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医疗改革下一步该怎么办?

What's next for healthcare reform

TEDMED演讲
I’m haunted by the stories of two women.
两名女性的故事让我难以释怀
The first is Andrea.
第一个是Andrea
Andrea is a stay-at-home mom of 3 small children
在Andrea36岁被诊断为乳癌时
when she was diagnosed with breast cancer at age 36.
她是有着三个小孩的居家妈妈
Fortunately, her husbund’s in a good health insurance.
幸运的是 她丈夫有好的医疗保险
So she was able to get the preventive care she needed,
因此 她得到了所需的预防性治疗
including mastectomy.
包括乳房切除术
But when symptoms persisted, genetic testing revealed
但病症仍持续出现 后经基因检测发现
she carried the gene for breast and ovarian cancer,
她携带有乳癌和卵巢癌的基因
despite no family history of cancer.
尽管她没有癌症的家族遗传史
A 1 in 800 chance.
这样的几率是1/800
She was then able to get additional protective surgery,
之后 她接受了额外的保护性手术
including the removal of her breasts and reproductive organs.
包括乳房及生殖器官切除术
The second is Verda.
另一个女性是Verda
Verda was a single mom of two children
Verda是单亲母亲 有两个孩子
when she felt a lump in her breast at age 38.
38岁时 她发现乳房有肿块
A state-sponsored screening program revealed it to be cancerous,
一项国家资助的筛查计划诊断其为癌症
and her state-funded health insurance paid for its removal.
由国家医保买单 为她做了切除手术
But shortly thereafter she lost that insurance.
但不久之后 她失去了这份医保
Several years later, while working as a waitress witn no health insurance,
几年后 在她做服务员 仍无医保时
she felt a pain in her chest.
她感到胸部疼痛
Despite her history, she decided not to go to the oncologist.
尽管有之前的病史 她决定不看肿瘤专家
Cuz she was afraid she couldn’t pay his(her) bill.
因为怕付不起医疗费
By the time she went to the ER with dizziness,
到她因眩晕去急诊就医时
the cancer metastasized throughout her body.
癌症已经扩散到了全身
The first woman, Andrea, is my beautiful wife.
第1位女性Andrea 是我漂亮的妻子
Today, she’s healthy and cancer-free.
如今她很健康 没有癌症困扰
The second woman, Verda Wells, a Springfield Illinois,
第2位是伊利诺伊州春田市的Verda Wells
died on July 2nd 2009, shortly after that ER visit.
她急诊就医后不久 于2009年7月2日离世
Both women got the same diagnosis, at roughly the same time,
两名女性差不多同时查出了一样的疾病
and both lived in the richest nation on Earth.
同样生活在全球最富裕的国家
But they also lived in the only wealthy country
而她们生活的国家也是世界上
that doesn’t guarantee health insurance for all.
唯一无法确保全民医保的富裕国家
The result is enormous disparities in financial protection and health outcomes,
而结果是经济保障和健康状况的巨大差异
as illustrated by my wife’s story and that of Verda.
我的妻子和Verda的故事就是明证
This isn’t just about stories, but also hard facts.
而这不仅仅是故事 是残酷的事实
A white baby born in America today
如今 在美国的白人新生儿
has the same chance of seeing their first birthday as one born in Europe.
活到一周岁的几率与欧洲的新生儿相同
While a black baby has a lower chance than one born in Libya.
而美国黑人新生儿这个几率要低于利比亚
The Roland Park neighborhood of Baltimore
在巴尔蒂摩的罗兰德公园地区
has a life expectancy of 84 years, higher than the national average.
人均预期寿命84岁 高于全国平均水平
While 3 miles away,
而仅三英里之外
the Sandtown neighborhood has a life expectancy of 67,
沙镇地区预期寿命只有67岁
lower than that of North Korea.
比朝鲜还低
Before the Affordable Care Act came along,
在《平价医疗法案》通过之前
80% of Americans had quality health insurance, like my wife and I,
80%的美国人 如妻子与我有良好的医保
through their employer or through government programs
或由雇主提供 或通过政府项目获得
like Medicare or Medicaid.
如联邦医疗保险和联邦医疗补助
For some, this insurance was far from ideal,
对有些人来说 这种医保远非完美
as it featured high costs and a limited choice of providers.
因为它花费高 可选择的保险提供者有限
But overall, this was substantive coverage
但总体来说 它实质的覆盖率
which enrollees were by and large satisfied.
基本能让参与者满意
On the other hand,
另一方面
the other 20% of Americans were either uninsured
其余20%的美国人或者没有医保
or faced the prospect of buying insurance
或者只能寄希望于在不稳定的
in the unstable and discriminatory non-group insurance market.
又有歧视的非团体医保市场买医保
This is a market where it was totally legal
在这个市场里 保险公司可以
for insurers to discriminate against the sick for any reason.
完全合法地以任何理由歧视已生病的人
Insurers could deny the sick coverage;
他们可能会拒绝病人投保
they could charge them much more than the healthy for insurance
或向病人收取远高于健康人的保费
or they could exclude their pre-existing illnesses from coverage.
或者不允许病人为已有的疾病投保
As a result, if you were healthy, you could get health insurance.
结果是 如果你健康 就能得到医保
But if you were sick, like Verda, you are out of luck.
如果像Verda一样已经生病 就没这个运气了
This defeats the whole notion of health insurance.
这完全违背了整体的医保理念
Health insurance is supposed to protect you against financial risk,
医保本该是保护你对抗财务风险的
not protect your insurance company against the sick.
而不是保护保险公司来对抗病人的
And as a result, people in this market
而这样的结果就是 在这个市场里
were just one bad gene or one bad traffic accident away from bankruptcy.
一条有缺陷基因或一场车祸就足以使人破产
Now, if you’re part of the fortunate 80%,
现在 如果你像我妻子和我一样
like my wife and I, why should you care?
属于幸运的80% 还要关心这个吗?
I would argue you should care for 3 reasons.
我认为你应该关心 有三个理由
The first is risk.
一是要考虑风险
Unless you have a tenure job with lifetime employment,
除非你有一份终身雇佣的工作
you are always at risk of losing your Employer Sponsored Insurance, indeed.
你就总有失去雇主资助保险的风险 一定的
In the decade before the Affordable Care Act passed,
在《平价医疗法案》通过前的十年间
10 million Americans lost their Employer Sponsored Insurance.
就有1000万美国人失去了雇主资助保险
That’s 10 million people who thought they were financially secure,
这1000万人本以为他们财务是有保障的
only to face the risk of devastating medical spending.
结果却要面临巨额医疗支出的风险
The second is cost.
第二个原因是成本
The uninsured actually impose a high cost on the insured.
没保险者会拉高有保险者的支出成本
Under US law, hospitals must treat anyone who comes to the emergency room
根据美国法律 医院必须收治急诊病人
regardless of insurance status.
不管病人有没有医保
When the uninsured are unable to pay their bills,
当无医保者没能力付医药费时
this becomes uncompensated care,
这部分医疗服务就无法得到补偿
a 50-billion-dollar-a-year cost
这每年500亿美元的医疗成本
that’s passed on to the insured in the form of higher bills.
转嫁到投保者身上就是更高的医保账单
The third is economic efficiency.
第三个原因是经济效率
The very lack of universal coverage lowers the efficiency of the US economy.
医保普及率不足会降低美国经济的效率
Individuals with health insurance on their job
因某份工作而得到医保的人
are afraid to leave those jobs for fear of losing that insurance.
会因为担心失去医保而害怕辞职
An economic research has shown
一项经济研究表明
that many individuals are unwilling to move on to productive new jobs
因为这种担心 人们不愿换更有成效的新工作
or to start new businesses because of these fears.
或者开办自己的新公司
Given that mobility is the lifeblood of the US labor force,
鉴于流动性是美国劳动力市场的命脉
this hurts all of us by shrinking the size of our economy.
这会缩小我们的经济规模 伤害到每个人
Now, Americans have had a long-standing interest
如今 美国人已长期致力于
in fixing our broken insurance markets.
修复我们极不完善的医保市场
But here we run into a problem—
但这里我们遇到了一个问题
you can’t just legislate the removal of insurer discrimination in a vacuum.
你无法不受干扰地立法禁止保险歧视行为
Indeed, 7 states tried in the 1990s,
确实 20世纪90年代 7个州曾尝试
banning the ability of insurers to discriminate in their non-group insurance markets.
禁止保险公司在非团体医保市场的歧视行为
And in all 7 states, the same thing happened.
结果 所有7个州发生了同样的事
Insurers were worried that if they couldn’t discriminate against the sick,
保险公司担心 如果不得歧视患病申保人
they’d be swamped by sick enrollees and lose money.
它们会被患病的参保者拖垮而亏钱
So insurers either fled the market, or raise prices through the roof,
因此它们要么逃离市场 要么天价收费
cratering the non-group insurance market in all 7 states.
这严重破坏了这7个州的非团体医保市场
One of these states was my home state of Massachusetts,
这些州中 就有我的家乡马萨诸赛州
and our non-group insurance market was a disaster.
我们的非团体医保市场是一场灾难
Then our governor, and future Republican presidential nominee
之后 我们州长 即后来的共和党总统候选人
Mitt Romney had an interesting idea.
米特·罗姆尼 有了个有趣的想法
Romney thought it was unfair
罗姆尼认为
that the insured could avoid buying insurance
被保险人不用购买医保 却能在生病时
and yet get healthcare for free when they were sick at the emergency room.
在急诊接受免费治疗 这是不公平的
Romney’s idea was to mandate that everyone buy insurance
他的想法是强制每个人都要购买医保
so the healthy pay their fair share,
健康的人也要分摊费用
And so the insurers, don’t get…get to…just get stuck with sick enrollees.
这样保险公司就不会受困于患病参保人
And to make that mandate affordable, Romney proposed subsidies
为使这种强制措施可负担 罗姆尼主张
to offset the cost of health insurance for low-income individuals.
要提供补贴 以支付低收入者的医保费用
Governor Romney asked me to use economic modeling to assess
罗姆尼州长让我用经济模型评估一下
whether such a plan was viable and affordable for the state.
该计划在我们州是否可行 人们能否负担
I found that it was.
我发现是可行的
And I’m proud to say,
我可以骄傲地说
this played a key role in the passage of our state’s healthcare reform
这对我们州2006年春医疗改革的通过
in the spring of 2006.
起到了关键性作用
Romney’s three-legged stool, banning insurer discrimination,
罗姆尼的“三角凳”方案 即禁止保险歧视
an individual mandate and generous insurance subsidies
强制个人购买医保以及优厚的医保补贴
became the basis for Massachusetts’
成为马萨诸塞州
first-in-the-nation universal health insurance coverage law.
国内首个全民医保法案的基础
The uninsurance rate in Massachusetts fell to 3%,
该州未参保人比例降到了3%
compared to 18% nationwide.
而全国的比例为18%
And premiums in our non-group insurance market
我们非团体医保市场的保费
fell by 50% relative to the rest of the country.
与国内其他州相比下降了50%
Meanwhile, there were no negative effects on the vast majority of state residents
同时 对于本州已经拥有良好医保的
that already had quality health insurance.
绝大多数居民没有负面影响
Indeed, this law was so successful,
确实 这项法案如此成功
it became the basis, 4 years later, for the federal Affordable Care Act.
它成了4年后联邦《平价医保法案》的基础
Once again, Presiden Obama and the US Congress
再一次 总统奥巴马及美国国会
asked me to use economic modeling to assess
要求我用经济模型评估一下
whether the Massachusetts’ Three-Legged Stool model
马萨诸赛州的“三脚凳”方案
could work for the nation as a whole.
在全国范围内是不是行得通
The first leg was a ban,
“三脚凳”方案第一只“脚”
for the first time in our nation’s history,
是在我国历史上第一次
on the ability of insurers to discriminate.
禁止保险公司的歧视行为
No longer can insurers deny coverage to the sick,
保险公司不能再拒绝患病者参保
charge women more than men for health insurance,
不能再向女性收取高于男性的保费
or exclude asthmatics or cancer survivors from coverage.
不能拒绝哮喘或癌症病人参保
The second was an individual mandate,
第二只“脚”是强制个人购买医保
albeit with exemptions for low-income individuals
尽管不包括低收入个人
and those whose insurance is too expensive.
和医保费用过于昂贵的人
The third was a two-pronged approach to health insurance affordability
第三只“脚”是 双管齐下使医保人人可负担
an expansion of the low-income Medicaid program for our poorest citizens,
一是把低收入医疗补助扩展到最贫困居民
and the introduction of generous tax credits
二是引入优厚的税额抵免
to offset the cost of health insurance
来补偿下层中产阶级
in the new state ACA exchanges for the lower middle class.
在新的州立ACA医保交易所的医保消费
I found that such a plan could work for the country,
我发现这个方案在我国是可行的
and work it did.
事实也是如此
Within 2 years of implementation in 2014,
2014年实施该方案后 两年内
20 million Americans have gained health insurance coverage.
已有2000万美国人成功获得医保
Economic research has shown that because of the ACA,
经济研究表明 由于《平价医疗法案》的实施
the uninsured faced reduced financial distress,
无医保者陷入财务困境的情况变少了
were more likely to have a regular source of care
也更可能得到所需的经常性医疗照顾
and got more of the preventive care they needed.
和更多的预防性医疗服务
Indeed, recent studies have found that
确实 最近一些研究表明
tens of thousands of lives were saved by the ACA.
《平价医疗法案》已经拯救了数万人的生命
Meanwhile, premiums on the new state exchanges were below projections
同时 新的州医保交易所的保费低于预期
leading the cost of the law to be well under budget.
这使该法案的支出远低于预算
And predictions of negative effects proved unfounded,
由于美国就业率增长势头持续不减
as employment growth in the US continued unabated,
雇主资助医保保费增长处于历史最低水平
and Employer Sponsored Insurance premiums grew at their slowest rate in measured history.
法案的实施并未出现所预计的负面影响
But while the ACA was a policy success,
然而 《平价医疗法案》尽管成功
it was a near-term political failure.
但短期内在政治上却是失败的
Partly this reflects the fact the law wasn’t implemented until 2014,
部分原因是该法案直到2014年才实施
4 years after its passage.
已是法案通过4年后
This gave opponents 4 years to vilify the law in theory,
这理论上给了反对者四年时间对其污名化
while supporters had no tangible benefits to point to in practice.
而这期间支持者们并没有得到切实的好处
Then, when implementation of the law was hounded by technical failures,
之后 当法案的实施遇到技术问题困扰时
it strengthened the narrative that the law wasn’t working,
称该法案不可行的论述又被强化了
even though those failures were fixed within a few months.
尽管这些问题在几个月内就得到了解决
The ACA was an early success
《平价医疗法案》初期是成功的
delivering coverage to millions at below budgetary cost,
以低于预算的成本让数百万人获得了医保
but these successes could not break through the noise,
但这些成功没能突破杂音的压制
and the supporters of the ACA suffered enormous political losses.
法案的支持者遭受了严重的政治损失
By 2017, with a new president and a new congressional majority,
到2017年 新总统上任 国会多数党易主
who had campaigned on repealing the ACA,
该总统曾推动废除《平价医疗法案》
and things look dire for the law.
法案处境看来很糟糕
But then, a funny thing happened.
但这时 有趣的事情发生了
The law had been in place for a few years,
法案已经实施几年了
and folks started to appreciate its benefit.
人们开始认可它的好处
Many individuals had benifited from the ACA,
许多个人已经从中受益
and then, who wanna see those benefits go away?
这时候 谁愿意眼睁睁失去这些好处呢
Meanwhile, opponents could not deliver on an alternative
与此同时 反对者也拿不出替代法案
that did not result in tens of millions of Americans losing insurance coverage,
来避免数万美国人失去医保
and the reintroduction of pernicious insurance market discrimination.
避免再次造成医保市场的恶性歧视
As a result, by 2017,
结果 到2017年
public support for the ACA crossed 50% for the first time,
《平价医疗法案》公众支持率首次超过50%
and the efforts of repeal failed.
废除该法案的努力也失败了
So, where does the ACA stand today?
那么 如今该法案状况如何呢?
It’s still the law of the land, and it’s largely working as intended.
它在我国依然有效 大致按计划运行
But the battle over repeal weakened the law,
但废除与保留之争弱化了法案的力量
in particular, through the removal of the individual mandate,
特别是由于个人强制条款的去除
and the erosion of insurance market protections.
和医保市场保护主义的侵蚀
As a result, 2 to 3 million Americans lost health insurance coverage,
结果有200到300万美国人失去了医保
and premiums on the state exchanges risen rapidly,
州立医保交易所的保费价格也快速攀升
because we no longer insure the participation by the healthiest individuals.
因为我们不再能确保最健康个人的参与
Fortunately, there’re changes we can make to strengthen the ACA.
幸运的是 我们能做些改变来加强该法案
Some are relatively modest.
有些是比较小的改变
While the ACA features tax credits
尽管《平价医疗法案》有税收抵免
to offset the cost of health insurance for low-income families,
来补偿低收入家庭的医保花费
too many Americans continue to find health insurance unaffordable.
有太多的美国人仍感觉负担不起保费
An expansion of those tax credits could make health insurance attainable
增加税收抵免的额度就有可能
for low-income families struggling to make ends meet.
让正在艰难量入为出的低收入家庭获得医保
Some problems are more fundamental.
有一些是更基本的问题
Perhaps the biggest failure of implementation of the Affordable Care Act
也许《平价医疗法案》实施时最大的失败
was the rejection by some states of the Medicaid expansions.
是有部分州拒绝扩展联邦医疗补助
Medicaid is a state-run program,
联邦医疗补助是州运营项目
but under the ACA, the federal government agreed to pay
但根据《平价医疗法案》 联邦政府愿意承担
90 to 100 percent of the costs of covering all the poor.
覆盖全部穷人所需费用的90~100%
An incredibly good deal for states.
这对各州来说是非常划算的
Yet, due to political opposition, a number of states turned this down.
然而由于政治反对 法案在多州未获通过
This means women like Verda, could have had life-saving health insurance
这意味着 不用各州花钱 Verda这样的女性
at virtually no cost to the state.
本该得到医保来救命的
But politics got in the way.
但政治斗争成了绊脚石
Another problem is the lack of competition on the state ACA exchanges.
另一个问题是 州ACA医保交易所缺乏竞争
In many areas, these exchanges feature only one or two insurers,
很多地方的交易所仅有一两个保险公司
resulting in very high premiums.
结果就是保费非常得高
One approach to addressing these issues is the public option.
解决这些问题的一个办法 是公众选择
The idea is quite simple.
这个思路很简单
Let’s make private insurers compete with a new government-run plan,
让私营保险公司与新的国营计划
like Expanded Medicare.
如扩展版联邦医疗保险竞争
Low-income citizens in states that didn’t expand Medicaid
没有扩展医疗补助的州的低收入居民
could then enroll in this new plan,
可以来这个新计划登记
bringring millions into coverage.
让数百万人得到医保
And it’ll provide robust competition for private insurers
这也会给交易所的私营保险公司
on the exchanges, bringing down premiums.
带来有力的竞争 把保费降下来
But even this approach faces some limitations.
但即使这种方法也是有局限的
Millions of Americans like Verda will continue to fall through the insurance cracks
仍有数百万像Verda这样的美国人会继续
because of issues of life transitions or affordability.
因生活转变或负担能力问题得不到医保
And more broadly,
更广泛地说
our fragmented multi-payer private health insurance system
我们碎片化的多支付者私营医保系统
features high and wasteful administrative spending.
管理成本高昂 浪费巨大
An approach to address these shortcomings
解决这些弊端的方法之一
would be to move to a single-payer healthcare system,
是转向单一支付者医保系统
where all private health insurance is replaced
用一个免费的国营医保系统
with a single free government-run plan.
替代所有的私营医保
Americans will be enrolled in this plan from birth,
美国人将从出生时登记入这个系统
insuring truly universal protection against health risks.
以真正确保全民免于疾病威胁
And healthcare cost in the US would fall, as we got rid of the administrative waste
一旦消除了与多支付者医保系统相关的
associated with our multi-payer health insurance system.
管理资源浪费 美国的医疗成本就会下降
Sounds good! But it runs into 3 political hurdles.
听起来好极了 但这会有三个政治障碍
First, while those who buy insurance would no longer have to pay for it,
第一 虽然购买医保的人不用自己花钱
the government would have to pay instead in the form of higher taxes.
政府却要征更多的税 来为这笔费用买单
This is a simple trade in theory,
这在理论上是简单的交易
but in practice, it feels like a politically traumatic tax increase.
但这实际在政治上感觉是令人痛苦的加税
Second, the 170 million Americans
第二个障碍是
who are by and large satisfied with their Employer Sponsored Insurance
1.7亿对雇主资助医保基本满意的美国人
would like to revolt against being fored into a single-government system.
会反对被强迫纳入单一的政府医保系统
And third, and perhaps the most important,
第三 可能也是最重要的障碍是
this would mean wiping out a nearly 1-trillion-dollor private health insurance industry.
这意味着摧毁近万亿美元的私营医保行业
This industry will not go quietly into the night.
这个行业肯定不会默默地黯然退场
As a result, single-payer is not a near-term political possibility.
因此 单一支付者体系短期内政治上不可行
So, where does this leave us?
那我们还有什么选择呢?
I like the healthcare reform like bowling.
我希望的医疗改革像“打保龄球”
Our goal is to knock down all the pins
我们的目标是撞倒所有
that block us from universal health insurance.
阻止我们实施全民医保的“球瓶”
But we have to be careful not to throw the ball too far to either side,
但又得小心 扔球别太靠边儿
in which case we could end up in the gutter,
以免球滚落到
of millions of newly uninsured facing discriminatory insurance coverage,
数百万失去医保者面临医保歧视的“边沟”里
or the gutter of political impossibility leading to inaction.
和因政治上的失望导致不作为的“边沟”里
Fortunately, there’s plenty of room down the lane,
幸运的是 “球道”里还有巨大空间
for creative approaches like a public option
让公众选择或增加税收抵免等创意方法
or expanded tax credits.
来充分发挥作用
We just have to keep throwing the ball between the gutters
我们只需不断在两边沟之间扔球
till we knock down all those pins.
直至撞倒所有的球瓶
I used to start all my healthcare speeches with a joke,
我以前所有的医疗演讲都用一个笑话开场
that’s well known among the health policy wonks.
这个笑话在医疗政策专家中流传很广
The health economist dies and goes to heaven
一个医疗经济学家死后到了天堂
and when she gets there, she’s told she can ask God one question.
然后 她被告知可以问上帝一个问题
So she asked, “Will we ever see universal health insurance coverage in America?”
于是她问“我们能见到美国实现全民医保吗?”
To which God replies yes, “but not in my lifetime”.
上帝回答是的 “但在我这一生看不到”
[Audience laughing]
[观众笑声]
I’m proud to say, I don’t use that joke in my speeches anymore,
我骄傲地说 我演讲里不再用这个笑话了
because we have shown the willingness to take the difficult steps necessary
因为我们已经展示了做所有艰苦努力的意愿
to fundamentally expand health insurance in America,
以从根本上扩大美国医保覆盖范围
and Americans wanna move forward to build on the ACA,
美国人愿意继续推进《平价医疗法案》
not backwards to the bad old days of discriminatory insurance.
不愿退回到有医保歧视的糟糕的旧时代
I don’t know how we’re gonna get to universal health insurance coverage in America,
我不知道我们会怎样让美国实现全民医保
but I know we will eventually,
但我知道我们终将成功
because it makes economic sense,
因为这是有经济意义的
it makes political sense and it’s the right thing to do.
有政治意义的 是正确之举
Thank you.
谢谢大家
[Audience applausing]
[观众掌声]

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视频概述

演讲者是美国推出《平价医疗法案》的贡献者。他开头用两名患癌女性因医保状况不同,结局不同的故事,引出了实现全民医保的重要性,然后介绍了美国旧式医保体系的弊端和不完善,介绍了《平价医疗法案》曲折的诞生和实施过程,树立了全面实行全民医保的信心,并提出实施方案。

听录译者

Han

翻译译者

melan

审核员

审核员DY

视频来源

https://www.youtube.com/watch?v=0FXa9SJM-EQ

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