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心情忐忑话医改 2010-03-31 13:24:06

心情忐忑话医改


继上周二签署最初的医疗改革法案后,奥巴马总统又于本周二在参众两院通过的修改法案上签下了大名。至此,吵吵闹闹一年多的医疗改革终于结束了第一个阶段。我这个在一旁紧张地看热闹的,也不觉长长地出了一口气。是该告一段落了,再也不能这样争执下去了。写这篇小东西,并不是我有多么支持这个法案,有多激动,事实上心情比较复杂,还有些忐忑不安。回想一年多来,看了听了太多的辩论和评述,见识了Tea Party上那一张张因愤怒而变形的脸,我也从最初的期盼,渐渐地焦急、失望,直到最后看到峰回路转、柳暗花明而如释重负。下面就说说我对这整个过程的一点感想,以及对后续发展的些许期待。

一 、我很庆幸此事能有这样的结局。法案本身还在其次,但它的通过粉碎了某些极右人物希望医改成为奥总的滑铁卢(Waterloo),并最终毁灭他的总统任期的梦想。共和党内,象Rush Limbaugh那样盼望奥巴马早早地重重地跌下去的大有人在。那个来自南卡名叫DeMint的参议员就公开叫嚣要让医改成为奥总的Waterloo。很多人对奥巴马的反对要追溯到他赢得选举胜利之前。Sarah Palin在竞选时就把奥和恐怖主义、不爱国联系在一起。后来,人们又妄图借他的出生地来证明他的不合法性。小奥的不少政策,实际上是上届政府的延续,象 7000亿元救市,在民事法庭审判恐怖分子,等等。医保改革中最有争议的条款 – 要求个人买保险,事实上最初出自John McCain,共和党另一个大佬Mitt Romney也曾经双手赞成。现在小奥和民主党要来实施,他们就都极力反对了。很多人是逢奥必反,根本就不管他说了什么干了什么。调查显示,只有18%的民众知道CBO评估最终通过的法案会减少赤字(知道了信不信是另外一回事)。热热闹闹争吵了十几个月了,知道这过程中的关键人物之一Max Baucus是谁的,也寥寥无几。民众参与的热情如此之高,然而他们又如此闭塞,无知,或者是有选择地接受符合自己观点和立场的信息。这就是为什么所谓的death panel和government take over这样的谣言和误解能够大行其道的原因。那些嚷嚷政府接管的人,能告诉我政府将会怎么接管吗?希望善良的不要被那些激烈的言辞(比如社会主义)所蒙蔽。一个少数族裔长住白宫,白宫已不那么白了,加上管辖着众议院的又是个女性,这就足够让很多人抓狂。看看Tea Party中坚分子都是些什么人,你大概就明白了。

也有些人原来是支持小奥的,现在很失望甚至已经反对他了。我觉得这些人应该仔细想想这样三个问题。首先,你当初是否抱有不切实际的幻想和期望?其次,你是否在这震耳欲聋的争吵中迷失了方向?最后,你是否被当前严峻的国际国内形势吓破了胆?如果有一个答案是肯定的,也许首先应该从自己身上找找原因?

二、 但愿两党和国民的严重分歧不要酿成暴力冲突,至少不要有大规模的暴力冲突。健保法通过后,Sara Palin竟然教唆她的追随者“don’t retreat; instead reload”。没有打过枪放过炮的人也知道“reload”有什么意思。看来这个,嗯,人,不仅头脑简单,而且还很容易冲动发热。至少有十个民主党议员得到这样那样的威胁,当然也有个别的共和党人受到攻击。看看众院投票前夕,示威者对某些黑人民权领袖和同性恋议员的言语攻击,让我更加强化了自己那个某些人是批着羊皮的狼的看法。

三、期望医改逐渐顺利实施并取到不比预期差的效果,法案能逐步得到完善而不是相反。希望政府能着手解决医生护士短缺问题,药品、设备、服务要价过高等问题。美国公司研究制造的药品,美国人民享用却要花高很多的价钱,这恐怕也是美国人民的性命值钱的一种体现吧?世上没有完满的事,这个法案也还差得远。但它是个良好的重要的开端。改革难,因为它不仅颠覆人们固有的观念,还要对社会财富和利益进行重新洗牌,会损害某些人的既得利益。在我看来,这牌早就该洗洗了。

四、奥巴马的民主党在11月的选举中别输太惨。民主党人的民调支持率很低,更低的是共和党人的支持率。可美国眼下就这么两个有些气候的政党,所以在十一月的大选中,执政的民主党要损失些席位,似乎早已经是定论了,这也颇有些讽刺意味啊。1993年,克林顿上台的第一年,也是以reconciliation的方式,也是没有一个共和党议员的支持,通过了平衡预算法案,大幅度地增税。当时反对派也预言了两点,其一,第二年的中期选举民主党将受到重创。其二,增税将会毁了美国经济。第一点是成了现实,这个法案当然是原因之一。至于第二点嘛,小克八年,美国经济可是一片红火。前四年,赤子逐渐减少,后四年盈余逐渐增加。当然有人会嗤之以鼻,那是.com bubble。增税能增出泡沫来倒也很不错。看布什连续多次减税,他的任期内基本上没有增加就业机会。看来共和党人动辙减税的法宝并不管用啊。

五、对法案的法律诉讼尽快驳回。好象这里涉及到州和联邦政府的权力之争,还有那个individual mandate,有人说它违反宪法。其实我看政府并没强迫个人买保险,你可以选择多缴点税(罚款)。你没有保险,就有可能给国家财政造成负担,多缴点税合理得很。难道国家收税也违法?大家现在缴纳的大笔社安税和医疗税,要几十年以后才能可能享受 – 如果它们没破产的话,如果有幸能活那么长的话。这个东西至少还是个现货。

六、失败并不可怕,不丢人。可怕丢人的是非要做个sore loser。那些还在叫嚣选举以后要取消这个法案的反对党领袖们就属于此列。选民们在08选举中选择了奥巴马们。没有法律规定议员们一定要按照民调的结果进行投票吧。法案的通过就是民主过程的产物,所以他们最好认命。先不说取消的可能性微乎其微,即使他们拥有了这个权力基础,如果法律条款比较顺应民心,他们有这个胆量去动它吗?

台前幕后的英雄们

奥总无疑是最大的赢家和英雄,还有他的那个“革命同志”Nancy Pelosi,这个人真不简单。小奥偏左,老南希更左,但他们为了赢得支持愿意放弃某些原则,比如堕胎,这是难得的。这次的斗争,有点象“大脚女人”和 “小脚男人”之间的斗争,就是以Pelosi为首的改革者和诸如John Boehner,Mitch McConnell之类希望开历史倒车的男人之间的争执。

其实共和党人是这次改革法案通过的幕后英雄。他们的坚决反对,在民主党内部引起了强烈反弹。尤其是在那个kill bill的Scott Brown赢得了麻州的选举以后,民主党很是挫败,慌张。奥总接受他的白宫主管的建议,想搞个缩小版的改革,希望共和党人能够参加。刚刚开完庆功会的人们更是铁了心不合作,希望奥巴马们交白卷。俗话说“置之死地而后生”,小奥的最后一博,其实也是被逼上梁山,把所有的政治资本都赌上了,很悬呐。

幕后英雄还有Natoma Canfield。不知道她?Yahoo一下吧。还有Anthem保险公司,就是那个在加州给某些计划涨39%保费的那个,涨得很是时候,就象及时雨一样,简直就是小奥的救命稻草。还有那些尼姑姐妹们。她们在关键时刻站出来,支持这个法案,戳穿有关堕胎的谎言。不知道她们给那些举棋不定的保守民主党议员们带来了多少力量,在政治上又给了他们多少cover?奥巴马们在百忙之余,应该好好谢谢这些英雄!
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作者:xyz1980 留言时间:2012-10-14 12:10:08
美国医疗费高的拫源是因为美国医生通过医生工会限制医生人数, 人为造成医生短缺, 来提高医生工资. 再不允许非处方药。打去charity free care. 任何医疗改革不觧除医生工会对医生人数的控制都是徒劳的.
回复 | 0
作者:寄自美国 留言时间:2010-04-16 07:30:16
谢谢以栋这么快的的回复。

“如果病人自己也出一部分钱,问题就容易解决得多。”我同意这个。医改里头的“individual mandate”也是让大家为自己的医疗保健多少负点责任。

美国的医疗从业人员门槛太高,收费太高,这是大家公认的。麻醉专业的护士,平均年薪就达18万,麻醉师更高达几十万。这个行业的协会把门关得严严的,只让少数精英进入。类似问题,不可能一下全部解决。但医改是朝正确的方向迈出了一小步。政府通过Medicare, Medicaid,和exchnage与保险公司、服务提供者谈判,力求降低成本,减少浪费,希望能至少减缓医疗费用飞涨的速度。如何增加医生护士及其它相关从业人员以应对新增的三千多万顾客,也是这几年要解决的问题之一。
回复 | 0
作者:刘以栋 留言时间:2010-04-15 17:47:12
美国:

谢谢你的回复。

我的意义是,如果病人自己也出一部分钱,问题就容易解决得多。

政府出80%,病人出20%。

引人赤脚医生,没钱看便宜的医生。

告医生分等级,低级医生赔偿也低。

光靠医改,根本不能解决问题。
回复 | 0
作者:寄自美国 留言时间:2010-04-15 14:19:04
以栋,由于某些原因,最近到万维来得少了。我这人管不住自己的手,心里想什么手上不敲出来就不舒服,把不多的几个网友,包括网管,一个个都得罪了。心里想,在这小小万维给海外侨胞们添那堵干啥呀,还是上英文网站骂洋鬼子去吧。写洋博客是没时间精力也没那金刚钻的,发发评论就算了。所以回复晚了,抱歉。

对于你的问题,回复如下。

“1.85岁老人心脏搭桥手术,国家付钱;”
我想这个老人肯定享受MediCare。85岁了还能作心脏搭桥手术,除
了心脏,身体应该还不错。法律确实没规定一个人只能享用MediCare
多少年,过了,要么死去,要么自负。说起老人,美国老人死前半年所花的医疗费用确实惊人,这也是为什么去年医改法案里有建议家属咨询的条款。可话音刚落,反对派就造谣说民主党搞“death panel”,要到医院拔爷爷奶奶的管子。当人们对奥巴马的反对已经成了造谣中伤妖魔化的时候,我这个普通的支持者也不得不弱弱地为他说几句话,并不一定是多么支持他的医改法案。当然我觉得这个东东还是有远胜于无的。

“2。一病人,抽烟,喝酒,吸毒,同性恋,政府出钱治病。”
这个同志哥肯定吃的是“MediCaid”?政府项目,还有慈善事业,都
会有浪费,都有人钻空子,还有不法分子专靠此挣钱。不过,总不能因噎废食,因为有浪费,因为养了懒人,就连需要照顾的人也不管了吧?
我了解你对美国未来的忧虑,知道美国人付出的太少,得到的太多。另
一方面,美国的贫富差距又越来越大,这一方面是市场的因素,另一方
面也是里根布什的税收政策的结果。我想,不会有哪个政客有勇气,或
者是傻气,对95%的美国人说,你们要勒紧裤腰带,那5%的精英才可以
逍遥快活。个人感觉奥巴马还是比较中间、务实的,不那么激进,Tea Party和其它极右人士对他的污蔑,让我很恼火。
回复 | 0
作者:刘以栋 留言时间:2010-04-10 20:50:17
大题目。

一医生告诉我的故事:

1.85岁老人心脏搭桥手术,国家付钱;

2。一病人,抽烟,喝酒,吸毒,同性恋,政府出钱治病。

这些人自己是否应当承担地费用?
回复 | 0
作者:寄自美国 留言时间:2010-04-02 06:35:32
昭君好。我下载那东西也就当个参考书什么,哪有时间和兴趣去读它?

觉得所谓的“exempt”实际上是共和党议员们耍的政治把戏,想让自己“look good”,让对手“look bad”,甚至影响议员们对法案的支持。最后的结果,确实是让人不爽。政治,总是丑陋的。

至于政府职能,增加是肯定的,但幅度可能没有想象的那么大。比如,谁有合格的保险,好象是要求保险公司每年向IRS递报表,就象银行现在递交的Mortgage和存款利息报表类似,网络时代,这些事情还是好对付的。IRS也不会象人们声称的那样会带枪上门收钱。这罚金其实是税,在报税的时候才体现出来。总之,事在人为,如何去施行也是成败的关键之一。

谢谢评论,周末快乐!
回复 | 0
作者:寄自美国 留言时间:2010-04-02 05:58:49
西岸你好。奥巴马上台后的这一揽子计划,确实把不少人吓破了胆。也许民主党在国会拥有如此多数的时候不多,他们想借此机会把很多总统一个世纪以来想办而没办到的事情给折腾出来?你说的“这个东西见效时间太长”,所以再也不能耽误了,这也是紧迫感的来源之一吧。

说起移民问题,也不好弄啊。经济糟糕,失业率居高不下,选民们反移民倾向就越严重;另一边,移民团体又在施压。有些移民领袖说的话已经变得很难听了,他们已经失去耐心了。

我这样的小男人,管个小家,有时还焦头烂额的;治理这么个国家,看起来风光,如果不是超常的人,或者是凡人但不具有“who cares!”的态度,还真干不了。

周末好!
回复 | 0
作者:昭君 留言时间:2010-04-01 19:38:52
Wow, I really admire your devotion to this, Meiguo!! As much as I care about this bill, I never downloaded the whole thing and never really intended to read it in its entirety!

I appreciate your comments, and agree that now that it's "the law of the land", all of us should have a balanced mind to think about what it really means to all of us. Yes, we might also be exempt from it just like the "upper level congressional leaders and their staffers" because we have "better coverage", but I would still be bothered if this is indeed the case.

What worries me the most, is the huge additional expenses on all the governmental functions that will be created to "implement" this whole thing. All the people who have "pre-existing conditions" and "high risk" categories have to be tracked and somehow categorized, everyone has to report (on their tax form, I guess) what kind of insurance they have purchased and if they don't, they'll be tracked down and a fine will be issued. In this sense, I actually would rather have a "single payer" option, because that way you just deal with one new system, and don't have to worry about all these additional layers of bureaucracies.

I agree with Xi An that Obama's timing for this whole thing is kind of off, although I understand why he's so eager to accomplish this before everything else. Now that he has this under his belt, I'm sure he'll turn to other things, such as China-US trade relations (by the way, Pelosi's probably one of the most anti-China, anti-free trade democratic leaders out there), immigration, financial regulation, etc. And he might even win the immigration thing because just like Xi An pointed out, this issue is not as partisan as the health care thing, so he might even be able to make it a case of "bipartisan" effort to reform and change. Although I personally think that's a "can of worm" with all kinds of negative consequences for this country.

Enough for now.
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作者:西岸 留言时间:2010-04-01 15:31:21
这个法案是通过了,但还是有很多遗憾。
首先没有PUBLIC OPTION,等于还是给保险公司漏洞。因为保险公司是私营,有权利在第一时间不卖你保险。

所以这个胜利是个惨胜,甚至加入什么不许联邦经费用于堕胎之类的右翼无聊玩意。

我感觉奥巴马是没有把握住事情的优先权,不应该在上任之后首先折腾医改。这个东西见效时间太长不宜说服社会,加上经济不好政府增加开支不讨好,引起的社会抵触太大,要是克林顿后期折腾就容易的多,无奈这厮关不住裤子拉链,被缠在丑闻里干不了什么。

假如先把战争停下来,行政命令就可以了,就可以有一笔钱用于经济,不管是否有效,给人们的心理上是一剂强心针,会提高支持率。

有一种说法是急慌慌地医改是为了肯尼迪的愿望,毕竟老头子折腾了几十年,想在死前完成夙愿。另外参院占绝对多数,太自信了。

这是白宫行政总管的不合格,使得奥巴马不得不赌上自己的全部政治资本,我对此人不看好。

希望下面的移民问题会弄得好些。折腾移民问题容易给驴党挣分,因为边界四州的共和党参议员过去都是支持移民法案的,如果这次服从“党性”反对,等于自打耳光,中期选举就是把柄。
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作者:寄自美国 留言时间:2010-04-01 09:30:33
Thanks 昭君. Actually I think Politico is quite fair and balanced. So let’s assume there is such a loophole in the bill indeed, which allows the senior staff to keep their current plans if they like them and forces the junior employees to participate in state-created exchange. Here is my personal take on this.
1. The whole idea of this reform is that “if you like your current plan, you can keep it”. In that sense, people like you and me are “exempt” too. It may not be a great idea to just discriminate against the staffers at the bottom. The exchange is set up for the uninsured folks so that they can pool together to buy plans for which they will have to pay higher premiums if they purchase individually. But still, it may not be as good as what the federal employees have now. Unlike the House bill passed last year, this bill doesn’t have a national exchange. That’s one of the reasons I like that House bill better. So the real point of this issue perhaps should be “why a small group of people are not exempt while the others are?”
2. This bill is far from great. And it’s no surprise that some bill drafters will always inject some “bugs” into the mountain of papers – both intentionally and unintentionally. But I think Washington Post said it best in one of its editorials, it’s a risk worth taking. People intend to say “we should not make perfect the enemy of good”. I would tell them we should not make “better” the enemy of good.
3.It’s a reform. So it’s an experiment – and a compromised one. It could fail. But I hope it will succeed. Its success depends on not only the bill itself, but also how to implement them and other factors. Let’s wait and see. Expect the best, prepare for the worst. I know it’s easier said than done.
I have the bill loaded to my laptop after it's passed. I went there to look at page 158. These text is not there. They may be talking some amendments. But anyway, I don't want to spend too much time on it. We have too much contradicting information available and sometimes it's just unrealistic to set the record straight.
I hope I made myself clear. So nice chatting with you.
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作者:昭君 留言时间:2010-04-01 07:21:07
Hi Meiguo:

Thanks for the information. I heard about this from a show at NPR, and the guest was someone who's supposed to give the "facts" about the bill and clarify some "misunderstandings" about it (I forgot her name and title), so I took its face value without doing my own digging. I clearly remembered she distinguished the "lower level staff members" who will be covered by this new plan, and the "upper level leaders and their staff members" who can be exempt. After reading your link, I am still not sure about this because I also saw the following claims. I know it's not from the same "non-partisan" source, but it could be true:

"The bill requires “congressional staff” to buy insurance from the exchanges – with a stipend from the Office of Personnel Management But page 158 of the bill defines “congressional staff” narrowly, as “employees employed by the official office of a member of Congress, whether in the district office or in Washington.”


"The Congressional Research Service believes a court could rule that the legislation "would exclude professional committee staff, joint committee staff, some shared staff, as well as potentially those staff employed by leadership offices.”


"If that’s so, staffers who work for Nancy Pelosi in her capacity as representative from California would go into the exchange program, while staffers who work for her in her capacity as speaker would stay on the government’s plan. Other Capitol employees, like those who work for the clerk of the House or the House historian, would be similarly exempted.


"Reid spokesman Jim Manley acknowledged that the bill exempts committee staff but argued that leadership staff is not excluded. As for why committee staff is excluded, Manley said that when leaders merged the health care bills from the Finance Committee and the Health, Education, Labor and Pensions (HELP) Committee, they took Coburn’s language from the HELP Committee rather than Grassley’s Finance Committee proposal because they feared Grassley’s language was so broad that it would have required “people like legislative counsel, Architect of the Capitol, etc.” to participate in the exchanges, too."



Read more: http://www.politico.com/news/stories/0310/34900.html#ixzz0jrGwUDcD


Read more: http://www.politico.com/news/stories/0310/34900.html#ixzz0jrFZG8xw


Read more: http://www.politico.com/news/stories/0310/34900.html#ixzz0jrFRgsd4
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作者:寄自美国 留言时间:2010-04-01 05:36:47
Hey good morning 昭君. Thanks for your comments. About Congress and the White House being exempt, my first reaction was like, is this an April Fools' Day joke? Then I started to question if I had been wrong and could use a little more Yahoo!. Anyway, here is something I got from factcheck.com, a nonpartisan, nonprofit website. I hope that you found this bit of information creditable and helpful.

Q: Does the health care bill specifically exempt members of Congress and their staffs from its provisions?

A: No. This twisted claim is based on misrepresentations of the House and Senate bills, neither of which exempts lawmakers.

http://www.factcheck.org/2010/01/congress-exempt-from-health-bill/
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作者:昭君 留言时间:2010-03-31 15:43:09
One thing you were right on: Pelosi is indeed a super woman!! Obama owes much of his victory to her will power, diplomatic maneuver and negotiation skill. Using one cliche: 这个女人不简单,呵呵,although I don't agree with a lot of her political ideologies and agenda. The next question is: How will Obama pay her back? Maybe he'll do what she wants him to do for a long time: push her pet project of immigrant reform? To his credit, I think today's announcement about starting drilling on the Mexican coastline is a good move. Maybe he'll be able to achieve what Bush has been trying to do for many years, although the Republicans don't think it's nearly enough.

You know my position on this whole thing so I'm not going to repeat it again. But one thing I don't understand is this: If the reformed insurance program is so good for everyone in the country, then why do the "upper level" congressional leaders and their staff members can be "exempt" and stay with their current insurance program? This also includes the White House staff members and the president himself.
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