Barack Obama’s reforms should avoid squandering a rare opportunity, but probably won’t
LAST year, when he was still the head of the independent Congressional Budget Office, Peter Orszag used to warn bleakly that the rising costs of health care would, if not subjected to radical reform, one day bankrupt the government. Over the past few decades, these costs have risen at a consistent 2.5 percentage points above the growth rate of the economy. Projected out to 2050, he reckoned, Medicare and Medicaid (the government schemes that insure the elderly and the poor) would together consume some 20% of America’s GDP, almost as much as the entire federal budget of today.
Perhaps Mr Orszag, now the budget director in Barack Obama’s White House, is about to storm out of his grand new office. For the health bill that this week moved a big step closer to Mr Obama’s desk (see article) fails—not completely, but very largely—to address the government-exploding problem of cost inflation. Instead, its focus rests squarely on the long-cherished Democratic Party goal of making sure that virtually everyone in America has some form of health coverage; at the moment, over 46m people have none. Even on this score, the plan that finally emerged from the Senate Finance Committee on October 13th looks incomplete (by 2019, 25m people are expected to remain uninsured), is likely to cost much more than has been claimed, and is paid for with hypothetical savings that are sure to be found wanting.
Mr Obama and his team will naturally declare victory if any health bill at all makes it out of Congress, as it now looks rather more likely that one will. They have some grounds for doing so. Anything that mitigates the obscenity of so rich a country leaving so many people without coverage will be a change for the better. But the bill also looks likely to represent a terribly wasted opportunity. Perverse incentives constantly drive up the costs of American health care, and the legislation will do little to remove them. Mr Obama and his Democratic colleagues on Capitol Hill are in grave danger of throwing away a rare chance. Health-care entitlements are by far the biggest chunk of America’s out-of-control budget, and it will probably be another decade, perhaps two, before anyone again dares to tackle them. A president with a big personal mandate, solid majorities in both chambers of Congress and a silver tongue ought to have been much braver.
Courage, Mr President
That braver president could have demanded far more. The worst flaw in the Finance Committee’s bill is its failure to address the way that providers of health care are paid. Most payments to doctors and hospitals are made on a “fee-for-service” basis—which means that, unconstrained either by medical necessity or value for money, the industry’s revenues rise with every test it does, procedure it carries out and prescription it writes. Yes, the bill provides funds for research into electronic record-keeping, comparative effectiveness research and other good things. But it should mandate these practices, not just encourage study of them. None of the five different bills that have been passed by various House and Senate committees and are now on the way to being melded into a single compromise version includes anything like the sort of root-and-branch overhaul that would see health care paid for by results.
Nor do any of the bills do anything much to tackle the other big distortion in health-provision—tax exemption for employer-provided private health-insurance. By subsidising the health plans of those lucky enough to have them, this encourages over-consumption and amounts to a distorting taxpayer-funded subsidy for the well-off. The latest bill merely sets a very high cap (of $8,000 per person, or $21,000 for a family) on this exemption, and the House of Representatives will try to water down even this feeble effort at the behest of the unions whose members enjoy some of the most lavish policies. It may also dilute the administration’s only really good proposal, for a committee of experts empowered to order changes to the way Medicare payments are made. Finally, the bills make no attempt to address the matter of greedy lawyers forcing doctors to practise expensive “defensive medicine” for fear of being sued to kingdom come.
What was produced this week was not the final outcome; the legislation will change as the work of reconciling the different versions of the bill continues. There is no shortage of good ideas that might yet find their way into the final one. Payments by the government could, for instance, be tied to best national practice, and Mr Obama has already said that he is open to the idea of medical tort reform. But time is running out.
译文:
奥巴马改革措施恐已错过良机
奥巴马改革措施恐已错过良机
去年，担任美国国会预算办公室主任Peter Orszag曾忧心的指出，如果不彻底改革日渐增长的医疗保险支出，终有一天将拖垮政府，使其破产。在过去的几十年里，种种医疗保险支出以高出经济增长率的2.5%的速度持续升高。Peter Orszag预计到2050年，医疗保险和医疗补助（政府保障老年人和贫困人口的计划）将总共消耗美国GDP的20%，几乎与现在联邦预算总额持平。
Orszag现为白宫预算主管，可能会在就职不久愤然离职。因为本周向奥巴马提出的医疗议案在很大程度上并没有成功地向政府表明一触即发的成本膨胀问题。相反，议案焦点大部分集中在民主党重视的确保每个美国人都能以各种方式享受医疗保险这一长期目标，然而目前超过四千六百万人无法享受医疗保障。即使是这一目标，十月十三号参议院金融委员会最终出台的计划很有可能超过声明的数字，毫无疑问，支付这一账目的是假定的储蓄金。
奥巴马和他的团队当然会声明国会出台的任何医疗议案都是成功的，正如现在看上去的这样。他们有理由这样做。在一个如此富裕的国家，竟有这样多的人无法享受医疗保险，任何能够缓和这一糟糕局面的议案都可能使其变得更好。但议案也可能是错失良机的信号。保守的政策刺激美国医疗消费不断的上涨，而法规很难降低增长。 奥巴马及其国会山的民主党同事们由于错失良机而陷入危机。政府医疗保险津贴到目前为止占美国失控预算的最大份额，在人人能够享受医疗保险前，未来的十到二十年中，还将保持这一局面。
总统先生，拿出勇气来
勇敢的总统应该要求更多。金融委员会议案最大的失误在于，没有成功的表明医疗保险的提供方的薪酬方式。多数医生和医院的报酬是基于“服务费用”基础上的——这意味着产业岁入在实施及撰写计划前，随每次测试增长而增长，受医疗需求或费用限制。是的，议案向电子记录保存研究，相对效率研究及其他有益事项提供基金。但应该强制执行这些常规，而不是仅仅鼓励学习常规。众议院及参议院各委员会通过的五个不同议案，没有迹象要融合为一个单一的妥协方案，方案包括各个方面，如彻底的改革，只对有疗效的医疗项目支付医疗保险。
这些议案中也没有一个专注于处理其他重大医疗供给的失真问题——提供雇工的私人医疗保险机构免税。通过对拥有雇工的幸运儿的医疗计划补贴，这促使消费过度并导致纳税人提供给富裕人群的津贴失真。最新的议案仅对这一免税设定可一个很高的上限（$8,000每人，或$21,000每户），尽管努力可能化为泡影，但众议院将按照那些公民享受多数优惠政策的联邦的命令，尽量降低这一上限。这可能仅仅淡化那些真正行之有效的提案，因为专家委员会有权修改医疗保险的支付方式。最终，议案无法表明贪婪的律师们强加于医生的惯例，医生只能开高价的“防范性治疗药物”，以防日后被起诉。
本周生成的并不是最终结果，法规随着对不同版本提案的调和一致工作的进行而变化。目前看来，最终结果还没有提出十分完美的解决方案。例如，政府支付的薪酬绑定最有力的国家法规，奥巴马曾表示过，他欢迎任何与医疗侵权相关的改革方案，然而时间却不够了。