经济学人下载:美国医疗改革遇阻

Health reform
医疗改革

Mississippi spurning
密西西比吐槽不断

Obamacare hits trouble in the states
奥巴马的医保改革在美国麻烦不小

Jul 13th 2013 | JACKSON, MISSISSIPPI

2013年7月13日

BARACK OBAMA’S health reform was supposed to bring universal health coverage to America on January 1st, 2014. It won’t. To understand why, consider states such as Mississippi.

奥巴马的医疗改革原本预计从2014年1月1日开始实施，大范围的美国人将享受医保待遇，但事实上事与愿违。为什么？让我们以密西西比州为例一探究竟。

Terry Brown, a Republican state senator there, stood before his colleagues on June 28th, as they lounged in summer poplin and seersucker. They had assembled to decide whether Mississippi would expand Medicaid, the public health program for the poor, as Obamacare urges. That day Mississippi said it would not. “I don’t want Mississippi to be a part of that train wreck,” said Mr Brown.

泰瑞·布朗，是一名共和党议员，6月28日那天他带领他的同僚聚在一起，商讨密西西比是否要扩大医保范围。此举，用奥巴马的话讲，是惠及广大贫困群众的公共医疗项目。但当天密西西比就表示不会实施新医保。“我不想密西西比受到新医保的牵连而蒙受损失”布朗说。

Obamacare aims to extend insurance to the poor in two main ways, both starting in 2014. First, it required states to offer Medicaid to all those with incomes of up to 138% of the federal poverty level, or $15,856 for an individual. (At present Medicaid must cover only some poor people, such as pregnant women.) The federal government and the states usually share the cost of Medicaid. But Obamacare would pay for the expansion through 2016, with the feds’ share falling to 90% in 2020.

奥巴马的医疗改革，旨在从2014年开始使医保覆盖到广大贫困群众，主要通过两项政策实现。政策一，对于收入不高于联邦贫困线38%的人员，或者个人收入不高于15,856美金的人员，州政府需要为他们提供医保（目前的医保只覆盖到部分贫困人群，例如怀孕妇女）。联邦政府和州政府一般共同提供医保资金，但是奥巴马的医保普及政策是2016年之前联邦政府会支付新医保的费用，2020年支付90%的费用，其余由州政府承担。

Second, individuals would be able to shop for insurance on new state-based markets, called health exchanges. Those with incomes between 100% and 400% of the federal poverty level would qualify for federal subsidies.

政策二，今后个人可从州政府主导的医疗保险交易所购买保险。个人收入在联邦贫困标准及其4倍之间的人群才有资格申请联邦补贴。

Neither provision is going as planned. Last year the Supreme Court made the Medicaid expansion optional. At least 21 states say they will opt out. Even more are refusing to set up their own exchanges, leaving the task to federal bureaucrats. 

不管是以上哪条新政，估计都要搁浅了。去年最高法院宣布此次医疗普及政策并非强制执行。至少有21个州宣布他们不会参与其中。甚至多数拒绝建立各自的医疗保险交易所，将这一难题留给联邦政府处理。

Mississippi would seem the ideal place to cover more poor people. It is America’s poorest state and has the shortest life expectancy. Its current Medicaid programme is among America’s least generous. Mississippians devote an unusually large share of their income to health care (see chart). One resident in five is uninsured.

作为美国最贫穷以及居民寿命最短的州，密西西比看上去是此次医疗改革的理想试点。它现有的医保计划位列全美最不惠民的政策之一，尽管出人意外地，它的大部分政府收入用于医保支出，（见图表），但两成居民都不能享受医保。

But Obamacare’s main provisions have gone nowhere in the Magnolia State. The fight over the Medicaid expansion involved hair-raising brinkmanship. Had lawmakers not voted before July 1st, the state’s entire Medicaid programme would have stopped functioning. Republicans insisted an expansion was unaffordable. State Medicaid costs would have increased by 7% from 2013 to 2022, estimates the Urban Institute, a think-tank. That is much less than the expected 30% increase in Medicaid subsidies from the central government. But the 7% rise would have been bigger than in any other state, mostly because Mississippi’s current Medicaid programme is so skimpy. 

但是奥巴马的医疗保障政策在马格诺利亚州却悄无声息。为了抵抗医保普及政策，反对者不惜铤而走险。要不是立法机关7月1日前没有进行投票表决，不然马格诺利亚的全部医保计划都将暂停。共和党人坚称州政府根本支付不起医保普及政策。据智囊团“城市研究所”预估，若新医保从2013年开始实施，密西西比州政府因此承担的医保资金到2022年要增加7%。而中央政府的医保补贴预计要增加三成。而其他州的的资金投入增幅远远不及7%，主要是因为密西西比目前的基数太小了。

The fight over the state’s exchanges was equally bareknuckle. Mississippi’s elected insurance commissioner wanted a state-based exchange. The Republican governor, Phil Bryant, wanted nothing to do with Obamacare. After a messy spat, plans for a state exchange dissolved. By default, Mississippi will have a “federally facilitated exchange”, managed by the health secretary’s deputies. So far only two insurers have made bids to sell health plans on it. Residents of 42 counties will have a choice of only one subsidised plan; 36 counties will have none. And many poor Mississippians will be ineligible for Medicaid.

对于另一条医保交易政策，反对的声音同样激烈坚决。在密西西比，推举出的医保代理机构希望医保交易所是由州政府主导的。但是州长费勒·布莱恩特是共和党人，不想参与奥巴马的新医保。经过一番舌战，政府主导的医保交易计划也搁浅了。大家心照不宣，密西西比的医保交易所将由“联邦政府辅助引导”，由卫生部的副秘书长们管理。至此只有两家保险公司竞价参与医保计划。42个郡的居民将可以选择性的享受一项医疗补贴计划，也是唯一的一项；另外36个郡将不参与。另外还有许多人将无权享受医保。

Stansel Harvey is the boss of the Delta Regional Medical Centre, in the heart of old cotton country. The Mississippi Delta contains some of America’s poorest counties. About 10% of Mr Harvey’s patients fail to pay their bills. The insurance expansion would have made many of them paying customers. Crucially, that new revenue would have helped offset another Obamacare change: lower payment rates to hospitals. Without new insurance revenue, Mr Harvey reckons that he may need to cut services. If other hospitals follow suit, Mississippians will have a problem. In the age of Obamacare, they may have less access to health care, not more.

斯坦索尔·哈雷，是位于科顿郡中心的德尔塔医疗中心的老板。很多美国最穷的郡就位于密西西比河三角洲。在哈雷的医疗中心看病的病人中，大约一成都无法支付医疗费用。医保普及后他们中的许多人将看得起病。重要的是，因此受益的医院收入将增加，这将抵消奥巴马医改带来的另外一个变化：医院的缴费率将下降。如果没有新医保带来的增收，哈雷说他可能不得不关门大吉。如果其他的医院也纷纷歇业，密西西比将面临一个新问题。奥巴马医改之下，尽管医保覆盖范围广了，但是人民可以看病的地方也少了。