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Trumpcare, version three

特朗普医改,3.0版本

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

参议院修订的医疗保健方案是一个好法案吗?它会被通过吗?



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.

参议院修订的医疗保健方案是一个好法案吗?它会被通过吗?这两个问题理所当然有关联。但这其实是像灌香肠般草率且不透明,所以他们没有关联。首先让我们讨论第一个问题。

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.

如果你想要实现全民医保覆盖,有三种方法。第一种,政府从公民收税并用税金投入医保(单一支付模式)。第二种,资助公民购买医疗保险。这只会在资助足够购买保险时有用。第三种是通过立法或罚款强迫人们购买保险。

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.

目前美国三件事都在做。退伍军人、老人、穷人和印第安人保留区的居民都有通过退伍军人健康管理局、医疗保险、医疗补助和印第安人医疗服务的单一支付系统。人们从这些项目中得到的关注往往很贫乏,但这又是另外一回事了。自从《平价医疗法案》通过后,联邦政府还向人们资助了购买保险的费用,并对那些没有购买保险的人实施罚款。根据盖洛普的数据,这种混合体系的实施使得没有购买医疗保险的人数下降,从2013年的18%到现在的12%。

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.

这些项目仍留下了一些没有覆盖到的人群。这可以通过扩大单一支付系统覆盖的范围来解决,通过增加购买保险的补贴或者增加对不这样做的罚款。或者也可以三个都做。

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).

当然,这一逻辑只适用于一个假设,即法律应该以覆盖尽可能多的人为目标。大多数国会的中共和党人都不同意这种假设。当然,如果每个人都有保险的话,他们会同意的。但他们不认为这是政府的责任(当然,有些人在共和党内部持不同观点)。

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.

为了实现这一目标,需要平衡单一付款系统的覆盖范围和补贴罚款不再适用的范围。参议院的法案及时地免除了不购买保险的罚款。它降低了补贴的总额,同时和目前的计划相比也减少了医疗补助计划(针对最贫困人口的计划)。该法案的支持者指出,在修订后的法案中医疗补助支出仍然增加了,只是没有那么快。这是事实,但国会预算办公室认为,参议院的第一版法案中,比现行法案相比将会有少于1000万的人加入医疗补助计划。

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.

参议院的法案还允许出售那些不包括在《平价医疗法案》规定的“基本福利”的计划。包括儿科、心理健康治疗和妇产科。这意味着保险公司将能够销售更便宜的产品,这可能意味着更多的人购买。但消费者可能会发现,他们并没有得到他们所需要的治疗。他们购买的保险也可能以不同的方式被证明是无用的。“奥巴马医改”限制了免赔额(对那些没有通过这一系统的人来说,这是一个人在保险开始前支付的费用,这是一种防止无效医疗的系统)。一项扣除1万美元的计划和一套廉价的福利将比目前出售的任何东西都要便宜得多。不利的一面是对于一个收入较低的家庭来说,这样的计划将毫无用处。

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.

还有另外两件没有引起他们注意的事值得注意。首先,在法案中有很多陈述试图减少对堕胎的资助。其次,有一些规定旨在保护精神病病房的床位数量。在心理治疗界里,那些认为患有精神疾病的病人应该被迫接受治疗甚至是违背他们的意愿,以及那些不接受必须治疗的人之间存在着长久的争论。共和党在这方面的立场倾向于强迫,因此就没有减少精神病病房的床位数量。

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.

一个理想的医疗保健法不仅会增加被覆盖的人数。在提高医疗质量的同时还可以降低医疗费用。这是很困难的,因为成本和质量完全相反。在将我的部分内脏器官摘除后,在经历狗单一支付系统(英国的NHS)和美国的系统(使用雇主提供的保险)后,我可以证明,对于那些足够幸运能承受费用的人来说,美国的医疗系统更好。这是其高成本的直接作用。正如奥巴马医改所做的那样,参议院的法案为创新提供了资金,但是成本和质量之间的权衡在短期内是不会创新的。回顾一下:修订后的建议可能会让更多的美国人失去可用的医疗保健,但也不太会降低医疗费用或提高医疗质量。这不是一个好法案。

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。