经济学人下载:瞧瞧山姆大叔 医疗改革

Last year the actuaries at CMS projected that health reform would not lower spending, as Democrats hoped. From 2009 to 2019 average annual growth for health spending would be 0.2 percentage points higher with Mr Obama’s health reform than without it. This slight net rise would mask dramatic shifts, the actuaries said. For example, reform’s efforts to contain costs for Medicare, the government programme for the old, would be dwarfed by the expansion of Medicaid, the government programme for the poor.

正如民主党希望的那样，去年CMS的精算师预计医疗改革支出不会减少。和没有奥巴马的医疗改革相比，从2009年到2019年医疗支出平均每年增加高出0.2个百分点。精算师说，这种轻微的净增加掩饰了戏剧性的转变。例如，政府针对穷人的医疗补助费用大幅增加,使得政府为控制老年人医疗保险成本所作的努力大打折扣。

The actuaries’ newest study estimates that health spending grew little last year, mostly because of the weak economy. The next decade, however, will bring rapid growth. Government spending will be the main driver. Ageing baby-boomers will enroll in Medicare; Medicaid coverage will swell; Washington will subsidise many of those on the new state exchanges. CMS expects Washington’s share of health spending to grow from 27% in 2009 to 31% by 2020. Together with spending by states and cities, the public sector will pay for nearly half of America’s health care.

精算师最新的研究估计，去年医疗支出没怎么增加主要是因为经济的疲软。然而，接下来的十年，医疗支出会迅速增加。政府支出将会是主要的驱动力量。婴儿潮时出生的人正在变老，并将加入到医疗保险的行列；医疗补助覆盖范围将会扩大；华盛顿将会资助许多新建的州医疗保险交易所。CMS预计华盛顿医疗支出份额将会从2009年的27%增加到2020年时的31%。和州以及市的支出一起，公共部门支出几乎达到美国医疗保健的一半。

This is a sobering prediction. However, even this may be an underestimate. The actuaries at CMS assume that only 2m people who now have employer-sponsored insurance will lose it, as companies drop coverage and workers move to exchanges or to Medicaid. But more may make the switch. In June McKinsey, a consultancy, found in a survey that 30% of firms would definitely or probably stop offering insurance after 2014, when the exchanges are in place. On July 25th the National Federation of Independent Business, which represents small firms, published its own survey. If some workers begin to move to exchanges, the report found, 57% of companies would consider dropping insurance completely. If these surveys are borne out in firms’ actions, government spending will be even higher than CMS expects. The debt disaster on August 2nd may be averted. The bigger problem remains.

这是一个触目惊心的预测。然而，即使是这样，也许是低估。由于企业降低覆盖面以及工人转向医疗保险交易所或医疗补助，CMS的精算师假设只有200万人将会失去了雇主提供的保险。然而也许更多人遭遇了此种情况。6月份咨询公司麦肯锡调查发现2014年后，医疗保险交易所到位后，30%的公司肯定或也许会停止提供保险。7月25日代表小公司的美国独立企业联合会发表了它自己的调查报告。报告指出，如果一些工人开始转向医疗保险交易所，57%的公司会考虑完全取消保险。如果这些调查刺激了公司的实际行动，政府支出甚至将会超过CMS的预期。8月2日的债务危机也许会避免。但是更大的问题仍然存在。