年入10万却买不起医保，更多美国人选择听天由病

对于很多美国人来说，他们的医疗保险在2018年都迎来了压死骆驼的最后一根稻草。

首先，美国的医保还是太贵了，很多人都买不起。其次，医保在美国的覆盖率也远远不够。而随着美国政治越来越烂，政府再一次未能解决医疗保险这个难题，即便大多数选民都表示医保是他们最关心的问题。

相比于购买医保的沉重财务负担，医保带来的医疗效益真的值得吗？这是一个很多人都在纠结的问题。2018年，我和我的同事花了大量时间，采访了不少有这种疑虑的人。结果发现大，多数受访者都决定“赌一把”，因为他们觉得，“我拿明天赌健康”要比花钱买医保更划算。

一开始，我们只关注了十几个家庭，其中有人正在找工作，有人正在抚养孩子，有人正在攒钱买房或者上大学。后来，我们邀请了其他人跟我们分享没有医保的生活，结果人数让我们吃了一惊——有5000多人分享了他们的故事。很多人的故事都会让读者心碎或血压升高。

来自弗吉尼亚州的乔丹一家分享了他们因为意外的医疗费用而陷入破产的故事——即便他们已经买了保险。

由于医保费用逐年升高，得克萨斯州的马尔多纳多夫妇没法给全家人都上保险，无奈只能给部分家庭成员买医保，家里的其他人只能就这么算了。

还有一些人希望创造性地解决医保的问题，比如住在爱达荷州博依西市的伯格文一家，他们在传统医保之外拼凑出了一套替代方案。南卡罗来纳州的一位护士告诉我们，她每隔一年才买一次医保，每逢双数年才去做体检，单数年则祈祷上帝保佑了。

一个值得关注的现象是，买不起医保并非只是穷人的问题，它影响的收入阶层之广泛，是我们所始料未及的。在我们采访过的100多人中，很多人的年收入都在10万美元以上。从表面看，这样的收入可以让他们过得很舒服了。然而实际上，一看到他们的家庭账本，我们就明白了他们得多努力才能买得起医保。

换句话说，一个家庭可能不得不对医保搞“配给制”。这些决定并不是轻易做出的。他们并非迷信自己“青春无敌”的身体才不买医保，他们并非鲁莽，也不是无知。恰恰相反，他们中的很多人是受过教育的专业人士、企业家和创业人。在生活的压力下，他们只能选择哪些家庭“需要”必须降级成“不需要”。

“我们连出去吃饭或者带孙子看电影的钱都没有，更别说买医保了。”

对于无医保“裸奔”，有些人的心态也比其他人更平和。

来自北卡罗来纳州的基思·布坎南和戴安娜·布坎南在2018年放弃购买昂贵的医保，而是买了一套健身器材。基思表示，现在他的身材已经练到了有生以来的最好水平。“这很大程度上是因为我们知道自己必须要照顾好自己的健康。”他表示。

不过其他人就没那么幸运了。比如来自西弗吉尼亚州的塔拉·沙利文，直到她的流感转成了肺炎，才去医院看了医生，然后开了250美元的药物。由于经济条件结据，为了凑买药的钱，她只得将天然气费晚交几天。为此，天然气公司威胁她要在隆冬时节关掉她的暖气。

“我们连出去吃饭或者带孙子看电影的钱都没有，更别说买医保了。”沙利文对我们说。

我们还采访了一些由于客观原因而不购买医保的人。美国有1.33亿人属于“带病投保”。在《平价医疗法案》（Affordable Care Act）出台之前，其中相当一部分人可能根本不会有购买医保的资格。

印第安纳州的布鲁明顿市有一位名叫安德里亚·普雷斯顿的妇女，今年38岁的她患有一种罕见的自体免疫疾病，导致了她的呼吸道衰竭。她需要反复接受手术治疗以保持呼吸道畅通。到现在为止，她已经接受了7次手术，同时还在服用15种药物。普雷斯顿是一名科技写手，她的工作单位也提供了保险。即便如此，高额的医疗费用还是超过了她的负担能力。她在一封电子邮件中说：“这是一个越滚越大的雪球，它正在慢慢地压垮我。”

乔·德拉·克罗齐是一名居住在芝加哥的越战老兵，他两次从癌症中挺了过来。他本来应该在79岁时退休的，不过为了给他61岁的妻子罗丝购买医保，他又在家得宝（Home Depot）找了一份低薪的工作。罗丝患有多发性硬化症，但她的年龄还不足以享受联邦医保，如果没有医保的话，又负担不起治疗的费用。

罗丝表示：“打工并不是他原本的晚年计划。”

“这是一个越滚越大的雪球，它正在慢慢地压垮我。”

如果说2018年是美国医保体系濒临崩溃的一年，2019年也并不令人乐观。在2018年12月中旬一个周末的晚上，得克萨斯州的一名法官裁定，整个《平价医疗法案》都应该被废除。对于上亿拥有医保的人来说，随着案件进入法院系统，大家的医疗保险能否保住，又要取决一场高风险的法律闹剧了。

在这种背景下，民主党即将在1月接管众议院。对于医保问题，民主党人也有自己的方案。有些民主党人试图扩大政府在保险方面的角色，比如让政府搞全民医保。虽然在国会存在分歧的情况下，此类议案通过的可能性不大，但它至少可以为民主党2020年的总统大选打下一个基础。

由于政治解决方案依旧迟迟不能出台，很多受够了医保体系功能失调的大企业正在自己找出路。比如摩根大通、亚马逊和伯克希尔-哈撒韦公司搞了一个三方方案，希望能提高美国的医保质量，并解决医保成本日益上升的问题。亚马逊和谷歌母公司Alphabet等科技巨头也在试水制药和电子病历等行业。部分创业公司也在探索提供购买医保和获取医疗服务的新途径。

然而这种努力也得很多年才能见效。对于我们采访过的那些人来说，这意味着他们还是要努力拼凑出一个医保方案，或是祈祷自己能一直保持健康。

弗吉尼亚的乔丹夫妇虽然有了医保，但仍然付不起自付的部分，他们的破产状态很可能要持续到2020年。得克萨斯州的马尔多纳多一家给上大学的女儿和癌症幸存者的老母亲玛丽贝尔买了医保，然而为了省钱，作为一家之主的大卫今年则仍然没有购买医保。塔拉·沙利文从1月开始即将在佛罗里达开始一份新工作，这样她就可以享受医保了。

不过，沙利文仍然觉得200美元每月的费用难以承受，因此，2019年她将继续“裸保”一年。（财富中文网）

译者：朴成奎

For many Americans, 2018 was the year that health care reached a breaking point.

Insurance was still too expensive to buy. It didn’t cover nearly enough. And as the country’s politics festered, the government once again failed to solve the insurance conundrum, even as a large majority of Americans who flocked to voting booths said health care was their top concern.

My colleagues and I spent much of this year talking to people who had weighed the health benefits against the financial burden of purchasing insurance. Most decided to risk it, betting that going without made more sense than paying for coverage.

We started off following a dozen families: people who were trying to work, raise children and pay for a house or college. When we invited others to share their stories about going uninsured, an overwhelming number did — more than 5,000. Many sent us messages that could break your heart or raise your blood pressure.

In Virginia, the Jordan family shared their tale of sinking into bankruptcy because of unexpected medical expenses, even though they had insurance.

The Maldonados, in Texas, were forced to choose which members of their family to keep on insurance policies as costs ratcheted ever higher.

Others tried to find creative solutions, like the patchwork of alternatives to traditional coverage that the Bergevin family in Boise, Idaho, assembled. A nurse in South Carolina told us that she buys insurance every other year, getting screenings and care in even years and rolling the dice in odd years.

One theme that came up over and over again was that this is a problem reaching far higher into the economic spectrum than we first thought. Many of the more than 100 people we interviewed over the year had incomes of $100,000 or more. These were comfortable families, from outside. Yet, when they opened up their books to us, it became clear how much they needed to stretch to afford health care.

That often meant self-imposed health-care rationing. They didn’t make these decisions lightly. These weren’t uninsured-by-choice “young invincibles.” They weren’t reckless or ignorant — quite the opposite. Many were educated professionals, entrepreneurs and business owners. They had bad options and were forced to make a choice about which family “need” had to be downgraded to a “want.”

“We don’t have enough money to go out to eat, or take my grandchildren to the movies, much less pay for health insurance.”

Some were more comfortable with the risks they were taking than others.

Keith and Diana Buchanan of North Carolina gave up their expensive health insurance in 2018, and bought a Bowflex exercise machine. Keith said he got into the best shape of his life: “A lot of it is a result of knowing that we’re going to have to take care of our own health a little better,” he said.

Others weren’t so lucky. In West Virginia, Tara Sullivan, didn’t go to the doctor until her flu turned into pneumonia. The drugs she needed cost $250. Among the more financially strapped of those we chronicled, she was able to buy her meds only by skipping a payment on her gas bill. The utility threatened to turn off her heat in the middle of winter.

“We don’t have enough money to go out to eat or take my grandchildren to the movies, much less pay for health insurance,” Sullivan told us.

We also talked to people who couldn’t afford to go without insurance — some of the 133 million people with pre-existing conditions who might have been shut out of insurance markets before the Affordable Care Act.

Andrea Preston in Bloomington, Indiana, lives with a rare autoimmune disease that causes her airway to collapse. At 38, she needs repeated surgeries to keep it open; she has already had seven and takes 15 medications. Preston has insurance through her job as a technical writer, but even then, her medical bills accumulate faster than she can pay them. “It’s a rolling ball I can’t get ahead of,” she said in an email. “It’s slowly steamrolling me.”

In Chicago, Joe Della Croce, a Vietnam veteran and two-time cancer survivor, should be retired at the age of 79. Instead, he holds down a low-wage job at a Home Depot to get insurance for his wife Rose, 61, who has multiple sclerosis. She’s too young to get on Medicare and can’t afford medication without insurance.

“It wasn’t what he had planned to do in his later years,” Rose said.

“It’s a rolling ball I can’t get ahead of. It’s slowly steamrolling me.”

If 2018 was the year that health care fell apart, 2019 isn’t looking much better. On a Friday night on mid-December 2018, a Texas judge ruled that the entire Affordable Care Act ought to be struck down. For millions of people who have coverage, whether they get to keep it may come down to yet another high-stakes legal drama as the case works its way through the court system.

Against that backdrop, the Democrats will take over the House of Representatives in January with ideas of their own. Some are pushing for an expanded role for government insurance such as Medicare for All. Though such proposals aren’t likely to pass a divided Congress, they’ll lay the groundwork for debate as Democrats vie for their party’s 2020 presidential nomination.

With a political fix as elusive as ever, large employers are signaling they are fed up with the current state of health insurance dysfunction. A three-way effort between JPMorgan Chase & Co., Amazon.com Inc. and Berkshire Hathaway Inc. is attempting to increase quality and deal with rising costs. Amazon and such other tech powers as Google parent Alphabet Inc. have begun to delve into pharmacy and health records. And a handful of startups are offering new ways to buy coverage and get care.

But those sorts of fixes are years away — if they ever happen. For the people we spoke with, that means more last-ditch compromises to cobble together a plan or stay healthy.

In Virginia, the Jordans’ deductible still isn’t affordable, and their bankruptcy proceeding will likely stretch into 2020. In Texas, the Maldonado family was able to buy coverage again for a college-age daughter and her mother Maribel, a cancer survivor. But, David, the father, is keeping himself off the policy for an additional year to save money. Tara Sullivan will be eligible for health coverage at a new job in Florida, starting in January.

But, at $200 a month, Sullivan doesn’t think she can afford it — so she’ll remain in the ranks of Americans risking it, for 2019.