经济学人:医疗保健-不快乐的生日

 　　What will become of Barack Obama’s health reforms? 奥巴马的医疗改革会带来什么？

　　WHEN Barack Obama signed a sweeping¹ set of health reforms into law on March 23rd 2010, he knew it was a historic moment—and not just because Joe Biden, the vice-president, whispered into his ear that it was a “big fucking deal”. He had successfully ridden the wave of popular support that brought him into office to deliver universal health coverage², a feat³ that eluded⁴ all his predecessors⁵.

　　奥巴马于2010年3月23日签下一系列医改法案时，就算副总统乔·拜登没对他耳语道“这该死的大手笔”，他就已知晓那是历史性的时刻。他借民意支持成功上位以推行全民健康保险，这项功绩可谓前无古人。

　　But the reality of politics has obstructed⁶ that grand dream. Republican leaders in Congress are trying to repeal⁷ the law outright⁸. Several federal judges have ruled that one of the central provisions of the new reforms, an “individual mandate⁹” requiring everyone to purchase coverage, is unconstitutional. And a recent poll by the Kaiser Family Foundation (KFF), a non-partisan outfit¹⁰, revealed that hostility¹¹ to the laws among politically vital independents has shot up sharply. One year on, how fares Mr Obama’s proudest achievement?

　　但政治的现实性使得这一伟大梦想障碍重重。议会中的共和党领导试图彻底废除该法案。联邦法官判定新政策的核心条款为“个人强制医保”，而强制所有人购买保险显然有悖宪法精神。由非党派机构--凯萨家庭基金会近日作出的投票结果显示，政治独立派对新法的敌意与日俱增。一年年以后，奥巴马的得意之作又会有何进展？

　　The chief strategy used by the administration to win over sceptics and to undermine legal challenges is to present the new laws as an unstoppable juggernaut. For example, when Kathleen Sebelius, the secretary of health and human services, spoke¹² about the reform to the Senate Finance Committee on March 16th, she pointed¹⁴ to evidence of an “enormous difference it has made in the lives of Americans”.

　　政府打击怀疑论者或化解法律挑战的首要策略便是将新法案呈现为不可逆挡的强大力量。例如卫生和公共服务部部长凯瑟琳?西贝利厄斯谈及参议员财政委员会于3月16日推行的改革时，指出“其在美国社会中业已产生的巨大影响”这一证词。

　　True, the administration has rushed into force provisions affecting consumers directly, in an effort to win popular support. For example, some forbid insurers from denying coverage to children with pre-existing conditions, or imposing¹⁵ lifetime payout caps on anyone. The new laws also already require insurers to cover children up to 26 on their parents’ policies, which will benefit some 1.2m young people. Nearly 48m people on Medicare, the government health scheme for the elderly, are to get free preventive services such as colonoscopies and mammograms. In 2010 nearly 4m of them got $250 tax-free rebates¹⁶ to help pay for drugs.

　　的确，政府部门试图通过直接影响消费者的有力措施赢得民意支持。如禁止保险公司拒绝为已患病的孩童投保；或是将终身投保强加于人。新法案同样规定，年轻人在26岁以前都可以依靠其父母的保单，这将使约120万的年轻人受益。政府推行的老年医改为约4800万的老年人提供诸如结肠镜、乳腺检测等的免费预防性健康服务。

　　All that seems impressive, but here’s the rub: many Americans do not believe Mrs Sebelius. Roughly half of those polled by KFF thought Obamacare had already been repealed¹⁷ or were unsure of its legal footing. It remains¹⁸ the law of the land.

　　这一切听起来甚是美好，可问题在于：许多美国人并不信任西贝利厄斯女士。凯萨家庭基金会所收集的近一半投票都认为奥式医改方案已被废止或是仍缺失法律基础。这仅是一时之策。

　　The administration is also forging ahead with less visible aspects of the new laws. By 2014, when the bulk of the reform’s provisions kick in, states are required to have put regulated insurance exchanges in place so that consumers can buy plans that meet minimum standards for coverage. All would be required to buy insurance, but the less well-off will get subsidies¹⁹. The federal government is offering technical assistance as well as money to states to nudge them towards establishing such market-places.

　　政府仍推行着不甚显眼的新法案。大部分条约至2014年生效，届时要求各州建立起规范的保险交流中心，以便投保人根据一己之需购买保险。所有人都必须投保，但会生活水平较低者将被给予补助。联邦政府向各州提供技术及资金的支持，已推动此类市场的建立。

　　Alas²⁰, in this too Mr Obama has hit snags. Some Republican-led states, first among them Alaska and Florida, are refusing to take the money, while many others are demanding flexibility²¹ in implementing²² the rules. To the surprise of some, Mr Obama announced at a recent meeting of governors at the White House that he supports a plan—first proposed by Ron Wyden, a sparky Democratic senator—to grant “innovation waivers” starting in 2014. As long as states meet general goals on covering more people and curbing²³ costs, they will be given flexibility in how they set up their local insurance markets.

　　奥巴马同样在此受阻。部分由共和党占主导的州—阿拉斯加至弗罗里达—拒绝接受资助；其他各州或有呼吁政策推行的灵活性。让一些人意外的是，奥巴马在近日的白宫州长会议中声称自己支持由活跃的民主党参议员罗恩·怀登提出的议案—于2014年实行“对创新放宽政策”—只要该州达到使更多人参保并抑制成本的目标，就能拥有如何创建当地保险市场的自主权。

　　That compromise comes only at the point of a gun, however. And Republican attacks on Obamacare will increase as next year’s presidential race gets under way. That points to a second question: can such attacks actually kill the reform? It seems unlikely. While Mr Obama is president, he would veto any such bill. So the legislative²⁵ path to “repeal and replace”, as conservatives call it, hinges on winning back both the Senate and the White House. But that is far from a certainty, and the short-term strategy of defunding bits of the scheme looks more likely to score points than actually stop the law.

　　不过这种让步完全是屈从暴力的产物。共和党抨击奥式医改会干扰到下届总统大选。这就引出第二个问题：此类抨击会扼杀此改革吗？似乎并非如此。奥巴马在位时可以否决类似提案，那么保守派口中“取缔并取代”的立法途径取决于能否同时拿下参议院和白宫的双方面许可。这并无保障，而从项目撤资的短期计划似乎仅仅是为了讨巧，并不能废止这项法案。

　　The other great hope for enemies of reform is that the Supreme²⁶ Court will declare that the individual mandate is unconstitutional, and that this will lead directly to the unravelling²⁷ of the dread²⁸ laws. This too may prove unsatisfying for conservatives. For one thing, the court may not immediately take up this matter, giving boosters of the laws the chance to dig in their heels. For another, the individual mandate can be replaced with other policies—a mix of carrots and sticks to get punters to buy insurance—that imitate it. So such a ruling would be a political nightmare, but need not be a death blow to reform itself.

　　反对派还寄希望于最高法院对个人强制医保非法化的断言，最高法院的决策将直接瓦解这一令人闹心的法案。同样保守派很难心满自足。首先法院鉴于担心支持者会固执己见，因而不太可能立刻着手此案。另外，个人强制医保极有可能被其他相似的政策取代—软硬兼施，总之让顾客投保。因此，这种裁决必定是政界梦魇，但未必对改革本身造成致命打击。

　　Given all this, what will be the likely long-term impact of Obamacare? Critics say that if the law stays in place, it will destroy employer-provided health coverage. Boosters insist that if it is given a chance to work, it will bring costs down, and not merely extend coverage. Both camps are probably wrong.

　　考虑到这些因素，奥式医改的长远影响是什么呢？批评家认为如果该法案仍持续下去，将会破坏由雇主提供的医疗保险。而支持者坚持如果实行该法案，不仅会扩大保险覆盖率，也能降低投资成本。可能这两个阵营都错了。

　　Republicans have often claimed that employers will scrap²⁹ corporate³⁰ insurance, preferring to pay a fine and dump their workers on the subsidised exchanges. That sounds plausible³¹, but two new studies—by the RAND Corporation and the Urban Institute, both non-partisan think-tanks—debunk the argument. In fact, the boffins at RAND calculate that the new reforms could even increase employer-sponsored coverage, as employees confronted with the new mandate clamour for (tax-assisted) coverage from their employers now that they are obliged to have it.

　　共和党通常声称雇主会无视企业保险，宁愿上交罚金并给其工人补贴。这种说法似乎言之有理，但两项由非党派智囊团—兰德公司和城市学院所做的新研究项目提供了反驳。兰德公司的专家预计新的改革措施甚至能增加雇主提供的医疗保险，因为雇员在新政策的条件下有权向雇主争取自己应得的（含税）保险。

　　As for costs, Mr Obama’s reforms deserve praise for expanding coverage, but they do this by adding millions of people to an unsupportably expensive system. Analysts³² estimate that America’s health spending will continue to soar under the reforms (see chart). That is a point hotly contested by Mr Obama’s team, who usually point to theoretical future efficiency gains and innovations that will save pots of money.

　　说到开支，奥巴马推广保险的改革措施值得称赞，但实施的结果是，上百万人被牵扯进这一无保障的高消费体系中。分析家估计美国医疗卫生支出在改革背景下仍会继续膨胀（如表所示）。这是向来推崇理论收益和创新性的奥式小组强烈抗议的地方。

　　So it came as a shock when Deval Patrick, the governor of Massachusetts and one of Mr Obama’s closest friends, took a different tack²⁴. Asked recently about the pioneering health reforms in his state, which served as a model for the national reforms, he first gave a backhanded compliment to Mitt¹³ Romney (the state’s former Republican governor, now distancing himself from those reforms as he repackages himself to run for president in 2012). Mr Patrick then revealed the dirty little secret of Obamacare: “What these folks did in Massachusetts is frankly³³ the same thing that the Congress did, which is to take on access first, and come to cost-control next.” In other words, America will soon have no choice but to come to grips with costs. Whatever one thinks of Mr Obama’s reforms, there is no denying that they have brought that day of reckoning closer.

　　因此，当奥巴马的密友，马萨诸塞州州长戴沃·帕特里克转变阵营时人们大跌眼镜。问及州内作为全国模范的开创性医疗改革时，他先是暗含讽刺的恭维了米特·罗姆尼（前州长，共和党人士，现为准备2012的总统选举而回避医改话题），接着透露了奥式医改不光彩的小秘密：“马萨诸塞州和议会做的工作实际大抵相同，先使提案通过，再考虑节省开支。”换言之，美国即将除缩减开支外别无他选。无论别人怎么评价奥式改革，不可否认的是最终盘点日的脚步更近了。

1 sweeping   

adj.范围广大的，一扫无遗的

参考例句：

• The citizens voted for sweeping reforms.公民投票支持全面的改革。
• Can you hear the wind sweeping through the branches?你能听到风掠过树枝的声音吗？

2 coverage   

n.报导，保险范围，保险额，范围，覆盖

参考例句：

• There's little coverage of foreign news in the newspaper.报纸上几乎没有国外新闻报道。
• This is an insurance policy with extensive coverage.这是一项承保范围广泛的保险。

3 feat   

n.功绩；武艺，技艺；adj.灵巧的，漂亮的，合适的

参考例句：

• Man's first landing on the moon was a feat of great daring.人类首次登月是一个勇敢的壮举。
• He received a medal for his heroic feat.他因其英雄业绩而获得一枚勋章。

4 eluded   

v.（尤指机敏地）避开( elude的过去式和过去分词 )；逃避；躲避；使达不到

参考例句：

• The sly fox nimbly eluded the dogs. 那只狡猾的狐狸灵活地躲避开那群狗。 来自《现代汉英综合大词典》
• The criminal eluded the police. 那个罪犯甩掉了警察的追捕。 来自《现代英汉综合大词典》

5 predecessors   

n.前任( predecessor的名词复数 )；前辈；（被取代的）原有事物；前身

参考例句：

• The new government set about dismantling their predecessors' legislation. 新政府正着手废除其前任所制定的法律。 来自《简明英汉词典》
• Will new plan be any more acceptable than its predecessors? 新计划比原先的计划更能令人满意吗？ 来自《简明英汉词典》

6 obstructed   

阻塞( obstruct的过去式和过去分词 )； 堵塞； 阻碍； 阻止

参考例句：

• Tall trees obstructed his view of the road. 有大树挡着，他看不到道路。
• The Irish and Bristol Channels were closed or grievously obstructed. 爱尔兰海峡和布里斯托尔海峡或遭受封锁，或受到了严重阻碍。

7 repeal   

n.废止，撤消；v.废止，撤消

参考例句：

• He plans to repeal a number of current policies.他计划废除一些当前的政策。
• He has made out a strong case for the repeal of the law.他提出强有力的理由，赞成废除该法令。

8 outright   

adv.坦率地；彻底地；立即；adj.无疑的；彻底的

参考例句：

• If you have a complaint you should tell me outright.如果你有不满意的事，你应该直率地对我说。
• You should persuade her to marry you outright.你应该彻底劝服她嫁给你。

9 mandate   

n.托管地；命令，指示

参考例句：

• The President had a clear mandate to end the war.总统得到明确的授权结束那场战争。
• The General Election gave him no such mandate.大选并未授予他这种权力。

10 outfit   

n.（为特殊用途的）全套装备，全套服装

参考例句：

• Jenney bought a new outfit for her daughter's wedding.珍妮为参加女儿的婚礼买了一套新装。
• His father bought a ski outfit for him on his birthday.他父亲在他生日那天给他买了一套滑雪用具。

11 hostility   

n.敌对，敌意；抵制［pl.］交战，战争

参考例句：

• There is open hostility between the two leaders.两位领导人表现出公开的敌意。
• His hostility to your plan is well known.他对你的计划所持的敌意是众所周知的。

12 spoke   

n.（车轮的）辐条；轮辐；破坏某人的计划；阻挠某人的行动 v.讲，谈（speak的过去式）；说；演说；从某种观点来说

参考例句：

• They sourced the spoke nuts from our company.他们的轮辐螺帽是从我们公司获得的。
• The spokes of a wheel are the bars that connect the outer ring to the centre.辐条是轮子上连接外圈与中心的条棒。

13 mitt   

n.棒球手套，拳击手套，无指手套；vt.铐住，握手

参考例句：

• I gave him a baseball mitt for his birthday.为祝贺他的生日，我送给他一只棒球手套。
• Tom squeezed a mitt and a glove into the bag.汤姆把棒球手套和手套都塞进袋子里。

14 pointed   

adj.尖的，直截了当的

参考例句：

• He gave me a very sharp pointed pencil.他给我一支削得非常尖的铅笔。
• She wished to show Mrs.John Dashwood by this pointed invitation to her brother.她想通过对达茨伍德夫人提出直截了当的邀请向她的哥哥表示出来。

15 imposing   

adj.使人难忘的，壮丽的，堂皇的，雄伟的

参考例句：

• The fortress is an imposing building.这座城堡是一座宏伟的建筑。
• He has lost his imposing appearance.他已失去堂堂仪表。

16 rebates   

n.退还款( rebate的名词复数 )；回扣；返还（退还的部份货价）；折扣

参考例句：

• The VAT system offers advantages, such as rebates on exports. 增值税有其优点，如对出口商品实行回扣。 来自辞典例句
• In more recent years rate rebates have been introduced for households. 近年地方税的减免已适用于家庭。 来自辞典例句

17 repealed   

撤销，废除( repeal的过去式和过去分词 )

参考例句：

• The Labour Party repealed the Act. 工党废除了那项法令。
• The legislature repealed the unpopular Rent Act. 立法机关废除了不得人心的租借法案。

18 remains   

n.剩余物，残留物；遗体，遗迹

参考例句：

• He ate the remains of food hungrily.他狼吞虎咽地吃剩余的食物。
• The remains of the meal were fed to the dog.残羹剩饭喂狗了。

19 subsidies   

n.补贴，津贴，补助金( subsidy的名词复数 )

参考例句：

• European agriculture ministers failed to break the deadlock over farm subsidies. 欧洲各国农业部长在农业补贴问题上未能打破僵局。
• Agricultural subsidies absorb about half the EU's income. 农业补贴占去了欧盟收入的大约一半。 来自《简明英汉词典》

20 alas   

int.唉(表示悲伤、忧愁、恐惧等)

参考例句：

• Alas!The window is broken!哎呀！窗子破了！
• Alas,the truth is less romantic.然而，真理很少带有浪漫色彩。

21 flexibility   

n.柔韧性，弹性，（光的）折射性，灵活性

参考例句：

• Her great strength lies in her flexibility.她的优势在于她灵活变通。
• The flexibility of a man's muscles will lessen as he becomes old.人老了肌肉的柔韧性将降低。

22 implementing   

v.实现( implement的现在分词 )；执行；贯彻；使生效

参考例句：

• -- Implementing a comprehensive drug control strategy. ――实行综合治理的禁毒战略。 来自汉英非文学 - 白皮书
• He was in no hurry about implementing his unshakable principle. 他并不急于实行他那不可动摇的原则。 来自辞典例句

23 curbing   

n.边石，边石的材料v.限制，克制，抑制( curb的现在分词 )

参考例句：

• Progress has been made in curbing inflation. 在控制通货膨胀方面已取得了进展。
• A range of policies have been introduced aimed at curbing inflation. 为了抑制通货膨胀实施了一系列的政策。

24 tack   

n.大头钉；假缝，粗缝

参考例句：

• He is hammering a tack into the wall to hang a picture.他正往墙上钉一枚平头钉用来挂画。
• We are going to tack the map on the wall.我们打算把这张地图钉在墙上。

25 legislative   

n.立法机构，立法权；adj.立法的，有立法权的

参考例句：

• Congress is the legislative branch of the U.S. government.国会是美国政府的立法部门。
• Today's hearing was just the first step in the legislative process.今天的听证会只是展开立法程序的第一步。

26 supreme   

adj.极度的，最重要的；至高的，最高的

参考例句：

• It was the supreme moment in his life.那是他一生中最重要的时刻。
• He handed up the indictment to the supreme court.他把起诉书送交最高法院。

27 unravelling   

解开，拆散，散开( unravel的现在分词 )； 阐明； 澄清； 弄清楚

参考例句：

• Nail head clamp the unravelling of nail exteriorize broken nails and clean. 钉头卡钉，拆开钉头取出碎钉并清洁。
• The ends of ropes are in good condition and secured without unravelling. 缆绳端部状况良好及牢固，并无松散脱线。

28 dread   

vt.担忧，忧虑；惧怕，不敢；n.担忧，畏惧

参考例句：

• We all dread to think what will happen if the company closes.我们都不敢去想一旦公司关门我们该怎么办。
• Her heart was relieved of its blankest dread.她极度恐惧的心理消除了。

29 scrap   

n.碎片；废料；v.废弃，报废

参考例句：

• A man comes round regularly collecting scrap.有个男人定时来收废品。
• Sell that car for scrap.把那辆汽车当残品卖了吧。

30 corporate   

adj.共同的，全体的；公司的，企业的

参考例句：

• This is our corporate responsibility.这是我们共同的责任。
• His corporate's life will be as short as a rabbit's tail.他的公司的寿命是兔子尾巴长不了。

31 plausible   

adj.似真实的，似乎有理的，似乎可信的

参考例句：

• His story sounded plausible.他说的那番话似乎是真实的。
• Her story sounded perfectly plausible.她的说辞听起来言之有理。

32 analysts   

分析家，化验员( analyst的名词复数 )

参考例句：

• City analysts forecast huge profits this year. 伦敦金融分析家预测今年的利润非常丰厚。
• I was impressed by the high calibre of the researchers and analysts. 研究人员和分析人员的高素质给我留下了深刻印象。

33 frankly   

adv.坦白地，直率地；坦率地说

参考例句：

• To speak frankly, I don't like the idea at all.老实说，我一点也不赞成这个主意。
• Frankly speaking, I'm not opposed to reform.坦率地说，我不反对改革。