義氛圍里,，喜歡事事親力親為,，我是可以給自己拔牙，去沃爾瑪買瓶漱口水對(duì)付了事,?？杉幢隳茏龅侥且徊剑疫€是沒法給自己開抗生素（拔牙以后需要服用）,。處方藥可能看上去實(shí)現(xiàn)了自由市場(chǎng),，因?yàn)檫^(guò)去幾年里商家已經(jīng)證明可以隨意叫價(jià)。不過(guò),，政府有上千條法規(guī)規(guī)定哪些藥丸和藥方可以賣給誰(shuí),，誰(shuí)來(lái)賣，具體用途以及發(fā)售時(shí)間,。這些門檻對(duì)對(duì)有意開拓市場(chǎng)和推廣新藥的商家來(lái)說(shuō)也是極高的,，所以推升了價(jià)格。

坦白說(shuō),，假如醫(yī)療市場(chǎng)真能像自由市場(chǎng)一樣運(yùn)作再好不過(guò),。目前有一些還不錯(cuò)的想法在推動(dòng)醫(yī)療走向自由市場(chǎng)。比如美國(guó)科氏工業(yè)集團(tuán)掌門人查爾斯?科赫與大衛(wèi)?科赫兩兄弟支持的非營(yíng)利組織Freedom Partners最近發(fā)布了一份戰(zhàn)略備忘錄,。其中建議,，立法者改變當(dāng)前的規(guī)定，允許個(gè)人和企業(yè)跨州購(gòu)買保險(xiǎn)項(xiàng)目,，“鼓勵(lì)培育”多年期保單甚至壽險(xiǎn)保單市場(chǎng),，至少在某種程度上可以避免投保人因長(zhǎng)年身纏重病陷入赤貧。同時(shí),，我們應(yīng)該大幅提高稅前健康儲(chǔ)蓄賬戶的存款上限,，拓寬賬戶資金的用途（最明顯的例子，可以支付保費(fèi)或者基礎(chǔ)醫(yī)療團(tuán)體計(jì)劃的會(huì)員費(fèi)）,。重要的是,，我們應(yīng)該修改當(dāng)前嚴(yán)重阻礙跨州遠(yuǎn)程醫(yī)療服務(wù)發(fā)展的法令,。（點(diǎn)擊此處了解相關(guān)背景。）

隨著國(guó)會(huì)的領(lǐng)袖翻開醫(yī)改新篇章（他們最近開玩笑似地表示會(huì)采取行動(dòng)）,，可以考慮下我提的建議,，眾所周知醫(yī)療市場(chǎng)盤根錯(cuò)節(jié)，距自由市場(chǎng)機(jī)制還有漫漫征途,。任何“改革”,，如果想著僅僅改變誰(shuí)為醫(yī)保付錢以及如何支付就轉(zhuǎn)為自由市場(chǎng)，在熱愛自由的美國(guó)人心中,，可能還不如眼下這個(gè)破綻百出的系統(tǒng),。（財(cái)富中文網(wǎng)）

譯者：Pessy

審稿：夏林

I spent the week in paradise—on a “spring break” vacation with my family—and I can attest with the utmost certainty that it is better to spend a week not thinking about healthcare than thinking about it.

But truth be told, not thinking about healthcare got me thinking of it. And eventually in need of it. That’s because in the midst of a whale-watching, snorkeling, waterfall-exploring, pool-supersliding, beach-bumming island vacation, I had one heck of a toothache. I grimaced with each bite of anything harder than papaya, jumped from my chaise with the babiest baby-sip of colada—but still pushed off calling a dentist until…my wife called one for me. (The one thing worse than having a toothache on vacation, it appears, is vacationing with a spouse who has a toothache.)

She found an amazing dentist and I’m grateful for it. But the long and short of this episode was that the need for healthcare found me. And therein lies a lesson or two for anyone who hopes (in earnest) to reform it.

As we saw in the past few weeks, as Republican party leaders pushed for Trumpcare and then abandoned it, there is a small and determined group of lawmakers who don’t want to “fix” or replace Obamacare, but rather to repeal it outright and then institute a purely free market system in its place. That system, in theory, would let those so inclined buy healthcare (or insurance coverage for healthcare) when—and only when—they want it, and would leave those who don’t want it (or can’t afford it) alone. That’s, after all, how the market for Froot Loops works—and the one for mobile phones and for Supergirl-inspired Halloween tutus for your dog or cat.

There is a certain appeal to such economic liberty. And for four days or so, I myself was a Freedom Caucus’er—dead set against trading an afternoon of precious vacation for one in a Maui strip mall with a jawful of drill.

I lost that intellectual battle not because of the nature of free markets, but rather because of the nature of healthcare itself. Here are two fundamental reasons why:

A medical need—whether it be a tooth infection, pancreatic surgery, chemotherapy, or gunshot wound—is called a “need” for a reason. Dare the thought that you can’t afford a box of Froot Loops or a new iPhone or a tutu for your pet. It’s okay: You can probably live without it. But those who require urgent care will still have the same need for urgent care whether or not they have insurance. In the end, they might storm an emergency room to get it—which is what many without coverage still do (and which we still, collectively, pay for). And if they don’t address the need, they might well die.

As a society, we’re pretty good about recognizing that distinction in other contexts. When your neighbor’s house catches fire, chances are you’d want firefighters to race to the scene to put it out. You’ll probably even be okay with the fact that the fire department won’t send your neighbor a bill afterward—and I’m guessing you won’t post a sign on his front lawn saying, “Entitled!” or “Freeloader!” Freedom-loving folks though we are, we treat need differently than want.

Some of that distinction is due to the perception of shared risk, of course. A fire in your neighbor’s house could spread to yours. But then, the same can be said for many infectious diseases.

This market may have unlimited buyers, but sellers are strictly limited by law. There is, apparently, no federal or state law that prohibits a person from selling a tutu for your shih tzu on eBay, or for dressing your pet in one (though one might argue there should be). But our medical systems are thoroughly enveloped in laws and regulations, as well as practices so entrenched by guild or industry convention that they have the force of law.

Start with the obvious: We, as a society, don’t give everyone the keys to the operating room, any more than we let Joe from the mailroom fly a commercial jet—not without many moons of training and a license, that is. So the healthcare market has a bunch of built-in monopolies, depending on the particular service being offered.

Those guild-protected medical providers also have another uncanny market-controlling power: They can demand that you pay (or more commonly, have proof that you can pay through insurance) before they see you—and before you see the bill. So medical consumers are on the hook for payment long before they know what the total cost of the service is, or how well that service was provided. Indeed, those who require a stay in the hospital will almost certainly have to promise to pay for services from providers they may never see—and who can charge pretty much whatever they want. Not many free markets work like that.

Sure, in the euphoria of liberty-cherishing DYI-philia, I could have pulled my own tooth and gargled in Walmart peroxide. But even then, I couldn’t prescribe myself an antibiotic (which, it turns out, I needed). Our prescription drug trade may look like a free market—because sellers have proven over the past several years that they can charge whatever they want. But the government has thousands of rules about which pills and nostrums can be sold to whom, by whom, for what purpose, and when. The barriers to entry for those who want to create and market a new medicine are enormous—which drives up prices on its own.

It would be great, frankly, if healthcare did operate more like a free market. And there are some good ideas out there for how to push it in that direction. For example, Freedom Partners, a group supported by Charles and David Koch, suggested in a recent strategy memo that lawmakers change the current rules to let individuals and businesses purchase insurance plans across state lines, and “foster the creation of a market” for multiyear and even lifetime insurance contracts that would enable people to protect themselves, at least somewhat, from the financial ravages of a serious illness years down the line. At the same time, we should significantly raise the contribution caps on pre-tax health savings accounts and broaden the scope of what they can be used for (including, quite obviously, paying for insurance premiums or membership fees for primary care group plans). And importantly, we should rewrite the current statutes that largely prevent the expansion of telemedicine offerings across state lines. (Here’s some background reading on that.)

As leaders in Congress take up healthcare legislation anew (as they have recently teased they will), they might consider these options—along with the sobering fact that healthcare, as we know it, is a long way from a free-market system now. And any “reforms” that try to instill this ethos by simply changing who pays for insurance and how is likely to be even less embraced by freedom-loving Americans than the flawed system we have now.