The document provides an overview of SQL Server including:
- The architecture including system databases like master, model, msdb, and tempdb.
- Recovery models like full, bulk-logged, and simple.
- Backup and restore options including full, differential, transaction log, and file group backups.
- T-SQL system stored procedures for administration tasks.
- SQL commands and functions.
- SQL Agent jobs which are scheduled tasks consisting of steps to perform automated tasks.
The document provides an overview of SQL Server including:
- The architecture including system databases like master, model, msdb, and tempdb.
- Recovery models like full, bulk-logged, and simple.
- Backup and restore options including full, differential, transaction log, and file group backups.
- T-SQL system stored procedures for administration tasks.
- SQL commands and functions.
- SQL Agent jobs which are scheduled tasks consisting of steps to perform automated tasks.
1. 外 易大学对 经济贸
University of International Business and Economics
毕业论文
美国医疗保险体制与医改现状
对中国医保的启示
学号 201030010
姓名 陈仪卿
学院 保险学院
专业 精算与风险管理
导师 陈茵
论文编号____________ __
____________
2. 时间 2014 年 3 月 25 日
外 易大学对 经济贸
University of International Business and Economics
Graduation Thesis
Revelation from American
Health Care System and ObamaCare
Reforms
Student ID No. 201030010
Student Name Yiqing Chen
Department/School School of Insurance
Major Field Actuarial Science
Advisor Yin Chen
No.__________
13. 美国医疗保险体制与医改现状对中国医保的启示—英文摘要
Revelation from American Health Care System and
ObamaCare Reforms
Yiqing Chen
ABSTRACT
Due to the failure of reaching agreement on Patient Protection and
Affordable Care Act (hereinafter referred to as ‘ObamaCare reforms’),
American Federal government was unable to pass budget motion on time.
It directly led to the shutting down of government non-core departments
on 1st
Oct. 2014. Similarly, there still be many challenges in the health
care reforms of China. Therefore the purpose of this study was to raise
further improvement suggestions by studying the main reforms of
ObamaCare reforms motion and collecting, analysing government data.
Furthermore, after deeply understanding American health care insurance
system, try to summarise experiences and lessons for the health care
reforms of China by comparing with the US.
Keywords: ObamaCare reforms health care reforms
III
14. 美国医疗保险体制与医改现状对中国医保的启示—正文
一、文献综述
在本文研究的课题上，中文文献与外文文献的侧重点有很大不同。
英 文 文 献 大 多 是 由 政 府 相 关 机 构 （ HealthCare.gov 和 American Medical
Association）或统计机构网站发布的文章和数据表格，其内容可以概括为三种：
第一种是从宏观层面总结了奥巴马医改的主要政策，并做出简略介绍，例如参
考文献中英文部分[1] [2]。《Health Care Law Rights and Protections》和《Getting the Most
for Our Health Care Dollars》， 介绍了会对普通民众生活产生影响的医改政策，例
如私人保险交易平台的建立、消除医疗歧视、取消保险公司年度赔付上限等； 第
二种是针对某一具体医改政策进行详细介绍，例如参考文献中英文部分[3][4][5].
《What If Someone Doesn't Have Health Coverage in 2014? 》是从具体实施细节阐述了医改
为了扩大保障范围而提出的强制个人投保（Individual Penalty ），《Health Insurance
Premium Credits in the Patient Protection and Affordable Care Act》和《New Health Insurance
Tax Credits for Americans》则是针对政府将对贫困个人和小企业提供的税收优惠政策进
行细节说明与举例（包括税收优惠比例、符合政策的条件、美国各州收入统计等）；第
三种基本只提供数据，很少文字描述，例如参考文献中英文部分[8][9] 。
中文文献是国内的学术期刊上发表的文章和学术论文，都是在简要概括美国现行
医疗体制存在的问题的基础上，结合奥巴马医改的大体内容进行评论。具体如下：
叶明华、徐文虎在《奥巴马医改法案的冷思考》中指出，医改法案的实施会对美国医
保体系产生承保、理赔、欺诈及道德风险等方面的影响：全民医保会增大承保风险，推
动政府医疗开支迅速增长，并且医保反欺诈将面临持续性考验。在文中他们也提出了对
以上问题的解决办法：政府分摊高风险群体的超额保费；强化激励—约束机制，树立
“预防疾病比治疗疾病重要“的理念，支持预防和保健项目的推广和投资建设；强化投保
人的医保信息管理，完善全美医疗信息体系。
郝望月在其学术论文《奥巴马政府医疗保险制度改革述评及对我国的启示》中详细
介绍了美国现行的医疗保险体制与中国社会医疗保险制度的结构，比较了中美两国社
会情况的异同。她将美国现存医疗体制的主要问题概括为：医疗保障覆盖范围不广，医
药费用支出居高不下，医疗服务质量的效率与公平却有待提高。对于奥巴马医改对于中
国医改的借鉴作用，她认为应该在中国医改过程中，对不同群体分类优化、加大财政投
入、建立健全医保法规和监督机制、改革医疗费用支付方式、在医疗服务领域引入“管理
型竞争”机制、大力推动医疗技术革新及药品生产流通体制改革。
曹源和杜庆在《美国新医改的实施情况及对我国的借鉴》一文中总结了美国医保体
制存在的问题（具体内容与郝望月相同），并对我国医改提出以下意见：实行差别财
政税收；推广公共卫生、疾病预防以降低医疗费用支出；实现全民普及式医保，扩大医
保范围；实施倾斜性医疗政策，提高卫生服务公平；加强医疗信息共享，提高医疗效
率与质量；注重政府与市场协作。
1
28. 美国医疗保险体制与医改现状对中国医保的启示—参考文献
参考文献
一、中文部分
[1] 叶明华、徐文虎：《奥巴马医改法案的冷思考》，上海，《中国社会保障》2010 年第 3 期，
第 78-79 页。
[2] 郝望月：《奥巴马政府医疗保险制度改革述评及对我国的启示》，山西财经大学，2012。
[3] 曹源 杜庆：《美国新医改的实施情况及对我国的借鉴》，湖北，《当代经济》2011 年 9 月
（上），第 30-31 页。
[4] 蔺洁：《美国医疗保险制度演变及对我国的启示》，北京，《医院院长论坛》，2012 年 7 月
第 4 期，第 57-63 页。
[5] 王梅：《美国医疗体制改革的困境与启示》，北京，《新视野》2010 年 3 月，第 95-96 页。
[6] 杨剑仙：《中美医疗保险制度改革比较研究》，河北经贸大学，2011。
二、英文部分
[1] 《Health Care Law Rights and Protections》 , HealthCare.gov,
https://www.healthcare.gov/how-does-the-health-care-law-protect-me/#part=1.
[2] 《Getting the Most for Our Health Care Dollars》, American Medical Association,
https://www.ama-assn.org/ama/pub/advocacy/topics/health-care-costs.page
[3] 《What If Someone Doesn't Have Health Coverage in 2014? 》, HealthCare.gov,
https://www.healthcare.gov/what-if-someone-doesnt-have-health-coverage-in-2014/
[4] Bernadette Fernandez , Thomas Gabe , 《Health Insurance Premium Credits in the Patient
Protection and Affordable Care Act》, Congressional Research Service, July 31, 2013.
[5] Elizabeth Hagan，Kathleen Stoll，Kim Bailey，《 New Health Insurance Tax Credits for
Americans》, Families USA, April 2013
[6] http://www.census.gov/hhes/www/hlthins/data/incpovhlth/2012/Table8.pdf
[7] Centers for Medicare and Medicaid Services
http://en.wikipedia.org/wiki/File:U.S._Healthcare_Costs_as_a_Percentage_of_GDP.png
[8] OECD, Brookings Institute 2013
http://www.oecd-ilibrary.org/social-issues-migration-health/public-health-spending_20743904-table4
[9] the World Bank，http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?page=1
[0] The Kaiser Family Foundation, 《The Uninsured: A Primer》, October 2009
15
29. 美国医疗保险体制与医改现状对中国医保的启示—外文翻译
附录 外文译文两篇
译文一 什么是“甜甜圈洞”
Jonathan Blum
陈仪卿 译
Medicare 是一个面向 65 岁以上老年人、65 岁以下的特定种类残疾人以及肾病
晚期（永久性肾衰竭）患者的医疗保险计划。享受 Medicare 保障的人可以选择
缴纳月度保费并加入名为“Medicare D 计划”的处方药报销计划。
在 2010 年，Medicare D 计划具体实行办法如下：
全年支付 Medicare D 计划的月度保费。
在药物开销到达 310 美元的免赔额之前，全部药物开销需自付。
超过免赔额之后，个人支付药物开销的 25%，剩余部分由 Medicare
D 计划支付，直到药物开销总额达到 2800 美元的赔付上限。
到达赔付上限之后，就踏入了所谓的“甜甜圈洞”。此时个人需要对药
物开销全额付款，直到个人支付总额达到 4550 美元的年度个人支付
上限。
药物开销超过年度个人支付上限之后个人只需承担之后药物开销的
5%。
有一些 Medicare D 计划提供对于“甜甜圈洞”的保障，但这些计划会收取更
高的月度保费。也有一些加强型 Medicare D 计划对处方药提供定额的支付额度
（对不同药物有不同额度）而不是上述的 25%自付比例，这些计划也将收取更
高的月度保费。
毋庸置疑，对 Medicare D 计划中大多数人来讲，“甜甜圈洞”使他们不得不
面临严重的财政挑战，有些人甚至要通过缩减租金以及日常杂货开销来支付他
们的药物。
但是最近的奥巴马医改法案提出了一些重大改进来帮助那些在 Medicare D
计划中陷入“甜甜圈洞”的人们减轻负担：
如果今年陷入“甜甜圈洞”，将会收到一个一次性的金额为 250 美元的
退款支票。支票的邮寄将会从六月开始。如果符合退款条件却没有收
到支票，请致电咨询
2011 年起，在“甜甜圈洞”中的期间将会享受对品牌处方药的 50%优
惠，并且在“甜甜圈洞”中的自付比例将会逐年降低。
16
31. 美国医疗保险体制与医改现状对中国医保的启示—外文翻译
附原文
What is the Donut Hole?
By Jonathan Blum, Deputy Administrator and Director for the Center of Medicare at the
Centers for Medicare and Medicaid Services
If you aren’t familiar with Medicare, it is a health insurance program for people 65 or
older, people under 65 with certain disabilities, and people with End-Stage Renal Disease
(permanent kidney failure). People with Medicare have the option of paying a monthly
premium for outpatient prescription drug coverage. This prescription drug coverage is called
Medicare Part D.
In 2010, basic Medicare Part D coverage works like this:
■You pay out-of-pocket for monthly Part D premiums all year.
■You pay 100% of your drug costs until you reach the $310 deductible amount.
■After reaching the deductible, you pay 25% of the cost of your drugs, while the Part D
plan pays the rest, until the total you and your plan spend on your drugs reaches $2,800.
■Once you reach this limit, you have hit the coverage gap referred to as the “donut
hole,” and you are now responsible for the full cost of your drugs until the total you have
spent for your drugs reaches the yearly out-of-pocket spending limit of $4,550.
■After this yearly spending limit, you are only responsible for a small amount of the
cost, usually 5% of the cost of your drugs.
There are some Medicare Part D plans that offer coverage in the donut hole—but these
plans may charge a higher monthly premium. There are also some Part D plans that are
“enhanced” and offer fixed co-pays (for example $5, $10, and $20) for prescription drugs
instead of the deductible and 25% cost-sharing that was described above. These plans also
may charge a higher monthly premium.
Needless to say, for most people with Medicare Part D, the donut hole presents serious
financial challenges. Some people have had to choose between their rent or groceries and
their prescription drugs.
But, the recent health reform law – the Affordable Care Act – has some important
changes that will help to relieve this burden for the people with Medicare that hit the donut
hole each year :
■This year, if you enter the Part D donut hole, you will receive a one-time, $250 rebate
check. The mailing of these checks began in June. If you are eligible and do not receive your
check, call your Part D plan first and then 1-800-Medicare.
■Starting in 2011, you will receive a 50% discount on brand-name drugs in the donut
hole, and you will start to pay less and less for your generic Part D drugs in the donut hole.
18
32. 美国医疗保险体制与医改现状对中国医保的启示—外文翻译
■By 2020, the coverage gap will be closed, meaning there will be no more “donut
hole,” and you will only pay 25% of the costs of your drugs until you reach the yearly out-of-
pocket spending limit.
19
35. 美国医疗保险体制与医改现状对中国医保的启示—外文翻译
附原文
Federal deficit
CBO estimates of impact on deficit
The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200
billion during the 2012–2021 period: it calculated the law would result in $604 billion in total
outlays offset by $813 billion in total receipts, resulting in a $210 billion net reduction in the
deficit. The CBO separately noted that while most of the spending provisions do not begin
until 2014, revenue will still exceed spending in those subsequent years. The CBO averred
that the bill would "substantially reduce the growth of Medicare's payment rates for most
services; impose an excise tax on insurance plans with relatively high premiums; and make
various other changes to the federal tax code "—ultimately extending the solvency of
the Medicare trust fund by 8 years.
However, this estimate was made prior to the Supreme Court's ruling that enabled states to
opt out of the Medicaid expansion, thereby forgoing the federal funding.
The CBO subsequently updated the budget projection, estimating the impact of the ruling
would reduce the cost estimate of the insurance coverage provisions by $84 billion.
Major sources of deficit reduction include: higher Medicare taxes on the wealthy; new
annual fees on health insurance providers; similar fees on the healthcare industry such as
manufacturers and importers of brand-name pharmaceutical drugs and certain medical
devices; limits on tax deductions of medical expenses and flexible spending accounts; a new
40% excise tax on "Cadillac" insurance policies - plans with annual insurance premiums in
excess of $10,200 for an individual or $27,500 for a family; revenue from mandate penalty
payments; a 10% federal sales tax on indoor tanning services; and spending offsets such as a
reduction in Medicare reimbursements to insurers and drug companies for private Medicare
Advantage policies that the Government Accountability Office and Medicare Payment
Advisory Commission found to be overpaid (relative to government Medicare); and
reductions in Medicare reimbursements to hospitals that do not meet standards of efficiency
and care.
Although the CBO generally does not provide cost estimates beyond the 10-year budget
projection period because of the degree of uncertainty involved in the projection, it decided to
do so in this case at the request of lawmakers, and estimated a second decade deficit reduction
of $1.2 trillion. CBO predicted deficit reduction around a broad range of one-half percent of
GDP over the 2020s while cautioning that "a wide range of changes could occur".
Source：3.1.6.1/ 3.1.6.2, Patient Protection and Affordable Care Act, WIKIPEDIA.
22
36. 美国医疗保险体制与医改现状对中国医保的启示—外文翻译
A commonly heard complaint regarding the CBO cost estimates is that CBO was required
to exclude from its initial estimates the effects of likely "doc fix" legislation that would
increase Medicare payments by more than $200 billion from 2010 to 2019. However, the "doc
fix" is a separate issue that would have existed whether or not the ACA became law - omitting
its cost from the ACA is no different than omitting the cost of the Bush tax cuts.
Opinions on CBO projections
There was mixed opinion about the CBO estimates. Uwe Reinhardt, a health economist at
Princeton, wrote that "The rigid, artificial rules under which the Congressional Budget Office
must score proposed legislation unfortunately cannot produce the best unbiased forecasts of
the likely fiscal impact of any legislation", but went on to say "But even if the budget office
errs significantly in its conclusion that the bill would actually help reduce the future federal
deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as
was the financing of the Medicare Modernization Act of 2003." Douglas Holtz-Eakin, CBO
director during the George W. Bush administration, who later served as the chief economic
policy adviser to U.S. Senator John McCain's 2008 presidential campaign, alleged that the bill
would increase the deficit by $562 billion because, he argued, it front-loaded revenue and
back-loaded benefits.
The New Republic editors Noam Scheiber and Jonathan Cohn, countered critical
assessments of the law's deficit impact, arguing that it is as likely, if not more so, for
predictions to have underestimated deficit reduction than to have overestimated it. They noted
that it is easier, for example, to account for the cost of definite levels of subsidies to specified
numbers of people than account for savings from preventive healthcare, and that the CBO has
a track record of consistently overestimating the costs of, and underestimating the savings of
health legislation; "innovations in the delivery of medical care, like greater use of electronic
medical records and financial incentives for more coordination of care among doctors, would
produce substantial savings while also slowing the relentless climb of medical expenses... But
the CBO would not consider such savings in its calculations, because the innovations hadn't
really been tried on such large scale or in concert with one another—and that meant there
wasn't much hard data to prove the savings would materialize."
David Walker, former U.S. Comptroller General now working for The Peter G. Peterson
Foundation, has stated that the CBO estimates are not likely to be accurate, because they are
based on the assumption that Congress is going to do everything they say they're going to
do. The Center on Budget and Policy Priorities objected: in its analysis, Congress has a good
record of implementing Medicare savings. According to their study, Congress followed
through on the implementation of the vast majority of provisions enacted in the past 20 years
to produce Medicare savings.
23
