谁从在美国引起公愤的医疗账单中获利？——正是那些应该解决问题的人
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
译文：观察者
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.
在美国，几乎每一位政治人物都在谴责一种现象——“意料之外”的医疗账单（
"surprise" medical bills）。川普总统在今年的国情咨文讲话中提到的为数不多的政策
建议内容，就包括他在2019年针对这个问题下达的行政令。此外，国会的两个委员会本周
就这个问题展开了新一轮讨论；在民主党的竞选辩论会上，参选人均对医疗账单问题进行
了猛烈批评。即便代表医生和保险公司利益的团体也在一个又一个的电视广告中，表示医
疗行业同样对这种勒索患者的美国独有的现象相当厌恶。
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.
当然，最痛恨这种意外医疗账单的莫过于患者本人了。关于这种账单，我在这里描述一个
很典型的情况：一位有心脏病的患者被急救车送往最近的医院抢救，患者在抢救成功后收
到了医院开出的一张10万美元的高额账单，他的心脏受到了更大的打击，因为那家医院没
有进入这位患者所购买的医疗保险的报销目录。在美国，一个人为了一个简单的结肠镜检
查一般会选择去一家被列入报销目录的医院，可是如果负责检查的医生没有进入保险公司
的报销目录的话，他还是会收到一张数千美元的医疗账单。
And yet, no one with authority in Washington has done much of anything about
it.
而且，截至目前没有任何一个华盛顿的当权者曾做出过什么努力来改变这一现状。
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：医疗行业的几大主要参与方促成了这一丑陋现象的出现，如果解决这一问题意
味着自身利益受损，那么他们是不会有意愿促成问题的解决的。此外，他们在华盛顿也有
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.
这就是川普总统去年下达的行政令最终毫无结果的真正原因。由众议院能源和商务委员会
、参议院健康委员会就解决意外医疗账单问题共同推动的跨越两党的国会立法工作，为何
一直停滞不前呢？意外医疗账单问题被排除在去年12月通过的《支出法案》之外，而对诸
多医疗产业进行减税的条款却被涵盖其中，这又是什么原因呢？
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年为例，美国社会每年的医疗费用总支出约为3.6万亿美元。在已经延续了数十年
的医疗产业从业者瓜分患者财富的大战中，意外医疗账单正在成为最新式的武器。
Here’s how they came to be:
下面我介绍一下这个问题的来龙去脉。
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，当时的美国医疗保险还不以营利为目的，从医还不是进入1%高收入阶层的一条捷
径。那时候美国的医疗费用比今天低得多，几乎都可以通过医疗保险获得报销，而且保险
费用也不高，雇主大多会给员工购买这项保险。当时共付额和扣除额（co-payments and
deductibles，这里指美国医疗保险计画中需患者自费负担的部分——观察者网注）的比
例极低，或者患者根本不必负担此类费用。就在这时，逐利的商业思维开始渗透进入美国
的医疗体系。
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?
其实这很容易理解，如果无论你要多少钱人们都乖乖付款，那么为何不多要一点呢？
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.
一些商业保险公司以及蓝十字与蓝盾协会（Blue Cross Blue Shield，由蓝十字蓝盾医保
联合会和39家独立经营的蓝十字蓝盾地区医保公司组成，是美国历史最悠久、规模最大、
知名度最高的专业医疗保险服务机构——观察者网注）在2000年时已经开始带有一定的营
利色彩，他们开始对医疗费用上涨进行抵制并要求医疗机构给账单打折。
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，医院和医生们也开始就治疗收入的分配比例发生争执。随后，医生们为了与
医院抢夺医疗市场，开始设立属于自己的公司并开设自己的门诊手术中心。
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.
在今天的美国，声称协调一致共同关爱患者健康的医院、医生和保险公司，实际上为了你
口袋里的钱经常处于一种三方竞争的局面。
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.
随着各方对患者手中金钱的争夺日趋白热化，他们各自都拿出了新的招数：医院加收了医
疗设施使用费和注射费；保险公司一直在上调共付额和扣除额的比例，其中最为关键的一
点是，保险公司仅仅把那些收费较低的医院和医生纳入自己的报销目录。
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.
不过，当医院或医生觉得保险公司在与自己签署的合同中确定的医疗服务收费价格过低时
，他们会拒绝进入保险公司的报销目录，有时候是医院或医生主动拒绝，有时候是保险公
司把这样的医院或医生排除在外不予考虑。有时候，一些医生甚至会拒绝进入任何一家保
险公司的报销目录。在这种情况下，他们可以直接向患者收取自己确定的治疗费用。然而
只要还有一些比离开报销目录的医生收费更高的医生留在报销目录里，保险公司就不会太
过在意。
And, for a time, all sides were basically fine with this arrangement.
曾有一段时间，各方对这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?
在过去5年里，意外医疗账单现象的规模和波及范围越来越大，受其影响的人越来越多，
它对社会造成的恶劣影响已经累积到了难以忽视的程度。一位肾透析14周的患者收到一张
50万美元的账单不值得大惊小怪，一位没进入任何保险公司报销目录的对新生儿进行重症
监护的医生收费1万美元也不足为奇。在美国的一些地方，当地的急救车公司没有与任何
保险公司进行合作，使用一次急救车花费数百甚至数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.
很显然，上述现象已经引发了公愤。但无论医院、医生还是保险公司都不愿单方面做出妥
协。保险公司希望按照固定比例进行报销，而医院和医生们则倾向于通过仲裁来确定一个
合理的价格。双方都有支持自己阵营的政治势力。
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.
虽然在美国已经很难找到一个能凝聚如此广泛共识的问题，但在联邦层面上来说，还没有
任何进展。有三分之二的美国人表示令自己最为担心的一项家庭支出是意料之外的医疗账
单，其他任何家庭支出都没有让美国人如此忧虑过。有80%接受问卷调查的美国人认为应
该通过联邦立法来防止意外高额账单损害患者的权益。
States are passing their own surprise billing laws, though they lack power
since much of insurance is regulated at a national level.
目前各州正在针对这一现象进行立法，但它们实际上并没有足够的力量来解决这个问题，
因为涉及保险的很多监管措施都是在联邦层面执行的。
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?
国会议员们为美国人伸张正义的时候到了。他们会接受医院、医生和保险公司的说法吗？
在这个大选年，他们最终会倾听选民的声音吗？