2016年经济学人 医疗改革 医改的闹剧（在线收听）

Health reform

医疗改革

Medicare, the opera

医改的闹剧

Another election, another nonsensical fight over the elderly

又一场选举，又一场关于老年人的荒谬斗争

APRIL has been a cheerful month for the Affordable Care Act, better known as Obamacare. More than 7m Americans have signed up for private coverage through the law's exchanges and, by the end of February, more than 3m people had enrolled in Medicaid, the health programme for the poor. According to the latest Gallup poll, America's share of uninsured has fallen to its lowest level since 2008. These figures are good news for anyone keen to expand health coverage. They may not be so helpful for the Democrats' election prospects.

四月对平价医疗法案（或者称其为奥巴马医改）来说是值得欢呼的一个月。截至二月末，已有超过七百万美国人通过法律交换签署了私人保险，以及超过三百万人参加了专为穷人设置的健康计划—医疗补助。根据盖洛普最新的调查显示，美国人未参加保险的比例已降至2008年以来的最低水平。这些数据对所有热衷扩大医保范围的人来说都无疑是个好消息。但对民主党竞选前景的改善可能没有太大裨益。

To understand why, consider another set of figures. More than 40m older Americans are enrolled in Medicare, the public-health programme for those aged 65 and older, with more than 15m of them in private Medicare plans. These are reliable voters in elections. And Republicans are singing them the same aria again and again: Democrats are raiding their benefits to pay for Obamacare.

看看另外一组数据便知原因。美国参加了医保的老年人数量已超过4千万，该医保是一项为65岁及以上的老年人制定的公共健康计划，其中超过一千五百万人同时参与了个人医保计划。这些人都是在选举中所能够依赖的选民。共和党人频频高唱同一叹调：民主党人为了支付奥巴马医改而损害了他们的利益。

Democratic politicians are desperate to convince them otherwise. On April 7th health officials provided some help: after proposing in February to cut payments to private Medicare plans by 1.9%, the Centres for Medicare and Medicaid Services (CMS) said they would rise slightly instead. This will not quiet Republicans.

民主党的政治家竭尽全力的想要说服他们。4月7日，卫生部官员也参与其中：在提出将在二月份削减个人医保计划支出费用的1.9%后，医疗保险和医疗补助服务中心（CMS）表示，其支出并非降低，反而微升。但这并不能安抚共和党人。

Obamacare does indeed lower Medicare spending by $716 billion from 2013 to 2022. Of this, $156 billion comes from Medicare Advantage, which lets the elderly use public money to buy private health plans. For years the government has paid more for these private plans, per person, than for traditional Medicare. Private insurers passed along the extra subsidy to consumers in the form of additional benefits or lower fees. Obamacare sought to bring private payments in line with traditional Medicare.

奥巴马医改确实会在2013至2022年间降低医疗开支约7160亿美元。其中，1560亿美元来自医疗照顾优先计划（Medicare Advantage），该计划允许老年人使用公共资金购买个人健康计划。多年来，政府为每个人在个人健康计划上的花费要高于传统医保。私人保险公司以给予额外好处或降低保费的形式，对消费者提供额外补贴。奥巴马医改试图将个人支付带回传统医保的正轨上来。

This was not a radical idea, but it is politically controversial nevertheless. Medicare Advantage is increasingly popular—about three in ten Medicare beneficiaries are enrolled in a private plan. Insurers argue that Obamacare's cuts, combined with other measures, will force them to raise prices or cut benefits.

这个想法并不激进，但在政治上却引起争议。医疗照顾优先计划愈发流行，约有三成的医保受益者参加了个人计划。保险公司抱怨到，奥巴马医改中与其他措施相配合的缩减政策，会迫使他们提价或削减福利。

Last month's special election in Florida was a cautionary tale for Democrats. “To pay for Obamacare, Washington is forcing seniors to endure deep cuts to Medicare Advantage,” purred an advertisement. “Sadly, Alex Sink supports these cuts.” Ms Sink lost her campaign. Not surprisingly, Republicans as well as many anxious Democrats implored CMS not to lower payments. In February 40 senators wrote to CMS to ask as much. On April 3rd 29 congressional Democrats and Republicans sent their own letter.

上月佛罗里达的补选一事，值得民主党警惕。一则竞选标语这样写道：“为了支付奥巴马医改，华盛顿正迫使老年人忍受医疗照顾优先计划的削减。不幸的是，Alex Sink支持这项削减政策。”随后Sink失掉了竞选。不出意料，共和党人以及许多焦虑的民主党人恳求医疗保险和医疗补助服务中心（CMS）不要削减这项支出。2月，40名参议员致函医疗保险和医疗补助服务中心（CMS）提出同样的要求。4月3日，国会中29名民主党人和共和党人致函医疗保险和医疗补助服务中心（CMS）。

In the end CMS said it would raise payments by 0.4%. The true effect on Medicare Advantage is more complex. America's Health Insurance Plans, the industry group that had lobbied against cuts, maintains that CMS's changes still amount to lower payments. Ana Gupte of Leerink Swann, an investment bank, points out that delaying cuts now may mean a bigger cut next year.

最后，医疗保险和医疗补助服务中心（CMS）表示将支付金额提高0.4个百分点。医疗照顾优先计划的真正影响比这更加复杂。美国健康保险计划是一个反对削减支出的行业组织，他们认为，医疗保险和医疗补助服务中心（CMS）的承诺仍旧意味着降低支付。来自Leerink Swann投行的Ana Gupte指出，现在的推迟可能意味着明年更大幅度的削减。

The ruckus belies a simple fact. Both Democrats and Republicans agree that Medicare spending must be contained. The budget proposed by congressional Republicans, written by Paul Ryan, would preserve all Obamacare's cuts to Medicare, including those to Medicare Advantage. Just don't expect Republicans to mention that on the campaign trail.

骚动掩盖了一个简单的事实：民主党人和共和党人均认为，必须遏制医疗支出。国会共和党提出的预算由Paul Ryan撰写，该预算保留了所有奥巴马医改中对医疗支出的削减政策，其中也包括了医疗照顾优先计划。但别指望着共和党人会在竞选中提及此事。