American healthcare systems are probably the most convoluted healthcare system in the world. The US probably has the world most advanced medical device and pharmaceuticals industry, many brilliant doctors and great hospitals, e.g., the BJC hospital in the St. Louis area, which is one of the top research hospital in the USA. At the same time, we can see the average life expectancy in the USA is dropping in recent years. The Covid obviously has impact on that. But the overall issues of population health in the USA and the healthcare system were there before pandemic. 美国的医疗保健系统可能是世界上最复杂的医疗保健系统。美国可能拥有世界上最先进的医疗器械和制药工业，许多优秀的医生和一流的医院，例如圣路易斯地区的BJC医院，它是美国顶尖的研究型医院之一。与此同时，我们可以看到近年来美国的平均预期寿命正在下降。 Covid显然对此产生了影响。但美国的人口健康和医疗体系的整体问题在大流行之前就已经存在。
Back to the healthcare system, on both hospitals and the payer (insurance companies for the most part, individuals do have some responsibility). I did not realized the seriousness of the issue until I joined the workforce. I come to the US for graduate school in 1997, I was relatively young and partially due to that I did not visit the hospital or the clinic in the university, another reason was I did not know how to describe medicine in English. At work I got better coverage, and I had first hand knowledge of surgery and emergency room in early 2000s. I vaguely recall the “tonsil removal” surgery cost about $50 from my perspective: the insurance company probably paid $5,000. The personal out of pocket cost will be much higher today. So will be the insurance company’s payment. An emergency room visit, I vaguely it was about $2,300 for about 6, 7 hours stay, with some testing and medicine obviously. There is another bill from the X-ray, MRI office which is a few hundred dollars. We eventually negotiated with the hospital as the patient (a relative) doesn’t have insurance, and we paid $700 and settled it. It as also during that time I realized that patient can negotiate bill with the providers. 回到医疗保健系统，对医院和付款人（大部分是保险公司，个人确实有一些责任）。直到我加入劳动力大军，我才意识到问题的严重性。我是 1997 年来美国读研究生的，当时我还比较年轻，部分原因是我没有去过大学里的医院或诊所，另一个原因是我不知道如何用英语描述医学。在工作中，我得到了更好的报道，并且在 2000 年代初期我对手术和急诊室有了第一手的了解。我依稀记得“摘除扁桃体”的手术费用在我看来是50美元左右：保险公司大概赔了5000美元。今天的个人自付费用会高得多。保险公司的赔付也是如此。一次急诊室就诊，我大概花了 2,300 美元，停留了大约 6、7 个小时，显然还做了一些测试和药物。 X 光、核磁共振办公室还有一张几百美元的账单。由于患者（亲属）没有保险，我们最终与医院协商，我们支付了700美元并解决了。也是在那段时间里，我意识到患者可以与提供者协商账单。
But remember always pay the bills, even after negotiation sometimes. Don’t ignore the bills. Because the bill ignored will be sent to collection (a 3rd party), and it will put a dent on one’s credit score. And we know credit score is quite important for many things range from rent an apartment, buy a car house, find a job and so on.
但请记住始终支付账单，即使有时经过谈判。不要忽视账单。因为被忽略的账单将被发送到收款处（第 3 方），并且会降低一个人的信用评分。我们知道信用评分对很多事情都非常重要，从租房、买房、找工作等等。
From patient point of view, the insurance premium went up a lot in last 20 years or so. And there are some improvements such as the Obama Care, meaning individuals who don’t work for a company can buy health insurance from marketplace. But those plans sometimes don’t have great coverage. Here is one example. Jeff is my former coworker at Mercy Health: ironically Mercy is a large provider in the St. Louis area. I think ultimately one root cause is most those insurances are for profit. From provider (hospital)’s point of view, the Medicare did not pay great, the Medicaid pays horribly, and the regular insurance made up most of the cost or profit for them. 从病人的角度来看，保险费在过去20年左右涨了很多。还有一些改进，例如奥巴马医改，这意味着不为公司工作的个人可以从市场购买健康保险。但这些计划有时覆盖面并不广。这是一个例子。 Jeff 是我在 Mercy Health 的前同事：具有讽刺意味的是，Mercy 是圣路易斯地区的一家大型供应商。我认为最终的一个根本原因是大多数保险都是为了盈利。从提供者（医院）的角度来看，Medicare 支付的不多，Medicaid 支付的很惨，常规保险占了他们的大部分成本或利润。
The medical workers need to eat too. And support family. And the doctors pay are still fairly good in the USA. But as my former boss at Mercy used to say (we were both at IT dept), the 50% of people who visited emergency room don’t have insurance or put wrong names. You can refer to the example above in which we negotiated the price. Another hidden cost for the providers, mainly for the doctors and the nurse practitioners, they have this burden of electronic health records, both for record keeping, for meeting regulation and insurance reimbursement need. One direct result is less face time with patients. 医护人员也要吃饭。并支持家庭。而且美国的医生待遇还是不错的。但正如我在 Mercy 的前任老板曾经说过的（我们都在 IT 部门），50% 的去急诊室的人没有保险或输入错误的名字。您可以参考上面我们协商价格的例子。供应商的另一个隐性成本，主要是医生和执业护士，他们有电子健康记录的负担，既用于记录保存，也用于满足监管和保险报销需求。一个直接的结果是减少了与患者面对面的时间。
To be continued… 未完待续。。。