经济学人210:奥巴马医改 实验医学

 　　Obamacare

　　奥巴马医改

　　Experimental medicine

　　实验医学

　　A year after the big launch, is Obamacare working?

　　实施一年的奥巴马医改到底奏效吗？

　　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.

　　堪萨斯州未参与医疗保险的人数比美国其他任一州都多。直到近期来自休斯顿38岁的谢恩才刚刚参保。他说，“我只是无法负担医疗保险费。”谢恩是艾滋病患者，他的工作薪金无法负担他的医药费。由于他的疾病，保险公司只愿意提供有限福利但保费昂贵的保险方案。但是现在，这样的歧视是非法的。自今年一月平价医疗法案，即人们熟知的奥巴马医改要求保险公司向患病及健康的投保人收取同样的保费。这是20年来首次谢恩能够支付得起他的医疗费用。

　　奥巴马医改.jpg

　　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.

　　城镇另一端的Suezen Salinas就没有那么幸运了。最近刚返回大学校园继续深造的她还没有工作。她的两个孩子有资格享受专为穷人设置的公共医疗项目—医疗补助计划，但是她不行。尽管奥巴马医改表示联邦政府将会支付医保的绝大部分开支，堪萨斯州是近20个未扩大医疗补助计划覆盖面的州之一。

　　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.

　　由于奥巴马医改以及锐意创新的私人企业的努力，美国的医疗保健正在改变。在此之前，作为全球最大的医疗体系，美国的医疗体系包含有一堆杂乱无章的规章制度以及混乱的公私机构。它集毫无节制地购买令人眼花缭乱的科技产品和零星的覆盖面于一体。2012年，尽管医疗体系开支占GDP17.2%，但仍然有0.48亿人未享受到医疗保险的福利，而这一数据远远高出其他国家的医疗保险开支，并且远远高出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.

　　奥巴马医改重新整顿了这个原本应该弃置的医疗体系。它扩大了医疗补助计划的覆盖范围，将那些不是那么富裕但又处于贫困线以上的数百万人纳入新的医疗救助体系中。它试图创造一个个人能够负担得起的医疗保险市场，在没有大型雇主的支持下让风险集中。最终达到以更低的价格扩大医疗保险的覆盖率同时提供更好的医疗服务。目前为止奥巴马医改所创的记录是多方面的。

　　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.

　　奥巴马医改创造了新的健康交易模式，在该种模式下，若个体收入在46680美元一下11670美元以上就有资格获得补助金，能够购买私人医疗保险。同时由于它阻止保险公司向病人收取更高的保费，它要求个体购买医疗保险或者缴纳罚款。

　　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.

　　在有些州奥巴马医改实施得非常好，但是在另一些州则不然。许多共和党人治理的州由于担心纳税人在支付账单时有困难而拒绝扩大医疗救助计划的覆盖面。这让像萨林纳斯小姐一样年收入在11670美元以下的将近900万成年人既没有资格获得医疗救助又无法负担得起购买医疗保险的金额。

　　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个州没有像国会预设的那样建立他们自己的医疗保险交易，而是寄希望于联邦政府去做这件事。这给联邦保险网站—医疗保健政府官网极大的压力，而该网站自去年十月一日上线以来几乎没做任何工作。尽管现在运转良好但是问题依然存在。新的审计警告要使该网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.

　　目前奥巴马医改似乎已经扩大了其覆盖面。在哈佛大学、盖洛普、城市研究所及联邦基金会搞数据工作的人同意，在奥巴马医改交易实施以前，登记截止之时，未参保的美国成年人的比例由2013年第三季度到2014年第二季度的比例下降了22%-26%。大约有800万至1030万成人被纳入医疗保险中。但是，这其中的绝大多数人似乎是来自公共基金支持的医疗救助计划的扩展。根据城市研究所的数据，在医疗救助计划未扩展的州府将近20%的成人未被纳入医保中，而在医疗救助计划扩展的州府纳入医保的成人的比例是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.

　　到底有多少人通过新的交易被纳入到医保中还不是很明确。官员声称超过800万人已签订合同，但这包含那些原本就参保的人。五月份，麦肯锡咨询公司估计在个体市场26%购买保险的人之前都未参保。

　　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.

　　政治上来讲，奥巴马医改依然备受争议。民意测验的比较发现51%的美国民众不赞同该医改，仅有41%的人支持它。共和党人在竞选演说中猛烈抨击奥巴马医改，而民主党只是顺便提一提。Halbig v Burwell诉讼案件争论法律只允许通过国营的交易而非联邦交易给予保险补助金。如果原告获胜，他们将保障整个改革。

　　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.

　　假设奥巴马改革能够挺过法律这一挑战，它的成功依然在很大程度上依赖于最终多少未参保的人会在医疗保险单上签字。法律上说，他们应该被纳入到医保覆盖范围，但是倘若保费泰国高昂，有些人将会选择付罚金而非保费。教育程度应该会起作用——许多未参保的人都意识不到他们能得到的补助金。但是保险费所起的作用更大，并且价格一直在上涨。根据普华永道咨询公司的数据在33个州府中，保费平均涨幅达7%。并且各地的保费差异很大——在科罗拉多州保费的平均涨幅仅2.4%，而在田纳西州涨幅高达14%。下一轮的参保将在一月展开，在中期选举之前许多人将会讨论他们的保费到底是会涨还是会跌。

　　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.

　　用于医疗保险的开支年增长率在1980年至2009年是7.4%，但是到2009年至2012年却急剧降至3%。或许它还可能上涨。疲软的经济在某种程度上也导致了近段时间增长率的下滑。政府精算师希望今年医疗开支能够上涨5.6%，2015年至2023年能上涨6%。由于越来越多的美国人年龄增长并参保，他们更需要医疗保健。比如说，谢恩在未参保时，会忽视肩膀的酸痛以及因鼻窦炎堵塞的鼻子。现在既然他享受医疗保险他也会寻求治疗。大型医院称他们迎来越来越多的病患。大型医疗公司特内特报告指出相较一年以前，病人的数量增长了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.

　　在医保上投入更多的公共支出会将缩减用于教育、基础设施建设及其他更多方面的公共支出。七月，国会预算局预计，尽管近几年用于医疗保险的共公开支有所减少，在今后的20年，政府的医保项目将仍然是唯一的最大的公共开支支出领域，到2039年前，其占GDP的比重将由现在的4.8%涨至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.

　　美国的医保体系由于两大原因在控制成本方面做得很糟糕。第一，保险公司和医疗保险经常在医生提供服务而非他们治好病人时支付薪水。第二，美国依赖于医生和保险公司的私人市场，然而他们的成本及质量都模棱两可、不清不楚。数十年来，医生的游说者试图隐藏医生工作表现及治疗价格的详细数据。罗伯特·柯歇尔和伊其基尔·伊曼纽尔报告指出30%至40%的顶级学院型医院订有合同阻止保险公司给予投保人或病人医院原有的价格。什么样的质量检测的存在与结果无关而在很大程度上于步骤过程有关。

　　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.

　　因此病人就被这样的机制遗漏在病痛的黑暗中。当他们去找医生时，他们对那些药品的花费或者药费最终出自于他们的工资一无所知。因此，当医生要求他们做不必要的检查或收取高额费用时他们不会拒绝。

　　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，根据一个名为“揭露真相”的一家加利福尼亚公司的资料，在纽约，脊背扫描检查的费用在416美及甚至高于这一数据的十倍之多之间波动。在费城，一项前列腺特定抗体检查费用可能在20美元至407美元之间波动。并且检查的质量也有很大的不确定性。罗切斯特大学的劳伦·格兰仕发现美国剖腹产并发症的概率变化达到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.

　　奥巴马医改试图通过多种途径抑制医疗开支。比方说，它敦促医生团体及医院成为负责任医疗组织，该组织奖励那些将医疗保险病人的支出控制在一定的限制一下的医护行为。但是，9月16号公布的数据表明所节约的资金中仅有四分之一用于奖金。奥巴马医改同时要求卫生部门进一步将成本与质量透明化。这同样也在顺利稳步进行。四月，卫生官员想特定的医生公开医疗保险开支。这透露哪些医生执行了一系列的程序步骤。但是它并不能说明哪些干涉是合适并且成功地。有关医疗保险更为有用的资料，即能表现哪些医生治好了病人的疾病却还没能广泛地公开。因为人们担心会侵犯相关人员的隐私。

　　A long way to go

　　医疗改革任重道远

　　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.

　　智囊团布鲁金斯学会的马克·麦克莱伦指出保险公司及医生行业正在检测他们自己的负责任的医疗组织版本，这将比政府的版本更为成功。公司也逐渐揭开医生看病成本及治疗质量的面纱。“揭露真相”根据雇员的保险单编制资料，然后将价格告知病患。联合医疗保险公司、安泰保险公司、瑚玛纳及凯撒永久医疗集团这四家大型保险及医疗公司已经给一个独立的研究中心大量的资料。明年它将推出一个专门网站，在该网站任何参保的病人都能登录进去查看特定医院特定医生诊治的开支以及医治质量。

　　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.

　　现在病患也越来越追求变化。雇主驱使工人参保高的自付额的医疗保险，这意味着在医保生效之前他们必须自己掏腰包为健康付费。有自付额的工人的比重由2006年的55%增加到2014年的80%。这是病患货比三家寻求更廉价治疗方案的一个很好的理由。在某些情况下，雇主会建议工人通过货比三家选择医疗保险，为他们提供资金购买私人运营的医疗保险交易。

　　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.

　　当病患像消费者一样货比三家时，提供医疗服务的人将会更好的微病患服务。根据商业药品这个咨询公司的消息，八月，那些在大型商场或者在紧急时段治疗病患的零售药房的数量自去年以来增长了17%。奥巴马医改交易激励了新的保险企业家。奥斯卡，通过纽约哥布林工程师开始，试图与病患组成同盟以厘清保险公司令人费解的说辞获取清晰的信息。医保利益组织，作为传统年长者公共计划的补充，在一身个提供医疗服务时通常支付他们限定额治疗费。当治好病患并且治疗费用减少时提供服务的而机构将会有所收获。长久以来，美国的医疗市场已成为一个典型的反面教材。但倘若它能为病患服务，那么它将成为典型的正面教材，成为大家效仿的楷模。