Op-Ed Columnist
California, Here We Come?
November 27, 2013
It goes without saying that
the rollout of Obamacare was an epic disaster. But what kind of
disaster was it? Was it a failure of management, messing up the initial
implementation of a fundamentally sound policy? Or was it a
demonstration that the Affordable Care Act is inherently unworkable?
We know what each side of
the partisan divide wants you to believe. The Obama administration is
telling the public that everything will eventually be fixed, and urging
Congressional Democrats to keep their nerve. Republicans, on the other
hand, are declaring the program an irredeemable failure, which must be
scrapped and replaced with ... well, they don’t really want to replace
it with anything.
- 查看大图
Fred R. Conrad/The New York TimesPaul Krugman
At a time like this, you
really want a controlled experiment. What would happen if we unveiled a
program that looked like Obamacare, in a place that looked like America,
but with competent project management that produced a working website?
Well, your wish is granted. Ladies and gentlemen, I give you California.
Now, California isn’t the
only place where Obamacare is looking pretty good. A number of states
that are running their own online health exchanges instead of relying on
HealthCare.gov are doing well. Kentucky’s Kynect is a huge success; so
is Access Health CT in Connecticut. New York is doing O.K.
And we shouldn’t forget that Massachusetts has had an Obamacare-like
program since 2006, put into effect by a guy named Mitt Romney.
California is, however, an
especially useful test case. First of all, it’s huge: if a system can
work for 38 million people, it can work for America as a whole. Also,
it’s hard to argue that California has had any special advantages other
than that of having a government that actually wants to help the
uninsured. When Massachusetts put Romneycare into effect, it already had
a relatively low number of uninsured residents. California, however,
came into health reform with 22 percent of its nonelderly population uninsured, compared with a national average of 18 percent.
Finally, the California authorities have been especially forthcoming with data tracking the progress of enrollment. And the numbers are increasingly encouraging.
For one thing, enrollment
is surging. At this point, more than 10,000 applications are being
completed per day, putting the state well on track to meet its overall
targets for 2014 coverage. Just imagine, by the way, how different press
coverage would be right now if Obama officials had produced a
comparable success, and around 100,000 people a day were signing up
nationwide.
Equally important is the
information on who is enrolling. To work as planned, health reform has
to produce a balanced risk pool — that is, it must sign up young,
healthy Americans as well as their older, less healthy compatriots. And
so far, so good: In October, 22.5 percent of California enrollees were
between the ages of 18 and 34, slightly above that group’s share of the
population.
What we have in California, then, is a proof of concept. Yes, Obamacare is workable — in fact, done right, it works just fine.
The bad news, of course, is
that most Americans aren’t lucky enough to live in states in which
Obamacare has, in fact, been done right. They’re stuck either with
HealthCare.gov or with one of the state exchanges, like Oregon’s, that
have similar or worse problems. Will they ever get to experience
successful health reform?
The answer is, probably
yes. There won’t be a moment when the clouds suddenly lift, but the
exchanges are gradually getting better — a point inadvertently
illustrated a few days ago by John Boehner, the speaker of the House.
Mr. Boehner staged a publicity stunt in which tried to sign up
in the DC Health Exchange, then triumphantly posted an entry on his
blog declaring that he had been unsuccessful. At the bottom of his post,
however, is a postscript admitting that the health exchange had called
back “a few hours later,” and that he is now enrolled.
And maybe the transaction
would have proceeded faster if Mr. Boehner’s office hadn’t, according to
the D.C. exchange, put its agent — who was calling to help finish the
enrollment — on hold for 35 minutes, listening to “lots of patriotic hold music.”
There will also probably be
growing use of workarounds — for example, encouraging people to go
directly to insurers. This will temporarily defeat one of the purposes
of the exchanges, which was to make price comparisons easy, but it will
be good enough as a short-term patch. And one shouldn’t forget that the
insurance industry has a big financial stake in the success of
Obamacare, and will soon be pitching in with big efforts to sign people
up.
Again, Obamacare’s rollout
was a disaster. But in California we can see what health reform will
look like, beyond the glitches. And it’s going to work.
專欄作家
加利福尼亞證明了奧巴馬醫改的成功
保羅·克魯格曼 2013年11月27日
不用說，奧巴馬醫改的推出是一個巨大的災難。但它是一種怎樣的災難呢？是因為管理的失敗，搞砸了一項根本上頗為健全的政策的初步實施？還是說它已經證明《合理醫療費用法案》(Affordable Care Act)根本不具有可行性？
我們都知道存在分歧的兩黨分別希望你會持何種觀點。奧巴馬政府告訴公眾，一切問題最後都會得到解決，他們還呼籲國會民主黨人保持冷靜。而共和黨人則宣稱，這個項目簡直就是無可救藥地失敗，它必須被取消或者用其他東西來代替……哎，其實他們根本不願意用任何東西來代替它。
在這樣的時刻，你會很想進行一次受控實驗。如果我們在一個看似美國的地方，推出一個看似奧巴馬醫改的項目，但是項目管理人員有能力，推出了一個運行正常的網站，情況又將如何？
好吧，你的心愿得到了滿足。女士們、先生們，我們來看看加利福尼亞。
奧巴馬醫改並不只是在加利福尼亞運行良好。許多運行自己在線醫保交易所，而不是依賴於政府醫改網站HealthCare.gov的州都表現良好。肯塔基州的網站Kynect就取得了巨大成功；康涅狄格州的
Access Health
CT也是一樣。紐約的情況也還不錯。而且我們也不應該忘記，從2006年開始，馬薩諸塞州就有了一個類似奧巴馬醫改的項目，該項目的實施者叫做米特·羅姆
尼(Mitt Romney)。
不過，加利福尼亞是一個非常有用的案例。首先，它規模巨
大：如果一個系統能為3800萬人服務，它就能為所有美國人服務。此外，加利福尼亞除了有一個真心想幫助無保險人員的政府以外，很難說它有任何其他的特殊
優勢。當馬薩諸塞州開始實施羅姆尼醫改的時候，它的無保險居民人數已經相對較少了。然而，當加州開始進行醫療改革時，它22%的非老齡人口都未參保，而全
國平均水平為18%。
最後，加州官方對追蹤登記進程的數據尤為坦誠。而且相關數據越來越鼓舞人心。
首先，登記量在急速增加。此時此刻，每天都有1萬多名申請者完成登記，按照這種勢頭，加州可以順利完成2014年的總體覆蓋目標。還有，請試想一下，如果奧巴馬政府的官員取得了與之相當的成功，全國每天大約有10萬人完成登記，媒體現在的報道將會多麼不同。
同樣重要的是登記者的信息。按照計劃，醫療改革必須生成一
個平衡的風險池——也就是說，除了較年長的、健康狀況較差的美國人以外，年輕的健康美國人也需要登記。目前為止，一切順利：10月，22.5%的加州登記
者的年齡都在18歲到34歲之間，略微超過這群人在總人口中所佔的比例。
所以，加州的情況是一個概念驗證。對，奧巴馬醫改具有可行性——實際上，如果能得到正確實施，它將會取得很好的效果。
當然，壞消息是，大多數美國人都沒能足夠幸運地住在奧巴馬醫改得到正確實施的州。他們要麼被聯邦政府醫改網站所困，要麼就遇到了有着相似或更嚴重問題的州醫保交易網站，比如俄勒岡的網站。他們究竟能否體驗到成功的醫療改革？
答案是，或許能。烏雲絕不會瞬間消散，但交易網站卻在逐漸
改善——幾天前，眾議院議長約翰·博納(John Boehner)無意中說明了這一點。博納在一次作秀中嘗試在哥倫比亞特區醫保交易(DC
Health
Exchange)網上進行登記，然後神氣地在博客上發訊息稱，他沒有登記成功。然而，他在文章底部發了一條附言，承認醫保交易網站在「幾小時後」打電話
給他，目前他已成功登記。
而且哥倫比亞特區的交易網站稱，博納的辦公室讓打電話過來幫他完成登記的工作人員拿着電話、聽着「大量愛國的等待音樂」等了35分鐘；如果博納的辦公室沒有這樣做的話，這次交易就會更快完成。
變通方案的使用或許會越來越多，例如，鼓勵人們直接去找承保人。這樣做將暫時使交易網站失去其中一項功能——使價格比較變簡單，但它將是一個很好的短期應對措施。人們也不應該忘記，奧巴馬醫改的成敗於保險行業有巨大的經濟利益，而且很快就會大力爭取讓人們登記。
再說一遍，奧巴馬醫改的推出是個災難。但是，拋開那些小問題不論，我們在加州看到了醫療改革的前景。它會成功的。
翻譯：陳柳
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