Thir_last gossip

把这期ECO头条的文章阅读笔记贴出来，很不完善，很业余。一直断断续续看ECO，没能坚持做笔记。有人说看四年ECO抵得上读四年大学。我想说，真踏踏实实读下来比当下国内四年大学要实在的多。
这里贴的内容是从word上导出的，如果有看官要word文档，可以到这个邮箱里去荡：notonlyenglish@gmai.com 密码：20080412 新概念四小组的创建日期。
Health-care reform in America
This is going to hurt
Jun 25th 2009
From The Economist print edition
                
                
【小识】奥巴马之所以是奥巴马绝不仅仅是因为那几场富丽堂皇的演说。这个星球上最大经济体的领导人是靠着许诺和行动的链条一点点在通向未来的悬崖上一点点攀爬的。对于ECO选题的时效性，要求读者对当下的世界经济局势和当今社会的各行各业有着一定的知识储备，和关注现实的高远胸襟。否则那些似曾相识却模棱两可的词汇会让阅读变得磕磕绊绊，绵延不绝的长句和潇洒飘逸的插入语则令思维频频短路。这期的“医改”头条让人兴致盎然。之前听说过有部关于美国医疗顽疾的纪录片“Sicko”，导《华氏911》的那个戴棒球帽的胖子Michael Moore的作品，据说非常犀利，若是看了恐怕会对理解当前这个issue有更切肤的体会。但花一晚上把文章梳理完一遍，最容易得出的就是“天下乌鸦”的牢骚。也许这种现象既不是什么“普遍真理”，也非“纯属巧合”。大概是因为三十年来中国就是把跟跑对象选在了赛道最靠前的那位。所以当别人挠到其咯吱窝时，我们也会觉得痒痒。
Barack Obama was elected in part to fix America’s health-care system. Now is the time for him
to keep his word
be elected in part to fix 也就是说医改是Obama之所以当选的重要原因之一。短小的词组in part在这里表达非常有效，学校里的书本只会The reason why …… mainly lies in……
DIAGNOSING what is wrong with America’s health-care system is the easy part. Even though one dollar in every six generated by the world’s richest economy is spent on health—almost twice the average for rich countries—infant mortality, life expectancy and survival-rates for heart attacks are all worse than the OECD average. Meanwhile, because health insurance is so expensive, nearly 50m Americans, an obscene number in such a rich place, have none; those that are insured pay through the nose for their cover, and often find it bankruptingly inadequate if they get seriously ill or injured.
问题总是明显的，所谓事倍功半。one dollar in every six应该指的是“每六个人一美元”的投入，但结果通过三个指标来看却不尽人意。让人感兴趣的是这样三个点便可以折射出整个医疗水平的低效，可供参考。
 infant mortality 新生儿存活率
 life expectancy 人均寿命
 survival-rates for heart attacks 心脏病成活率
最让人痛心的那五千万没有任何医保的美国人。50m被称为是一个obscene的数字，译的话最好是“令人耻辱的”。美国的人口据09年元旦的调查显示，已达3.05亿,新增人口四成为移民。
【探讨】后面的pay through nose不太懂什么意思，后面coverd的意思也很宽。 反正那些拥有医保的人也并没过上好日子。ECO中文官网上也标记了这个词组。很多人认为是“花费了很大代价来付费”的意思。。
The costs of health care hurt America in three other ways. First, since half the population (most children,
the very poor, the old, public-sector workers) get their health care via the government, the burden on the
taxpayer is heavier than it needs to be, and is slowly but surely eating up federal and state budgets.
Second, private insurance schemes are a huge problem for employers: the cost of health insurance helped bring down GM, and many smaller firms are giving up covering employees. Third, expensive premiums depress workers’ wages.
总结下来有三个方面：政府的医疗保险负担；大型企业的医保投入；还有就是个人所缴纳的保险份额premiums。
Every rich country faces some of these problems (see article), but nobody suffers worse from them than
America. This summer’s debate about health care may determine the success of Barack Obama’s
presidency. What should he do?
Uncomfortably numb
If he were starting from scratch, there would be a strong case (even to a newspaper as economically liberal as this one) for a system based mostly around publicly funded health care. But America is not starting from scratch, and none of the plans in Congress shows an appetite for such a European solution. America wants to keep a mostly private system—but one that brings in the uninsured and cuts costs. That will be painful, and require more audacity than Mr Obama has shown so far.
显然美国不可能按照欧洲的方法来进行国家福利医保（publicly funded health care）。这里的start from scratch想必并不是“从零开始”或者“白手起家”，而是说“重新来”，或者重新洗牌的意思。而固守着原来的主要依赖私营组织的医保系统，既会让更多的人参保还可以削减开支。但这种维持需要奥巴马更大的胆识来抗，因为它已经证明是低效的，而且是必须要改革的。
这一段看来是先把白宫的底线划出来——不可能按照欧洲模式改革的。
The uninsured are the relatively straightforward bit. All you need do is “mandate” 【v 委任】everyone to take out health insurance, much as drivers are legally required to have car insurance. Poorer Americans would get subsidies, and (as with car insurance) insurance-providers would be forced to offer affordable plans and not exclude the sick or the old. This has already happened in Massachusetts as well as in a raft【n 救生筏；这里指“大量的”】 of countries, including the Netherlands, Israel and Singapore. All the main proposals now working their way through Congress include some version of a mandate. Mr Obama opposed a mandate on the campaign trail, but since he has not come up with any plausible alternative, he should quietly swallow one.
这里mandate一词的确切含义并不得知，联系上面的straightforward，“直接”，可以推断是“强行征收”。对于穷苦的人可以领到津贴（subsidies），而提供保险的机构（insurance-providers）也被强制制订切实的（affordable）计划对于老弱病残提供险种。无论怎样，这样一种做法对于底层美国人是一项比较可行的方法而且在很多地方已经实施。但问题在于这似乎是美国新总统在竞选时是反对这种“强制”投保的提案，也难怪作者提到这一点时用了 working their way through，“through”一词体现出这一提案在国会很难通过。最后的症结在于若是拿不出一个得到认同的可选方案，只能默许这一计划。quietly swallow是很形象的描写，但译成中文暂时只能先达意了。
The snag 【n.阻碍】is that all these subsidies are expensive. Those congressional plans might cost $1.2 trillion to $1.6 trillion over ten years: the White House is feverishly trying to massage the estimates downward, as well as working out how to plug the hole through various savings and tax increases. But the sticker-shock for the mandate is really just a reflection of the second big problem: the overall cost structure of American health care. Indeed, one of the worst things about Mr Obama’s oddly hands-off approach to health reform (see article) is that he is concentrating on a symptom, not the underlying disease.
奥巴马先生之所以反对不是没有道理，高昂的subsidies让国会不得不一方面把估算压低，（massage这个词太巧妙了，感觉“估算”被人格化了，非常疲惫，需要休息。）另一方面还要提高税收，广开财路填补这一财政缺口（plug the hole）。医保措施背后的关键问题是整体的医疗开支结构。而奥巴马这次进行医疗改革似乎并不稳妥，仅仅关注表象而非实质。approach前面的修饰：“oddly hands-offf”很难从字面上看明白，是不是和汉语中“撒手一搏”相关，只是这一搏太蹩脚 （oddly）。
A bolder president would start by attacking two huge distortions that make American health care more
expensive than it needs to be. The first is that employer-provided health-care packages are tax-deductible.
This is unfair to those without such insurance, who still have to subsidise it via their taxes. It also
encourages gold-plated insurance schemes, since their full cost is not transparent. This tax break costs the government at least $250 billion a year. Mr Obama still shies away from axing it, as do the main
congressional plans on offer; but it ought to go (albeit perhaps in stages).
看来总统大人的魄力还不够（a boulder …would…虚拟），否则就该大刀阔斧地改革美国畸形的医疗制度。可以揣摩到这里面也有一个利益分配的问题：那些由企业提供的保险项目（employer-provided health-care packages）是免税（tax-decuctible）的，这对于那些没有保险依靠国家的人来说是不公平的，（看来我们的观念还比较落后，西方人已经把缴税看作是一种保险形式）。由于免税给政府带来很大的财政开支，而那些镀金保险（gold-plated insurance）计划则钻了空子。但问题在于无论总统还是国会都缩手缩脚(shies away from axing it)。
这里做一下揣测，其实在大洋彼岸也是一样的黑暗，财富都是向少数特权阶级那里汇集。所谓社会问题归结下来都是一个利益再分配的问题，怎样将当下的获利集团的羹分到真正需要的人手上。
Perversity on stilts【n 高跷】, or crutches【n 拐杖】
The second big distortion is that most doctors in America work on a fee-for-service basis; the more pills
they prescribe, or tests they order, or procedures they perform, the more money they get—even though
there is abundant clinical evidence that more spending does not reliably lead to better outcomes. Private
providers everywhere are vulnerable to this perverse incentive, but in America, where most health care is
delivered by the private sector rather than by salaried public-sector staff, the problem is worse than
anywhere else.
看完第一句不知怎的脑海中冒出一个大妈的形象，拍着洋人的肩膀说：娃儿，恁那来怎么比俺这儿好不了哪去？在语言上，abundant evidence这个搭配值得借鉴；另一个副词reliably在这里很恰当：药开得再好再贵不见得凑效。这里既有positively,又有effectively的含义。
The trouble is that many Americans are understandably happy with all-you-can-eat health care【见新概念四Lesson 28 Patients and doctors】, which allows them to see any doctor they like and get any test that they are talked into thinking they need. Forcing people into “managed” health schemes, where some species of bureaucrat decides which treatments are cost-effective, is politically toxic; it was the central tenet 【n 原则】of Hillary Clinton’s disastrous failed reform in 1994.
talked into两个词作为分词被动的用法太老练了，这两个词是完全可以拿掉的，直接接thinking毫无问题，但区区两个词放在那里，把think的动因点出来了，把美国医生的贪婪和病人轻率刻画得入木三分！
强迫公民选择力所能及的医保计划，但哪一个是最有效的则是政府机关人士说了算，这种做法看来希拉里还没参选08时就已经在自己的地盘上实践过了。“对行政有很大危害”或“危害政治”这样的表达在英文可以灵活地用副词加形容词表述。politically toxic；这种英汉互译的技巧肯定有专业书提过，已经在很多地方遇到。
But to some extent it will have to be done. There is solid evidence to suggest that by cutting back on
unnecessarily expensive procedures and prescriptions, anything from 10% to 30% of health costs could be saved: a gigantic sum. The Mayo Clinic in Minnesota and the California-based Kaiser Permanente system have shown that it is possible to save money and produce better outcomes at the same time. So reform must aim to encourage more use of managed health care, provided by doctors who are salaried, or paid by results rather than for every catheter【n 导液管】 they insert. Medicare, the government-run insurance scheme for those over 65, could show the way, by making much more use of results-based schemes and encouraging more competition among its various providers and insurers.
以治疗效果作为政策改革的目标而不是出售的药品价格总量和。这本来是医病的根本目的，兜了那么大圈子回来却成了分析一个超级大国医保顽疾的根本出路，资本驱逐的市场经济总是给人以这样返璞归真的无言惊喜。另外，“量力而行”还是要实行，当初克林顿夫人失败的恐怕只是方法而不是方向。当然关于这段史实缺乏了解，只是信口。Salaried doctors 应该是说保障医疗人员的收入，而非和其出售的医药品关联。后面一个catheter they insert的借代用法很形象，很讽刺，很到位。
But in the end it will be up to the private health-care system. One thing that should be unleashed
immediately is antitrust【n 反托拉斯】: on a local level many hospitals and doctors work as price-fixing cabals【n.(政治)阴谋小集团, (尤指政治上的)阴谋】. Another option, favoured by many Democrats and the president, is for the government to step in with a resultsbased plan of its own, to compete against the private industry. That could harm innovation and distort the market further. Mr Obama should use it as a threat, rather than implement it now. If the private sector does not meet certain cost-cutting targets in, say, five years, a public-sector plan should automatically kick in. Such a prospect would encourage hospitals and doctors to accept a painful but necessary reform now.
很奇怪，连“总统应该拿它当做威胁而不是真正实施”这样的话都挑明了，不是说那些被威胁的对象也了然于胸了吗？后面讲的painful but necessary太过隔靴搔痒了。任何一种积极的改变无疑都是阵痛的，就像吃药一样。可讳疾忌医的人依然不在少数。
N4 链接：
【医疗话题】
Lesson 28 Patients and doctors
【snag】
Now the snag in this sort of anecdote is of course that one cannot distinguish cause and effect.
Lesson 25 Non-auditory effects of noise
痛，在所难免
奥巴马赢得大选，部分是因为他提出改善美国医疗体系。如今是他兑现诺言的时刻了。
诊断美国医疗体系的问题并不难。在美国，虽然每六美元中就有一美元用于医疗保健—几乎是发达国家平均水平的两倍，但是人均寿命及心脏病患者存活率却都低于OECD成员国家平均水平。与此同时，由于医疗保险太过昂贵，将近5000万美国人没有买医疗保险，在美国这样的富裕国家，这就是天文数字；那些买了保险的人，若是伤病严重时，常会发现这些保险远远不够。
医疗花费还在另外三个方面困扰着美国人。首先，由于半数人群（多数为儿童，贫困人群，老年人和公共部门员工）都是通过政府获得医疗保险，纳税人因此要承担更重负担，这种负担慢慢地消耗联邦政府及州政府预算。其次，私人保险体系对许多雇主是极其棘手的问题：医疗保险开支是通用破产的原因之一，许多小公司都在放弃为员工提供医保。第三，昂贵的额外保险费用减少了员工的薪水。
每个发达国家都面临其中一些问题，但是美国受害最深。今夏针对医疗体系的商讨，可能决定奥巴马担任总统的成功与否。他该怎么做？
Uncomfortably numb
如果奥巴马选择从零开始，那么对于一个几乎建立在公共医疗基础上的体系来说，将是一项大工程（甚至对像本刊这样经济自由的杂志也这样认为）。但是美国并没有从零开始，国会的各项方案中没有一项现出这种欧洲的解决方法。美国人希望保持以私有体系为主—但是又能使未投保的群体受益，还能削减开支。这将会很艰难，奥巴马需要比现在更大胆。
未投保人群相对来说是最好处理的部分。只需“强制”每个人购买医疗保险，就像司机必须给汽车投保一样。贫困群体可获得补贴，（和汽车保险一样）保险公司必须提供价格合理的保险项目，不论老弱都能支付。这在马萨诸塞州和许多其他国家都已经实施，包括荷兰，以色列和新加坡。所有主要提案目前都正在国会审议，其中包括一些提出强制性医保的提案。奥巴马在竞选时反对强制性医保，但由于并未提出任何更好的方案，他应该默默接受其他方案。
问题是这些补贴是昂贵的。国会的那些方案10年可能需要1.2至1.6万亿。白宫奋力降低预估,同时试图通过各种节约手段以及税收增加来填补这个漏洞。但是昂贵的强制性医保刚好反应了第二个大问题：美国医疗体系的整体花费结构。奥巴马反常地放手进行医疗改革最糟糕的事情是，他集中解决的是表面病症，而非潜在疾病。
总统若是够勇敢的话，应该从解决导致美国医疗保险开支过高的两大畸形问题开始。一是雇主提供的医疗保险是可以减税的。这对于没有投保的人来说是不公平的，因为通过交税，他们仍然补贴了这部分保险。同时，这一政策还助长了镀金保险计划的发展，因为这一计划的全部花费是不透明的。这项减税政策每年至少消耗政府2500亿美元。奥巴马仍在回避取消该政策，国会的议案也如此。但是现在应该行动了（即使是一步一步行动）。
Perversity on stilts, or crutches
第二个畸形问题是美国大部分医生的收入是与服务挂钩的；药开得越多，测试做得越多，程序越多，他们的收入就越多—尽管大量临床证据显示钱花的越多结果不一定越好。任何一个地方的私人医生都经不起这种不合理提成的诱惑。而在美国，大部分医疗护理都是由私人医院提供而不是拿固定薪水的公共医院医生提供，因此美国的问题比任何一个地方都严重。
麻烦的是，许多美国人对这样一种是药就能开的医疗体系相当满意，在这一体系下，他们可以看自己想看的医生，医生说做什么测试，他们就深信自己需要做这些测试。强制实行受监管的医疗方案在政治上是有害的，在此方案下，由官员们可以决定那种治疗是经济的；这一方案也是1994年希拉里彻底失败的医疗改革方案的核心条款。
但是从某种程度上又必须实行这样的方案。证据表明，减少不必要的昂贵治疗和处方，医疗花费可以降低10%-30%。这不是个小数目。明尼苏达州Mayo诊所和总部位于加利福利亚的Kaiser Permanente体系研究显示，既省钱又有效的治疗是可能的。因此医疗改革必须鼓励实施监管医疗，由固定收入的医生提供方案，或是根据治疗结果收费，而不是每一个治疗步骤。政府向65岁以上老年人提供的老年医保可以作为示范，更多地使用结果导向型方案，鼓励不同医院和保险公司之间的竞争。
但是最终还是要靠私人医疗体系。反垄断必须马上进行。一些地方医院和医生就像定价集团一样。还有一个受到许多民主党员和总统青睐的方法是，政府建立自己的结果导向型收费体系，来与私人医院竞争。这可能会阻碍创新，使市场进一步畸形。当前，奥巴马应该把这一方案当成威胁的手段，而不是强制实施。比如，如果私人医院在五年内不能将花费降低到一定水平，公共医院计划将自动启动。这样的前景可以刺激医院和医生现在就接受痛苦但必要的改革。
ECO中文论坛 梦梦 译http://www.ecocn.org/bbs/viewthread.php?tid=20386&extra=&pag