For all it flaws, medical care in the United States has been reformed gigantically over the past several decades. Deaths from heart disease have fallen by 40 percent since 1970. thanks to better detection and treatment, cancer advances have helped to raise U.S. life expectancy from an average of 68 years in 1950 to 77 years today.
　　Not only have American lives grown longer, but their quality has improved. The proportion of people over 65 with one or more chronic disabilities—such as the inability to walk, or to get dressed, without aid—declined from greater than 25 percent in 1982 to less than 20 percent in 1999. and the development of vision-correction surgery, among many other drugs and procedures, has allowed many Americans to prolong pleasures historically with youth.
　　Of course, not all the recent improvements in American health and longevity can be directly attributed to our health-care system; some are as much the result of adopting healthier habits( exercise, better diet) or of dropping unhealthy ones (smoking, too much alcohol-drinking). Still, better medical care is the principal cause of improvements in American health and life span over the past 50 years.
　　But the problem is that since 1960 health-care spending has grown significantly faster than the economy, meaning that we’re spending an ever larger portion of our incomes on medical core. In 1960 health care constituted 5.1 percent of the U.S. economy; in 1980 it constituted 8.8 percent; today it constitutes 13.3 percent. Meanwhile, private health-insurance premiums—which rose by 14 percent last year alone —are becoming unaffordable for ever Americans. The number of things we can do to pay for them. 41 millions of our citizens are now uninsured. So the key question is not whether health care should be rationed in the United States; it already is. Rather the question is how health care should be rationed. How should the potential benefits of reduced pain, improved quality of life, or extended life be weighted against the high costs of the medications or procedures involved? And who should weigh them? These are hard questions with high moral stakes. But we do hope that the health-care system will cover more people.
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　　因為存在缺陷，所以美國的醫療保健在過去幾十年里進行了重大改革。心臟疾病導致的死亡自1970年以來下降了40%。由于較先進的監測和治療，癌癥死亡率自1990年以來一直處于下降趨勢?？偟膩砜?，醫療進步使美國人均壽命從1950的68歲提高到現在的77歲。
　　美國人不僅提高了壽命，而且還提高了生活質量。65歲以上患有至少一種長期殘疾——如在無人幫助下不能獨立行走，或不能自己穿衣——的比例從1982年的20%以上下降到1990年的20%以下。視力矯正手術的發展，以及其他藥品和治療程序的發展，使得許多美國人歷史性地延長了與年輕有關的生活樂趣。
　　當然，并不是美國人健康和長壽方面取得的所有進步都直接歸功于我們的醫療保健系統。有些是養成健康習慣(鍛煉身體、合理飲食)或戒除不健康習慣(吸煙、過量飲酒)的直接結果。然而，良好的醫療保健依舊是過去50多年來產美國人健康改善和生命延長的主要因素。
　　但問題是，自1960年以來，醫療保健費用的增長速度遠遠超過了經濟增長速度，這意味著我們的收入中用于醫療保健上的比例越來越大。1960年醫療保健費用占美國經濟的5.1%;到1980年的時候，就升高到了8.8%;而現在已達到13.3%了。與此同時，私人健康保險費用——僅去年一年就上升了14%——讓越來越多的美國人感到難以承受。我們為健康而采取措施的數量已經超過了美國人的承受能力。目前有4100萬人口還沒有上醫療保險。因此，關鍵問題不是在于美國醫療保健是否應該定量配給，因為我們已經實現了這個目標，而是在于醫療保健怎樣定量配給。美國人民在痛苦減少、生活質量改善或壽命延長等方面所獲得的潛在益處，怎樣才能抵消伴隨而來的藥品或就醫高消費呢?誰來負責平衡呢?沒有很高的道德責任，這些問題是難以解決的。但是，我們還是希望醫療保健系統能夠涵蓋更多的人。