你之所以负担不起医疗，是因为：医疗保险保费太高了。 多向杰夫·贝索斯征税，出于其他原因也许是对的， 但这对解决医疗负担问题毫无帮助。 保费之所以这么高，是因为保险公司在利用《奥巴马医改》（Obamacare）引入的定价机制进行博弈。 《奥巴马医改》将毛利率上限设为 15%。结果是，医疗保险公司如果想赚更多钱，并不需要提高效率或加剧竞争，他们只需要协同提价即可——而他们确实这么做了。 对他们来说，在 10,000 美元的保费上赚 15%，远比在 1,000 美元的保费上赚 15%（甚至更高）、但要面对激烈竞争，更划算。 现在，《奥巴马医改》要求这些多出来的钱必须“用于医疗服务”，但如果你看看医疗体系中行政人员数量的暴涨，以及预期寿命的停滞不前，真正发生的事情是： 这些额外资金只是在系统内部来回流转，最终以各种形式流向了股东，却没有对医疗质量产生任何可衡量的改善——看看预期寿命 vs 医疗行政人员增长，或者医疗股股价 vs 预期寿命，你就明白了。 因此，要让医疗重新变得负担得起，就必须改变毛利率规则，并强制私营保险公司 / 药品福利管理机构（PBMs）/ 医疗服务提供者之间展开真正的竞争。 The reason you can’t afford healthcare: Healthcare premiums are too high. Taxing Jeff Bezos more may be right for other reasons but it will do nothing to fix this. Premiums are too high because insurance companies game the pricing model brought by Obamacare. Obamacare capped gross margins at 15%. So for healthcare companies to make more money, they didn’t have to find efficiency or compete harder, they could coordinate and raise prices. And they did that. Making 15% on $10,000 with little competition is better for them than making 15% or more on $1,000. Now Obamacare says you must spend these extra dollars on services but if you look at the growth of administrative staff and the flatlining of life expectancy, what really happened was that the extra dollars just sloshed around in the system and eventually made its way to stockholders with no measurable impact to quality - look at life expectancy vs admin staff growth in healthcare or stock price of health care stocks vs life expectancy. So to make healthcare affordable again, change the gross margin rules and force competition between the private insurers/PBMs/providers.
Chamath PalihapitiyaFounder & CEO, Social Capital
目录
观点原文
你之所以负担不起医疗，是因为：医疗保险保费太高了。
多向杰夫·贝索斯征税，出于其他原因也许是对的，
但这对解决医疗负担问题毫无帮助。
保费之所以这么高，是因为保险公司在利用《奥巴马医改》（Obamacare）引入的定价机制进行博弈。
《奥巴马医改》将毛利率上限设为 15%。结果是，医疗保险公司如果想赚更多钱，并不需要提高效率或加剧竞争，他们只需要协同提价即可——而他们确实这么做了。
对他们来说，在 10,000 美元的保费上赚 15%，远比在 1,000 美元的保费上赚 15%（甚至更高）、但要面对激烈竞争，更划算。
现在，《奥巴马医改》要求这些多出来的钱必须“用于医疗服务”，但如果你看看医疗体系中行政人员数量的暴涨，以及预期寿命的停滞不前，真正发生的事情是：
这些额外资金只是在系统内部来回流转，最终以各种形式流向了股东，却没有对医疗质量产生任何可衡量的改善——看看预期寿命 vs 医疗行政人员增长，或者医疗股股价 vs 预期寿命，你就明白了。
因此，要让医疗重新变得负担得起，就必须改变毛利率规则，并强制私营保险公司 / 药品福利管理机构（PBMs）/ 医疗服务提供者之间展开真正的竞争。
The reason you can’t afford healthcare:
Healthcare premiums are too high.
Taxing Jeff Bezos more may be right for other reasons but it will do nothing to fix this.
Premiums are too high because insurance companies game the pricing model brought by Obamacare.
Obamacare capped gross margins at 15%. So for healthcare companies to make more money, they didn’t have to find efficiency or compete harder, they could coordinate and raise prices. And they did that. Making 15% on $10,000 with little competition is better for them than making 15% or more on $1,000.
Now Obamacare says you must spend these extra dollars on services but if you look at the growth of administrative staff and the flatlining of life expectancy, what really happened was that the extra dollars just sloshed around in the system and eventually made its way to stockholders with no measurable impact to quality - look at life expectancy vs admin staff growth in healthcare or stock price of health care stocks vs life expectancy.
So to make healthcare affordable again, change the gross margin rules and force competition between the private insurers/PBMs/providers.
ABAB AI 解读
这段话不是情绪化的“反医保”宣言，而是在提出一个典型的激励失灵（incentive failure）案例：当你用“比例上限”去监管一个规模可被操纵的行业时，结果往往是价格上移，而不是效率提升。我从激励机制、为何税收无效、真正的改革杠杆三个层面给你解读。
一、核心问题不在“谁赚太多”，而在怎么赚钱
这段话抓住的关键不是利润大小，而是利润函数：
《奥巴马医改》限制的是毛利率（15%）
但没有限制价格水平或成本真实性
结果是什么？当利润=15%×价格时，提高价格比降低成本更简单、更安全。
在这种规则下，理性企业的最优策略不是：
- 提高效率
- 技术创新
- 激烈竞争
而是：
- 行业协调提价
- 扩大保费基数
- 把“合规支出”做成行政与流程膨胀
这不是阴谋，是制度诱导的理性行为。
二、为什么“多向富人征税”解决不了保费问题
文中点得很清楚：税收和价格是两条不同的因果链。
即便多向富人征税：政府财政可能改善，再分配可能增强
但只要：保费定价机制不变，行业竞争结构不变，医疗保费仍然会继续上涨。
换句话说：税收是“事后再分配”，保费是“事前定价权”
你不触碰定价权，就永远在为同一套结构买单。
三、“必须用于医疗服务”的钱，为什么没有改善结果
这是最有杀伤力的一点。
按法律要求：多出来的钱要“花在服务上”
但现实中：
- 行政人员暴增
- 流程、审核、合规成本膨胀
- 生活预期寿命停滞
这说明什么？“花钱”不等于“改善结果”。
当结果不与资金直接挂钩时：钱会流向最容易合规、最难问责的地方
即：行政、管理、系统复杂化
最终形成：成本被合法消化，质量却没有提升。
四、真正的改革杠杆：不是“压利润”，而是逼竞争
这段话给出的结论是：要改变毛利规则，并强制竞争。
这背后的逻辑是：
1️⃣ 让利润来自效率，而不是规模
2️⃣ 让价格下降成为竞争手段
3️⃣ 让失败真的会失败（退出机制）
可行的方向包括：
- 用固定费用/人头付费替代比例毛利
- 放开跨州竞争
- 打破 PBM、保险、医疗机构之间的封闭联盟
- 把支付与结果指标（而非支出）挂钩
五、一句话的最高层总结
这段话真正想说的是：当你用“百分比上限”去管一个可抬价的行业，你得到的不是节约，而是通胀。
医疗负担问题不是“钱不够”，而是钱被允许以错误的方式赚钱。
六、站在最高认知的判断
要让医疗真正变得可负担，社会必须区分两件事：
- 道德问题（谁该多付）
- 结构问题（价格为何失控）
前者解决不了后者。而后者，只有在竞争被恢复、激励被校正时，才会改变。
这不是左或右的问题，而是制度是否尊重基本经济学的问题。
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