【英语社会】奥巴马医改正步入歧途

The Obama administration had hoped that this month's town hall meetings would smooth the way for healthcare reform. Things do not seem to be working out that way. Across the country, loud and furious protesters have turned up. They accuse the White House of wishing, among other things, to bankrupt the nation, destroy the American way of life and bring in “death panels” to mitigate the excessive healthcare demands of the elderly.

Unruly protest makes good television and is especially welcome in a slow month for news. The protesters have been dominating US newspapers and news programmes in recent days.

It is all a little misleading. Many who are sceptical about the Democrats' plans have asked intelligent questions. But this is too dull for prime-time, and before you know it, intelligent questions bog you down in complex details. Better to make the protests the story.

Rowdy demonstrations are not what the administration wanted, but in a way they have played into its hands. They have shifted the focus from the reform measures to the unreasoning anger of the least appealing opponents. In three town hall meetings the president conducted last week, he decided to attack his attackers. The idea that he ran for office “to go around pulling the plug on grandma”, as he put it, is “simply dishonest”.

“Dishonest” is putting it politely – but the point is that reasonable people will agree with him about that. And the views of reasonable people will matter much more to the fate of health reform than the protesters would lead you to think.

The gap between the right of the Republican party, which is providing the angriest critics of the reforms, and the left of the Democratic party, which thinks the proposals too timid, is unbridgeable. These groups do not merely disagree. They despise each other. Their differences are only secondarily about policy. They hold each other's values in contempt.

These snarling extremes are nonetheless somewhat alike. They have an equal and opposite penchant for conspiracy theories. Almost a third of Republicans, according to a recent poll, believe the unsupported story that Mr Obama was not born in the US (in which case he would be disqualified from serving as president). But remember that more than a third of Democrats subscribe to the even more outlandish theory that the Bush administration knew about the attacks of September 2001 in advance.

These factions are incapable of intelligent conversation with each other, or indeed with anybody else. But the important thing to remember is that the political significance of the cultural jihadists is smaller than the noise they generate. They will not decide the issue.

Mr Obama's health proposals are not in trouble because conservative Republicans oppose them. Conservative Republicans were always going to oppose them. They are in trouble because moderate Republicans oppose them, and even more because many moderate Democrats also have doubts.

Mr Obama has to persuade centrists – the voters who elected him president – to support health reform. It is as simple as that. If he brings moderates and independents on board, reform will succeed. If he fails, the effort will either be abandoned or, more likely, the plans will be watered down.

The town hall protesters, with their “death panel” hysterics and posters depicting Mr Obama with a Hitler moustache, may help push centrists back to the Obama camp. If not, they should. So far, though, Mr Obama's lamentable salesmanship has pushed harder the other way. Hindered no doubt by the fact that there is still no finished plan to sell, he has failed to come up with a plausible line to put to the country.

He continues to insist, as he has from the beginning, that control of costs is the principal reason for embarking on reform – more important, even, than achieving universal coverage. Once, this seemed to make strategic sense, because the great majority of US citizens have health insurance and are happy with it. To appeal to this majority, Mr Obama argued that health insurance, both public and private, would soon become unaffordable unless healthcare inflation was brought under control.

Fine – until the independent Congressional Budget Office examined the Democrats' plans and found that they all added substantially to long-term costs. The CBO's estimates attacked the core of Mr Obama's case and they especially rattled moderate Democrats. Yet the line from the White House never deviated. This entire exercise, the administration blithely repeated, is about controlling costs. Can anyone be surprised that moderates are having doubts?

It would have been better to accept from the start that the reform would cost a lot and that universal coverage, with particular emphasis on a guarantee of continued coverage for those currently insured, was worth paying for. But the promise not to raise taxes except on the rich foreclosed that approach. Instead, the plans all aim to cover costs with big savings on Medicare, the public programme for the elderly – and many Medicare recipients doubt the assurance that their services will not worsen as a result.

The battle is by no means lost, but Mr Obama needs to rethink his approach. His mistake all along was to promise nearly all Americans something for nothing. The sensible, pragmatic, Obama-supporting centre of the country looks askance at that, and it is right to.

奥巴马(Obama)政府本希望，本月的市政厅会议将为医疗改革铺平道路。然而，事情并不像预想的那样。在全美范围内，愤怒的抗议者纷纷涌现。他们给白宫安上了一系列罪名，其中包括：希望让国家破产，破坏美国人的生活方式，以及引入“死亡专家组”(Death Panels)以减少老年人过度的医疗需求。

难以控制的抗议活动成为很好的电视题材，在这个新闻寡淡的月份里，这些抗议活动尤其受到欢迎。最近几日，抗议活动成了美国报纸和新闻节目的主要话题。

所有这些都起到了一定的误导作用。许多怀疑民主党医改计划的人士提出了颇有见地的问题。但对电视台的黄金时段而言，这些显得过于枯燥。而且在不知不觉中，这些有见地的问题会使你陷在复杂的细节里面。最好还是让抗议活动成为主题。

喧嚣的示威活动虽并非奥巴马政府所愿，但在某种程度上，这些示威活动帮了政府的忙。它们把人们的注意力，从医改措施转移到了最不具吸引力的反对者那毫无理性的愤怒上面。在奥巴马上周举行的3次市政厅会议上，他决定对这些攻击者展开反击。正如他所言，那种认为他竞选总统是为了“扼杀老奶奶的生路”的看法，是“完全不诚实”的。

“不诚实”是客气的说法，但关键之处在于，理性人士会赞同奥巴马的观点。人们认为，相对于抗议者，理性人士将对医改的命运产生更重要的影响。这一看法促使你做出思考。

共和党右翼与民主党左翼之间的隔阂是不可弥合的。前者对医改提出了最愤怒的批评，后者则认为这些提案过于懦弱。双方不仅在观点上不一致，还互相鄙视。双方在政策上的分歧还只是次要的，他们鄙视的是彼此的价值观。

然而，这水火不容的两派竟然也有相似之处。他们对于阴谋论有着程度相当、倾向相反的喜好。根据最近的一份民意测验，近三分之一的共和党人相信一则未经证实的传闻：奥巴马并非生于美国（在这种情况下，奥巴马不具备担任美国总统的资格）。但人们要记得，超过三分之一的民主党人相信一个更离奇的理论：小布什(Bush)政府事先就知道2001年9月会有恐怖袭击。

这两派彼此之间无法展开理性谈话，实际上，他们也无法与其他派别展开对话。但需要记住重要的一点：这些“文化圣战主义者”对政治的影响至多是制造一些噪音，他们决定不了医改的进程。

奥巴马的医改提案并非因共和党保守派的反对而陷入困境。共和党保守派向来反对此类提案。这些提案之所以陷入困境，部分是因为共和党温和派表示反对，更大程度上则是因为许多民主党温和派也对此提出质疑。

奥巴马必须说服中间派议员——正是他们推选他当上了总统——支持医改。事情就是这么简单。如果他能获得温和派和无党派议员的支持，医改就将获得成功。如果他做不到这一点，要么这项努力会遭放弃，要么这些计划会遭弱化（后者更有可能出现）。

市政厅抗议者的歇斯底里言论（“死亡专家组”）、以及他们所举的海报（画有蓄着希特勒式小胡子的奥巴马），可能有利于中间派回到奥巴马阵营。即使它们没起到这种作用，中间派也应该那样做。但迄今为止，奥巴马那糟糕的推销术却起到了更大的反效果。奥巴马之所以受阻，无疑是因为仍拿不出一个成型的医改计划。因此，他未能向国人提供一个合理的医改方针。

奥巴马仍在坚称（就像他最初说的那样），成本控制是启动医改的主要原因——它甚至比实现全民医保还重要。这在战略上似乎一度是合理的，因为绝大多数美国公民拥有医疗保险，并对此感到满意。为了迎合这部分美国公民，奥巴马辩称，除非医疗成本上升得到控制，否则医疗保险（不管是公共还是私营）很快就将变得无法负担。

听上去不错——直到独立的国会预算办公室(Congressional Budget Office)对民主党的计划进行了核查、发现这些计划大大增加了长期成本为止。国会预算办公室的评估削弱了奥巴马的核心论据，这尤其令民主党温和派感到恼火。但白宫却从未调整方针。美国政府乐此不疲地重复：整个医改都围绕控制成本。那么温和派对此提出质疑，还会有人感到意外吗？

如果一开始就承认医改将耗资庞大、而全民医保（尤其关注于保障目前的投保人群持续得到医保）值得付出，那么现在的局面将会更有利。但不加税（除了对富人加税之外）的承诺令这一策略无法实施。相反，这些计划都旨在利用联邦医疗保险(Medicare，老年人的公共医疗计划)的巨额储蓄来为医改买单，许多Medicare的投保人不太相信对他们所享服务不会因此变差的保证。

奥巴马并未输掉医改之战，但他需要重新思考自己的战略。他的错误一直在于，向几乎所有美国人承诺他们可以吃到免费午餐。那些明智、务实、支持奥巴马的美国中间派们对此并不赞许。他们这样做是对的。

译者/梁艳裳