對于很多美國人來說，他們的醫(yī)療保險在2018年都迎來了壓死駱駝的最后一根稻草。

首先，美國的醫(yī)保還是太貴了，很多人都買不起。其次，醫(yī)保在美國的覆蓋率也遠(yuǎn)遠(yuǎn)不夠。而隨著美國政治越來越爛，政府再一次未能解決醫(yī)療保險這個難題，即便大多數(shù)選民都表示醫(yī)保是他們最關(guān)心的問題。

相比于購買醫(yī)保的沉重財務(wù)負(fù)擔(dān)，醫(yī)保帶來的醫(yī)療效益真的值得嗎？這是一個很多人都在糾結(jié)的問題。2018年，我和我的同事花了大量時間，采訪了不少有這種疑慮的人。結(jié)果發(fā)現(xiàn)大，多數(shù)受訪者都決定“賭一把”，因為他們覺得，“我拿明天賭健康”要比花錢買醫(yī)保更劃算。

一開始，我們只關(guān)注了十幾個家庭，其中有人正在找工作，有人正在撫養(yǎng)孩子，有人正在攢錢買房或者上大學(xué)。后來，我們邀請了其他人跟我們分享沒有醫(yī)保的生活，結(jié)果人數(shù)讓我們吃了一驚——有5000多人分享了他們的故事。很多人的故事都會讓讀者心碎或血壓升高。

來自弗吉尼亞州的喬丹一家分享了他們因為意外的醫(yī)療費用而陷入破產(chǎn)的故事——即便他們已經(jīng)買了保險。

由于醫(yī)保費用逐年升高，得克薩斯州的馬爾多納多夫婦沒法給全家人都上保險，無奈只能給部分家庭成員買醫(yī)保，家里的其他人只能就這么算了。

還有一些人希望創(chuàng)造性地解決醫(yī)保的問題，比如住在愛達(dá)荷州博依西市的伯格文一家，他們在傳統(tǒng)醫(yī)保之外拼湊出了一套替代方案。南卡羅來納州的一位護(hù)士告訴我們，她每隔一年才買一次醫(yī)保，每逢雙數(shù)年才去做體檢，單數(shù)年則祈禱上帝保佑了。

一個值得關(guān)注的現(xiàn)象是，買不起醫(yī)保并非只是窮人的問題，它影響的收入階層之廣泛，是我們所始料未及的。在我們采訪過的100多人中，很多人的年收入都在10萬美元以上。從表面看，這樣的收入可以讓他們過得很舒服了。然而實際上，一看到他們的家庭賬本，我們就明白了他們得多努力才能買得起醫(yī)保。

換句話說，一個家庭可能不得不對醫(yī)保搞“配給制”。這些決定并不是輕易做出的。他們并非迷信自己“青春無敵”的身體才不買醫(yī)保，他們并非魯莽，也不是無知。恰恰相反，他們中的很多人是受過教育的專業(yè)人士、企業(yè)家和創(chuàng)業(yè)人。在生活的壓力下，他們只能選擇哪些家庭“需要”必須降級成“不需要”。

“我們連出去吃飯或者帶孫子看電影的錢都沒有，更別說買醫(yī)保了。”

對于無醫(yī)保“裸奔”，有些人的心態(tài)也比其他人更平和。

來自北卡羅來納州的基思·布坎南和戴安娜·布坎南在2018年放棄購買昂貴的醫(yī)保，而是買了一套健身器材。基思表示，現(xiàn)在他的身材已經(jīng)練到了有生以來的最好水平。“這很大程度上是因為我們知道自己必須要照顧好自己的健康。”他表示。

不過其他人就沒那么幸運了。比如來自西弗吉尼亞州的塔拉·沙利文，直到她的流感轉(zhuǎn)成了肺炎，才去醫(yī)院看了醫(yī)生，然后開了250美元的藥物。由于經(jīng)濟(jì)條件結(jié)據(jù)，為了湊買藥的錢，她只得將天然氣費晚交幾天。為此，天然氣公司威脅她要在隆冬時節(jié)關(guān)掉她的暖氣。

“我們連出去吃飯或者帶孫子看電影的錢都沒有，更別說買醫(yī)保了。”沙利文對我們說。

我們還采訪了一些由于客觀原因而不購買醫(yī)保的人。美國有1.33億人屬于“帶病投保”。在《平價醫(yī)療法案》（Affordable Care Act）出臺之前，其中相當(dāng)一部分人可能根本不會有購買醫(yī)保的資格。

印第安納州的布魯明頓市有一位名叫安德里亞·普雷斯頓的婦女，今年38歲的她患有一種罕見的自體免疫疾病，導(dǎo)致了她的呼吸道衰竭。她需要反復(fù)接受手術(shù)治療以保持呼吸道暢通。到現(xiàn)在為止，她已經(jīng)接受了7次手術(shù)，同時還在服用15種藥物。普雷斯頓是一名科技寫手，她的工作單位也提供了保險。即便如此，高額的醫(yī)療費用還是超過了她的負(fù)擔(dān)能力。她在一封電子郵件中說：“這是一個越滾越大的雪球，它正在慢慢地壓垮我。”

喬·德拉·克羅齊是一名居住在芝加哥的越戰(zhàn)老兵，他兩次從癌癥中挺了過來。他本來應(yīng)該在79歲時退休的，不過為了給他61歲的妻子羅絲購買醫(yī)保，他又在家得寶（Home Depot）找了一份低薪的工作。羅絲患有多發(fā)性硬化癥，但她的年齡還不足以享受聯(lián)邦醫(yī)保，如果沒有醫(yī)保的話，又負(fù)擔(dān)不起治療的費用。

羅絲表示：“打工并不是他原本的晚年計劃。”

“這是一個越滾越大的雪球，它正在慢慢地壓垮我。”

如果說2018年是美國醫(yī)保體系瀕臨崩潰的一年，2019年也并不令人樂觀。在2018年12月中旬一個周末的晚上，得克薩斯州的一名法官裁定，整個《平價醫(yī)療法案》都應(yīng)該被廢除。對于上億擁有醫(yī)保的人來說，隨著案件進(jìn)入法院系統(tǒng)，大家的醫(yī)療保險能否保住，又要取決一場高風(fēng)險的法律鬧劇了。

在這種背景下，民主黨即將在1月接管眾議院。對于醫(yī)保問題，民主黨人也有自己的方案。有些民主黨人試圖擴(kuò)大政府在保險方面的角色，比如讓政府搞全民醫(yī)保。雖然在國會存在分歧的情況下，此類議案通過的可能性不大，但它至少可以為民主黨2020年的總統(tǒng)大選打下一個基礎(chǔ)。

由于政治解決方案依舊遲遲不能出臺，很多受夠了醫(yī)保體系功能失調(diào)的大企業(yè)正在自己找出路。比如摩根大通、亞馬遜和伯克希爾-哈撒韋公司搞了一個三方方案，希望能提高美國的醫(yī)保質(zhì)量，并解決醫(yī)保成本日益上升的問題。亞馬遜和谷歌母公司Alphabet等科技巨頭也在試水制藥和電子病歷等行業(yè)。部分創(chuàng)業(yè)公司也在探索提供購買醫(yī)保和獲取醫(yī)療服務(wù)的新途徑。

然而這種努力也得很多年才能見效。對于我們采訪過的那些人來說，這意味著他們還是要努力拼湊出一個醫(yī)保方案，或是祈禱自己能一直保持健康。

弗吉尼亞的喬丹夫婦雖然有了醫(yī)保，但仍然付不起自付的部分，他們的破產(chǎn)狀態(tài)很可能要持續(xù)到2020年。得克薩斯州的馬爾多納多一家給上大學(xué)的女兒和癌癥幸存者的老母親瑪麗貝爾買了醫(yī)保，然而為了省錢，作為一家之主的大衛(wèi)今年則仍然沒有購買醫(yī)保。塔拉·沙利文從1月開始即將在佛羅里達(dá)開始一份新工作，這樣她就可以享受醫(yī)保了。

不過，沙利文仍然覺得200美元每月的費用難以承受，因此，2019年她將繼續(xù)“裸保”一年。（財富中文網(wǎng)）

譯者：樸成奎

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.