奥巴马医改正在土崩瓦解

​​Obamacare Is Falling Apart
分崩离析的奥巴马医改

Insurers are bolting from the exchanges.

保险公司正在逃离交易所。

President Obama has been hammered for his failure on ISIS in the wake of the Paris attacks. But there’s at least one bright spot for him in that criticism: At least it deflected the spotlight from the unfolding catastrophe that is Obamacare.

巴黎恐怖袭击发生之后，奥巴马总统已经因其对ISIS的政策失败而遭广泛抨击。不过，对他来说，这种批评至少有一个好处：它转移了公众对于“奥巴马医改”走向失败的关注。

Indeed, last month brought arguably the worst news for the program since the healthcare.gov debacle: UnitedHealthcare, the nation’s largest insurer, announced that it might quit Obamacare’s exchanges next year. Should UnitedHealthcare act on this threat, there may not be enough (red) tape in the desk drawer of even future President Hillary Clinton to put the Obamacare Humpty Dumpty back together again.

实际上，医改计划上个月得到的消息之糟糕，可说是自Healthcare.gov网站崩溃以来之最。全国最大的保险公司“联合健保”宣布，明年可能会退出奥巴马医改的交易所。如果联合健保兑现这一威胁，那么即使未来的希拉里·克林顿总统想要修好医改这个摔碎了的矮冬瓜，恐怕她抽屉里也找不出多少（红色）胶带可用。

United announced during an investor briefing Thursday that it was expecting a whopping $425 million hit on its earnings this year, primarily due to mounting losses on its Obamacare exchange business. “We cannot sustain these losses,” United CEO Stephen Hensley declared. “We can’t really subsidize a marketplace that doesn’t appear at the moment to be sustaining itself.”

联合健保在周二举行的一场投资者通气会上宣布，公司预期今年收入将要减少425亿美元之多，主要是因为它的奥巴马医改交易业务亏损不断增加。“我们无法承受这一损失”，联合健保首席执行官Stephen Hensley如此宣布。“我们不可能补贴一个目前似乎仍不能维持其自身存在的交易市场。”

Avik Roy, who serves as GOP presidential candidate Marco Rubio’s health care advisor, suspects United may just be the first domino to fall. Other commercial insurers, such as Aetna, Anthem, and Cigna, have raised premiums by double digits and still say they can’t make the numbers work in their favor. Hence, they have withdrawn from counties where their losses were particularly acute.

据共和党总统候选人Marc Rubio的医保问题顾问Avik Roy预计，联合健保恐怕只是倒下的第一块多米诺骨牌。包括Aetna, Anthem和Cigna在内的其他一些商业保险公司，在保费已经提高了两位数百分点的情况下，仍然宣称它们无法令数据对自己有利。因此，它们也已经从亏损特别惨重的县份撤离。

For-profit companies that have shareholders breathing down their necks don’t have much latitude to absorb losses. But even companies that don’t face similar profit-maximizing pressures can’t escape the basic dilemma confronting the industry.

由于股东们就站在身后监督，这些营利性公司并没有多少空间来承受这种亏损。但是，即便是那些并没有类似的利润最大化压力的企业，也难逃这一行业正在遭遇的基本困境。

For example, state filings of the non-profit Blue Cross Blue Shield show that the company barely broke even in the first half of 2015. In Texas last year, BCBS collected $2.1 billion in premiums and paid out $2.5 billion in claims. If Obamacare’s condition worsens, such companies will have to scale back their participation too.

比如，根据其提交给州政府的申报材料，非营利性的“蓝十字与蓝盾”公司2015年上半年几乎破产。该公司去年在德州一共收取到21亿美元保费，但支付的索赔款却有25亿美元。如果奥巴马医改的形势继续恶化，这类公司也将不得不收缩其参与度。

And Obamacare’s condition will worsen. Why? Because not only are far fewer patients enrolling in the exchanges than projected, but those signing up are too old or sick for anything resembling a balanced risk pool.

而奥巴马医改的形势必将继续恶化。为什么？因为，与此前预期相比，参加计划的人数要少得多；不仅如此，那些参加了计划的，要么年纪过大，要么病情过重，根本无助于形成收支平衡的风险池。

Even the administration has admitted that Obamacare enrollment has essentially flatlined, with only 1.3 million new members expected to buy coverage next year, compared to the 8 million projected when the law was passed. This means that overall enrollment by 2016 will be somewhere between 9.4 million and 11.4 million. That’s half—half—of the 21 million initially predicted. So much for universal coverage!

连政府都承认奥巴马医改的参保实质上已经完蛋了，预计明年将只有130万新成员购买保险，与之相比，医改立法通过时设想的可有800万。这就是说，到2016年，全部登记总数大概为940万至1140万之间。离最初预计的2100万还差一半，一半！所谓全民参保，不过如此！

The reason for this pathetic take-up rate is that the lavish benefits—in-vitro fertilization for 50-year-old women*, for example—that Obamacare mandated for qualifying plans have backfired. This mandate was intended to make sure that the young and healthy would purchase full—not bare-bones, catastrophic—coverage so that they would offset the cost of sicker patients.

接受度如此之惨，原因在于奥巴马医改在批准保险计划时强制要求企业提供一些慷慨优惠（如向50岁妇女提供试管受精*），而这导致了意料之外的不良后果。这一强制的本来用意是想要确保年轻和健康的人购买全额保险，而不是仅仅购买基本的重病保险，以此来冲抵重症患者造成的成本。

Instead, it has forced companies to jack up rates so much that only those eligible for full subsidies (the relatively poor) or the sick find it worth their while to buy coverage. The relatively young and healthy are opting to pay the penalty and “go naked.” This, in turn, is forcing insurers to raise prices even more, which is causing more healthy people to drop out, unleashing the dreaded adverse selection spiral.

但实际上，它却迫使企业抬高保险费率，导致只有那些有资格领取全额补贴的人（相对较为贫困的群体）或者身患疾病的人才觉得购买保险划得来。相对年轻、相对健康的群体都选择缴罚款并“裸奔”。而这反过来又会迫使保险公司更进一步提高价格，从而导致更多的健康人群放弃参保，开启了逆向选择的可怖螺旋。

Obamacare tried to prevent this downward spiral by, ironically, insuring the insurers against losses until 2017 through something called the risk corridor provision. Basically, the plan was to shake down companies making higher than expected profits and handing their proceeds to companies with higher than expected losses.

奥巴马医改曾试图阻止这种恶性循环，方法是通过所谓的“风险走廊”条款向保险公司提供亏损保险至2017年，这倒是颇具讽刺意味。简单地说，这个计划就是要打劫盈利超过预期的公司，把他们获得的收益转移到亏损超过预期的公司。

Setting aside the perversity of forcing successful companies to subsidize failing competitors, the program hasn’t worked because the entire industry is confronting losses and Congress has barred the administration from dipping into general funds—aka taxpayer pockets—to bail it out. (United withdrew partially because it sees no relief in sight from the government. “We see no indication of anything actually improving,” CEO Henley said.)

且不说强迫成功企业补贴失败对手的做法有多错乱，这个计划之所以没能实施，是因为整个行业都在亏本，而国会禁止政府为了实施救援把手伸向一般性资金（即纳税人的口袋）。（联合健保退场的部分原因就是在它看来短期内无法得到政府救助。“我们看不到事情真正在发生好转的迹象”，首席执行官Henley说。）

The best medicine for the exchanges? It might involve letting the insurance industry offer pared back, cheap coverage at prices that reflect the risk profile of patients. This would bring back the young invincibles, but jack up prices for sicker patients. That problem could be solved by targeting subsidies on these patients on a strict means-tested basis rather than showering them on everyone up to 400 percent of the poverty level.

拯救交易所的最好良药是什么？可能需要让保险行业供应简化的、廉价的险种，其价格要能反映患者的风险状况。这将会把青春无敌之辈拉回市场，但也会抬高对于重病患者的要价。要解决这个问题，可能需要基于严格的经济调查对这些人进行精准补贴，而不能像泼水一样发补贴，凡是收入在贫困线4倍以下的都能雨露均沾。

The crucial upside to this approach is that it would allow the insurance marketplace to function again. However, market pricing based on health is against the religion of liberals. Clinton won’t go there. She could twist the screws on opt-outs by raising their penalty to something close to the price of the coverage they are refusing. But that would require Congress to override the statutory limits on these penalties in Obamacare. And so long as the House remains in Republican hands, that ain’t going to happen.

这种方法的关键优点是，它能够让保险市场重新运转起来。然而，基于健康状况进行市场定价的做法违反自由派的信仰。克林顿不会这么做。她可以提高不参保者的罚金，让它高到和现在拒绝接受的保险价格相去不远，从而拧紧退出之门的螺丝。但是，这也需要国会推翻奥巴马医保为此类罚金所设定的法定限制。只要众议院还在共和党手里，这种事就绝不会发生。

Hillary’s only other option will be to impose price controls on the health care industry. She’s recently taken to demonizing drug companies but, notes Roy, they account for only 12 percent of health care costs. The real “savings” that could lower the price of coverage would be from going after doctor and hospital reimbursement, but that would be the political equivalent of stepping on a land mine.

希拉里唯一剩下的另外一个选项是对医疗保健行业强加价格管制。最近，她已经开始妖魔化药品企业，但是Roy也提到，药品在医疗保健开支中只占有12%。真正可以用来降低保险价格的“节约”只能通过盯紧医生和医院报销而得到。但在政治上，这种做法相当于踩地雷。

Obamacare is falling apart limb by limb, and there is really no keeping it together. It could well become President Obama’s Iraq: A costly and conceited intervention that destroyed an imperfect but functioning system just because it didn’t fit his utopian designs.

奥巴马医改正在一块一块地分崩离析，而且真的没有什么办法能够阻止其支离破碎。它很有可能会变成奥巴马总统的伊拉克：发动一场成本高昂、狂妄自负的干涉行动，捣毁了一个并不完美但能够运转的系统，仅仅因为它不符合自己的乌托邦设想。

Update: *Although Obamacare — aka ACA — does not have a universal mandate to cover in-vitro fertilization, states with this mandate are expected to offer this benefit in their benchmark ACA plans.

更新：*尽管奥巴马医改（即平价医疗法案，ACA）并没有普遍性地强制要求保险公司支付试管受精费用，但实行这一强制的州预计会在其ACA基准计划中提供这一福利。​​​​