原创翻译:龙腾网 http://www.ltaaa.com 翻译:周天寰宇2 转载请注明出处

Trumpcare, version three


Is the Senate’s revised health-care proposal a good bill? And will it pass?


IS THE Senate’s revised health-care proposal a good bill? And will it pass? Ideally these two questions would be related. But this is sausage-making, so they are not. Let’s take the first one first.


If you want something approaching universal health-care coverage, there are three ways to do it. One is for the government to tax citizens and then use revenue to fund their care (the single-payer model). The second is to subsidise people to buy coverage. This only works if the subsidies are generous enough for the decision to buy insurance to be a no-brainer. The third is to compel people to buy insurance, by law or by a fine.


At the moment America does all three. Veterans, the elderly, the poor and inhabitants of reservations for native Americans all have versions of the single-payer system, via the Veterans Health Administration, Medicare, Medicaid and the Indian Health Service. The care people receive from these programmes is often poor, but that’s another story. Since the passage of the Affordable Care Act, aka Obamacare, the federal government has also subsised people to buy insurance and introduced fines for those who do not. The result of this mixed system has been a decline in the number of people who have no health insurance, from a high of 18% in 2013 to 12% now,  according to Gallup.


That still leaves a lot of people with no coverage. This could be fixed by expanding the share covered by the single-payer system, by increasing the subsidies for buying insurance or by increasing the fines for not doing so. Or you could do all three.


Of course, this logic only applies if you start from the assumption that laws should be written with the aim of covering as many people as possible. Most Republicans in Congress do not share this assumption. They would, of course, like it if everyone had insurance. But they do not think it is the government’s role to make it happen (there are, of course, some people who take a different view within the Republican Party).


Shorn of that aim, the need to balance single-payer coverage, subsidies and fines no longer applies. The Senate’s bill duly gets rid of the fines for not buying insurance. It reduces the value of subsidies and it also reduces spending on Medicaid, the programme for the poorest, compared with current plans. The bill’s supporters point out that Medicaid spending still rises under the revised bill, just not as fast. That is true, but the Congressional Budget Office thinks that under the first version of the Senate bill, 10m fewer people would be enrolled in Medicaid than under the current law.


The Senate bill also allows plans to be sold that do not cover the “essential benefits” laid out by the Affordable Care Act. These include things like paediatrics, mental-health treatment and childbirth. Removing them means insurers will be able to sell cheaper plans, which could mean more people buy them. But customers might find they are not covered for treatment that they end up needing. And the insurance they buy could prove useless in a different way, too. Obamacare limited the cost of deductibles (for those who haven’t navigated the system, this is the amount of money a person pays for care before their insurance kicks in, a system designed to prevent ). A plan with a $10,000 deductible and a skimpy set of benefits would be much cheaper than anything currently on sale. The downside is that for a family with a low income, who cannot afford a $10,000 deductible, such a plan would be useless.


Two other quick things to note that have not received the attention they might: first, there is a lot of language in the bill that seeks to reduce funding for abortions. Second, there are provisions aimed at preserving the number of beds in psychiatric wards. In the mental-health world there is a long-running argument between those who think patients who are mentally ill should be compelled to receive treatment, even against their will, and those who do not. The Republican position on this leans towards compulsion, hence the language about not cutting the number of beds on psychiatric wards.


An ideal health-care law would not only increase the number of people covered. It would do more to bring down the cost of care while increasing the quality. This is hard, because cost and quality push in opposite directions. After having parts of my internal organs removed in a single-payer system (Britain’s NHS) and in the American system (using employer-provided insurance), I can attest that for those fortunate enough to be able to pay, the American system is miles better. That is a direct function of its high cost. The Senate bill sets up funds for innovation, as Obamacare did, but the trade-off between cost and quality will not be innovated away any time soon. To recap: the revised proposal would probably leave more Americans without usable health care and it does not do much to reduce the cost or to increase the quality of care. It is not a good bill.


Will it pass? Unlike the first version of the Senate bill, this one does not give a very large tax-cut to those who have the most expensive insurance plans. That softens one line of criticism, that the original bill was a tax cut disguised as a health reform. It also gives the Senate majority leader, Mitch McConnell, money to bring over wavering senators with funding for things they are particularly concerned about (for example, the bill contains money for treating the opioid epidemic, which is killing an American every 15 minutes). Three “no” votes would stop it in its tracks. There are two already, Rand Paul of Kentucky and Susan Collins of Maine. But senators who have campaigned for years to repeal Obamacare are now being given the chance to vote for something that would mean less regulation of the insurance market and allow states more leeway to do as they please. I think it’s 50:50 whether the bill, or something like it, becomes law.

它会通过吗?与第一个版本的参议院法案不同,这个法案没有给那些拥有最昂贵保险计划的人减税。这是一种温和的批评,最初的法案是一种伪装成医疗改革的减税政策。它还为参议院多数党领袖米奇·麦康奈尔(Mitch McConnell)提供资金,为那些犹豫不决的参议员们提供资金,为他们特别担心的事情提供资金(例如,该法案包括用于治疗阿片类药物流行的资金,即每15分钟杀死一名美国人)。三个“否决”选票将阻止它的发展。已经有两个人否决,包括肯塔基州的兰德·保罗和缅因州的苏珊·柯林斯。但是,那些为废除奥巴马医改而奔走多年的参议员们现在有机会投票支持一些可能意味着对保险市场的监管更少的事情,并允许各州有更多的余地来做他们想做的事情。我认为是50:50,这个法案或者类似的法案会成为法律。