2014年经济学人 奥巴马医改 实验医学

Obamacare

Experimental medicine

A year after the big launch, is Obamacare working?

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 costly¹ plan with limited benefits. Such discrimination is now illegal. Since January the Affordable² 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.

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 subsidies³. So she used some of her college financial aid to buy health cover.

Health care in America is changing, thanks to Obamacare and the efforts of innovative⁴ private firms (see article). And not before time. America's health system, the world's biggest, involves a tangled⁵ mess of rules and a hotch-potch of public and private institutions. It combines dazzling technology with minimal⁶ cost controls and spotty coverage⁷. In 2012 it left some 48m people uninsured despite gobbling up 17.2% of GDP, a figure that dwarfs⁸ spending in any other country and has shot up from 4.4% in 1950.

Rather than scrap⁹ 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.

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.

In some states Obamacare works well. In others, it does not. Many Republican-run states refused to expand Medicaid on the grounds that taxpayers¹⁰ 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.

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 audit¹¹ warns that more must be done to make the site secure.

For now Obamacare seems to have expanded cover. Data-crunchers at Gallup, Harvard University, the Urban Institute and the Commonwealth¹² 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.

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 previously¹³ uninsured.

Politically, Obamacare remains¹⁴ highly controversial. A poll of polls finds that 51% of Americans disapprove¹⁵ of it; only 41% approve. Republicans bash it in stump¹⁶ speeches; Democrats¹⁷ mention it only in passing. A lawsuit¹⁸, 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.

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 opt¹⁹ to pay the penalty instead. Education should help—most of the uninsured are unaware²⁰ of the subsidies available to them. But premiums²¹ 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.

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, alas²². 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.

Higher public spending on health threatens to crowd out education, infrastructure²³ 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.

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 opaque²⁴. For decades the doctors' lobby has fought to hide detailed²⁵ 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.

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.

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 erratic²⁶, too. Laurent Glance of the University of Rochester found that rates of complications from caesarean deliveries varied²⁷ nearly fivefold among American hospitals.

Obamacare tries various ways to curb²⁸ 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 transparent²⁹. This, too, is proceeding³⁰ 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 interventions³¹ 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.

A long way to go

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.

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.

When patients act like shoppers, health-care providers serve them better. In August the number of retail³² 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, swapping³³ insurers' usual perplexing drivel for clear information. Medicare Advantage, a complement³⁴ 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.

1 costly   

adj.昂贵的，价值高的，豪华的

参考例句：

• It must be very costly to keep up a house like this.维修这么一幢房子一定很昂贵。
• This dictionary is very useful,only it is a bit costly.这本词典很有用，左不过贵了些。

2 affordable   

adj.支付得起的，不太昂贵的

参考例句：

• The rent for the four-roomed house is affordable.四居室房屋的房租付得起。
• There are few affordable apartments in big cities.在大城市中没有几所公寓是便宜的。

3 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》

4 innovative   

adj.革新的，新颖的，富有革新精神的

参考例句：

• Discover an innovative way of marketing.发现一个创新的营销方式。
• He was one of the most creative and innovative engineers of his generation.他是他那代人当中最富创造性与革新精神的工程师之一。

5 tangled   

adj. 纠缠的，紊乱的 动词tangle的过去式和过去分词

参考例句：

• Your hair's so tangled that I can't comb it. 你的头发太乱了，我梳不动。
• A movement caught his eye in the tangled undergrowth. 乱灌木丛里的晃动引起了他的注意。

6 minimal   

adj.尽可能少的，最小的

参考例句：

• They referred to this kind of art as minimal art.他们把这种艺术叫微型艺术。
• I stayed with friends, so my expenses were minimal.我住在朋友家，所以我的花费很小。

7 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。

8 dwarfs   

n.侏儒，矮子（dwarf的复数形式）vt.（使）显得矮小（dwarf的第三人称单数形式）

参考例句：

• Shakespeare dwarfs other dramatists. 莎士比亚使其他剧作家相形见绌。 来自《简明英汉词典》
• The new building dwarfs all the other buildings in the town. 新大楼使城里所有其他建筑物都显得矮小了。 来自辞典例句

9 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。

10 taxpayers   

纳税人，纳税的机构( taxpayer的名词复数 )

参考例句：

• Finance for education comes from taxpayers. 教育经费来自纳税人。
• She was declaiming against the waste of the taxpayers' money. 她慷慨陈词猛烈抨击对纳税人金钱的浪费。

11 audit   

v.审计；查帐；核对；旁听

参考例句：

• Each year they audit our accounts and certify them as being true and fair.他们每年对我们进行账务审核，以确保其真实无误。
• As usual,the yearly audit will take place in December.跟往常一样，年度审计将在十二月份进行。

12 commonwealth   

n.共和国，联邦，共同体

参考例句：

• He is the chairman of the commonwealth of artists.他是艺术家协会的主席。
• Most of the members of the Commonwealth are nonwhite.英联邦的许多成员国不是白人国家。

13 previously   

adv.以前，先前（地）

参考例句：

• The bicycle tyre blew out at a previously damaged point.自行车胎在以前损坏过的地方又爆开了。
• Let me digress for a moment and explain what had happened previously.让我岔开一会儿，解释原先发生了什么。

14 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。

15 disapprove   

v.不赞成，不同意，不批准

参考例句：

• I quite disapprove of his behaviour.我很不赞同他的行为。
• She wants to train for the theatre but her parents disapprove.她想训练自己做戏剧演员，但她的父母不赞成。

16 stump   

n.残株，烟蒂，讲演台；v.砍断，蹒跚而走

参考例句：

• He went on the stump in his home state.他到故乡所在的州去发表演说。
• He used the stump as a table.他把树桩用作桌子。

17 democrats   

n.民主主义者，民主人士( democrat的名词复数 )

参考例句：

• The Democrats held a pep rally on Capitol Hill yesterday. 民主党昨天在国会山召开了竞选誓师大会。
• The democrats organize a filibuster in the senate. 民主党党员组织了阻挠议事。 来自《简明英汉词典》

18 lawsuit   

n.诉讼，控诉

参考例句：

• They threatened him with a lawsuit.他们以诉讼威逼他。
• He was perpetually involving himself in this long lawsuit.他使自己无休止地卷入这场长时间的诉讼。

19 opt   

vi.选择，决定做某事

参考例句：

• They opt for more holiday instead of more pay.他们选择了延长假期而不是增加工资。
• Will individual schools be given the right to opt out of the local school authority?各个学校可能有权选择退出地方教育局吗？

20 unaware   

a.不知道的，未意识到的

参考例句：

• They were unaware that war was near. 他们不知道战争即将爆发。
• I was unaware of the man's presence. 我没有察觉到那人在场。

21 premiums   

n.费用( premium的名词复数 )；保险费；额外费用；（商品定价、贷款利息等以外的）加价

参考例句：

• He paid premiums on his life insurance last year. 他去年付了人寿保险费。 来自《现代英汉综合大词典》
• Moves are afoot to increase car insurance premiums. 现正在酝酿提高汽车的保险费。 来自《简明英汉词典》

22 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。

23 infrastructure   

n.下部构造，下部组织，基础结构，基础设施

参考例句：

• We should step up the development of infrastructure for research.加强科学基础设施建设。
• We should strengthen cultural infrastructure and boost various types of popular culture.加强文化基础设施建设，发展各类群众文化。

24 opaque   

adj.不透光的；不反光的，不传导的；晦涩的

参考例句：

• The windows are of opaque glass.这些窗户装着不透明玻璃。
• Their intentions remained opaque.他们的意图仍然令人费解。

25 detailed   

adj.详细的，详尽的，极注意细节的，完全的

参考例句：

• He had made a detailed study of the terrain.他对地形作了缜密的研究。
• A detailed list of our publications is available on request.我们的出版物有一份详细的目录备索。

26 erratic   

adj.古怪的，反复无常的，不稳定的

参考例句：

• The old man had always been cranky and erratic.那老头儿性情古怪,反复无常。
• The erratic fluctuation of market prices is in consequence of unstable economy.经济波动致使市场物价忽起忽落。

27 varied   

adj.多样的，多变化的

参考例句：

• The forms of art are many and varied.艺术的形式是多种多样的。
• The hotel has a varied programme of nightly entertainment.宾馆有各种晚间娱乐活动。

28 curb   

n.场外证券市场，场外交易；vt.制止，抑制

参考例句：

• I could not curb my anger.我按捺不住我的愤怒。
• You must curb your daughter when you are in church.你在教堂时必须管住你的女儿。

29 transparent   

adj.明显的，无疑的；透明的

参考例句：

• The water is so transparent that we can see the fishes swimming.水清澈透明，可以看到鱼儿游来游去。
• The window glass is transparent.窗玻璃是透明的。

30 proceeding   

n.行动，进行，(pl.)会议录，学报

参考例句：

• This train is now proceeding from Paris to London.这次列车从巴黎开往伦敦。
• The work is proceeding briskly.工作很有生气地进展着。

31 interventions   

n.介入，干涉，干预( intervention的名词复数 )

参考例句：

• Economic analysis of government interventions deserves detailed discussion. 政府对经济的干预应该给予充分的论述。 来自辞典例句
• The judge's frequent interventions made a mockery of justice. 法官的屡屡干预是对正义的践踏。 来自互联网

32 retail   

v./n.零售；adv.以零售价格

参考例句：

• In this shop they retail tobacco and sweets.这家铺子零售香烟和糖果。
• These shoes retail at 10 yuan a pair.这些鞋子零卖10元一双。

33 swapping   

交换，交换技术

参考例句：

• The slow swapping and buying of horses went on. 马匹的买卖和交换就是这样慢慢地进行着。
• He was quite keen on swapping books with friends. 他非常热衷于和朋友们交换书籍。

34 complement   

n.补足物，船上的定员；补语；vt.补充，补足

参考例句：

• The two suggestions complement each other.这两条建议相互补充。
• They oppose each other also complement each other.它们相辅相成。