There is no shortage of proposals for U.S. health insurance reform. In our recent book, We've Got You Covered: Rebooting American Health Care (Einav & Finkelstein, 2023), we offered one more. It grew out of our internal debates over healthcare reform, between two academic economists who work (often together) on U.S. health policy but have not yet been involved in making that policy.

We started by trying to define the goal: what is the problem that healthcare policy should address? There are many good reasons for government to be involved, but the reasons are usually assumed rather than articulated when proposing or evaluating a specific policy proposal. That's unfortunate. It's hard to have a constructive debate about solutions unless we've articulated—and hopefully agreed upon—goals.

We therefore spent a fair amount of time trying to identify the driving impetus behind our history of health policy reforms and attempted reforms. From this, we ended up concluding that our health policy has been motivated by an enduring, if unwritten, social contract: access to essential health care, regardless of resources.

We expected a fair amount of push back on this definition of the goal of U.S. health policy. After all, we are a society known for advocating independence and liberty, and for lifting oneself up by the bootstraps. We are also, (in)famously, the only high-income country without universal health insurance coverage. We therefore devoted about a third of our book to trying to convince our readers that in fact this social contract exists, and that the myriad problems with the current U.S. health insurance “system” reflect our failure to fulfill our obligations, not their absence.

Somewhat to our surprise, in the many reactions we've received from readers across the political spectrum, there has been near-universal agreement with our premise: that the U.S. is committed as a society to trying to ensure access to essential medical care for everyone, whether or not they can pay for it. Reactions have instead focused on particular elements of our proposal for how to fulfill this commitment.

We described what we thought an ideal system would look like, freed from political, but not economic, constraints. It contains two main elements. The first is universal coverage that is automatic, free to the patient, and basic. The second is the option—for those who want and can afford it—to purchase supplemental coverage in a well-functioning marketplace. We argued that we could thus fulfill our social contract without tackling the other multi-trillion-dollar elephant in the room: the problem of high and often inefficient healthcare spending.

In what follows, we briefly describe how we arrived at these key elements.

美国医疗保险改革的建议并不乏。在我们最近出版的《我们为您服务：重启美国医疗保健》（Einav & Finkelstein，2023）一书中，我们又提供了一个。它源于我们关于医疗改革的内部辩论，两位学院派经济学家（通常一起）研究美国卫生政策，但尚未参与制定该政策。

我们首先尝试定义目标：医疗保健政策应该解决什么问题？政府参与的理由有很多，但在提出或评估具体政策建议时，这些理由通常是假设的，而不是明确阐述的。那真不幸。除非我们阐明并希望达成一致的目标，否则很难就解决方案进行建设性辩论。

因此，我们花了相当多的时间试图找出我们卫生政策改革历史和改革尝试背后的驱动力。由此，我们最终得出的结论是，我们的卫生政策是由一项持久的、尽管不成文的社会契约推动的：无论资源如何，都能获得基本的卫生保健。

我们预计美国卫生政策目标的这一定义会受到相当大的阻力。毕竟，我们是一个崇尚独立、自由、自力更生的社会。众所周知，我们也是唯一没有全民医疗保险的高收入国家。因此，我们用了本书大约三分之一的篇幅来试图说服我们的读者，这种社会契约实际上是存在的，当前美国医疗保险“体系”的无数问题反映了我们未能履行我们的义务，而不是它们的缺失。

令我们感到惊讶的是，在我们从不同政治派别的读者那里收到的许多反应中，几乎所有人都同意我们的前提：美国作为一个社会致力于努力确保每个人都能获得基本医疗服务，无论他们是否能够支付费用。相反，反应集中在我们关于如何履行这一承诺的提案的特定要素上。

我们描述了我们认为的理想体系应该是什么样子，不受政治约束，但不受经济约束。它包含两个主要元素。第一个是自动的、免费的、基本的全民保险。第二个是对于那些想要并且能够负担得起的人来说，可以选择在运作良好的市场中购买补充保险。我们认为，这样我们就可以履行我们的社会契约，而无需解决房间里另一头价值数万亿美元的大象：高额且往往效率低下的医疗保健支出问题。

接下来，我们将简要描述我们如何得出这些关键要素。