American health care is remarkably diverse. In terms of how care is paid for and delivered, many of us effectively live in Canada, some live in Switzerland, some live in Britain, and some live in the unregulated market of conservative dreams. One result of this diversity is that we have plenty of home-grown evidence about what works and what doesn’t.
美國的健保系統最引人注目的地方莫過於其多樣性，以繳費及提供的服務來看，很多人其實是住在加拿大，有些是在瑞士，有的則是在英國，還有些人則是住在保守派夢想中沒有任何管制的市場。這些各式各樣的種類產生的成果，就是有了大量自家證據證明哪些管用，哪些沒用。
Naturally, then, politicians — Republicans in particular — are determined to scrap what works and promote what doesn’t. And that brings me to Mitt Romney’s latest really bad idea, unveiled on Veterans Day: to partially privatize the Veterans Health Administration (V.H.A.).
於是很自然的，有政客──尤其是共和黨人毅然而然的要把可行的健保服務作廢，同時大聲宣揚行不通的健保服務。這讓我想到羅尼最近在退伍軍人節披露的壞主意，說要把部分退伍軍人健康管理局(V.H.A.)民營化。
What Mr. Romney and everyone else should know is that the V.H.A. is a huge policy success story, which offers important lessons for future health reform.
羅尼先生和所有人都該了解，退伍軍人健康管理局是空前成功的政策，也給未來健保改革帶來貴重的啟示。
Many people still have an image of veterans’ health care based on the terrible state of the system two decades ago. Under the Clinton administration, however, the V.H.A. was overhauled, and achieved a remarkable combination of rising quality and successful cost control. Multiple surveys have found the V.H.A. providing better care than most Americans receive, even as the agency has held cost increases well below those facing Medicare and private insurers. Furthermore, the V.H.A. has led the way in cost-saving innovation, especially the use of electronic medical records.
很多人對退伍軍人健康管理局的印象還停在二十年前糟糕透頂的情況，然而在柯林頓主政時期，整個退伍軍人健康管理局已經大幅改造，成了提高品質與費用控制的耀眼組合。許多調查表明退伍軍人健康管理局提供的健保服務，比大多數美國人所擁有的還好，而且支出控制得宜，費用低於聯邦醫療保險(Medicare)以及民營保險。此外退伍軍人健康管理局在節省支出的創舉上算是領頭羊，特別像是使用電子醫療紀錄。
What’s behind this success? Crucially, the V.H.A. is an integrated system, which provides health care as well as paying for it. So it’s free from the perverse incentives created when doctors and hospitals profit from expensive tests and procedures, whether or not those procedures actually make medical sense. And because V.H.A. patients are in it for the long term, the agency has a stronger incentive to invest in prevention than private insurers, many of whose customers move on after a few years.
成功背後的原因是什麼？關鍵在於退伍軍人健康管理局是個綜合系統，同時提供健保及給付健保費，因此可以免除一些不良誘因，如醫生和醫院可以從昂貴的實驗與療程來獲利，不管這些療程是不是真的有醫學意義。而且相較於民營保險的顧客沒幾年就不續保了，退伍軍人健康管理局的病人都是長期保險，所以有更強的誘因去注重疾病預防。
And yes, this is “socialized medicine” — although some private systems, like Kaiser Permanente, share many of the V.H.A.’s virtues. But it works — and suggests what it will take to solve the troubles of U.S. health care more broadly.
沒錯，這是公費醫療系統，雖說有些民營系統如Kaiser Permanente也有許多退伍軍人健康管理局的優點，但這系統真的管用，同時在解決美國健保的問題上給了更廣泛的解答。
Yet Mr. Romney believes that giving veterans vouchers to spend on private insurance would somehow yield better results. Why?
不過羅尼先生深信，給退伍軍人可以用在民營保險的憑單會更好。為什麼呢？
Well, Republicans have a thing about vouchers. Earlier this year Representative Paul Ryan famously introduced a plan to convert Medicare into a voucher system; Mr. Romney’s Medicare proposal follows similar lines. The claim, always, is the one Mr. Romney made last week, that “private sector competition” would lower costs.
這個嘛，共和黨人對憑單特別感興趣。今年稍早眾議員萊恩引人注目的引進一套把聯邦醫療保險轉換為憑單制度的方案，而現在羅尼的聯邦醫療保險提案內容也是老生常談。羅尼先生上個星期發布聲明，又是千篇一律的說「民營企業競爭」會降低成本。
But we have a lot of evidence about how private-sector competition in health insurance works, and it’s not favorable. The individual insurance market, which comes closest to the conservative ideal of free competition, has huge administrative costs and has no demonstrated ability to reduce other costs. Medicare Advantage, which allows Medicare beneficiaries to buy private insurance instead of having Medicare pay bills directly, has consistently had higher costs than the traditional program.
可是我們已經有很多證據說明健保讓民營企業競爭的結果，而且這結果不太好看。如最接近保守派自由競爭理念的個人健康保險市場，不僅付出了龐大的行政成本，也沒顯示出其他降低成本的能力。像聯邦醫療保險優惠計畫(Medicare Advantage)允許聯邦醫療保險的受益人可以購買民營保險，代替直接付費給聯邦醫療保險，可是這項方案的成本持續攀高，還超過原本方案。
And the international evidence accords with U.S. experience. The most efficient health care systems are integrated systems like the V.H.A.; next best are single-payer systems like Medicare; the more privatized the system, the worse it performs.
國際上的證據也與美國經驗一致。最有效率的健保系統是綜合式系統如退伍軍人健康管理局，次佳的是單一付費者系統如聯邦醫療保險。系統越民營化，表現得越差。
To be fair to Mr. Romney, he takes a somewhat softer line than others in his party, suggesting that the existing V.H.A. system would remain available and that traditional Medicare would remain an option. In practice, however, partial privatization would almost surely undermine the public side of these programs. For example, one problem with the V.H.A. is that its hospitals are spread too thinly across the nation; this problem would become worse if a substantial number of veterans were encouraged to opt out of the system.
不過要幫羅尼先生說句公道話，他比起其他同黨人士說詞較為溫和，建議現存的退伍軍人健康管理局系統可以持續，傳統的聯邦醫療保險也可以列為選項。然而實際上，部分民營化最終一定會侵蝕公營部分的基礎。舉例來說，退伍軍人健康管理局的其中一個問題是全國有支援的醫院太少，如果鼓勵許多退伍軍人離開這體系，問題會很快惡化。
So what lies behind the Republican obsession with privatization and voucherization? Ideology, of course. It’s literally a fundamental article of faith in the G.O.P. that the private sector is always better than the government, and no amount of evidence can shake that credo.
所以共和黨熱情追求民營化與證券化的原因為何呢？當然是意識形態作祟。共和黨的基本信念就是民間企業一定好過政府，無論多少證據都不能撼動其信條。
In fact, it’s hard to avoid the sense that Republicans are especially eager to dismantle government programs that act as living demonstrations that their ideology is wrong. Bloated military budgets don’t bother them much — Mr. Romney has pledged to reverse President Obama’s defense cuts, despite the fact that no such cuts have actually taken place. But successful programs like veterans’ health, Social Security and Medicare are in the crosshairs.
事實上很難避免共和黨去廢除這些政府方案，因為這些方案就像是他們信念錯誤的活證明。對他們來說膨大的軍事預算無所謂，羅尼先生還誓言要推翻歐巴馬總統的國防預算縮編案，儘管根本就沒有要刪減，然而卻把準心瞄準成功的方案如退伍軍人健保、社福制度、聯邦醫療保險。
Which brings me to a final thought: maybe all this amounts to a case for Rick Perry. Any Republican would, if elected president, set out to undermine precisely those government programs that work best. But Mr. Perry might not remember which programs he was supposed to destroy.
我最後的想法如下，也許這一切只是為了要給培里(譯註：共和黨籍德州州長)一個機會。只要共和黨選上總統，一定會開始暗地破壞那些運作良好的政府方案，不過屆時培里先生可能早忘了他該破壞哪些方案了。
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