評(píng)論
打印
Obamacare
奧巴馬醫(yī)改
Experimental medicine
實(shí)驗(yàn)醫(yī)學(xué)
A year after the big launch, is Obamacare working?
實(shí)施一年的奧巴馬醫(yī)改到底奏效嗎？
TEXAS has a higher share of uninsured citizens than any state in America. Until recently Shane, a 38-year-old from Houston, was one of them. “I just couldn't afford it,” he says. Shane has HIV; his job does not cover him. Because of his illness, insurers would offer him only a costly plan with limited benefits. Such discrimination is now illegal. Since January the Affordable Care Act, better known as Obamacare, has required insurers to charge the healthy and the sick the same price. For the first time in 20 years, Shane can afford health cover.
堪薩斯州未參與醫(yī)療保險(xiǎn)的人數(shù)比美國(guó)其他任一州都多。直到近期來自休斯頓38歲的謝恩才剛剛參保。他說，“我只是無法負(fù)擔(dān)醫(yī)療保險(xiǎn)費(fèi)。”謝恩是艾滋病患者，他的工作薪金無法負(fù)擔(dān)他的醫(yī)藥費(fèi)。由于他的疾病，保險(xiǎn)公司只愿意提供有限福利但保費(fèi)昂貴的保險(xiǎn)方案。但是現(xiàn)在，這樣的歧視是非法的。自今年一月平價(jià)醫(yī)療法案，即人們熟知的奧巴馬醫(yī)改要求保險(xiǎn)公司向患病及健康的投保人收取同樣的保費(fèi)。這是20年來首次謝恩能夠支付得起他的醫(yī)療費(fèi)用。
Across town, Suezen Salinas is less fortunate. Having recently returned to college, she has no job. Her two children qualify for Medicaid, the public health programme for the poor, but she does not. Texas is one of the nearly two dozen states that did not expand Medicaid, despite Obamacare's offer that the federal government would cover most of the cost. Ms Salinas also earns too little to qualify for Obamacare's subsidies. So she used some of her college financial aid to buy health cover.
城鎮(zhèn)另一端的Suezen Salinas就沒有那么幸運(yùn)了。最近剛返回大學(xué)校園繼續(xù)深造的她還沒有工作。她的兩個(gè)孩子有資格享受專為窮人設(shè)置的公共醫(yī)療項(xiàng)目—醫(yī)療補(bǔ)助計(jì)劃，但是她不行。盡管奧巴馬醫(yī)改表示聯(lián)邦政府將會(huì)支付醫(yī)保的絕大部分開支，堪薩斯州是近20個(gè)未擴(kuò)大醫(yī)療補(bǔ)助計(jì)劃覆蓋面的州之一。
Health care in America is changing, thanks to Obamacare and the efforts of innovative private firms (see article). And not before time. America's health system, the world's biggest, involves a tangled mess of rules and a hotch-potch of public and private institutions. It combines dazzling technology with minimal cost controls and spotty coverage. In 2012 it left some 48m people uninsured despite gobbling up 17.2% of GDP, a figure that dwarfs spending in any other country and has shot up from 4.4% in 1950.
由于奧巴馬醫(yī)改以及銳意創(chuàng)新的私人企業(yè)的努力，美國(guó)的醫(yī)療保健正在改變。在此之前，作為全球最大的醫(yī)療體系，美國(guó)的醫(yī)療體系包含有一堆雜亂無章的規(guī)章制度以及混亂的公私機(jī)構(gòu)。它集毫無節(jié)制地購買令人眼花繚亂的科技產(chǎn)品和零星的覆蓋面于一體。2012年，盡管醫(yī)療體系開支占GDP17.2%，但仍然有0.48億人未享受到醫(yī)療保險(xiǎn)的福利，而這一數(shù)據(jù)遠(yuǎn)遠(yuǎn)高出其他國(guó)家的醫(yī)療保險(xiǎn)開支，并且遠(yuǎn)遠(yuǎn)高出1950年占GDP4.4%的比率。
Rather than scrap this system, Obamacare rejigs it. It expands Medicaid to include millions of not-quite-poor Americans. It seeks to create a market where individuals can buy health insurance, pooling risks without the backing of a large employer. Ultimately, it aims to expand coverage and deliver better care at a lower price. Its record is mixed so far.
奧巴馬醫(yī)改重新整頓了這個(gè)原本應(yīng)該棄置的醫(yī)療體系。它擴(kuò)大了醫(yī)療補(bǔ)助計(jì)劃的覆蓋范圍，將那些不是那么富裕但又處于貧困線以上的數(shù)百萬人納入新的醫(yī)療救助體系中。它試圖創(chuàng)造一個(gè)個(gè)人能夠負(fù)擔(dān)得起的醫(yī)療保險(xiǎn)市場(chǎng)，在沒有大型雇主的支持下讓風(fēng)險(xiǎn)集中。最終達(dá)到以更低的價(jià)格擴(kuò)大醫(yī)療保險(xiǎn)的覆蓋率同時(shí)提供更好的醫(yī)療服務(wù)。目前為止奧巴馬醫(yī)改所創(chuàng)的記錄是多方面的。
Obamacare created new health exchanges, where individuals can shop for private insurance and, if they earn between $11,670 and $46,680, qualify for subsidies. As well as barring insurers from charging the sick more, it requires individuals to have health insurance or pay a fine.
奧巴馬醫(yī)改創(chuàng)造了新的健康交易模式，在該種模式下，若個(gè)體收入在46680美元一下11670美元以上就有資格獲得補(bǔ)助金，能夠購買私人醫(yī)療保險(xiǎn)。同時(shí)由于它阻止保險(xiǎn)公司向病人收取更高的保費(fèi)，它要求個(gè)體購買醫(yī)療保險(xiǎn)或者繳納罰款。
In some states Obamacare works well. In others, it does not. Many Republican-run states refused to expand Medicaid on the grounds that taxpayers would be stuck with the bill. That left almost 9m adults who earn less than $11,670 a year, like Ms Salinas, too rich for Medicaid but too poor to receive subsidies on the exchanges.
在有些州奧巴馬醫(yī)改實(shí)施得非常好，但是在另一些州則不然。許多共和黨人治理的州由于擔(dān)心納稅人在支付賬單時(shí)有困難而拒絕擴(kuò)大醫(yī)療救助計(jì)劃的覆蓋面。這讓像薩林納斯小姐一樣年收入在11670美元以下的將近900萬成年人既沒有資格獲得醫(yī)療救助又無法負(fù)擔(dān)得起購買醫(yī)療保險(xiǎn)的金額。
Thirty-six states did not set up their own exchanges (as Congress had assumed they would), instead relying on the federal government to do the work. That put a lot of pressure on Healthcare.gov, the federal insurance website, which hardly worked at all when it was launched on October 1st last year. It is working better now, but problems remain. A new audit warns that more must be done to make the site secure.
36個(gè)州沒有像國(guó)會(huì)預(yù)設(shè)的那樣建立他們自己的醫(yī)療保險(xiǎn)交易，而是寄希望于聯(lián)邦政府去做這件事。這給聯(lián)邦保險(xiǎn)網(wǎng)站—醫(yī)療保健政府官網(wǎng)極大的壓力，而該網(wǎng)站自去年十月一日上線以來幾乎沒做任何工作。盡管現(xiàn)在運(yùn)轉(zhuǎn)良好但是問題依然存在。新的審計(jì)警告要使該網(wǎng)站安全要投入更多的工作。
For now Obamacare seems to have expanded cover. Data-crunchers at Gallup, Harvard University, the Urban Institute and the Commonwealth Fund agree that the proportion of American adults who are uninsured dropped by 22%-26% from the third quarter of 2013, just before Obamacare's exchanges opened, to the second quarter of 2014, when enrolment ended. Between 8m and 10.3m adults have gained cover. Much of this gain appears to have come from the expansion of publicly-funded Medicaid, however. Nearly 20% of adults are uninsured in states that did not expand Medicaid, about twice the share in states that did, according to the Urban Institute.
目前奧巴馬醫(yī)改似乎已經(jīng)擴(kuò)大了其覆蓋面。在哈佛大學(xué)、蓋洛普、城市研究所及聯(lián)邦基金會(huì)搞數(shù)據(jù)工作的人同意，在奧巴馬醫(yī)改交易實(shí)施以前，登記截止之時(shí)，未參保的美國(guó)成年人的比例由2013年第三季度到2014年第二季度的比例下降了22%-26%。大約有800萬至1030萬成人被納入醫(yī)療保險(xiǎn)中。但是，這其中的絕大多數(shù)人似乎是來自公共基金支持的醫(yī)療救助計(jì)劃的擴(kuò)展。根據(jù)城市研究所的數(shù)據(jù)，在醫(yī)療救助計(jì)劃未擴(kuò)展的州府將近20%的成人未被納入醫(yī)保中，而在醫(yī)療救助計(jì)劃擴(kuò)展的州府納入醫(yī)保的成人的比例是40%。
How many people have gained coverage through the new exchanges is unclear. Officials say that more than 8m have signed up, but this includes some who had insurance before. In May McKinsey, a consultancy, estimated that 26% of those who had bought policies on the individual market had been previously uninsured.
到底有多少人通過新的交易被納入到醫(yī)保中還不是很明確。官員聲稱超過800萬人已簽訂合同，但這包含那些原本就參保的人。五月份，麥肯錫咨詢公司估計(jì)在個(gè)體市場(chǎng)26%購買保險(xiǎn)的人之前都未參保。
Politically, Obamacare remains highly controversial. A poll of polls finds that 51% of Americans disapprove of it; only 41% approve. Republicans bash it in stump speeches; Democrats mention it only in passing. A lawsuit, Halbig v Burwell, contends that the law allows insurance subsidies only through state-run exchanges, not through the federal one. If the plaintiffs win, they could kneecap the entire reform.
政治上來講，奧巴馬醫(yī)改依然備受爭(zhēng)議。民意測(cè)驗(yàn)的比較發(fā)現(xiàn)51%的美國(guó)民眾不贊同該醫(yī)改，僅有41%的人支持它。共和黨人在競(jìng)選演說中猛烈抨擊奧巴馬醫(yī)改，而民主黨只是順便提一提。Halbig v Burwell訴訟案件爭(zhēng)論法律只允許通過國(guó)營(yíng)的交易而非聯(lián)邦交易給予保險(xiǎn)補(bǔ)助金。如果原告獲勝，他們將保障整個(gè)改革。
Assuming it survives legal challenges, however, Obamacare's success depends largely on how many uninsured people eventually sign up for coverage on the exchanges. Legally, they are obliged to have coverage, but if prices are too high, some will opt to pay the penalty instead. Education should help—most of the uninsured are unaware of the subsidies available to them. But premiums matter more, and are rising, by an average of 7% across 33 states, according to PwC, a consultancy. There is broad variation. Premiums are to rise by an average of only 2.4% in Colorado, but by a whopping 14% in Tennessee, according to PwC. The next round of enrolment starts in November; many people will discover whether their premiums are to rise or fall just before the mid-term elections.
假設(shè)奧巴馬改革能夠挺過法律這一挑戰(zhàn)，它的成功依然在很大程度上依賴于最終多少未參保的人會(huì)在醫(yī)療保險(xiǎn)單上簽字。法律上說，他們應(yīng)該被納入到醫(yī)保覆蓋范圍，但是倘若保費(fèi)泰國(guó)高昂，有些人將會(huì)選擇付罰金而非保費(fèi)。教育程度應(yīng)該會(huì)起作用——許多未參保的人都意識(shí)不到他們能得到的補(bǔ)助金。但是保險(xiǎn)費(fèi)所起的作用更大，并且價(jià)格一直在上漲。根據(jù)普華永道咨詢公司的數(shù)據(jù)在33個(gè)州府中，保費(fèi)平均漲幅達(dá)7%。并且各地的保費(fèi)差異很大——在科羅拉多州保費(fèi)的平均漲幅僅2.4%，而在田納西州漲幅高達(dá)14%。下一輪的參保將在一月展開，在中期選舉之前許多人將會(huì)討論他們的保費(fèi)到底是會(huì)漲還是會(huì)跌。
Growth in health spending per person slowed from a shocking 7.4% a year from 1980 to 2009 to 3% from 2009 to 2012. It may rise again, alas. The lousy economy caused some of the recent slowdown. The government's actuaries expect spending to jump by 5.6% this year and 6% a year from 2015 to 2023. As more Americans age and gain insurance, they will demand more health care. Shane, for example, ignored an aching shoulder and blocked sinuses when he was uninsured. Now that he has cover, he is seeking treatment. Big hospitals say they are seeing more patients: Tenet, a giant hospital firm, reported a 4% jump in patient volumes in the second quarter, compared with a year earlier.
用于醫(yī)療保險(xiǎn)的開支年增長(zhǎng)率在1980年至2009年是7.4%，但是到2009年至2012年卻急劇降至3%。或許它還可能上漲。疲軟的經(jīng)濟(jì)在某種程度上也導(dǎo)致了近段時(shí)間增長(zhǎng)率的下滑。政府精算師希望今年醫(yī)療開支能夠上漲5.6%，2015年至2023年能上漲6%。由于越來越多的美國(guó)人年齡增長(zhǎng)并參保，他們更需要醫(yī)療保健。比如說，謝恩在未參保時(shí)，會(huì)忽視肩膀的酸痛以及因鼻竇炎堵塞的鼻子。現(xiàn)在既然他享受醫(yī)療保險(xiǎn)他也會(huì)尋求治療。大型醫(yī)院稱他們迎來越來越多的病患。大型醫(yī)療公司特內(nèi)特報(bào)告指出相較一年以前，病人的數(shù)量增長(zhǎng)了4%。
Higher public spending on health threatens to crowd out education, infrastructure and more besides. In July the Congressional Budget Office predicted that, despite the recent slowdown, government health programmes would become the single biggest area of public spending within 20 years, and grow from 4.8% of GDP now to 8% in 2039.
在醫(yī)保上投入更多的公共支出會(huì)將縮減用于教育、基礎(chǔ)設(shè)施建設(shè)及其他更多方面的公共支出。七月，國(guó)會(huì)預(yù)算局預(yù)計(jì)，盡管近幾年用于醫(yī)療保險(xiǎn)的共公開支有所減少，在今后的20年，政府的醫(yī)保項(xiàng)目將仍然是唯一的最大的公共開支支出領(lǐng)域，到2039年前，其占GDP的比重將由現(xiàn)在的4.8%漲至8%。
America's health system is terrible at controlling costs for two main reasons. First, insurers and Medicare usually pay doctors when they deliver many services, rather than when they keep patients well. Second, America relies on a private market of doctors and insurers, yet their costs and quality remain opaque. For decades the doctors' lobby has fought to hide detailed data on doctors' performance and prices. Robert Kocher and Ezekiel Emanuel report that 30-40% of top academic hospitals have contracts that bar insurers from relaying hospital prices to employers or patients. What quality measures exist are mostly tied to procedures, not results.
美國(guó)的醫(yī)保體系由于兩大原因在控制成本方面做得很糟糕。第一，保險(xiǎn)公司和醫(yī)療保險(xiǎn)經(jīng)常在醫(yī)生提供服務(wù)而非他們治好病人時(shí)支付薪水。第二，美國(guó)依賴于醫(yī)生和保險(xiǎn)公司的私人市場(chǎng)，然而他們的成本及質(zhì)量都模棱兩可、不清不楚。數(shù)十年來，醫(yī)生的游說者試圖隱藏醫(yī)生工作表現(xiàn)及治療價(jià)格的詳細(xì)數(shù)據(jù)。羅伯特·柯歇爾和伊其基爾·伊曼紐爾報(bào)告指出30%至40%的頂級(jí)學(xué)院型醫(yī)院訂有合同阻止保險(xiǎn)公司給予投保人或病人醫(yī)院原有的價(jià)格。什么樣的質(zhì)量檢測(cè)的存在與結(jié)果無關(guān)而在很大程度上于步驟過程有關(guān)。
So patients have been left in the dark. When they have visited the doctor, they have had no idea what anything costs or that it all ultimately comes out of their wages. So they have not objected when doctors gave them unnecessary tests, or overcharged.
因此病人就被這樣的機(jī)制遺漏在病痛的黑暗中。當(dāng)他們?nèi)フ裔t(yī)生時(shí)，他們對(duì)那些藥品的花費(fèi)或者藥費(fèi)最終出自于他們的工資一無所知。因此，當(dāng)醫(yī)生要求他們做不必要的檢查或收取高額費(fèi)用時(shí)他們不會(huì)拒絕。
Thus the cost of a back scan in New York City ranges from $416 to more than ten times that amount, according to Castlight, a firm in California. A prostate-specific antigen test in Philadelphia could be $20 or $407 (see chart 3). Quality is erratic, too. Laurent Glance of the University of Rochester found that rates of complications from caesarean deliveries varied nearly fivefold among American hospitals.
因此，根據(jù)一個(gè)名為“揭露真相”的一家加利福尼亞公司的資料，在紐約，脊背掃描檢查的費(fèi)用在416美及甚至高于這一數(shù)據(jù)的十倍之多之間波動(dòng)。在費(fèi)城，一項(xiàng)前列腺特定抗體檢查費(fèi)用可能在20美元至407美元之間波動(dòng)。并且檢查的質(zhì)量也有很大的不確定性。羅切斯特大學(xué)的勞倫·格蘭仕發(fā)現(xiàn)美國(guó)剖腹產(chǎn)并發(fā)癥的概率變化達(dá)到5倍。
Obamacare tries various ways to curb costs. For example, it urges groups of doctors and hospitals to become Accountable Care Organisations (ACOs), rewarded for keeping Medicare patients' costs below a set limit. However, data published on September 16th show that only a quarter saved enough to earn a bonus. Obamacare also orders the health department to make costs and quality more transparent. This, too, is proceeding fitfully. In April health officials published Medicare payments to specific doctors. This revealed which doctors perform a lot of procedures. However, it did not reveal whether those interventions were appropriate or successful. Medicare's more useful data, which would show which doctors keep patients well, have yet to be broadly released; there are worries about privacy.
奧巴馬醫(yī)改試圖通過多種途徑抑制醫(yī)療開支。比方說，它敦促醫(yī)生團(tuán)體及醫(yī)院成為負(fù)責(zé)任醫(yī)療組織，該組織獎(jiǎng)勵(lì)那些將醫(yī)療保險(xiǎn)病人的支出控制在一定的限制一下的醫(yī)護(hù)行為。但是，9月16號(hào)公布的數(shù)據(jù)表明所節(jié)約的資金中僅有四分之一用于獎(jiǎng)金。奧巴馬醫(yī)改同時(shí)要求衛(wèi)生部門進(jìn)一步將成本與質(zhì)量透明化。這同樣也在順利穩(wěn)步進(jìn)行。四月，衛(wèi)生官員想特定的醫(yī)生公開醫(yī)療保險(xiǎn)開支。這透露哪些醫(yī)生執(zhí)行了一系列的程序步驟。但是它并不能說明哪些干涉是合適并且成功地。有關(guān)醫(yī)療保險(xiǎn)更為有用的資料，即能表現(xiàn)哪些醫(yī)生治好了病人的疾病卻還沒能廣泛地公開。因?yàn)槿藗儞?dān)心會(huì)侵犯相關(guān)人員的隱私。
A long way to go
醫(yī)療改革任重道遠(yuǎn)
18. Mark McClellan of the Brookings Institution, a think-tank, points out that insurers and doctors' groups are testing their own versions of ACOs, which might be more successful than the government's. Companies are also slowly lifting the veil from doctors' costs and quality. Castlight compiles data from employers' insurance bills, then presents prices to patients. UnitedHealthcare, Aetna, Humana and Kaiser Permanente, four huge insurance and health companies, have given reams of data to an independent research centre. Next year it will launch a website where any insured patient can log in and view quality and cost information for specific doctors and hospitals.
智囊團(tuán)布魯金斯學(xué)會(huì)的馬克·麥克萊倫指出保險(xiǎn)公司及醫(yī)生行業(yè)正在檢測(cè)他們自己的負(fù)責(zé)任的醫(yī)療組織版本，這將比政府的版本更為成功。公司也逐漸揭開醫(yī)生看病成本及治療質(zhì)量的面紗。“揭露真相”根據(jù)雇員的保險(xiǎn)單編制資料，然后將價(jià)格告知病患。聯(lián)合醫(yī)療保險(xiǎn)公司、安泰保險(xiǎn)公司、瑚瑪納及凱撒永久醫(yī)療集團(tuán)這四家大型保險(xiǎn)及醫(yī)療公司已經(jīng)給一個(gè)獨(dú)立的研究中心大量的資料。明年它將推出一個(gè)專門網(wǎng)站，在該網(wǎng)站任何參保的病人都能登錄進(jìn)去查看特定醫(yī)院特定醫(yī)生診治的開支以及醫(yī)治質(zhì)量。
Patients may increasingly demand change, too. Employers are pushing workers into plans with high deductibles, which means they must pay for more care out of their own pockets before insurance kicks in. The share of workers with deductibles jumped from 55% in 2006 to 80% in 2014. This gives patients a good reason to shop around for cheaper treatment. In some cases, employers are asking workers to shop around for insurance too, giving them cash to buy coverage on privately-run health exchanges.
現(xiàn)在病患也越來越追求變化。雇主驅(qū)使工人參保高的自付額的醫(yī)療保險(xiǎn)，這意味著在醫(yī)保生效之前他們必須自己掏腰包為健康付費(fèi)。有自付額的工人的比重由2006年的55%增加到2014年的80%。這是病患貨比三家尋求更廉價(jià)治療方案的一個(gè)很好的理由。在某些情況下，雇主會(huì)建議工人通過貨比三家選擇醫(yī)療保險(xiǎn)，為他們提供資金購買私人運(yùn)營(yíng)的醫(yī)療保險(xiǎn)交易。
When patients act like shoppers, health-care providers serve them better. In August the number of retail clinics, which treat patients at malls and outside regular hours, was up 17% over last year, according to Merchant Medicine, a consultancy. Obamacare's exchanges have inspired new insurance entrepreneurs. Oscar, started by techies in New York, tries to be the patient's ally, swapping insurers' usual perplexing drivel for clear information. Medicare Advantage, a complement to the traditional public scheme for the elderly, often pays doctors a capped fee to care for patients. Providers profit when patients are well and costs are cut. America's health market has long been an example of what not to do. If it can serve patients, it just might become the opposite.
當(dāng)病患像消費(fèi)者一樣貨比三家時(shí)，提供醫(yī)療服務(wù)的人將會(huì)更好的微病患服務(wù)。根據(jù)商業(yè)藥品這個(gè)咨詢公司的消息，八月，那些在大型商場(chǎng)或者在緊急時(shí)段治療病患的零售藥房的數(shù)量自去年以來增長(zhǎng)了17%。奧巴馬醫(yī)改交易激勵(lì)了新的保險(xiǎn)企業(yè)家。奧斯卡，通過紐約哥布林工程師開始，試圖與病患組成同盟以厘清保險(xiǎn)公司令人費(fèi)解的說辭獲取清晰的信息。醫(yī)保利益組織，作為傳統(tǒng)年長(zhǎng)者公共計(jì)劃的補(bǔ)充，在一身個(gè)提供醫(yī)療服務(wù)時(shí)通常支付他們限定額治療費(fèi)。當(dāng)治好病患并且治療費(fèi)用減少時(shí)提供服務(wù)的而機(jī)構(gòu)將會(huì)有所收獲。長(zhǎng)久以來，美國(guó)的醫(yī)療市場(chǎng)已成為一個(gè)典型的反面教材。但倘若它能為病患服務(wù)，那么它將成為典型的正面教材，成為大家效仿的楷模。
