BARACK OBAMAS health reform was supposed to bring universal health coverage toAmerica on January 1st, 2023. It wont. To understand why, consider states such asMississippi.

　　奧巴馬的醫療改革原本預計從2023年1月1日開始實施，大范圍的美國人將享受醫保待遇，但事實上事與愿違。為什么?讓我們以密西西比州為例一探究竟。

　　Terry Brown, a Republican state senator there, stood before his colleagues on June 28th, asthey lounged in summer poplin and seersucker. They had assembled to decide whetherMississippi would expand Medicaid, the public health program for the poor, as Obamacareurges. That day Mississippi said it would not. I dont want Mississippi to be a part of that trainwreck, said Mr Brown.

　　泰瑞布朗，是一名共和黨議員，6月28日那天他帶領他的同僚聚在一起，商討密西西比是否要擴大醫保范圍。此舉，用奧巴馬的話講，是惠及廣大貧困群眾的公共醫療項目。但當天密西西比就表示不會實施新醫保。我不想密西西比受到新醫保的牽連而蒙受損失布朗說。

　　Obamacare aims to extend insurance to the poor in two main ways, both starting in 2023.First, it required states to offer Medicaid to all those with incomes of up to 138% of thefederal poverty level, or $15,856 for an individual. The federal government and the states usuallyshare the cost of Medicaid. But Obamacare would pay for the expansion through 2023, withthe feds share falling to 90% in 2023.

　　奧巴馬的醫療改革，旨在從2023年開始使醫保覆蓋到廣大貧困群眾，主要通過兩項政策實現。政策一，對于收入不高于聯邦貧困線38%的人員，或者個人收入不高于15,856美金的人員，州政府需要為他們提供醫保。聯邦政府和州政府一般共同提供醫保資金，但是奧巴馬的醫保普及政策是2023年之前聯邦政府會支付新醫保的費用，2023年支付90%的費用，其余由州政府承擔。

　　Second, individuals would be able to shop for insurance on new state-based markets, calledhealth exchanges. Those with incomes between 100% and 400% of the federal poverty levelwould qualify for federal subsidies.

　　政策二，今后個人可從州政府主導的醫療保險交易所購買保險。個人收入在聯邦貧困標準及其4倍之間的人群才有資格申請聯邦補貼。

　　Neither provision is going as planned. Last year the Supreme Court made the Medicaidexpansion optional. At least 21 states say they will opt out. Even more are refusing to setup their own exchanges, leaving the task to federal bureaucrats.

　　不管是以上哪條新政，估計都要擱淺了。去年最高法院宣布此次醫療普及政策并非強制執行。至少有21個州宣布他們不會參與其中。甚至多數拒絕建立各自的醫療保險交易所，將這一難題留給聯邦政府處理。

　　Mississippi would seem the ideal place to cover more poor people. It is Americas pooreststate and has the shortest life expectancy. Its current Medicaid programme is amongAmericas least generous. Mississippians devote an unusually large share of their income tohealth care . One resident in five is uninsured.

　　作為美國最貧窮以及居民壽命最短的州，密西西比看上去是此次醫療改革的理想試點。它現有的醫保計劃位列全美最不惠民的政策之一，盡管出人意外地，它的大部分政府收入用于醫保支出，，但兩成居民都不能享受醫保。

　　But Obamacares main provisions have gone nowhere in the Magnolia State. The fight overthe Medicaid expansion involved hair-raising brinkmanship. Had lawmakers not votedbefore July 1st, the states entire Medicaid programme would have stopped functioning.Republicans insisted an expansion was unaffordable. State Medicaid costs would haveincreased by 7% from 2023 to 2023, estimates the Urban Institute, a think-tank. That ismuch less than the expected 30% increase in Medicaid subsidies from the centralgovernment. But the 7% rise would have been bigger than in any other state, mostly becauseMississippis current Medicaid programme is so skimpy.

　　但是奧巴馬的醫療保障政策在馬格諾利亞州卻悄無聲息。為了抵抗醫保普及政策，反對者不惜鋌而走險。要不是立法機關7月1日前沒有進行投票表決，不然馬格諾利亞的全部醫保計劃都將暫停。共和黨人堅稱州政府根本支付不起醫保普及政策。據智囊團城市研究所預估，若新醫保從2023年開始實施，密西西比州政府因此承擔的醫保資金到2023年要增加7%。而中央政府的醫保補貼預計要增加三成。而其他州的的資金投入增幅遠遠不及7%，主要是因為密西西比目前的基數太小了。

　　The fight over the states exchanges was equally bareknuckle. Mississippis electedinsurance commissioner wanted a state-based exchange. The Republican governor, PhilBryant, wanted nothing to do with Obamacare. After a messy spat, plans for a stateexchange dissolved. By default, Mississippi will have a federally facilitated exchange,managed by the health secretarys deputies. So far only two insurers have made bids to sellhealth plans on it. Residents of 42 counties will have a choice of only one subsidised plan; 36counties will have none. And many poor Mississippians will be ineligible for Medicaid.

　　對于另一條醫保交易政策，反對的聲音同樣激烈堅決。在密西西比，推舉出的醫保代理機構希望醫保交易所是由州政府主導的。但是州長費勒布萊恩特是共和黨人，不想參與奧巴馬的新醫保。經過一番舌戰，政府主導的醫保交易計劃也擱淺了。大家心照不宣，密西西比的醫保交易所將由聯邦政府輔助引導，由衛生部的副秘書長們管理。至此只有兩家保險公司競價參與醫保計劃。42個郡的居民將可以選擇性的享受一項醫療補貼計劃，也是唯一的一項;另外36個郡將不參與。另外還有許多人將無權享受醫保。

　　Stansel Harvey is the boss of the Delta Regional Medical Centre, in the heart of old cottoncountry. The Mississippi Delta contains some of Americas poorest counties. About 10% of MrHarveys patients fail to pay their bills. The insurance expansion would have made many ofthem paying customers. Crucially, that new revenue would have helped offset anotherObamacare change: lower payment rates to hospitals. Without new insurance revenue, MrHarvey reckons that he may need to cut services. If other hospitals follow suit, Mississippianswill have a problem. In the age of Obamacare, they may have less access to health care, notmore.

　　斯坦索爾哈雷，是位于科頓郡中心的德爾塔醫療中心的老板。很多美國最窮的郡就位于密西西比河三角洲。在哈雷的醫療中心看病的病人中，大約一成都無法支付醫療費用。醫保普及后他們中的許多人將看得起病。重要的是，因此受益的醫院收入將增加，這將抵消奧巴馬醫改帶來的另外一個變化：醫院的繳費率將下降。如果沒有新醫保帶來的增收，哈雷說他可能不得不關門大吉。如果其他的醫院也紛紛歇業，密西西比將面臨一個新問題。奧巴馬醫改之下，盡管醫保覆蓋范圍廣了，但是人民可以看病的地方也少了。

　　BARACK OBAMAS health reform was supposed to bring universal health coverage toAmerica on January 1st, 2023. It wont. To understand why, consider states such asMississippi.

　　奧巴馬的醫療改革原本預計從2023年1月1日開始實施，大范圍的美國人將享受醫保待遇，但事實上事與愿違。為什么?讓我們以密西西比州為例一探究竟。

　　Terry Brown, a Republican state senator there, stood before his colleagues on June 28th, asthey lounged in summer poplin and seersucker. They had assembled to decide whetherMississippi would expand Medicaid, the public health program for the poor, as Obamacareurges. That day Mississippi said it would not. I dont want Mississippi to be a part of that trainwreck, said Mr Brown.

　　泰瑞布朗，是一名共和黨議員，6月28日那天他帶領他的同僚聚在一起，商討密西西比是否要擴大醫保范圍。此舉，用奧巴馬的話講，是惠及廣大貧困群眾的公共醫療項目。但當天密西西比就表示不會實施新醫保。我不想密西西比受到新醫保的牽連而蒙受損失布朗說。

　　Obamacare aims to extend insurance to the poor in two main ways, both starting in 2023.First, it required states to offer Medicaid to all those with incomes of up to 138% of thefederal poverty level, or $15,856 for an individual. The federal government and the states usuallyshare the cost of Medicaid. But Obamacare would pay for the expansion through 2023, withthe feds share falling to 90% in 2023.

　　奧巴馬的醫療改革，旨在從2023年開始使醫保覆蓋到廣大貧困群眾，主要通過兩項政策實現。政策一，對于收入不高于聯邦貧困線38%的人員，或者個人收入不高于15,856美金的人員，州政府需要為他們提供醫保。聯邦政府和州政府一般共同提供醫保資金，但是奧巴馬的醫保普及政策是2023年之前聯邦政府會支付新醫保的費用，2023年支付90%的費用，其余由州政府承擔。

　　Second, individuals would be able to shop for insurance on new state-based markets, calledhealth exchanges. Those with incomes between 100% and 400% of the federal poverty levelwould qualify for federal subsidies.

　　政策二，今后個人可從州政府主導的醫療保險交易所購買保險。個人收入在聯邦貧困標準及其4倍之間的人群才有資格申請聯邦補貼。

　　Neither provision is going as planned. Last year the Supreme Court made the Medicaidexpansion optional. At least 21 states say they will opt out. Even more are refusing to setup their own exchanges, leaving the task to federal bureaucrats.

　　不管是以上哪條新政，估計都要擱淺了。去年最高法院宣布此次醫療普及政策并非強制執行。至少有21個州宣布他們不會參與其中。甚至多數拒絕建立各自的醫療保險交易所，將這一難題留給聯邦政府處理。

　　Mississippi would seem the ideal place to cover more poor people. It is Americas pooreststate and has the shortest life expectancy. Its current Medicaid programme is amongAmericas least generous. Mississippians devote an unusually large share of their income tohealth care . One resident in five is uninsured.

　　作為美國最貧窮以及居民壽命最短的州，密西西比看上去是此次醫療改革的理想試點。它現有的醫保計劃位列全美最不惠民的政策之一，盡管出人意外地，它的大部分政府收入用于醫保支出，，但兩成居民都不能享受醫保。

　　But Obamacares main provisions have gone nowhere in the Magnolia State. The fight overthe Medicaid expansion involved hair-raising brinkmanship. Had lawmakers not votedbefore July 1st, the states entire Medicaid programme would have stopped functioning.Republicans insisted an expansion was unaffordable. State Medicaid costs would haveincreased by 7% from 2023 to 2023, estimates the Urban Institute, a think-tank. That ismuch less than the expected 30% increase in Medicaid subsidies from the centralgovernment. But the 7% rise would have been bigger than in any other state, mostly becauseMississippis current Medicaid programme is so skimpy.

　　但是奧巴馬的醫療保障政策在馬格諾利亞州卻悄無聲息。為了抵抗醫保普及政策，反對者不惜鋌而走險。要不是立法機關7月1日前沒有進行投票表決，不然馬格諾利亞的全部醫保計劃都將暫停。共和黨人堅稱州政府根本支付不起醫保普及政策。據智囊團城市研究所預估，若新醫保從2023年開始實施，密西西比州政府因此承擔的醫保資金到2023年要增加7%。而中央政府的醫保補貼預計要增加三成。而其他州的的資金投入增幅遠遠不及7%，主要是因為密西西比目前的基數太小了。

　　The fight over the states exchanges was equally bareknuckle. Mississippis electedinsurance commissioner wanted a state-based exchange. The Republican governor, PhilBryant, wanted nothing to do with Obamacare. After a messy spat, plans for a stateexchange dissolved. By default, Mississippi will have a federally facilitated exchange,managed by the health secretarys deputies. So far only two insurers have made bids to sellhealth plans on it. Residents of 42 counties will have a choice of only one subsidised plan; 36counties will have none. And many poor Mississippians will be ineligible for Medicaid.

　　對于另一條醫保交易政策，反對的聲音同樣激烈堅決。在密西西比，推舉出的醫保代理機構希望醫保交易所是由州政府主導的。但是州長費勒布萊恩特是共和黨人，不想參與奧巴馬的新醫保。經過一番舌戰，政府主導的醫保交易計劃也擱淺了。大家心照不宣，密西西比的醫保交易所將由聯邦政府輔助引導，由衛生部的副秘書長們管理。至此只有兩家保險公司競價參與醫保計劃。42個郡的居民將可以選擇性的享受一項醫療補貼計劃，也是唯一的一項;另外36個郡將不參與。另外還有許多人將無權享受醫保。

　　Stansel Harvey is the boss of the Delta Regional Medical Centre, in the heart of old cottoncountry. The Mississippi Delta contains some of Americas poorest counties. About 10% of MrHarveys patients fail to pay their bills. The insurance expansion would have made many ofthem paying customers. Crucially, that new revenue would have helped offset anotherObamacare change: lower payment rates to hospitals. Without new insurance revenue, MrHarvey reckons that he may need to cut services. If other hospitals follow suit, Mississippianswill have a problem. In the age of Obamacare, they may have less access to health care, notmore.

　　斯坦索爾哈雷，是位于科頓郡中心的德爾塔醫療中心的老板。很多美國最窮的郡就位于密西西比河三角洲。在哈雷的醫療中心看病的病人中，大約一成都無法支付醫療費用。醫保普及后他們中的許多人將看得起病。重要的是，因此受益的醫院收入將增加，這將抵消奧巴馬醫改帶來的另外一個變化：醫院的繳費率將下降。如果沒有新醫保帶來的增收，哈雷說他可能不得不關門大吉。如果其他的醫院也紛紛歇業，密西西比將面臨一個新問題。奧巴馬醫改之下，盡管醫保覆蓋范圍廣了，但是人民可以看病的地方也少了。