誰從在美國引起公憤的醫療賬單中獲利？——正是那些應該解決問題的人
Who’s Profiting From Your Outrageous Medical Bills?
The same people who should be fixing them.
原文：The New York Times https://tinyurl.com/qmcmy2p
譯文：觀察者
https://www.guancha.cn/ElisabethRosenthal/2020_03_02_539315.shtml
作者：Elisabeth Rosenthal
Every politician condemns the phenomenon of “surprise” medical bills. This
week, two committees in the House are marking up new surprise billing
legislation. One of the few policy proposals President Trump brought up in
this year’s State of the Union address was his 2019 executive order
targeting them. In the Democratic debates, candidates have railed against
such medical bills, and during commercial breaks, back-to-back ads from
groups representing doctors and insurers proclaimed how much the health care
sector also abhors this uniquely American form of patient extortion.
在美國，幾乎每一位政治人物都在譴責一種現象——“意料之外”的醫療賬單（
"surprise" medical bills）。川普總統在今年的國情咨文講話中提到的為數不多的政策
建議內容，就包括他在2019年針對這個問題下達的行政令。此外，國會的兩個委員會本週
就這個問題展開了新一輪討論；在民主黨的競選辯論會上，參選人均對醫療賬單問題進行
了猛烈批評。即便代表醫生和保險公司利益的團體也在一個又一個的電視廣告中，表示醫
療行業同樣對這種勒索患者的美國獨有的現象相當厭惡。
Patients, of course, hate surprise bills most of all. Typical scenarios: A
patient having a heart attack is taken by ambulance to the nearest hospital
and gets hit with a bill of over $100,000 because that hospital wasn’t in
his insurance network. A patient selects an in-network provider for a minor
procedure, like a colonoscopy, only to be billed thousands for the
out-of-network anesthesiologist and pathologist who participated.
當然，最痛恨這種意外醫療賬單的莫過於患者本人了。關於這種賬單，我在這裡描述一個
很典型的情況：一位有心臟病的患者被急救車送往最近的醫院搶救，患者在搶救成功後收
到了醫院開出的一張10萬美元的高額賬單，他的心臟受到了更大的打擊，因為那家醫院沒
有進入這位患者所購買的醫療保險的報銷目錄。在美國，一個人為了一個簡單的結腸鏡檢
查一般會選擇去一家被列入報銷目錄的醫院，可是如果負責檢查的醫生沒有進入保險公司
的報銷目錄的話，他還是會收到一張數千美元的醫療賬單。
And yet, no one with authority in Washington has done much of anything about
it.
而且，截至目前沒有任何一個華盛頓的當權者曾做出過什麼努力來改變這一現狀。
Here’s why: Major sectors of the health industry have helped to invent this
toxic phenomenon, and none of them want to solve it if it means their
particular income stream takes a hit. And they have allies in the capital.
原因如下：醫療行業的幾大主要參與方促成了這一醜陋現象的出現，如果解決這一問題意
味著自身利益受損，那麼他們是不會有意願促成問題的解決的。此外，他們在華盛頓也有
自己的盟友。
That explains why President Trump’s executive order, issued last year, hasn’
t resulted in real change. Why bipartisan congressional legislation supported
by both the House Energy and Commerce Committee and the Senate Health
Committee to shield Americans from surprise medical bills has gone nowhere.
And why surprise billing provisions were left out of the end-of-year spending
bill in December, which did include major tax relief for many parts of the
health care industry.
這就是川普總統去年下達的行政令最終毫無結果的真正原因。由眾議院能源和商務委員會
、參議院健康委員會就解決意外醫療賬單問題共同推動的跨越兩黨的國會立法工作，為何
一直停滯不前呢？意外醫療賬單問題被排除在去年12月通過的《支出法案》之外，而對諸
多醫療產業進行減稅的條款卻被涵蓋其中，這又是什麼原因呢？
Surprise bills are just the latest weapons in a decades-long war between the
players in the health care industry over who gets to keep the fortunes
generated each year from patient illness — $3.6 trillion in 2018.
以2018年為例，美國社會每年的醫療費用總支出約為3.6萬億美元。在已經延續了數十年
的醫療產業從業者瓜分患者財富的大戰中，意外醫療賬單正在成為最新式的武器。
Here’s how they came to be:
下面我介紹一下這個問題的來龍去脈。
Forty years ago, when many insurers were nonprofit entities and being a
doctor wasn’t seen as a particularly good entree into the 1 percent, billed
rates were far lower than they are today, and insurers mostly just paid them.
Premiums were low or paid by an employer. Patients paid little or nothing in
co-payments or deductibles.
40年前，當時的美國醫療保險還不以營利為目的，從醫還不是進入1%高收入階層的一條捷
徑。那時候美國的醫療費用比今天低得多，幾乎都可以通過醫療保險獲得報銷，而且保險
費用也不高，僱主大多會給員工購買這項保險。當時共付額和扣除額（co-payments and
deductibles，這裡指美國醫療保險計畫中需患者自費負擔的部分——觀察者網注）的比
例極低，或者患者根本不必負擔此類費用。就在這時，逐利的商業思維開始滲透進入美國
的醫療體系。
That’s when a more entrepreneurial streak kicked in. Think about the
opportunities: If someone is paying you whatever you ask, why not ask for
more?
其實這很容易理解，如果無論你要多少錢人們都乖乖付款，那麼為何不多要一點呢？
Commercial insurers as well as Blue Cross Blue Shield Plans, some of which
had converted to for-profit status by 2000, began to push back on escalating
fees from providers, demanding discounts.
一些商業保險公司以及藍十字與藍盾協會（Blue Cross Blue Shield，由藍十字藍盾醫保
聯合會和39家獨立經營的藍十字藍盾地區醫保公司組成，是美國歷史最悠久、規模最大、
知名度最高的專業醫療保險服務機構——觀察者網注）在2000年時已經開始帶有一定的營
利色彩，他們開始對醫療費用上漲進行抵制並要求醫療機構給賬單打折。
Hospitals and doctors argued about who got to keep different streams of
revenue they were paid. Doctors began to form their own companies and built
their own outpatient surgery centers to capture payments for themselves.
在另一方面，醫院和醫生們也開始就治療收入的分配比例發生爭執。隨後，醫生們為了與
醫院搶奪醫療市場，開始設立屬於自己的公司並開設自己的門診手術中心。
So today your hospital and doctor and insurer — all claiming to coordinate
care for your health — are often in a three-way competition for your money.
在今天的美國，聲稱協調一致共同關愛患者健康的醫院、醫生和保險公司，實際上為了你
口袋裡的錢經常處於一種三方競爭的局面。
As the battle for revenue has heated up, each side has added new weapons to
capture more: Hospitals added facility fees and infusion charges. Insurers
levied ever-rising co-payments and deductibles. Most important they limited
the networks of providers to those that would accept the rates they were
willing to pay.
隨著各方對患者手中金錢的爭奪日趨白熱化，他們各自都拿出了新的招數：醫院加收了醫
療設施使用費和注射費；保險公司一直在上調共付額和扣除額的比例，其中最為關鍵的一
點是，保險公司僅僅把那些收費較低的醫院和醫生納入自己的報銷目錄。
Surprise bills are the latest tactic: When providers decided that an insurer’
s contracted payment offerings were too meager, they stopped participating in
the insurer’s network; either they walked away or the insurer left them out.
In some cases, physicians decided not to participate in any networks at all.
That way, they could charge whatever they wanted when they got involved in
patient care and bill the patient directly. For their part, insurers didn’t
really care if those practitioners demanding more money left.
不過，當醫院或醫生覺得保險公司在與自己簽署的合同中確定的醫療服務收費價格過低時
，他們會拒絕進入保險公司的報銷目錄，有時候是醫院或醫生主動拒絕，有時候是保險公
司把這樣的醫院或醫生排除在外不予考慮。有時候，一些醫生甚至會拒絕進入任何一家保
險公司的報銷目錄。在這種情況下，他們可以直接向患者收取自己確定的治療費用。然而
只要還有一些比離開報銷目錄的醫生收費更高的醫生留在報銷目錄裡，保險公司就不會太
過在意。
And, for a time, all sides were basically fine with this arrangement.
曾有一段時間，各方對這一局面基本都可以接受。
But as the scope and the scale of surprise bills has grown in the past five
years, more people have experienced these costly, unpleasant surprises. With
accumulating bad publicity, they have became impossible to ignore. It was
hard to defend a patient stuck with over $500,000 in surprise bills for 14
weeks of dialysis. Or the $10,000 bill from the out-of-network pediatrician
who tends to newborns in intensive care. How about the counties where no
ambulance companies participate in insurance, so every ambulance ride costs
hundreds or even thousands of dollars?
在過去5年裡，意外醫療賬單現象的規模和波及範圍越來越大，受其影響的人越來越多，
它對社會造成的惡劣影響已經累積到了難以忽視的程度。一位腎透析14周的患者收到一張
50萬美元的賬單不值得大驚小怪，一位沒進入任何保險公司報銷目錄的對新生兒進行重症
監護的醫生收費1萬美元也不足為奇。在美國的一些地方，當地的急救車公司沒有與任何
保險公司進行合作，使用一次急救車花費數百甚至數千美元都是非常正常的。
These practices are an obvious outrage. But no one in the health care sector
wants to unilaterally make the type of big concessions that would change
them. Insurers want to pay a fixed rate. Doctors and hospitals prefer what
they call “baseball- style arbitration,” where a reasonable charge is
determined by mediation. Both camps have lined up sympathetic politicians for
their point of view.
很顯然，上述現象已經引發了公憤。但無論醫院、醫生還是保險公司都不願單方面做出妥
協。保險公司希望按照固定比例進行報銷，而醫院和醫生們則傾向於通過仲裁來確定一個
合理的價格。雙方都有支持自己陣營的政治勢力。
So, nothing has changed at the federal level, even though it’s hard to
imagine another issue for which there is such widespread consensus.
Two-thirds of Americans say they are worried about being able to afford an
unexpected medical bill — more than any other household expense. Nearly
eight in 10 Americans say they want federal legislation to protect patients
against surprise bills.
雖然在美國已經很難找到一個能凝聚如此廣泛共識的問題，但在聯邦層面上來說，還沒有
任何進展。有三分之二的美國人表示令自己最為擔心的一項家庭支出是意料之外的醫療賬
單，其他任何家庭支出都沒有讓美國人如此憂慮過。有80%接受問卷調查的美國人認為應
該通過聯邦立法來防止意外高額賬單損害患者的權益。
States are passing their own surprise billing laws, though they lack power
since much of insurance is regulated at a national level.
目前各州正在針對這一現象進行立法，但它們實際上並沒有足夠的力量來解決這個問題，
因為涉及保險的很多監管措施都是在聯邦層面執行的。
Now members of Congress have yet another chance to tackle this obvious
injustice. Will they listen to hospitals, doctors, insurers? Or, in this
election year, will they finally heed their voter-patients?
國會議員們為美國人伸張正義的時候到了。他們會接受醫院、醫生和保險公司的說法嗎？
在這個大選年，他們最終會傾聽選民的聲音嗎？