对中低收入者和高风险人群保障不足,是以私人保险为主导的美国医保制度的内在缺陷。从美国大病保障发展历程来看,美国政府主要采取打补丁的方式,通过扩大保障项目和保障人群等措施修补制度的漏洞。但随着医疗费用的快速增长,未参保人群和保障不足的参保人群面临越来越大的大病经济负担,甚至陷入灾难性医疗支出的困境。因此,提高该群体的承受能力和对其保障水平,防止因病破产一直是美国医改的重要内容。但由于医疗改革涉及多元利益的博弈,导致美国医改在近一百多年的时间内成效并不明显。直到奥巴马医改采取政府强势干预的方式,逐渐扩大覆盖面,对中低收入者和弱势群体采取缴费和费用补偿双向倾向的方式提高其应对大病经济风险的能力,并建立绝对值的最大自付限额,化解灾难性医疗支出风险。 Insufficient protection for middle and low-income people and high-risk groups is the inherent flaw in the U.S. Medicare system led by private insurance. From the history of the development of serious illness in the United States, the U.S. government mainly adopts the method of patching up and repairs the loopholes in the system through such measures as expanding protection projects and safeguarding the population. However, with the rapid growth of medical expenses, uninsured and underinsured insured people face increasing financial burden of major illness and even catastrophe of catastrophic medical expenditures. Therefore, it is always an important part of the medical reform in the United States to raise the affordability of the group and its level of protection to prevent bankruptcy due to illness. However, because the medical reform involves the game of multiple interests, the effectiveness of the medical reform in the United States over the past one hundred years has not been obvious. Until the medical reform of Obama takes the form of strong government intervention, gradually expand the coverage of low-income and disadvantaged groups for low-income and fee-based compensation for two-way tendency to increase its ability to deal with serious economic risks and establish the maximum absolute payment limit, Resolve disastrous medical spending risks.