经济学人下载:医疗保健-不快乐的生日

The other great hope for enemies of reform is that the Supreme Court will declare that the individual mandate is unconstitutional, and that this will lead directly to the unravelling of the dread laws. This too may prove unsatisfying for conservatives. For one thing, the court may not immediately take up this matter, giving boosters of the laws the chance to dig in their heels. For another, the individual mandate can be replaced with other policies—a mix of carrots and sticks to get punters to buy insurance—that imitate it. So such a ruling would be a political nightmare, but need not be a death blow to reform itself.

反对派还寄希望于最高法院对个人强制医保非法化的断言，最高法院的决策将直接瓦解这一令人闹心的法案。同样保守派很难心满自足。首先法院鉴于担心支持者会固执己见，因而不太可能立刻着手此案。另外，个人强制医保极有可能被其他相似的政策取代—软硬兼施，总之让顾客投保。因此，这种裁决必定是政界梦魇，但未必对改革本身造成致命打击。

Given all this, what will be the likely long-term impact of Obamacare? Critics say that if the law stays in place, it will destroy employer-provided health coverage. Boosters insist that if it is given a chance to work, it will bring costs down, and not merely extend coverage. Both camps are probably wrong.

考虑到这些因素，奥式医改的长远影响是什么呢？批评家认为如果该法案仍持续下去，将会破坏由雇主提供的医疗保险。而支持者坚持如果实行该法案，不仅会扩大保险覆盖率，也能降低投资成本。可能这两个阵营都错了。

Republicans have often claimed that employers will scrap corporate insurance, preferring to pay a fine and dump their workers on the subsidised exchanges. That sounds plausible, but two new studies—by the RAND Corporation and the Urban Institute, both non-partisan think-tanks—debunk the argument. In fact, the boffins at RAND calculate that the new reforms could even increase employer-sponsored coverage, as employees confronted with the new mandate clamour for (tax-assisted) coverage from their employers now that they are obliged to have it.

共和党通常声称雇主会无视企业保险，宁愿上交罚金并给其工人补贴。这种说法似乎言之有理，但两项由非党派智囊团—兰德公司和城市学院所做的新研究项目提供了反驳。兰德公司的专家预计新的改革措施甚至能增加雇主提供的医疗保险，因为雇员在新政策的条件下有权向雇主争取自己应得的（含税）保险。

As for costs, Mr Obama’s reforms deserve praise for expanding coverage, but they do this by adding millions of people to an unsupportably expensive system. Analysts estimate that America’s health spending will continue to soar under the reforms (see chart). That is a point hotly contested by Mr Obama’s team, who usually point to theoretical future efficiency gains and innovations that will save pots of money.

说到开支，奥巴马推广保险的改革措施值得称赞，但实施的结果是，上百万人被牵扯进这一无保障的高消费体系中。分析家估计美国医疗卫生支出在改革背景下仍会继续膨胀（如表所示）。这是向来推崇理论收益和创新性的奥式小组强烈抗议的地方。

So it came as a shock when Deval Patrick, the governor of Massachusetts and one of Mr Obama’s closest friends, took a different tack. Asked recently about the pioneering health reforms in his state, which served as a model for the national reforms, he first gave a backhanded compliment to Mitt Romney (the state’s former Republican governor, now distancing himself from those reforms as he repackages himself to run for president in 2012). Mr Patrick then revealed the dirty little secret of Obamacare: “What these folks did in Massachusetts is frankly the same thing that the Congress did, which is to take on access first, and come to cost-control next.” In other words, America will soon have no choice but to come to grips with costs. Whatever one thinks of Mr Obama’s reforms, there is no denying that they have brought that day of reckoning closer.

因此，当奥巴马的密友，马萨诸塞州州长戴沃·帕特里克转变阵营时人们大跌眼镜。问及州内作为全国模范的开创性医疗改革时，他先是暗含讽刺的恭维了米特·罗姆尼（前州长，共和党人士，现为准备2012的总统选举而回避医改话题），接着透露了奥式医改不光彩的小秘密：“马萨诸塞州和议会做的工作实际大抵相同，先使提案通过，再考虑节省开支。”换言之，美国即将除缩减开支外别无他选。无论别人怎么评价奥式改革，不可否认的是最终盘点日的脚步更近了。