Health careA new prescription for the poor為貧窮者新開的處方America is developing a two-tier health system, one for those with private insurance, the other for the less well-off美國正在發(fā)展一個雙重的健康系統(tǒng)，一重是為那些有個人保險的人群，而另一重則是為那些不那么富裕的人群Oct 8th 2011 | NEW YORK | from the print edition“IT’S time for Dancing with the Stars!”, a woman announces enthusiastically. At this New York health centre, wedged between housing projects to the east and Chinatown to the west, “dancing with the stars” means dancing with a physical therapist. An old man stands up with a nurse and begins a determined samba.“是時候和明星一起跳舞了！”一位女士滿懷熱情地宣告。在這個坐落于房屋工程的西面，唐人街東面的紐約健康中心，“和明星起舞”的意思是和一位物理治療師跳舞。一位老者和一個護士站起來，開始跳事先確定好的桑巴舞。Comprehensive Care Management (CCM), which runs this centre, tries to keep old people active. To do so, explains Joseph Healy, the chief operating officer, is in the company’s best interest. The government pays CCM a capped rate for the care of its members. If someone gets sick, his health costs rise and the company’s margin shrinks. Mr Healy argues that the system is the best way to provide good care at a low cost. Increasingly others seem to agree.經(jīng)營這個中心的綜合護理管理部門（CCM）努力保持老人們的活力。約瑟夫-海莉，首席運營官解釋說，這樣做符合公司的最佳利益。政府給這個部門一個封頂?shù)慕蛸N來讓他們照顧這些人。如果有人生病了，他的健康成本就會上升，公司的利潤就會萎縮。海莉先生確定說這個系統(tǒng)能夠在一個低成本上提供最佳的護理。其他人也逐漸同意這個觀點。Medicaid, America’s health programme for the poor, is in the process of being transformed. Over the next three years, New York will move its entire Medicaid population into “managed care”, paying companies a set rate to tend to the poor, rather than paying a fee for each service. New York is not alone. States from California to Mississippi are expanding managed care. It is the culmination of a steady shift in the way most poor Americans receive their health-care treatment.公共醫(yī)療補助，即美國的窮人健康計劃，正在被改造的過程中。在接下來的 三年內(nèi)，紐約將把整個接受窮人健康計劃的人群納入“管理關(guān)懷”之中，付給公司們一個事先定好的費用來照顧那些窮人，而不是按照項目來付費。紐約不是唯一這樣做的州。加州，密西西比州正在拓展管理關(guān)懷計劃。這代表一種正在進行中的穩(wěn)步轉(zhuǎn)變，即大部分貧窮美國人接受健康關(guān)懷方式的轉(zhuǎn)變。Medicaid is America’s single biggest health programme. This year roughly one in five Americans will be covered by Medicaid for a month or more. It gobbles more federal and local money than any state programme, other than education. Costs will rise even more when Barack Obama’s health-care reform expands the programme by easing eligibility rules in 2014. Congress’s “supercommittee” is already considering cuts. However, there are more immediate pressures behind the present drive for change.公共醫(yī)療補助是美國最大的單一健康計劃。今年，五個美國人中的一個就會被納入該計劃一個月或更長時間。除了教育之外，它比其他任何州的財政計劃耗去更多聯(lián)邦和地方的經(jīng)費。當2014年奧巴馬的健康保險改革放寬適用人群而使整個計劃更加龐大的時候，成本將會進一步上升。眾議院的“超級委員會”已經(jīng)在考慮削減經(jīng)費。然而，選擇這種變化，將會有更多即刻的壓力存在。Enrolment in Medicaid jumped during the downturn, from 42.7m in December 2007 to 50.3m in June 2010. Mr Obama’s stimulus bill helped to pay for some of this, but that money has dried up. Faced with gaping deficits, some desperate governors slashed payments to hospitals and doctors, or refused to pay for trips to the dentist or oculist. But much the most important result has been structural: the expansion of managed care.公共醫(yī)療補助計劃的參與人數(shù)在經(jīng)濟滑坡期間從2007年12月的 4270萬人跳到了2010年6月的5030萬人。奧巴馬先生的經(jīng)濟刺激經(jīng)費能夠幫助付掉其中的一部分，但是錢已經(jīng)被用光。面對資金短缺，一些絕望的州長砍掉了給醫(yī)院和醫(yī)生的補助，或是拒絕支付牙醫(yī)和眼科醫(yī)生的旅行費用。但是，更多地，最重要的結(jié)果是結(jié)構(gòu)上的：管理關(guān)懷的拓展。States have dabbled in managed care for decades. The trend accelerated in the 1990s, with the share of Medicaid patients under this form of care reaching 72% by 2009. Now, however, there is a strong push for the remainder. States that did not have managed care, such as Louisiana, are introducing it. Other states are extending it to people previously deemed off limits: California and New York, for example, are moving the elderly and disabled into that system of care. Texas is targeting more than 400,000 Medicaid beneficiaries in the Rio Grande Valley. Local politicians had resisted the move, nervous that care might deteriorate. But the yawning deficit meant that they were overruled.各個州涉足管理關(guān)懷已經(jīng)有幾十年的歷史了。這個趨勢在90年代得到加速發(fā)展，在2009年前使用這種護理方式的公共醫(yī)療補助病人占到了72%。現(xiàn)在，對于剩下的人，這也是很強的推動力。像路易斯安那州這樣沒有管理關(guān)懷的州正在引進管理關(guān)懷。其他州也把這個拓展到原先被認為不適用的人群：舉例說像加州和紐約州，正在把老人和殘障人士納入這個系統(tǒng)中，德州的目標是在格蘭德河谷超過400000公共醫(yī)療補助收益人群。地方政治家反對這個舉動，他們擔心這個護理系統(tǒng)將會變質(zhì)。但是巨大的赤字意味著他們的觀點注定要被批駁。The result is a country with two distinct tiers of health care. Most Americans with private insurance are still horrified by thoughts of health-management organisations and prefer to pay fees for each medical service. For the poor, managed care is becoming the norm.結(jié)果就是一個國家有兩套截然不同的健康保險系統(tǒng)。大多數(shù)有個人保險的美國人仍舊害怕那些健康管理組織的想法而寧愿為單獨的醫(yī)療服務(wù)付費。對于窮人來說，管理關(guān)懷已經(jīng)成為一種常規(guī)。Advocates of managed care have high expectations. First, they hope that it will make costs more predictable. Second, they believe that the change will improve patients’ health. In managed care, a patient has a network of doctors and specialists. If the programme works properly, doctors can monitor all aspects of care, in contrast to the fragmented fee-for-service system. The contracts that states have with firms can set standards for quality. Texas, for instance, will cut 5% from a company’s payment if it does not meet what is required.管理關(guān)懷的鼓吹者有著很高的期待。首先，他們希望這能讓成本變得可以預(yù)測，其次，他們相信，這個改變可以改善病人的健康。在管理關(guān)懷中，一個病人有一個由醫(yī)生和專家組成的網(wǎng)絡(luò)。如果這個計劃運行良好，醫(yī)生可以監(jiān)測關(guān)懷的各個方面，相對于分離的的按服務(wù)付錢的系統(tǒng)來說。州政府和公司的合同可以為質(zhì)量定下標準。德州，舉例說，將會在付款中扣除5%如果公司沒有達到要求的標準。The next step is to integrate care for those eligible for both Medicaid and Medicare, the federal programme for the old. These “duals” account for almost 40% of Medicaid’s costs and just 15% of its population. “If managed care can really deliver better care than fee-for-service”, says Diane Rowland, chair of the commission that advises Congress on Medicaid, “this is the population that could prove it.”下一步是整合那些同時符合公共醫(yī)療補助和長者醫(yī)療補助計劃（聯(lián)邦老人醫(yī)療補助）的人群。這些“雙符合”人群占據(jù)了將近40%的公共醫(yī)療補助成本和僅僅15%的人口數(shù)量?！叭绻芾黻P(guān)懷能真正比按項目付費帶來更好的服務(wù)”，戴安-羅蘭德，委員會（指導(dǎo)國會在公共醫(yī)療補助政策上進行決策）主任說：“這是一群能證明管理關(guān)懷可行的人?！盉ut some, such as Norma Vescovo, are sceptical. As the head of the non-profit Independent Living Centre of Southern California (ILCSC), Ms Vescovo serves Medicaid patients with severe health problems. Over the years she has often sued California on policies that she thinks will hurt her vulnerable clients. On October 3rd her case moved to the Supreme Court.但是一些人，例如像諾瑪-凡斯科夫就對此表示懷疑。作為非盈利的南加州獨立生活中心主任，凡斯科夫女士服務(wù)于那些有嚴重健康問題的接受公共醫(yī)療補助的病人。在這些年間，她經(jīng)?？馗婕又菡谝恍┱呱蠒λ囊恍┐嗳醯目蛻?。在10月3日，她的案子被移到了上訴法院。The outcome of Douglas v Independent Living Centre will have profound implications for the future of Medicaid. Ms Vescovo’s suit concerns cuts to hospitals and doctors. But the case will also guide the course of managed care. If ILCSC and its co-plaintiffs win, private groups will continue to be able to challenge states on policies they think violate federal Medicaid law. Ms Vescovo, who argues that California’s payment cuts would eviscerate her clients’ access to services, worries that under managed care the disabled might not be able to see the specialists they need.道格拉斯 v 獨立生活中心的結(jié)果將會對公共醫(yī)療補助有深遠的意義。凡斯科夫女士的訴訟影響到醫(yī)院和醫(yī)生的津貼削減。但是這個案子將會引領(lǐng)管理關(guān)懷的進程。如果中心和其他原告勝訴，私人團體將會繼續(xù)在那些他們認為違反聯(lián)邦法律的政策上挑戰(zhàn)州政府。凡斯科夫女士認為說加州的支付削減計劃會讓她的客戶失去得到服務(wù)的機會，她還擔心，在管理關(guān)懷之下，那些殘障人士可能不能見到那些他們需要的專家。The question is how to supervise the experiments with managed care that are being carried out in various states. To date, Medicaid beneficiaries have been able to challenge the states in court. However, if the Supreme Court rules against ILCSC, that avenue will be closed. The Centres for Medicare and Medicaid Services (CMS) technically can intervene if states do not provide proper access to care. In reality, CMS has few tools to do so.問題是怎么監(jiān)管在不同州試運行的管理關(guān)懷。到目前為止，公共醫(yī)療補助受益者已經(jīng)能夠在法庭中挑戰(zhàn)政府。然而，如果上訴法庭結(jié)果不利于中心，那么這條路將會被關(guān)閉。如果州政府沒有提供合適的關(guān)懷的話，公共醫(yī)療補助和長者醫(yī)療關(guān)懷中心理論上是能對此進行干涉，但事實上，他們沒有太多辦法?！癐’m a big fan of managed care”, says Sara Rosenbaum, a professor at George Washington University, “but this transformation may happen with almost no federal oversight.” Medicaid beneficiaries are vulnerable, in worse health than Americans as a whole. Companies may struggle to cut costs and provide good care as well. If states do not draft their contracts properly, or fail to be vigilant in monitoring patients’ health, their experiment in managed care could be a disaster. On the other hand, if states are careful they could provide an answer to the question that has vexed America for years: how to provide good, cheap health care.“我是管理關(guān)懷的擁護者”，薩拉-羅森博姆，一位喬治華盛頓大學(xué)教授說，“但是這種轉(zhuǎn)變可能在沒有聯(lián)邦監(jiān)管的情況下發(fā)生。”公共醫(yī)療補助的受益者和你脆弱，健康程度整體上比一般美國人要差。公司可能在削減成本的同時掙扎著同樣提供良好的服務(wù)。如果州政府們不好好起草他們的合同，或沒有警覺地監(jiān)控病人的健康的話，他們在管理關(guān)懷上的實驗可能會是一場災(zāi)難。另一方面，如果州政府們認真的話，他們能為那個困擾美國人多年的問題提供答案，即怎么提供優(yōu)質(zhì)的便宜的健康關(guān)懷。