17.315医疗政策                                    Harvey M. Sapolsky

第九讲：加拿大的医疗护理制度

1. 虽然医疗政策专家喜欢到欧洲，惯常把加拿大与美国比较。加拿大不单止只是和美国接壤——经济，专业和文化融合。美国企业往往把加拿大作为美国的一部份；运动，北美洲自由贸易区。英国是相对的穷和社会主义；德国和日本是奇怪的外国；瑞典太小，不认识。

但加拿大只有美国十份之一的人口，面积比美国大，比沙特阿拉伯还要人口稀疏。

1. 政治分歧不少：分隔的大陆

美国革命催生了两个国家，不是一个——加拿大和美国。

我们是革命胜利者的后代；加拿大是输家。

在革命前，英国控制新法国／加拿大只有二十年（1759），新法国的部份有二百多年（1534）。

美国信念—反国家，个人主义，平等主义，民粹主义

没有加拿大信念—不是美国；善良的国民，国家主导，集体主义，权威主义。没有革命。没有内战。没有宪法。

美国西部的象征——牛郎（牛仔）

如拿大——骑警——恶劣的环境需要政府更多参与开发寒冷的西部

加拿大「宪法」：1867年英属北美法案合并了上加拿大和下加拿大——目标是「和平，秩序和良好政府」

美国独立宣言—生命，自由和追求快乐

直至第二次世界大战，英国支配加拿大

        这一边「英皇」什么，那一边「皇室」什么

        魁北克省被孤立

            没有建立新国家

到了现在，有六十年的美国文化支配——魁北克省的问题要解决

1980年代有了自己的宪法，最近有「美灿湖协议」和「人权法案」

        魁北克省民意不满日增，西部要独立，西部与魁北克省对抗

        1995年，魁北克省差点争取成功。联邦主义只以50.5%获胜

政党是地区性——有些省会投向美国

医疗制度定位加拿大——与美国不同；差异，分隔和加拿大社会和价值观的国家象征

2. 加拿大的医疗护理制度

1           ? 联邦政府补贴住院和医疗护理项目

2           ? 在联邦政府的监督下，省政府执行

3           ? 涵盖超过99%的人口

4           ? 福利全面，但不包括药物，牙医和养老院

1           ? 联邦政府拨款支付成本的33%，省税收支付其余，用家不用付费

1           ?支付医师，一般是依据省政府的收费表

2           ? 一半的病床是在非牟利机构，但医院的资金来自省政府的预算检讨制度

3           ? 有保险公司，但只包括半私人病房，牙医保险大多由雇主提供

3. 历史／背景

二十世纪初期，农村地区有一些公共医疗保险。自由党把这列入竞选政纲。

1935年的社会保障法案有包括「国民医疗保险」的立法，但法案被裁定为违宪——依据英属北美法案，这是省政府的权限（加拿大的省政府有已列明的权力—医疗是其中之一）

1945年建议类似「国民医疗服务」的制度，但因省政府和联邦政府不能达成协议而告吹

1947 萨斯喀彻温省医院保险计划

1948 国家医疗拨款计划

1957 医院保险和诊断服务法案(1958-1961)

1962 萨斯喀彻温省医疗保险计划

1965 医疗资源基金法案（倍增医生人数）

1966 医疗保险法案(Medicare) (1968-1971)

1977 现有项目融资法案（以一次性拨款替换税收资源）

         联邦政府的份额与国民生产总值挂勾     

1984 加拿大健康法案

加拿大的每人平均病床数目相当高——首先是农村，医院保险导致更多人住院，省政府试图缩减，把仪器集中，现在是大问题。

医生反对。1962年，萨斯喀彻温省罢工，医生要求有私营保险的选择；1971年，魁北克省的专科医生要求退出；1984年，安大略省要求更多收费项目。

时常声称医生流向美国。收费表的谈判亦即是医生收入的谈判。

4. 原则，困难，和引以为傲

A. 原则

1                ? 全面

2                ? 全民

3                ? 可转移

4                ? 取得服务

5                ? 公办执行

B. 困难

1              ? 医院短缺和轮候名单

2              ? 90%的加拿大人居住在美国边界150里之内

C. 引以为傲

1              ? 比美国开支少

2              ? 不是美国的两层制度

3              ? 不是美国的以盈利主导

良好国民

 

第二篇：19xx - 开放式课程计划

May 11, 2004

US and Sweden (“The Ultimate Welfare State”) Compared

I. Sweden is an interesting case study because it illustrates a radical departure from

traditional nuclear family

A. High degree of state involvement

B. 8 million people

II. Historical background

A. Movement for gender equality came much earlier than anywhere else

B. Why? Historical antecedents1

1. Sweden was always a poor country: no great hierarchies

a. Less concern about arranged marriages in order to maintain and

consolidate property than elsewhere in Europe

b. Few economic or political advantages to marriage, so for the most

part young people chose their partners

c. Also a tradition of late marriage: couples wouldn’t marry until they

could afford to

2. Also, men were seafarers, lumberers

a. Women had to be resourceful, self-reliant, economically

productive because men were gone for long periods of time

C. More recent history

1. Very poor country, lots of immigration out

2. Late industrialization

a. A labor shortage

b. Single women were drawn into the labor force

1 Some of this material taken from Charlotte G. O’Kelly and Larry S. Carney, Women & Men in Society: Cross-cultural Perspectives on Gender Stratification, 2nd ed., 1986. Belmont: Wadsworth: 182-198.

III.

3. 4. 5. And although it had been one of the poorest countries, it used “rational social planning” to avoid poverty, slums, unemployment a. Probably helped foster the notion that women were an underprivileged social group In 1842 free elementary school education for both boys and girls In 1845 women were given equal inheritance rights and other reforms a. It’s interesting that parliament instituted these reforms without pressure from women’s groups A form of democratic socialism evolved, following industrialization A. Socialist in the sense that legislation was passed to redistribute the surplus to the weaker members of society 1. Sweden continues to have of the highest standards of living in the world;

no poor people in Sweden

2. Literacy rate 99%2

3. Infant mortality rate 6 per 1,000

B. Almost all the production is in the hands of the private capitalists

C. Employment was a key goal of government

1. The Social Democrats had power to implement job creation schemes, and

Sweden pulled out of the Depression before the rest of the West

IV. Underpopulation crisis influenced family policy-making

A. There had been a decline in the birthrate during Sweden’s bout with widespread

poverty and unemployment in the 1920s

1. Arguments were made that the state had to take responsibility for making

it easier to have and support children

a. That children are a valuable contribution to society

V. The government instituted these policies on its own initiative

2 Some of this material from J. Ross Eshleman, 2000, The Family, 9th edition. Boston: Allyn and Bacon: 9.

3

A. As in the 19th century

B. Policies considered to be necessary for the good of the nation:

1. Provide employment

2. Increase population

3. These social policies supported gender equality and women’s issues

a. Not because women were in major offices

b. Not because candidates who supported these issues were supported

by mass support organizing campaigns

c. Not by changing the political/cultural climate so politicians see it

to their interest to support reforms

C. Government promoted affirmative action

1. Social Democrats blocked attempts at legislation banning discrimination

on the basis of gender

2. Because, they said, it undermines attempts to right past inequalities

VI. Sweden’s current policies related to families

A. Based on achieving a high quality of life for all citizens

B. Marriage

1. The Marriage code of 1921

a. Equality and legal independence of the husband and wife

b. Equated housework and earned income as contributions to the unit

c. Joint owners of any property

2. In the 1970s the government introduced the notion of shared roles

3. The distinction between marriage and cohabitation was made minimal

Sweden 2004 7/3/2004

4. 5. a. b. Receive the same government benefits The difference: no implied contract of marriage for couples cohabiting The stipulation of legitimacy was removed in 1917 a. b. c. Parents are responsible for 50-50 support The state will pay if the father is recalcitrant 90% do pay child support Changes in tax laws a. b. No longer do couples file a joint return If a woman works, she as an individual is taxed, which probably results in lower rates than if they filed a joint return, if he earns more they’re taxed more This is an incentive to get her to work: if together they earn the

same amount of money that they would if only he worked, c.

1) They will have more money

C. Divorce

1. If the situation is really bad, Swedes argue that there’s no reason to stay

together

2. So if long-term companionship and intimacy have ended, then yes, divorce

3. Very high rates

a. Divorce rate is about ? of U.S.

b. But if you include nonmarital cohabitation dissolution

c. Highest breakup rate in the industrialized world3

1) Note that Swedes have institutionalized nonmarital 3 Eshleman, 2000: 492

cohabitation much more than most other countries, so the

counts of these relationships are closer to 100%

4. Risk of divorce lower for women with one child, and even lower for

women with 2 children

D. Reproduction policies

1. There has been free prenatal and postnatal care since 1937

2. Maternity leave up to 6 months (without pay) was instituted in 1945

a. In 1954 3 months’ paid leave was instituted

b. As of 1995: parents entitled to 10 months’ leave at 80% regular

pay and an additional 3 months at a flat-rate4

1) Can be used any time before the child is 8 years old

c. And 60 days off with pay per child sick leave

d. The government is trying to encourage fathers to take paternity

leave more often, participate in prenatal care, parental education,

and delivery

3. Loans are available for newlyweds to purchase household goods

a. In 1953 such loans were extended to unmarried parents

4. And other state-initiated social welfare services: neighborhood laundries,

aid to the elderly, ill

5. In 1948 a family allowance per child rather than tax deduction was

instituted

a. This favors the poor

6. Sweden is very resistant to pushing parents of small children, especially

single parents, out to work

a. There is state-sponsored day care

7. And education is free, including university, including a stipend for living 4 Eshleman, 2000: 544

expenses regardless of parental income

E. Sexuality policies

1. Earlier in Sweden it had been illegal (1910) to disseminate birth control

information

a. But in 1938 the country committed itself to the principle that every

child should be wanted

2. Currently in Sweden: contraception is available to all sexually active

individuals

3. Compulsory sex education in schools since 1956 (begun in 1940s)

a. Policy: provide detailed information, and avoid taking a moral

stand against premarital sexuality

5. Abortion: frowned upon

a. Holdover from anti-contraception campaign, pro-natal movement

b. But abortions were allowed from 1938 on for rape, incest, and

threat to the mother's health

c. In1973 the law about abortions was liberalized because of

evidence of illegal abortions

d. Why teenagers get pregnant is a mystery

1) Only 1.4% of teens ages 15-19 became pregnant in 1990

2) In U.S. it was 11%

e. Abortion rate in 1993 was 19.8 per 1,000 women ages 15 to 44

1) U.S.: 25.95

6. Premarital sexuality is expected

a. No emphasis on virginity

b. Males are far less likely to try to “score” than here

5 Eshleman, 2000: 179

c. 1990s: Uppsala University students: about 70% believed it is

acceptable for a 15-year-old girl or boy to have sexual intercourse

with a steady boyfriend or girlfriend

d. 90% did not approve of a 15-year-old girl having sexual

intercourse with a casual partner

1) Far greater approval for a 15-year-old boy; double standard

7. Extramarital sexuality

a. Not approved of

8. Attitudes toward sexual freedom

a. Yes, if doesn’t impinge on rights of others

b. Prostitution, yes, solicitation, no

1) Poverty is low, so not as many women go into prostitution

c. Sex with children, no

d. Incest is a crime only if involves under 18 years old

e. Homosexuality is seen as a private matter

F. Cohabitation

1. Not seen as a problem

2. About 25% of relationships

3. A study published in 1988 of 5,000 women found that those who

cohabited premaritally had almost 80% higher marital dissolution rates

than those who did not

a. But the longer the marriage, the smaller the difference6

b. No differences for intact marriages of 8 years’ duration or longer

c. Virtually all Swedes cohabit prior to marriage now7

6 Eshleman, 2000: 156

4. 5. 35% of births not within a marriage in 1975 b. Unwanted pregnancies are seen as a problem Although some disapprove of marriage—see it as old fashioned—most

Swedes aren’t against marriage

6. Another semi-institution: LAT (living apart together): 2 domiciles

G. Work

1. The government continued to see married unemployed women as “hidden

unemployment”

2. The idea of shared roles occasioned a big debate in 1956

3. Two roles for women and one for men was inherently unequal

a. Led to the government developed policies for getting men into the

domestic arena

b. Developed policies to encourage parental leave and other ways of

getting men to accept half of the parental responsibilities

4. So by 1979 65% Swedish women worked (79% men)

a. Currently 82%8

5. Interest in getting women into the male domain

a. Government will bring women in to previously male jobs in areas

with labor shortage (unskilled and semiskilled work)

b. And males are given preference in many female-dominated social

service jobs

6. Not only government, but unions are behind ending gender-segregated

labor

a. Unions supported instituting a “Solidarity Wage”

7

8 Eshleman, 2000: 153 Eshleman, 2000: 86

b. c. A union negotiates for a larger percentage increase for those with the lowest wages Aims to gradually raise the wages of those on the bottom without

directly penalizing the higher-paid workers

7. In 1960: women earned 68.8% of men; by 1977 it was up to 87%

VII. Effects

A. All of this legislation produced only a slight increase in birthrate

1. Sweden’s population would decline except for immigration

2. Women’s higher education levels and participation in labor force is

associated with lower birthrates

3. More education correlates with later marriages

4. And children are expensive, even in Sweden

B. It’s a productive economy, there is little public resentment at the extremely high

taxes

C. Marriage rates low; late age at marriage

1. By 1980 in Sweden 78 marriages per 1,000 women in the 25-29 year age

group

a. 117 in France, 127 in the U.S., 168 in England

2. Mid-1980s median age at first marriage: 27 for women and nearly 30 for

men

D. Role Sharing

1. In the 1990s: 55% said equal partnerships preferred, with the youngest

parent generation more in favor than older ones9

2. The differences that remain are the result of attitudes about:

a. Having children (women still primarily responsible for home and

child care) 9 Eshleman, 2000: 267

3. 4. 5. 6. b. And the man’s role as breadwinner There’s still a ways to go a. b. c. Women still feel more dependent Many men say they do not want to take parental leave Employers disapprove of men doing this (counter to what the goverment wants) For parents, one solution is shift work a. But then they will never see each other Today: 85% of all women with at least one child younger than seven years old a. Are in the labor force10Government resists upgrading housework to status of a job: it is still

considered “hidden unemployment”

VIII. Political Participation

A. 90% Swedes vote

B. All major parties supportive of gender equality

1. High proportions of women holding office, but not 50-50

C. Women are less represented in unions than men

1. 90% of Swedes are unionized

2. Women participate in popular movements, but are less well represented in

leadership positions

IX. Discuss: how many values different from US?

A. Characteristics:

10 Eshleman, 2000: 246

1. Low marriage rate, high cohabitation rate, high rate of family

dissolution, small household size, extensive movement of mothers into the

labor force, high focus on family and children

B. Values

1. Moral assumptions about what is a just society

a. Minimum standards for all citizens

b. Ensure equality of opportunity

c. Social mobility for young people: education through college paid

for

2. About who is responsible for the welfare of its citizens

a. The state to a much greater extent in Sweden

3. About what is just treatment for citizens who do not, or cannot, manage

their own welfare