“奥巴马医改”真要难保了？,反对它的卫生部长获批上任

据《芝加哥论坛报》2月10日报道，美国参议院对卫生与公共服务部长提名人汤姆&普莱斯（tom price）进行投票表决，结果以52票同意、47票反对的结果涉险通过。

普莱斯的任命是两党围绕前总统奥巴马力推的医改法案的又一次角力，此次投票结果也彰显了参议院内共和党和民主党在此问题上的巨大分歧。目前，参议院中共和党有52人，民主党有48人，这意味着在普莱斯的任命上，当天出席投票的全体民主党员投了反对票，全体共和党员投了赞同票，两极化趋势明显。

“奥巴马医改法案”全称是患者保护与平价医疗法案(patient protection and affordable care act)，由奥巴马在2010年3月签署生效。该法案的受益方主要是处于医保体系之外的低收入群体，然而，医改实施以来，反对声不断。反对者认为医疗成本上升使得许多人的医保支出大幅增加，并引发了中产阶级的不满。

特朗普自竞选以来，一直宣称一旦上任就要废除奥巴马医改法案，同时制定一项新的医改法案进行替代，其上任后签署的第一道行政令就是“叫停” 奥巴马医改法案。

作为掌管医疗卫生领域的最高行政官员，普莱斯将受命改革奥巴马医改法案，但他为何招致参议院民主党的全体反对？

理念之争

民主党反对普莱斯的原因实质上是两党理念之争。在民主党实现奥巴马医保之前，美国医保体制的基本特点，一是劳动所得，二是完全的市场机制，没有政府参与。在这种制度下，美国的绝大部分人口是拥有医保的，可以解决病患之忧。但确实也有大约10% 的人口因为买不起，而没有医保。对于这部分人群，美国政府发挥辅助功能，主要是州政府出台一些政策提供帮助。

奥巴马医改颠覆这种美国式医保，他通过联邦政府的巨额补贴，资助低收入者去市场上买保险，因此被称为“平价”。如果失去这种补贴，价格就会比过去昂贵很多。虽然保留了市场，但其本质与福利派发一样，都是用纳税人的钱，去实现医保的平权化。

在美国，共和党主张小政府、大社会的传统观念，民主党则反之。当力推奥巴马医改法案的民主党认为联邦政府应该主导医疗保障，并染指联邦政府的巨额资金时，共和党人理所当然的一马当先跳出来，坚决反对。

因此，多年以来，共和党人一直想要达成废除奥巴马医改法案的目标， 而普莱斯则一直是该法案的强烈反对者。

普莱斯早在2011年就曾经表示，“医改的目的是提高可得性、支付能力、质量、响应能力和创新，而奥巴马的平价医疗法案做不到任何一点” 。

作为之前对奥巴马医改法案猛烈抨击地回应，此番民主党选择了集体反对。

涉嫌丑闻？

民主党反对的第二个主要原因是针对普莱斯个人的。据《华尔街日报》报道，普莱斯在过去四年中交易了超过30万美元医药类公司股票，并提出和推动了可能影响这些公司股价表现的诸多议案。

2012年以来，普莱斯买入和卖出了大约40家医疗保健、制药和生物医药公司股票，其中在当前国会任期内进行过十几家公司股票的买卖。

而普莱斯是美国众议院筹款委员会的成员之一，隶属掌管医疗保健事务的分委会，该分委会的监管对象就包括联邦医疗保险项目。因此，即便普莱斯没有获得任何内幕消息，他买卖医药股的行为也会让人觉得存在利益冲突，进而削弱公众对他的信任，招致民主党的反对。

具体举措

此外，普莱斯在改革奥巴马医改法案的具体举措上也令民主党不满。

普莱斯对奥巴马医改法案的抨击主要集中在该法案给予联邦政府以及卫生部的权力范围上，认为联邦政府不应该主导医疗保障，这与民主党的主张相反。

另据abc news分析，“个人强制医保”是奥巴马医改法案的核心条款，要求所有个人都必须购买保险，否则将处以罚金。但此条款被以普莱斯为代表的反对派认为是联邦政府过度侵入了个人选择，并将予以改革。

普莱斯还可能主张给予保险公司更大的灵活性，由他们决定是否承保法案中所列的具体条款，如奥巴马医改法案强制要求保险公司必须涵盖避孕项目，普莱斯则可能将拿此条款“开刀”。

改革已经执行了7年的奥巴马医改法案是一个巨大复杂的社会工程，加之民主党的强烈反对，由普莱斯“具体操刀”的改革是否能最终兑现特朗普竞选时的为每个美国人带来能负担得起的、容易获得的医保计划，目前尚难预料。此外，即使是废除奥巴马医改法案，特朗普当局也同样不能回避解决医保覆盖和降低医疗成本这两大政策难题。

奥巴马政府为推行医改做出了哪些举措

奥巴马医改演讲：
Good evening, everybody. Tonight, after nearly 100 years of talk and frustration, after decades of trying, and a year of sustained effort and debate, the United States Congress finally declared that America's workers and America's families and America's small businesses deserve the security of knowing that here, in this country, neither illness nor accident should endanger the dreams they've worked a lifetime to achieve.

各位晚上好。今天晚上，经过近100年的讨论和挫折，经过几十年的尝试以及过去一年来不懈的努力和辩论，美国国会终于宣布，美国的工人、家庭和小企业得到保证，在这个国家，不管是疾病还是意外事故都不会破坏他们为之奋斗一生的梦想。

Tonight, at a time when the pundits said it was no longer possible, we rose above the weight of our politics. We pushed back on the undue influence of special interests. We didn't give in to mistrust or to cynicism or to fear. Instead, we proved that we are still a people capable of doing big things and tackling our biggest challenges. We proved that this government - a government of the people and by the people - still works for the people.

今晚，就在许多批评人士认为不可能的时候，我们超越了政治的力量。我们向特殊利益的不正当压力发起反击，我们并没有向怀疑、恐惧、担忧和冷嘲热讽投降。相反，我们向世人证明，我们仍然是一个能够干大事和解决重大挑战的民族。我们向世人证明，美国政府--一个民有、民治的政府--仍然是一个民享的政府。

I want to thank every member of Congress who stood up tonight with courage and conviction to make health care reform a reality. And I know this wasn't an easy vote for a lot of people. But it was the right vote. I want to thank Speaker Nancy Pelosi for her extraordinary leadership, and Majority Leader Steny Hoyer and Majority Whip Jim Clyburn for their commitment to getting the job done. I want to thank my outstanding Vice President, Joe Biden, and my wonderful Secretary of Health and Human Services, Kathleen Sebelius, for their fantastic work on this issue. I want to thank the many staffers in Congress, and my own incredible staff in the White House, who have worked tirelessly over the past year with Americans of all walks of life to forge a reform package finally worthy of the people we were sent here to serve.

对于今天晚上每一位充满勇气和信念、站出来推动医疗改革成为现实的国会议员，我对他们表示衷心感谢。我知道，这对于许多人来说并不是一次简单的投票，但这是非常正确的决定。感谢众议院议长南希-佩洛西(Nancy Pelosi)的杰出领导；感谢多数党领袖斯特尼-霍耶(Steny Hoyer)和二号人物吉姆-克莱伯恩(Jim Clyburn)为这项工作圆满完成所作的努力；感谢副总统乔-拜登(Joe Biden)和联邦政府卫生与公众服务部部长凯瑟琳-西贝利厄斯(Kathleen Sebelius)为此做出的杰出贡献；感谢国会的工作人员，感谢白宫的工作人员，他们在过去一年不知疲倦地与各行各业的美国人一起努力，最终拟定了一份值得国会进行投票的改革议案。

Today's vote answers the dreams of so many who have fought for this reform. To every unsung American who took the time to sit down and write a letter or type out an e-mail hoping your voice would be heard - it has been heard tonight. To the untold numbers who knocked on doors and made phone calls, who organized and mobilized out of a firm conviction that change in this country comes not from the top down, but from the bottom up - let me reaffirm that conviction: This moment is possible because of you.

今天的投票结果实现了如此多为之奋斗的人的梦想。对于每一位花费时间坐下来写一封信或者电子邮件提出意见或建议的美国人而言，今天晚上我们听到了他们的声音。反对派认为，美国的改革不应是自上而下的，而应该是自下而上的。对于这一点，我想重申：因为大家的努力，此次此刻自上而下的改革是可能的。

Most importantly, today's vote answers the prayers of every American who has hoped deeply for something to be done about a health care system that works for insurance companies, but not for ordinary people. For most Americans, this debate has never been about abstractions, the fight between right and left, Republican and Democrat - it's always been about something far more personal. It's about every American who knows the shock of opening an envelope to see that their premiums just shot up again when times are already tough enough. It's about every parent who knows the desperation of trying to cover a child with a chronic illness only to be told "no" again and again and again. It's about every small business owner forced to choose between insuring employees and staying open for business. They are why we committed ourselves to this cause.

最重要的是，对于每一位深切希望能就医疗体系做出改革以便使其为普通人而非保险公司服务的美国人而言，今天的投票结果使他们的祈祷成真。对于大部分美国人来说，这场辩论从来都不是抽象的，右翼和左翼、共和党和民主党之间的斗争远超过个人层面。医疗改革事关每一个美国人、每一位父母、每一家小企业。

Tonight's vote is not a victory for any one party - it's a victory for them. It's a victory for the American people. And it's a victory for common sense.

今晚的投票结果对任何一个政党、对美国民众以及从情理上说，都是成功的。

Now, it probably goes without saying that tonight's vote will give rise to a frenzy of instant analysis. There will be tallies of Washington winners and losers, predictions about what it means for Democrats and Republicans, for my poll numbers, for my administration. But long after the debate fades away and the prognostication fades away and the dust settles, what will remain standing is not the government-run system some feared, or the status quo that serves the interests of the insurance industry, but a health care system that incorporates ideas from both parties - a system that works better for the American people.

现在，今晚的投票结果可能理所当然地引发大量的即时分析(instant analysis，前美国副总统斯皮罗-阿格纽所创的对电视广播员对总统讲话发表的评论的贬称)。可能存在对华盛顿赢家和输家的评论，以及这一投票结果对民主党和共和党、对我本人和我所领导的政府的支持率意味着什么的预期。不过随着时间流逝，关于这场辩论以及预言都消退之时、当尘埃落定之后，能够留下来的并不是有些人所担忧的政府经营的体系或者有利于保险业的现状，而是包含两党想法的医疗体系，并且该体系能更好地为美国民众服务。

If you have health insurance, this reform just gave you more control by reining in the worst excesses and abuses of the insurance industry with some of the toughest consumer protections this country has ever known - so that you are actually getting what you pay for.

如果你有医疗保险，这一改革能够提高你的控制权，通过利用我们国家最为严格的一些消费者保护措施来控制保险业的暴行，因此你能够获得应得的保险补偿。

If you don't have insurance, this reform gives you a chance to be a part of a big purchasing pool that will give you choice and competition and cheaper prices for insurance. And it includes the largest health care tax cut for working families and small businesses in history - so that if you lose your job and you change jobs, start that new business, you'll finally be able to purchase quality, affordable care and the security and peace of mind that comes with it.

如果你没有医疗保险，该改革能够给你加入医疗保险体系的机会，该体系能够给你提供选择、竞争力以及获得更便宜的保险。而且这一法案包含着有史以来对工薪家庭和小型企业最大的医疗税减税措施，这就是说如果你失业、换工作、刚开始创业的时候，你最终能够买到质量好并且支付的起的保险，这能够给你带来保障和内心的平静。

This reform is the right thing to do for our seniors. It makes Medicare stronger and more solvent, extending its life by almost a decade. And it's the right thing to do for our future. It will reduce our deficit by more than $100 billion over the next decade, and more than $1 trillion in the decade after that.

对于我们国家的老年人来说，我们实行这一改革是正确的事情。该改革后，医疗保险能够更加有力而且更具偿付能力，医疗保险的有效期会延长近10年。而且对于我们的未来而言，实行医改也是正确的事。实行医改的第一个10年，我们的赤字能够减少逾1000亿美元；第二个10年，赤字能够减少逾1万亿美元。

So this isn't radical reform. But it is major reform. This legislation will not fix everything that ails our health care system. But it moves us decisively in the right direction. This is what change looks like.

所以这不是一项激进的改革，但是一项重大改革。医改法案不会解决我们现在医疗系统中的所有问题，但绝对会让我们迈向正确的方向，改革就应该像这样。

Now as momentous as this day is, it's not the end of this journey. On Tuesday, the Senate will take up revisions to this legislation that the House has embraced, and these are revisions that have strengthened this law and removed provisions that had no place in it. Some have predicted another siege of parliamentary maneuvering in order to delay adoption of these improvements. I hope that's not the case. It's time to bring this debate to a close and begin the hard work of implementing this reform properly on behalf of the American people. This year, and in years to come, we have a solemn responsibility to do it right.

和今天同样重要的是，这并不是此次改革的终点。星期二，参议院将对已获众议院通过的医改法案进行修订，加强这一立法并移除一些不必要的规定。有些人预计，国会可能拖延采用修订后的法案。我希望不会如此。现在是结束辩论并开始努力为了美国民众恰当实施这一改革的时候了。今年以及随后几年，我们有一项庄严的责任，那就是正确实行这项改革。

Nor does this day represent the end of the work that faces our country. The work of revitalizing our economy goes on. The work of promoting private sector job creation goes on. The work of putting American families' dreams back within reach goes on. And we march on, with renewed confidence, energized by this victory on their behalf.

今天并不意味着我们国家所面临的工作的结束，促使经济复苏的工作仍将继续，促使私营部门增加就业机会的工作仍将继续，令美国家庭的梦想触手可及的工作仍将继续。而且我们将带着恢复的信心以及此次成功的鼓舞继续前进。

In the end, what this day represents is another stone firmly laid in the foundation of the American Dream. Tonight, we answered the call of history as so many generations of Americans have before us. When faced with crisis, we did not shrink from our challenge - we overcame it. We did not avoid our responsibility - we embraced it. We did not fear our future - we shaped it.

最后，今天意味着美国梦的又一坚实基石。今晚，我们回答了历史的呼唤。当面临危机时，我们没有因为挑战而退缩，而是勇于克服；我们没有回避自己的责任，而是勇于承担；我们没有恐惧未来，而是规划未来。

Thank you, God bless you, and may God bless the United States of America.

谢谢，愿上帝保佑你，愿上帝保佑美国。

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