聚焦关怀而非仅覆盖范围；经济学家主张更宏大的解决方案

你好。

Hi there.

我是迈尔斯·帕克斯。

It's Miles Parks.

好的。

Okay.

我知道今天是周日，但简单说下，我们确实需要谈谈上周二的事。

I know it's Sunday, but real quick, we do have to talk about last Tuesday.

本周是'捐赠星期二'活动，现在支持《Consider This》节目和你喜爱的所有NPR内容还为时不晚。

It was Giving Tuesday this week, and it's not too late to support Consider This and everything you love from NPR.

对NPR来说这是不同寻常的艰难一年，因为从10月1日起联邦对公共媒体的资助已被取消。

This was a difficult year unlike any other for NPR because federal funding for public media was eliminated as of October 1.

这意味着NPR历史上首次在没有联邦支持的情况下运作。

That means NPR is now operating without federal support for the first time in our history.

但NPR对您的承诺从未改变。

But NPR's commitment to you has not changed.

在《考虑一下》节目中，我们将继续为您深入剖析当天的重大新闻事件及其对您的影响。

Here at consider this, we're gonna keep bringing you a deep dive into one of the day's major news stories and what it means for you.

但我们需要您的帮助来实现这一目标，我们非常感谢每一位已经慷慨解囊的听众。

But we need your help to do it, and we are so grateful for everyone who has already stepped up to give.

比如蒙大拿州的凯瑟琳说，我绝对热爱NPR和他们制作的每一个播客。

Like Catherine in Montana who says, I absolutely adore NPR and every podcast they produce.

我每天都会收听《晨间速递》和《考虑一下》节目。

I listen to Up First and consider this every day.

感谢你所做的一切。

Thank you for all you do.

谢谢，凯瑟琳。

Thanks, Catherine.

如果你已经捐赠或是NPR Plus的会员，也感谢你。

And thank you if you've already made your gift or if you're an NPR Plus supporter.

如果还没有，今天就加入吧。

If not, sign up today.

支持公共媒体，获取NPR播客的专属福利，包括《Consider This》的额外剧集。

Support public media and get perks to NPR's podcasts, including bonus episodes of Consider This.

请访问+.npr.org注册。

Sign up at +.npr.org.

如果国会不延长《平价医疗法案》的补贴，数百万美国人可能会在新的一年面临医疗保险费用飙升。

Millions of Americans could see their health insurance premiums skyrocket in the new year if congress doesn't extend subsidies to the affordable care act.

这项资金的争议是今年秋季政府停摆的核心问题。

The debate over that funding was at the heart of the government shutdown this fall.

保持政府运转的最后期限已经过去。

The deadline has passed to keep the government open.

联邦探员数百万

Federal agents Millions

美国人现在面临更高的医疗保险费用。

of Americans now face higher health insurance costs.

政府停摆的实质是一场关于医疗保健的辩论。

Of the government shutdown is a debate about health care.

他们是否继续提供服务，并希望日后从医疗保险中获得补偿？

Do they continue offering services and hope to recoup payments from Medicare later?

一群参议院民主党人已转变立场，同意与共和党达成协议以结束政府停摆。

A group of senate Democrats have defected to agree to a deal with Republicans to end the government shutdown.

最终，政府确实重新开放了，条件是国会承诺在年底前就这些补贴进行投票表决。

Eventually, the government did reopen with the promise that congress would hold a vote on those subsidies by the end of the year.

问题在于，到目前为止，两院对于延期方案的具体形式尚未达成共识。

The problem is, so far, there is no consensus in either chamber on what an extension might look like.

我们正在努力向参议院领袖图恩和约翰逊提交一项计划，我认为该计划可获得60票支持，这将赋予美国人民选择权，他们可以选择较低的保费和健康储蓄账户。

We're working to deliver to speaker leader Thune and speaker Johnson a plan which I think could get 60 votes, which gives the American people the power, and they can choose a lower premium and an HSA.

我们正在推进此事，我可能会在今晚通过电子邮件向他们发送一份文件。

We're working on that, and I'll give them a piece of paper probably by email tonight.

这是共和党参议员比尔·卡西迪在福克斯新闻上谈论共和党医保计划时的发言。

That's Republican senator Bill Cassidy speaking about a Republican health care plan on Fox News.

民主党人也提出了自己的方案，希望将补贴政策延长三年。

Democrats proposed their own idea as well, hoping to just extend the subsidies for three years.

一个由两党参议员组成的小组提出了一项计划，拟将税收抵免延长两年，但附带一些限制条件。

And a bipartisan group of senators offered up a plan that would extend the tax credit for two years with some limitations.

但经济学家克雷格·加思韦特希望美国在医疗保健问题上能有更宏大的构想。

But economist Craig Garthwaite, he wants The US to think bigger when it comes to health care.

作为经济学家，看着这场争论令人沮丧——他们讨论补贴到期与否会改变医疗成本。

It's a frustrating thing, I think, for economists as we watch this debate where, you know, they're saying if the subsidies expire or they don't, it'll change the cost of healthcare.

这并非事实。

That's not true.

真正改变的只是支付主体。

All that's going to change is who pays for it.

是由联邦政府支付，还是由个人承担？

Does the federal government pay for it or do individuals pay for it?

虽然这个问题很重要，但并未触及我们真正关心的核心：我们在医疗上的总支出是多少？人们实际获得的医疗服务与支出是否匹配？

And while that's an important question, it doesn't get what I think we do care about, which is how much are we spending on healthcare overall and how much care are people actually getting for the money that we're spending?

试想：如果医疗的真实成本下降，更多人就能获得医疗服务。

Consider this, If the true cost of health care goes down, more people get access.

多项解决方案可能就摆在我们眼前，既能提高医疗效率，又能扩大可负担性。

And several solutions to make health care both more efficient and more affordable at scale could be right in front of us.

我是NPR新闻的迈尔斯·帕克斯。

From NPR News, I'm Miles Parks.

我是艾拉·格拉斯。

This is Ira Glass.

在本期《美国生活》节目中，我们将讲述关于人生转折的故事——比如大卫的人生突然遭遇意外且痛苦的剧变。

On This American Life, we tell stories about when things change, like for this guy David, whose entire life took a sharp, unexpected, and very unpleasant turn.

我确实花了不少时间才想明白，根本原因就是猴子按下了按钮。

And it did take me a while to realize that it's basically because the monkey pressed the button.

没错。

That's right.

就因为猴子按下了按钮。

Because the monkey pressed the button.

每周都有意想不到的故事，欢迎在任意播客平台收听。

Surprising stories every week wherever you get your podcasts.

狼类研究员杰夫·里德专门制作了录音设备，试图解读黄石公园狼群之间的交流内容。

Wolf researcher Jeff Reed built special recorders to try to understand what the wolves of Yellowstone Park are saying to each other.

当你初次听到这些狼群合唱时，它们听起来就像荒野中的鸡尾酒派对。

When you first start hearing these chorus howls, they kinda sound like a cocktail party in the wild.

关于自然语言翻译的构想。

Ideas about translating nature.

请在NPR应用或任意播客平台收听TED广播时间节目。

Listen to the TED Radio Hour on the NPR app or wherever you get your podcasts.

你关心世界正在发生的事。

You care about what's happening in the world.

通过NPR《世界现状》播客保持资讯畅通。

Stay informed with NPR's State of the World podcast.

短短几分钟内，我们将带你聆听全球故事。

In just a few minutes, we take you to stories around the globe.

你可能会听到世界冲突的最新进展，或是全球事件对你咖啡价格的影响。

You might hear the latest developments in world conflicts or about what global events mean for the price of your coffee.

请收听NPR的《世界现状》播客。

Listen to the State of the World podcast from NPR.

这里是NPR的《Consider This》节目。

It's Consider This from NPR.

我是迈尔斯·帕克斯。

I'm Miles Parks.

阿斯彭经济战略集团的新研究《Coverage Is In An Abundance Agenda for Medicaid》指出，既能提高效率又能降低成本的医疗解决方案已经存在，应该加以推广。

New research from the Aspen Economic Strategy Group, Coverage Is In An Abundance Agenda for Medicaid, argues that solutions to make health care both more efficient and more affordable already exist, and they should be expanded.

克雷格·加思韦特是西北大学凯洛格管理学院医疗项目的主任，也是该研究的作者之一。

Craig Garthwaite is the director of the program on health care at Northwestern University's Kellogg School of Management and one of the authors of the study.

他现在加入我们的节目。

He joins me now.

欢迎。

Welcome.

你好。

Hi.

感谢邀请我。

Thanks for having me.

嗯。

Yeah.

感谢你的到来。

Thanks for being here.

所以你的论文提出了一份路线图，旨在对美国医疗体系进行结构性改革，使医疗更加经济实惠。

So your paper says it offers a road map for structural reforms to America's health care system that would make health care more affordable.

这些建议中的第一条是放宽对在其他国家接受培训的医生的限制。

The first of these recommendations is to ease restrictions on doctors who have been trained in other countries.

你能解释一下这将如何运作吗？

Can you explain how that would work?

是的。

Yeah.

我的意思是，这个想法是我们要增加能够提供医疗服务的人员供应，如果有更多人专门为了治疗美国低收入群体而来，这将提供更多就医机会，并有望降低成本。

I mean, the idea would be that we want to increase the supply of people who can provide medical services with if we have more people who are intentionally coming here with the goal of treating low income Americans, it'll provide more access and ideally lower costs.

有一批现成的人才，他们毕业于国外信誉良好的正规医学院校，可以来到这里。我们可以开发一些项目，规定：只要你来美国并被允许在这里行医，就必须主要专注于服务低收入群体，特别是那些参加医疗补助计划的患者——这是我们国家为低收入和残障人士设立的保险计划。

There is a readily available set of people who have graduated from reputable credentialed medical schools abroad who could come here and we could develop programs that say, will, in exchange for you coming to The United States and being allowed to work here as a physician, you have to primarily concentrate on targeting low income particularly patients who are on Medicaid, which is our nation's insurance program for the low income and the disabled.

我想问的是，是否存在这样的风险：接受这种医疗覆盖的人群中，低收入者与高收入者获得的医疗服务会有所不同？

Is there any risk, I guess, in terms of people who receive this coverage, you know, having the care being different for people who are lower income versus higher income?

首先要认识到的是，在美国，我们早已为不同收入群体提供了不同级别的医疗服务或不同的医疗场所。

The first thing to recognize is we already have different levels of care or different sites of care for people who are lower income or higher income in The United States.

低收入人群通常去专门为他们服务的诊所就诊。

Lower income individuals are often going to clinics that concentrate on them.

绝大多数参加医疗补助计划的患者都在主要服务低收入人群的医疗机构接受治疗。

The vast majority of individuals on Medicaid are treated in facilities that primarily concentrate on low income individuals.

因此我们要做的是承认这一现实，并提供最高效的医疗获取途径——因为低收入美国人面临的最大问题或许不是获得的医疗水平不同，而是根本找不到医疗服务。

And so we want to do is recognize that reality and provide the most efficient way to get people access to care with the idea being that perhaps the biggest problem that low income Americans face is not that they get a different level of care, it's that they're unable to find care at all.

这项研究还提到通过允许执业护士和医师助理独立行医来扩大医疗服务提供者队伍。

So this study also mentions the idea of expanding the pool of providers by allowing nurse practitioners and physician assistants to practice independently.

你能再详细解释一下这部分内容吗？

Can you explain that bit of it a little bit more?

是的。

Yeah.

我们有一批现成的医疗从业者，这些中级从业者受过高级培训。

So we we have a ready made set of providers, these mid level providers who have advanced training.

他们并非传统意义上的医生，没有医学博士学位，但接受了大量高级培训。

They are not doctors in the sense that they have an MD or a DO degree, but they've gone through a lot of advanced training.

大量初级护理研究表明，他们能为患者提供卓越的医疗服务。

And for a lot of primary care research has shown that they provide exceptional care for individuals.

此外，他们的医疗成本更低，可以更便捷地部署在整个医疗体系中。

In addition, they are a lower cost input that could be more readily deployed across the healthcare ecosystem.

患者通常能与中级从业者交流的时间比医生更长。

You can often spend more time with a mid level provider than you can with a doctor.

对于初级护理而言，我认为这往往是患者真正需要的。

And for primary care, I think that's often what people want.

患者希望能够坐下来与医生详细讨论他们担忧的问题。

They want to be able to sit down and talk to a doctor about the things that are concerning them.

因此，这可以再次扩充医疗保健人员队伍。

And so this can again, augment the healthcare workforce.

我们看到在已经参与并被称为基于价值医疗的实践中，中级医疗提供者得到了广泛应用。

We we see a lot of use of mid level providers among practices that are already engaged and we refer to as value based care.

对吧？

Right?

但那些试图通过让人们更健康来赚更多钱的医疗机构。

But practices that are trying to, you know, make more money by making people healthier.

我们认为这在医疗补助和低收入人群中确实有其用武之地。

And we think that there's a real place for that in the Medicaid and low income population.

我能广泛地问一下这些变化吗？

Can I ask broadly about these changes?

我是说，其中一些变化有多激进？

I mean, how radical are some of these changes?

或者说是否已经有现成的方法或杠杆可以让其中一些变化更容易实施？

Or are there ways or levers in place already to allow for some of these changes to more easily be applied?

从许多方面来看，特别是在外国培训医生和中级医疗提供者的理念上，我们已经拥有各类项目的经验，这些项目有不同的住院医师要求，或我们称之为中级医疗提供者的执业范围法律，这些法律规定了他们可以独立进行多大程度的处方行为。

In many ways, certainly on the idea of foreign trained doctors and mid level providers, we already have experience with various kinds of programs that have different residency requirements or different what we refer to as scope of practice laws for the mid level provider kind of dictating how much prescribing behavior might they have independently.

所以我们实际上是在讨论扩展现有的一系列工具，但真正将其针对那些我们明确知道存在更多医疗需求的人群。

So we're really talking about expanding sort of an existing set of tools, but really targeting it on a population where we know there is an identifiable need for more access to care.

我认为这正是我和蒂姆（Tim Layton，这篇论文的合著者）开始这项研究的地方，也就是论文标题所表达的'覆盖不等于关怀'。

And I think that's where Tim and I, Tim Layton is my coauthor on this, where we started with this, which is the title of the paper, which is Coverage Isn't Care.

有太多讨论，太多我们将在国会进行的辩论，在未来两周都将围绕保险覆盖展开，这很好，但它是获得医疗服务的必要条件而非充分条件。

There's so much discussion, so much of the debate we're gonna have in Congress over the next two weeks is gonna be about insurance coverage, which is good, but it's a necessary, but not sufficient condition for getting access to healthcare.

我们希望看到辩论更多地聚焦于实际让人们获得医疗服务的因素。

And I think we'd like to see the debate focus more on what actually gets people care.

这必须是一个供给侧对话，我们需要思考谁在提供医疗服务，而不仅仅是经济学家所说的需求侧对话——即谁在支付医疗费用。

And that has to be a supply side conversation where we think about who's providing the care and not just what economists refer to as the demand side of conversation, which is who's paying for the care.

我不想表现得愤世嫉俗。

I don't wanna be cynical.

我讨厌在这里扮演愤世嫉俗的角色，但我想知道，当你审视国会当前的格局时，他们采纳这些建议的现实性有多大？相比他们现在正在谈判的对现有系统的小修小补而言？

I hate being the cynical voice here, but I guess when you look at the the current landscape in congress, how realistic is it that they would take on some of these things as opposed to the sort of tweaks that they're negotiating to the current system right now?

嗯，你是在跟一个经济学家说话，没人能比我更愤世嫉俗了。

Well, you're talking to an economist, you can't be more cynical than I am.

我想我已经几乎完全丧失了对国会能做好政府工作并通过法律的信心。

I think I've I've lost almost all faith in the idea that congress will do good government and pass laws anymore.

不过好在这里讨论的许多措施实际上可以在州一级实现。

The nice thing about this though is that a number of the things that we're talking about here can actually be accomplished at the state level.

需要认识到的是，虽然医疗补助计划由州和联邦政府共同出资，但它是由州政府管理的。

We have seen state governments be more active, but Medicaid, it's important to recognize is a program that while it's jointly funded by the state and the federal government, it is administered at the state level.

通过豁免权和其他程序，州医疗补助机构实际上可以获得Isn't Care。

And through waivers and other processes, state Medicaid agencies actually can obtain a lot of flexibility to implement these.

我认为这正是美国的可贵之处。

And I actually think that's a wonderful thing about America.

这正是我们建国先贤对这个国家的设想——让各州进行各种尝试。

It's what we thought about, The founders thought about for the country is let's let all these states experiment.

正如我们常说的，它们成为了民主的实验室。

They become, as we often refer to, as the laboratories of democracy.

在这里，它们可以成为低收入覆盖的实验场，找出为美国低收入人群提供真正医疗保障的最佳方式。

Here, they can be the laboratories of low income coverage and figure out what's the best way to provide true access to health care for low income Americans.

我觉得你的论文触及了一个观点，即医疗补助最初并未覆盖数千万人。

I feel like your paper touches on this idea that Medicaid didn't start out covering many tens of millions of people.

它最初并非为此设计，而我们却阴差阳错走到了这一步。

It wasn't really designed initially that way and that we've kind of ended up there.

你能为不了解这段历史的人解释一下吗？

Can you explain that for people who don't know the history of this thing?

好的。

Yeah.

医疗补助计划源于1965年'伟大社会'计划。

So Medicaid comes out of the great society programs in 1965.

它最初设计为针对极端贫困者、残疾人、寡妇和孤儿的极小规模计划。

It is intended as a very small program for the very, very poor and disabled and widows and orphans.

即使追溯到1990年也是如此，对吧？

Even if you go to 1990, right?

所以现在，我们谈论的只是35年前的情况。

So now now we're only talking thirty five years ago.

当时只有2000万美国人参与该计划。

There were only 20,000,000 Americans that were on the program.

而到了去年，参与该计划的美国人已接近8000万。

If we go to last year, there were nearly 80,000,000 Americans on the program.

它涵盖了儿童群体。

It includes kids.

也包括养老院的老年人。

It includes seniors in nursing homes.

美国近半数新生儿都包含在内。

It includes half of all births in The United States.

因此这个计划已演变成某种笨重的体系，其最初设计根本未考虑到当前所覆盖患者群体的规模和范围。

And so it has become this sort of unwieldy program that was never designed for the size and the scope of the patient population that it's currently covering.

这其实也是《平价医疗法案》面临的类似问题——这个庞然大物同时承载着太多不同的功能？

I mean, that a similar problem to the Affordable Care Act more broadly, too, in that it is this kind of massive thing that is doing a lot of different things?

我想我只是好奇，这两者之间有相似之处吗？

I guess I'm just wondering, are there parallels there?

既是也不是。

Yes and no.

我认为《平价医疗法案》附加了许多内容。

I think the Affordable Care Act has a bunch of things attached to it.

我们应该注意到《平价医疗法案》中与此相关的一个部分是它大幅增加了医疗补助计划。

One part of the ACA we should note that is relevant here is it involved a very large increase in Medicaid.

所以很多人能享受医疗补助计划，其中一个原因就是《平价医疗法案》。

So one of the reasons that a lot people are on Medicaid is because of the ACA.

关于《平价医疗法案》的保险交易所——这将是国会辩论的焦点——你知道，那主要是向人们提供相对标准化的保险产品。

On the ACA insurance exchanges, which is the debate that's going to happen in Congress, You know, that primarily is just providing a relatively standard insurance product to people.

我要指出的是，那里的大部分辩论并不是关于医疗保健的成本。

And most of the debate I will note there is not about the cost of health care.

实际上只是关于由谁来支付费用。

It's really just about who pays for it.

你的论文基本上是在论证，如果我们解决一些更广泛的问题，实际的医疗成本可能会下降。

And your paper basically is arguing like if we fix some of the broader issues here, then the actual cost of health care could go down.

是的。

Yes.

如果实际的医疗成本下降，我们就能更高效地为更多人提供医疗服务。

And if the actual cost of health care goes down, we can provide care to far more people more efficiently.

而这正是我们最终追求的目标。

And that's ultimately what we want.

作为一个社会，我们希望人们能够获得他们所需的医疗保健。

We as a society want people to get access to the healthcare they need.

我们应该专注于以最具成本效益的方式提供这种服务。

And we should focus on providing that in the most cost efficient manner.

这位是西北大学凯洛格管理学院的克雷格·加思韦特。

That's Craig Garthwaite of Northwestern University's Kellogg School of Management.

非常感谢你接受我们的采访。

Thanks so much for talking with us.

谢谢邀请。

Thank you for having me.

本期节目由艾弗里·基特利、杰弗里·皮埃尔和亨利·拉尔森制作。

This episode was produced by Avery Keatley, Jeffrey Pierre, and Henry Larson.

由莎拉·罗宾斯编辑。

It was edited by Sarah Robbins.

我们的执行制作人是萨米·耶尼根。

Our executive producer is Sammy Yenigan.

这里是NPR的《Consider This》节目。

It's Consider This from NPR.

我是迈尔斯·帕克斯。

I'm Miles Parks.

抽时间了解新闻很重要。

Making time for the news is important.

但当你需要放松时，我们NPR的音乐播客《All Songs Considered》会为你提供精彩内容。

But when you need a break, we've got you covered on All Songs Considered, NPR's music podcast.

把它想象成一档音乐探索节目，一次与朋友共度的应得逃离，没错，还有深刻的音乐见解。

Think of it like a music discovery show, a well deserved escape with friends, and, yeah, some serious music insight.

我实话实说。

I'm a keep it real.

我完全不知道这个故事讲什么。

I have no idea what the story is about.

每周二，无论您在哪里收听播客，都能获取《All Songs Considered》的新节目。

Here are new episodes of All Songs Considered every Tuesday wherever you get podcasts.

NPR播客《特朗普条款》为您提供关于特朗普政府重大新闻的当日最新动态。

NPR's podcast Trump's Terms is your source for same day updates on big news about the Trump administration.

简短而专注的节目，每次聚焦一个主题，时长约五分钟。

Short, focused episodes, one topic at a time, about five minutes or so.

我们汇集NPR所有报道内容，确保您始终获取最重要、最紧迫的新闻故事。

We carry out reporting from across all of NPR's coverage, so you are always getting the biggest, most urgent stories.

请在NPR应用程序或您常用的播客平台收听《特朗普条款》。

Listen to Trump's terms on the NPR app or wherever you get your podcasts.

拉丁音乐从未如此盛大，但在拉丁裔群体中它一直都很重要。

Latin music has never been bigger, but it's always been big on all Latino.

十五年来，我们持续通过音乐的视角庆祝拉丁文化，跨越边界传递精华。

Fifteen years in, we continue celebrating Latinidad through a music lens, transcending borders through primo.

深入了解来自拉丁文化的艺术家们，并将一些新的拉丁音乐佳作加入你的播放列表。

Get to know artists from La Cultura on a deeper level, and throw some new Latin music wrecks into your rotation.

在NPR应用或任何你获取播客的地方收听《Alt Latino》。

Listen to Alt Latino in the NPR app or wherever you get your podcasts.