WHEN Barack Obama signed a sweeping set of health reforms into law on March 23rd 2010, he knew it was a historic moment—and not just because Joe Biden, the vice-president, whispered into his ear that it was a “big fucking deal”. He had successfully ridden the wave of popular support that brought him into office to deliver universal health coverage, a feat that eluded all his predecessors.

　　奥巴马于2010年3月23日签下一系列医改法案时，就算副总统乔·拜登没对他耳语道“这该死的大手笔”，他就已知晓那是历史性的时刻。他借民意支持成功上位以推行全民健康保险，这项功绩可谓前无古人。

　　But the reality of politics has obstructed that grand dream. Republican leaders in Congress are trying to repeal the law outright. Several federal judges have ruled that one of the central provisions of the new reforms, an “individual mandate” requiring everyone to purchase coverage, is unconstitutional. And a recent poll by the Kaiser Family Foundation (KFF), a non-partisan outfit, revealed that hostility to the laws among politically vital independents has shot up sharply. One year on, how fares Mr Obama’s proudest achievement?

　　但政治的现实性使得这一伟大梦想障碍重重。议会中的共和党领导试图彻底废除该法案。联邦法官判定新政策的核心条款为“个人强制医保”，而强制所有人购买保险显然有悖宪法精神。由非党派机构--凯萨家庭基金会近日作出的投票结果显示，政治独立派对新法的敌意与日俱增。一年年以后，奥巴马的得意之作又会有何进展？

　　The chief strategy used by the administration to win over sceptics and to undermine legal challenges is to present the new laws as an unstoppable juggernaut. For example, when Kathleen Sebelius, the secretary of health and human services, spoke about the reform to the Senate Finance Committee on March 16th, she pointed to evidence of an “enormous difference it has made in the lives of Americans”.

　　政府打击怀疑论者或化解法律挑战的首要策略便是将新法案呈现为不可逆挡的强大力量。例如卫生和公共服务部部长凯瑟琳?西贝利厄斯谈及参议员财政委员会于3月16日推行的改革时，指出“其在美国社会中业已产生的巨大影响”这一证词。

　　True, the administration has rushed into force provisions affecting consumers directly, in an effort to win popular support. For example, some forbid insurers from denying coverage to children with pre-existing conditions, or imposing lifetime payout caps on anyone. The new laws also already require insurers to cover children up to 26 on their parents’ policies, which will benefit some 1.2m young people. Nearly 48m people on Medicare, the government health scheme for the elderly, are to get free preventive services such as colonoscopies and mammograms. In 2010 nearly 4m of them got $250 tax-free rebates to help pay for drugs.

　　的确，政府部门试图通过直接影响消费者的有力措施赢得民意支持。如禁止保险公司拒绝为已患病的孩童投保；或是将终身投保强加于人。新法案同样规定，年轻人在26岁以前都可以依靠其父母的保单，这将使约120万的年轻人受益。政府推行的老年医改为约4800万的老年人提供诸如结肠镜、乳腺检测等的免费预防性健康服务。

　　All that seems impressive, but here’s the rub: many Americans do not believe Mrs Sebelius. Roughly half of those polled by KFF thought Obamacare had already been repealed or were unsure of its legal footing. It remains the law of the land.

　　这一切听起来甚是美好，可问题在于：许多美国人并不信任西贝利厄斯女士。凯萨家庭基金会所收集的近一半投票都认为奥式医改方案已被废止或是仍缺失法律基础。这仅是一时之策。

　　The administration is also forging ahead with less visible aspects of the new laws. By 2014, when the bulk of the reform’s provisions kick in, states are required to have put regulated insurance exchanges in place so that consumers can buy plans that meet minimum standards for coverage. All would be required to buy insurance, but the less well-off will get subsidies. The federal government is offering technical assistance as well as money to states to nudge them towards establishing such market-places.

　　政府仍推行着不甚显眼的新法案。大部分条约至2014年生效，届时要求各州建立起规范的保险交流中心，以便投保人根据一己之需购买保险。所有人都必须投保，但会生活水平较低者将被给予补助。联邦政府向各州提供技术及资金的支持，已推动此类市场的建立。

　　Alas, in this too Mr Obama has hit snags. Some Republican-led states, first among them Alaska and Florida, are refusing to take the money, while many others are demanding flexibility in implementing the rules. To the surprise of some, Mr Obama announced at a recent meeting of governors at the White House that he supports a plan—first proposed by Ron Wyden, a sparky Democratic senator—to grant “innovation waivers” starting in 2014. As long as states meet general goals on covering more people and curbing costs, they will be given flexibility in how they set up their local insurance markets.

　　奥巴马同样在此受阻。部分由共和党占主导的州—阿拉斯加至弗罗里达—拒绝接受资助；其他各州或有呼吁政策推行的灵活性。让一些人意外的是，奥巴马在近日的白宫州长会议中声称自己支持由活跃的民主党参议员罗恩·怀登提出的议案—于2014年实行“对创新放宽政策”—只要该州达到使更多人参保并抑制成本的目标，就能拥有如何创建当地保险市场的自主权。

　　That compromise comes only at the point of a gun, however. And Republican attacks on Obamacare will increase as next year’s presidential race gets under way. That points to a second question: can such attacks actually kill the reform? It seems unlikely. While Mr Obama is president, he would veto any such bill. So the legislative path to “repeal and replace”, as conservatives call it, hinges on winning back both the Senate and the White House. But that is far from a certainty, and the short-term strategy of defunding bits of the scheme looks more likely to score points than actually stop the law.

　　不过这种让步完全是屈从暴力的产物。共和党抨击奥式医改会干扰到下届总统大选。这就引出第二个问题：此类抨击会扼杀此改革吗？似乎并非如此。奥巴马在位时可以否决类似提案，那么保守派口中“取缔并取代”的立法途径取决于能否同时拿下参议院和白宫的双方面许可。这并无保障，而从项目撤资的短期计划似乎仅仅是为了讨巧，并不能废止这项法案。

　　The other great hope for enemies of reform is that the Supreme Court will declare that the individual mandate is unconstitutional, and that this will lead directly to the unravelling of the dread laws. This too may prove unsatisfying for conservatives. For one thing, the court may not immediately take up this matter, giving boosters of the laws the chance to dig in their heels. For another, the individual mandate can be replaced with other policies—a mix of carrots and sticks to get punters to buy insurance—that imitate it. So such a ruling would be a political nightmare, but need not be a death blow to reform itself.

　　反对派还寄希望于最高法院对个人强制医保非法化的断言，最高法院的决策将直接瓦解这一令人闹心的法案。同样保守派很难心满自足。首先法院鉴于担心支持者会固执己见，因而不太可能立刻着手此案。另外，个人强制医保极有可能被其他相似的政策取代—软硬兼施，总之让顾客投保。因此，这种裁决必定是政界梦魇，但未必对改革本身造成致命打击。

　　Given all this, what will be the likely long-term impact of Obamacare? Critics say that if the law stays in place, it will destroy employer-provided health coverage. Boosters insist that if it is given a chance to work, it will bring costs down, and not merely extend coverage. Both camps are probably wrong.

　　考虑到这些因素，奥式医改的长远影响是什么呢？批评家认为如果该法案仍持续下去，将会破坏由雇主提供的医疗保险。而支持者坚持如果实行该法案，不仅会扩大保险覆盖率，也能降低投资成本。可能这两个阵营都错了。

　　Republicans have often claimed that employers will scrap corporate insurance, preferring to pay a fine and dump their workers on the subsidised exchanges. That sounds plausible, but two new studies—by the RAND Corporation and the Urban Institute, both non-partisan think-tanks—debunk the argument. In fact, the boffins at RAND calculate that the new reforms could even increase employer-sponsored coverage, as employees confronted with the new mandate clamour for (tax-assisted) coverage from their employers now that they are obliged to have it.

　　共和党通常声称雇主会无视企业保险，宁愿上交罚金并给其工人补贴。这种说法似乎言之有理，但两项由非党派智囊团—兰德公司和城市学院所做的新研究项目提供了反驳。兰德公司的专家预计新的改革措施甚至能增加雇主提供的医疗保险，因为雇员在新政策的条件下有权向雇主争取自己应得的（含税）保险。

　　As for costs, Mr Obama’s reforms deserve praise for expanding coverage, but they do this by adding millions of people to an unsupportably expensive system. Analysts estimate that America’s health spending will continue to soar under the reforms (see chart). That is a point hotly contested by Mr Obama’s team, who usually point to theoretical future efficiency gains and innovations that will save pots of money.

　　说到开支，奥巴马推广保险的改革措施值得称赞，但实施的结果是，上百万人被牵扯进这一无保障的高消费体系中。分析家估计美国医疗卫生支出在改革背景下仍会继续膨胀（如表所示）。这是向来推崇理论收益和创新性的奥式小组强烈抗议的地方。

　　So it came as a shock when Deval Patrick, the governor of Massachusetts and one of Mr Obama’s closest friends, took a different tack. Asked recently about the pioneering health reforms in his state, which served as a model for the national reforms, he first gave a backhanded compliment to Mitt Romney (the state’s former Republican governor, now distancing himself from those reforms as he repackages himself to run for president in 2012). Mr Patrick then revealed the dirty little secret of Obamacare: “What these folks did in Massachusetts is frankly the same thing that the Congress did, which is to take on access first, and come to cost-control next.” In other words, America will soon have no choice but to come to grips with costs. Whatever one thinks of Mr Obama’s reforms, there is no denying that they have brought that day of reckoning closer.

　　因此，当奥巴马的密友，马萨诸塞州州长戴沃·帕特里克转变阵营时人们大跌眼镜。问及州内作为全国模范的开创性医疗改革时，他先是暗含讽刺的恭维了米特·罗姆尼（前州长，共和党人士，现为准备2012的总统选举而回避医改话题），接着透露了奥式医改不光彩的小秘密：“马萨诸塞州和议会做的工作实际大抵相同，先使提案通过，再考虑节省开支。”换言之，美国即将除缩减开支外别无他选。无论别人怎么评价奥式改革，不可否认的是最终盘点日的脚步更近了。