经济学人下载:医疗保健-不快乐的生日

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 Roughly half of those polled by KFF thought Obamacare had already been repealed or were unsure of its legal footing. It remains 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 subsidies. 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。

Alas, 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 flexibility in implementing 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 curbing 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 legislative 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。