译者注：继第一部分（美国为什么要医改？），第二部分（美国医改的阻力），第三部分（美国医改改什么？）之后，奥巴马演讲的第四部分分析了实现美国医改的两个核心目的之一——全覆盖的具体设想（如何实现全覆盖？）。“我们必须确保每个美国人都能够获得他们能够负担得起的健康保障”，也就是通过一个公共保险计划，“为上亿的美国人提供可以负担的医疗服务”，但是这样的公共计划会受到很大的阻力，因此奥巴马无法实现统一的体系，只能妥协处理：“如果你不喜欢现在的健康保险，或者没有任何健康保险，你将有机会参与到被我们称为‘健康保险交换’（Health Insurance Exchange）的项目中来”。但是，仅仅实现医疗保险的全覆盖，必然要面对的一个问题就是医疗成本的上升，在第五部分，也就是最后一部分，奥巴马分析了如何实现另一个核心目的——控成本。 

 

June 15, 2009

Obama’s Speech on Health Care Reform

奥巴马：我们的医疗改革

Following is a text of President Obama's prepared address on health care reform to the American Medical Association, as released by the White House.

本文由白宫发布，是美国总统奥巴马对美国医疗协会所作的有关医疗改革政策的答辩词。

 

第五部分：如何实现控成本

Now, even if we accept all of the economic and moral reasons for providing affordable coverage to all Americans, there is no denying that it will come at a cost – at least in the short run. But it is a cost that will not – I repeat, not – add to our deficits. Health care reform must be and will be deficit neutral in the next decade.

现在，即使我们接受这些为每一个美国人提供负担得起的医疗保障的所有经济和道义上的理由，我们也不可避免的会面对改革的成本，至少是在短期里。但是，这样的成本不会，我重申一遍，绝不会，再增加我们的赤字。在下一个10年里，医疗改革必须，也必定会是赤字中性的。

 

There are already voices saying the numbers don't add up. They are wrong. Here's why. Making health care affordable for all Americans will cost somewhere on the order of one trillion dollars over the next ten years. That sounds like a lot of money – and it is. But remember: it is less than we are projected to spend on the war in Iraq. And also remember: failing to reform our health care system in a way that genuinely reduces cost growth will cost us trillions of dollars more in lost economic growth and lower wages.

已经有一些人们认为，赤字的数字不会增加。这是不对的。事实上，为了让医疗服务对每个美国人都是可以负担的，这在下一个十年里将会花费约1万亿美元。这看起来是相当大的一笔开销——确实也是。但是请记住，这少于我们在伊拉克战争中的花费；也请记住，如果我们不对医疗系统进行改革，不对其成本增长进行有效的控制，那么我们必将面对减缓的经济发展和降低的收入，我们失去的将比数万亿美元更多。

 

That said, let me explain how we will cover the price tag. First, as part of the budget that was passed a few months ago, we've put aside $635 billion over ten years in what we are calling a Health Reserve Fund. Over half of that amount – more than $300 billion – will come from raising revenue by doing things like modestly limiting the tax deductions the wealthiest Americans can take to the same level it was at the end of the Reagan years. Some are concerned this will dramatically reduce charitable giving, but statistics show that's not true, and the best thing for our charities is the stronger economy that we will build with health care reform.

尽管如此，让我再来解释，我们如何来为这样的一笔费用买单。首先，作为几个月前通过的财政预算的一部分，我们将在10年内投入6350亿美元来建立一项“健康保护基金”（Health Reserve Fund）。这其中的大约一半——3000亿美元多——将通过适度的限制对最为富有的一部分美国人的税收减免来达到，大致会将其降低到里根总统在位最后时期的水平。有人担心这样的改变会剧烈的减少对慈善事业的捐款，然而统计数据已经证实，这样的担心是多余的，而对我们的慈善事业最重要的事情，便是和我们的医疗改革一同建立起来的，一个更为强健的经济。

 

But we cannot just raise revenues. We also have to make spending cuts in part by examining inefficiencies in the Medicare program. There will be a robust debate about where these cuts should be made, and I welcome that debate. But here's where I think these cuts should be made. First, we should end overpayments to Medicare Advantage. Today, we are paying Medicare Advantage plans much more than we pay for traditional Medicare services. That's a good deal for insurance companies, but not the American people. That's why we need to introduce competitive bidding into the Medicare Advantage program, a program under which private insurance companies offer Medicare coverage. That will save $177 billion over the next decade.

但是，我们也不能仅仅通过提高财政收入这一项措施。我们也需要通过反思老年医疗保险计划中的缺乏效率的部分，来削减一部分开支。对于我们应该在哪些环节削减开支的问题，必定会有相当的争论，我也欢迎这些争论。不过，我也对这个问题有自己的看法。第一，我们应当终止对老年医疗保险计划中基于私人保险部分（Medicare Advantage，以下简称“私人老年医疗保险计划”）过高的偿付水平。如今，我们在私人老年医疗保险计划的花费已经远远高于传统的老年医疗保险计划的部分，这对保险公司而言当然是一笔好买卖，而对于美国人民却不是。也正因为此，我们需要在私人老年医疗保险计划中引入竞争，这在未来10年中将为我们节省1770美元的花费。

 

Second, we need to use Medicare reimbursements to reduce preventable hospital readmissions. Right now, almost 20 percent of Medicare patients discharged from hospitals are readmitted within a month, often because they are not getting the comprehensive care they need. This puts people at risk and drives up costs. By changing how Medicare reimburses hospitals, we can discourage them from acting in a way that boosts profits, but drives up costs for everyone else. That will save us $25 billion over the next decade.

第二，我们需要改革老年医疗保险计划的偿付方式，来减少那些本来可以避免的，医院对患者的重复接纳情况。当前，有大约20%的享受老年医疗保险计划的患者在出院后，一个月内又会重新入院。这往往是因为他们没有获得其需要的全面治疗。这不但增加了人们的风险，也同时促使了成本的升高。通过改变老年医疗保险计划对医院进行偿付的方式，我们可以打消他们这种旨在于增加自身利润，却同时提升他人成本的行为激励。这又将为我们在未来10年中节省250亿美元的花费。

 

Third, we need to introduce generic biologic drugs into the marketplace. These are drugs used to treat illnesses like anemia. But right now, there is no pathway at the FDA for approving generic versions of these drugs. Creating such a pathway will save us billions of dollars. And we can save another roughly $30 billion by getting a better deal for our poorer seniors while asking our well-off seniors to pay a little more for their drugs.

第三，我们需要将非专利生物药物引入医疗市场，比如用于治疗贫血症的药物。但是现在，在食品及药品管理局（FDA）却没有批准这些非专利药物的途径。创造这样的途径会为我们节省数十亿美元的花费。同时，通过让较为富有的老年人为他们的药物付出稍稍高一点的价格，并同时为贫穷的老年人提供更好的服务，我们还能额外节省大约300亿美元。

 

So, that's the bulk of what's in the Health Reserve Fund. I have also proposed saving another $313 billion in Medicare and Medicaid spending in several other ways. One way is by adjusting Medicare payments to reflect new advances and productivity gains in our economy. Right now, Medicare payments are rising each year by more than they should. These adjustments will create incentives for providers to deliver care more effectively, and save us roughly $109 billion in the process.

这就是这笔巨大的健康保护基金的来源。我还提出了若干其他的方案，让我们在老年医疗保险和贫困医疗保险两个项目上再节约额外的3130亿美元。其中一个方案是，通过调整老年医疗保险的支付水平，来反映我们整体经济的新发展和生产率进步情况。现在，老年医疗保险的支付水平正在以比其本应有的水平更快的速度增长。这样的调整能够为医疗服务提供者们创造提供更有效的服务的激励，并为我们节省大约1090亿美元。

 

Another way we can achieve savings is by reducing payments to hospitals for treating uninsured people. I know hospitals rely on these payments now because of the large number of uninsured patients they treat. But as the number of uninsured people goes down with our reforms, the amount we pay hospitals to treat uninsured people should go down, as well. Reducing these payments gradually as more and more people have coverage will save us over $106 billion, and we'll make sure the difference goes to the hospitals that most need it.

另一个让我们节省花费的方法，是减少医院从收治没有保险的人中获得的那些支付。我知道，医院常常会依赖于这些支付，因为他们收治的这些无保险者的人数往往十分可观。但是，随着在改革中没有保险的人逐渐减少，我们为收治无保险者所为医院支付的资金也将同时减少。通过逐渐减少这部分支出，并让更多的人获得保险覆盖，我们能够节约超过1060亿美元，同时，我们也会确保，这样的改革会根据具体医院的实际情况来推行。

 

We can also save about $75 billion through more efficient purchasing of prescription drugs. And we can save about one billion more by rooting out waste, abuse, and fraud throughout our health care system so that no one is charging more for a service than it's worth or charging a dime for a service they did not provide.

通过更有效的采购处方药物，我们还能节省大约750亿美元。同时，我们还能通过在整个医疗系统中杜绝浪费、滥用和欺骗行为，来节省额外的10亿美元。这样，不会再有人因为一项服务而付出不值得的花费，也不会再有人因为其根本没有获得的服务而多付一分钱。

 

But let me be clear: I am committed to making these cuts in a way that protects our senior citizens. In fact, these proposals will actually extend the life of the Medicare Trust Fund by 7 years and reduce premiums for Medicare beneficiaries by roughly $43 billion over 10 years. And I'm working with AARP to uphold that commitment.

让我说的更清楚一些：我承诺在保护我们老年人的利益的前提下来达成这些费用削减。实际上，这些提议将会把老年医疗保险信托基金（Medicare Trust Fund）的寿命延长7年，并在10年中让老年医疗保险项目受益者的保费总共下降约430亿美元。我将与美国退休人员协会（AARP）紧密合作，来兑现这些承诺。

 

Altogether, these savings mean that we have put about $950 billion on the table – not counting some of the longer-term savings that will come about from reform – taking us almost all the way to covering the full cost of health care reform. In the weeks and months ahead, I look forward to working with Congress to make up the difference so that health care reform is fully paid for – in a real, accountable way. And let me add that this does not count some of the longer-term savings that will come about from health care reform. By insisting that reform be deficit neutral over the next decade and by making the reforms that will help slow the growth rate of health care costs over coming decades, we can look forward to faster economic growth, higher living standards, and falling, not rising, budget deficits.

总之，这些节省的花费意味着我们将多出9500亿美元的资金——这还没有计算改革将在长期为我们带来的花费节省——将为我们医疗改革中的几乎所有环节提供足够的资金。在未来的几个星期，几个月里，我期待着能够和国会合作，以明确这之间可能存在的资金差距，从而为医疗改革提供实际而真正可行的财政基础。让我补充一句，这还完全没有考虑医疗改革将为我们带来的长期花费节省。通过坚持医疗改革在未来10年中的财政中性，通过坚持改革，我们能够有效的减缓医疗成本在未来的几十年中的上升速度，我们有理由期待更快的经济发展，更高的生活水平，和逐渐降低而不是上升的财政赤字。

 

I know people are cynical we can do this. I know there will be disagreements about how to proceed in the days ahead. But I also know that we cannot let this moment pass us by.

我知道，人们会怀疑我们是否真正能够做到这些；我知道，对于未来的改革如何进行也将会有各种异议和争论。但是，我也深知，我们决不能让这个机遇从身旁滑落。

 

The other day, my friend, Congressman Earl Blumenauer, handed me a magazine with a special issue titled, "The Crisis in American Medicine." One article notes "soaring charges." Another warns about the "volume of utilization of services." And another asks if we can find a "better way [than fee-for-service] for paying for medical care." It speaks to many of the challenges we face today. The thing is, this special issue was published by Harper's Magazine in October of 1960.

前些日子，我的朋友，国会议员艾尔·布鲁莫劳尔（Earl Blumenauer）给我一本杂志特刊，这份特刊的主题是：“美国医疗的危机”。其中一篇文章指出了“高涨的费用”，一篇对“医疗服务的利用量”提出了警告，另一篇则质问我们是否可以找到“一个（比现付医疗费，fee-for-service）更好的方式来为医疗服务买单”。这份特刊提到了我们如今面对的许多挑战。但是我想说的关键在于，这份杂志特刊，是哈珀杂志（Harper's Magazine）在1960年10月所出版的。

 

Members of the American Medical Association – my fellow Americans – I am here today because I do not want our children and their children to still be speaking of a crisis in American medicine fifty years from now. I do not want them to still be suffering from spiraling costs we did not stem, or sicknesses we did not cure. I do not want them to be burdened with massive deficits we did not curb or a worsening economy we did not rebuild.

美国医疗协会的同仁们——也是和我一样的普通美国人——我今天之所以来到这里，是因为我不希望我们的孩子，还有他们的孩子，还会在从现在起的五十年后依然谈论着美国医疗的危机。我不希望他们依然会受困于我们今天未能有效遏制的急剧成本上升，或是我们未能治愈的疾病。我不希望他们去面对那本应由我们控制的巨额赤字，或是那本应该由我们来重建的，可能恶化的整体经济。

 

I want them to benefit from a health care system that works for all of us; where families can open a doctor's bill without dreading what's inside; where parents are taking their kids to get regular checkups and testing themselves for preventable ailments; where parents are feeding their kids healthier food and kids are exercising more; where patients are spending more time with doctors and doctors can pull up on a computer all the medical information and latest research they'd ever want to meet that patient's needs; where orthopedists and nephrologists and oncologists are all working together to treat a single human being; where what's best about America's health care system has become the hallmark of America's health care system.

我希望他们能够从一个真正服务于每个美国人的医疗系统中受益。在这个系统中，我们的家庭可以放心的打开医生的账单，而不必担心里面写的是什么；我们的父母可以带着他们的孩子去接受定期的体检，并接受疾病预防，同时为孩子们提供更健康的食品，带他们参加更多的运动；我们的患者能够有更多的时间和医生在一起，而医生们则可以从广泛的医疗信息和最新的医学研究成果中获取他们所需的内容，来满足患者的需要；我们的整形外科专家、肾病专家和肿瘤专家能够一起合作，为一名患者带去健康。在这个系统中，我们美国医疗系统中最为可贵的部分，能够真正成为这一系统的铭刻。

 

That is the health care system we can build. That is the future within our reach. And if we are willing to come together and bring about that future, then we will not only make Americans healthier and not only unleash America's economic potential, but we will reaffirm the ideals that led you into this noble profession, and build a health care system that lets all Americans heal. Thank you.

这正是我们能够建设的医疗系统。这也是我们可以掌握的未来。如果我们愿意团结起来，共创未来，我们便不仅仅是让美国人的身体变得更健康，也不仅仅是释放美国经济的潜力；而是更深刻的印证了你们作为医生这一光辉的天职和理想，并建立一个为所有美国人带来全面健康的医疗系统。谢谢大家！

 

（感谢北京大学CCER“健康中国研究小组”的同学们对本文的贡献！）

 

延伸阅读

（感谢北京大学CCER“健康中国研究小组”的同学们对本文的贡献！）

 

延伸阅读