From Economist (双语版）

Health care
A new prescription for the poor
为贫穷者新开的处方
America is developing a two-tier health system, one for those with private insurance, the other for the less well-off
美国正在发展一个双重的健康系统，一重是为那些有个人保险的人群，而另一重则是为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.
“是时候和明星一起跳舞了！”一位女士满怀热情地宣告。在这个坐落于房屋工程的西面，唐人街东面的纽约健康中心，“和明星起舞”的意思是和一位物理治疗师跳舞。一位老者和一个护士站起来，开始跳事先确定好的桑巴舞。
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.
经营这个中心的综合护理管理部门（CCM）努力保持老人们的活力。约瑟夫-海莉，首席运营官解释说，这样做符合公司的最佳利益。政府给这个部门一个封顶的津贴来让他们照顾这些人。如果有人生病了，他的健康成本就会上升，公司的利润就会萎缩。海莉先生确定说这个系统能够在一个低成本上提供最佳的护理。其他人也逐渐同意这个观点。
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.
公共医疗补助，即美国的穷人健康计划，正在被改造的过程中。在接下来的 三年内，纽约将把整个接受穷人健康计划的人群纳入“管理关怀”之中，付给公司们一个事先定好的费用来照顾那些穷人，而不是按照项目来付费。纽约不是唯一这样做的州。加州，密西西比州正在拓展管理关怀计划。这代表一种正在进行中的稳步转变，即大部分贫穷美国人接受健康关怀方式的转变。
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.
公共医疗补助是美国最大的单一健康计划。今年，五个美国人中的一个就会被纳入该计划一个月或更长时间。除了教育之外，它比其他任何州的财政计划耗去更多联邦和地方的经费。当2014年奥巴马的健康保险改革放宽适用人群而使整个计划更加庞大的时候，成本将会进一步上升。众议院的“超级委员会”已经在考虑削减经费。然而，选择这种变化，将会有更多即刻的压力存在。
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.
公共医疗补助计划的参与人数在经济滑坡期间从2007年12月的 4270万人跳到了2010年6月的5030万人。奥巴马先生的经济刺激经费能够帮助付掉其中的一部分，但是钱已经被用光。面对资金短缺，一些绝望的州长砍掉了给医院和医生的补助，或是拒绝支付牙医和眼科医生的旅行费用。但是，更多地，最重要的结果是结构上的：管理关怀的拓展。
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.
各个州涉足管理关怀已经有几十年的历史了。这个趋势在90年代得到加速发展，在2009年前使用这种护理方式的公共医疗补助病人占到了72%。现在，对于剩下的人，这也是很强的推动力。像路易斯安那州这样没有管理关怀的州正在引进管理关怀。其他州也把这个拓展到原先被认为不适用的人群：举例说像加州和纽约州，正在把老人和残障人士纳入这个系统中，德州的目标是在格兰德河谷超过400000公共医疗补助收益人群。地方政治家反对这个举动，他们担心这个护理系统将会变质。但是巨大的赤字意味着他们的观点注定要被批驳。
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.
结果就是一个国家有两套截然不同的健康保险系统。大多数有个人保险的美国人仍旧害怕那些健康管理组织的想法而宁愿为单独的医疗服务付费。对于穷人来说，管理关怀已经成为一种常规。
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.
管理关怀的鼓吹者有着很高的期待。首先，他们希望这能让成本变得可以预测，其次，他们相信，这个改变可以改善病人的健康。在管理关怀中，一个病人有一个由医生和专家组成的网络。如果这个计划运行良好，医生可以监测关怀的各个方面，相对于分离的的按服务付钱的系统来说。州政府和公司的合同可以为质量定下标准。德州，举例说，将会在付款中扣除5%如果公司没有达到要求的标准。
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时符合公共医疗补助和长者医疗补助计划（联邦老人医疗补助）的人群。这些“双符合”人群占据了将近40%的公共医疗补助成本和仅仅15%的人口数量。“如果管理关怀能真正比按项目付费带来更好的服务”，戴安-罗兰德，委员会（指导国会在公共医疗补助政策上进行决策）主任说：“这是一群能证明管理关怀可行的人。”
But 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，例如像诺玛-凡斯科夫就对此表示怀疑。作为非盈利的南加州独立生活中心主任，凡斯科夫女士服务于那些有严重健康问题的接受公共医疗补助的病人。在这些年间，她经常控告加州政府在一些政策上会伤害她的一些脆弱的客户。在10月3日，她的案子被移到了上诉法院。
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 独立生活中心的结果将会对公共医疗补助有深远的意义。凡斯科夫女士的诉讼影响到医院和医生的津贴削减。但是这个案子将会引领管理关怀的进程。如果中心和其他原告胜诉，私人团体将会继续在那些他们认为违反联邦法律的政策上挑战州政府。凡斯科夫女士认为说加州的支付削减计划会让她的客户失去得到服务的机会，她还担心，在管理关怀之下，那些残障人士可能不能见到那些他们需要的专家。
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.
问题是怎么监管在不同州试运行的管理关怀。到目前为止，公共医疗补助受益者已经能够在法庭中挑战政府。然而，如果上诉法庭结果不利于中心，那么这条路将会被关闭。如果州政府没有提供合适的关怀的话，公共医疗补助和长者医疗关怀中心理论上是能对此进行干涉，但事实上，他们没有太多办法。
“I’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.
“我是管理关怀的拥护者”，萨拉-罗森博姆，一位乔治华盛顿大学教授说，“但是这种转变可能在没有联邦监管的情况下发生。”公共医疗补助的受益者和你脆弱，健康程度整体上比一般美国人要差。公司可能在削减成本的同时挣扎着同样提供良好的服务。如果州政府们不好好起草他们的合同，或没有警觉地监控病人的健康的话，他们在管理关怀上的实验可能会是一场灾难。另一方面，如果州政府们认真的话，他们能为那个困扰美国人多年的问题提供答案，即怎么提供优质的便宜的健康关怀。