Thank you so much. Please, everybody, be seated. Thank you very much. You're very kind. Thank you. 非常感谢大家。请大家坐下。非常感谢。你们太客气了。谢谢。
Let me begin by thanking Nancy for the wonderful introduction. I want to thank Dr. Joseph Heyman, the chair of the Board of Trustees, as well as Dr. Jeremy Lazarus, speaker of House of Delegates. Thanks to all of you for bringing me home, even if it's just for a day. 首先我要感谢南希的精彩介绍。我要感谢董事会主席约瑟夫·海曼博士，以及众议院议长杰里米·拉扎斯博士。感谢你们各位把我带回家乡，哪怕只是一天。
From the moment I took office as President, the central challenge we've confronted as a nation has been the need to lift ourselves out of the worst recession since World War II. In recent months, we've taken a series of extraordinary steps, not just to repair the immediate damage to our economy, but to build a new foundation for lasting and sustained growth. We're here to create new jobs, to unfreeze our credit markets. We're stemming the loss of homes and the decline of home values. 从我就任总统的那一刻起，我们作为一个国家所面临的核心挑战，就是让自己摆脱二战以来最严重的经济衰退。近几个月来，我们采取了一系列非凡的措施，不仅是为了修复经济的直接损害，更是为了建立持久和可持续增长的新基础。我们在这里是为了创造新的就业机会，解冻信贷市场。我们正在阻止房屋的流失和房屋价值的下降。
All this is important. But even as we've made progress, we know that the road to prosperity remains long and it remains difficult. And we also know that one essential step on our journey is to control the spiraling cost of health care in America. And in order to do that, we're going to need the help of the AMA. 所有这些都很重要。但即使我们取得了进展，我们知道通往繁荣的道路仍然漫长而艰难。我们也知道，在这条道路上至关重要的一步，就是控制美国医疗保健费用的螺旋式上升。为了做到这一点，我们需要AMA的帮助。
Today, we are spending over $2 trillion a year on health care -- almost 50 percent more per person than the next most costly nation. And yet, as I think many of you are aware, for all of this spending, more of our citizens are uninsured, the quality of our care is often lower, and we aren't any healthier. In fact, citizens in some countries that spend substantially less than we do are actually living longer than we do. 今天，我们每年在医疗保健上的花费超过2万亿美元——人均花费几乎是排名第二的最昂贵国家的50%以上。然而，正如你们许多人所意识到的，对于所有这些支出，我们更多的公民没有保险，我们的医疗质量往往较低，我们也没有更健康。事实上，在一些医疗支出大大低于我们的国家，公民的寿命实际上比我们长。
Make no mistake: The cost of our health care is a threat to our economy. It's an escalating burden on our families and businesses. It's a ticking time bomb for the federal budget. And it is unsustainable for the United States of America. 毫无疑问：我们的医疗保健费用是对我们经济的威胁。它是压在我们家庭和企业身上的日益沉重的负担。它是联邦预算的定时炸弹。对美利坚合众国来说，这是不可持续的。
It's unsustainable for Americans like Laura Klitzka, a young mother that I met in Wisconsin just last week, who's learned that the breast cancer she thought she'd beaten had spread to her bones, but who's now being forced to spend time worrying about how to cover the $50,000 in medical debts she's already accumulated, worried about future debts that she's going to accumulate, when all she wants to do is spend time with her two children and focus on getting well. These are not the worries that a woman like Laura should have to face in a nation as wealthy as ours. 对像劳拉·克利茨卡这样的美国人来说，这是不可持续的。她是我上周在威斯康星州遇到的一位年轻母亲，她发现自己以为已经战胜的乳腺癌已经扩散到骨骼，但现在却被迫花时间担心如何支付她已经积累的5万美元医疗债务，担心未来会累积的债务，而她真正想做的只是花时间陪两个孩子，专注于康复。这些不是劳拉这样的女人在我们这样富裕的国家应该面临的烦恼。
Stories like Laura's are being told by women and men all across this country -- by families who've seen out-of-pocket costs soar, and premiums double over the last decade at a rate three times faster than wages. This is forcing Americans of all ages to go without the checkups or the prescriptions they need -- that you know they need. It's creating a situation where a single illness can wipe out a lifetime of savings. 像劳拉这样的故事正在全国各地的男女中流传——家庭看到自付费用飙升，保险费在过去十年中以工资增速三倍的速度翻番。这迫使各年龄段的美国人放弃他们需要的检查或处方——你们知道他们需要这些。这造成了一种局面：一场疾病就能抹去一生的积蓄。
Our costly health care system is unsustainable for doctors like Michael Kahn in New Hampshire, who, as he puts it, spends 20 percent of each day supervising a staff explaining insurance problems to patients, completing authorization forms, writing appeal letters -- a routine that he calls disruptive and distracting, giving him less time to do what he became a doctor to do and actually care for his patients. 我们昂贵的医疗保健系统对新罕布什尔州的迈克尔·卡恩医生来说是不可持续的，他说他每天花20%的时间监督工作人员向病人解释保险问题，填写授权表格，撰写申诉信——他称之为破坏性和分散注意力的日常工作，这让他花更少的时间做他当初成为医生的事情：真正照顾病人。
Small business owners like Chris and Becky Link in Nashville are also struggling. They've always wanted to do right by the workers at their family-run marketing firm, but they've recently had to do the unthinkable and lay off a number of employees -- layoffs that could have been deferred, they say, if health care costs weren't so high. Across the country, over one-third of small businesses have reduced benefits in recent years and one-third have dropped their workers' coverage altogether since the early '90s. 田纳西州纳什维尔的小企业主克里斯和贝基·林克也在挣扎。他们一直想善待自己家族营销公司的员工，但最近不得不做出不可思议的决定——裁员；他们说，如果医疗费用没有那么高，这些裁员本可以推迟。在全国范围内，超过三分之一的小企业近年来减少了福利，还有三分之一的企业自90年代初以来完全取消了员工的保险。
Our largest companies are suffering, as well. A big part of what led General Motors and Chrysler into trouble in recent decades were the huge costs they racked up providing health care for their workers -- costs that made them less profitable and less competitive with automakers around the world. If we do not fix our health care system, America may go the way of GM -- paying more, getting less, and going broke. 我们的大公司也在受苦。通用汽车和克莱斯勒近几十年来陷入困境的很大一部分原因，是他们为员工提供医疗保健所积累的巨额成本——这些成本使他们利润降低，与世界各地的汽车制造商相比竞争力下降。如果我们不修复我们的医疗保健系统，美国可能会走上通用汽车的老路——付出更多，得到更少，最终破产。
When it comes to the cost of our health care, then, the status quo is unsustainable. So reform is not a luxury; it is a necessity. When I hear people say, well, why are you taking this on right now, you've got all these other problems, I keep on reminding people I'd love to be able to defer these issues, but we can't. I know there's been much discussion about what reform would cost, and rightly so. This is a test of whether we -- Democrats and Republicans alike -- are serious about holding the line on new spending and restoring fiscal discipline. 那么，当谈到我们的医疗保健费用时，现状是不可持续的。因此，改革不是奢侈品；它是必需品。当我听到人们说，"你为什么现在要处理这个问题，你还有这么多其他问题"，我一直提醒人们，我很想推迟这些问题，但我们不能。我知道关于改革成本已经有很多讨论，这是正确的。这是对我们——民主党和共和党一样——是否真的愿意坚持新支出、恢复财政纪律的考验。
But let there be no doubt -- the cost of inaction is greater. If we fail to act -- if we fail to act -- and you know this because you see it in your own individual practices -- if we fail to act, premiums will climb higher, benefits will erode further, the rolls of the uninsured will swell to include millions more Americans -- all of which will affect your practice. 但请毫无疑问——不采取行动的代价更大。如果我们不采取行动——如果我们不采取行动——你们在自己的实践中也看到了这一点——如果我们不采取行动，保险费将攀升得更高，福利将进一步侵蚀，未参保人数将增加到包括数百万更多的美国人——所有这些都将影响你的实践。
If we fail to act, one out of every five dollars we earn will be spent on health care within a decade. And in 30 years, it will be about one out of every three -- a trend that will mean lost jobs, lower take-home pay, shuttered businesses, and a lower standard of living for all Americans. 如果我们不采取行动，十年内我们挣到的每五美元中就有一美元会花在医疗保健上。30年后，这个比例将达到三分之一——这一趋势意味着就业机会减少、实际收入降低、企业倒闭，以及所有美国人的生活水平下降。
And if we fail to act, federal spending on Medicaid and Medicare will grow over the coming decades by an amount almost equal to the amount our government currently spends on our nation's defense. It will, in fact, eventually grow larger than what our government spends on anything else today. It's a scenario that will swamp our federal and state budgets, and impose a vicious choice of either unprecedented tax hikes, or overwhelming deficits, or drastic cuts in our federal and state budgets. 如果我们不采取行动，联邦政府在医疗补助和医疗保险上的支出将在未来几十年增长，其金额几乎等于我们政府目前在国防上的支出。事实上，它最终会变得比我们政府今天在任何其他项目上的支出都要大。这将是一个压垮我们联邦和州预算的情景，并强加一个恶性循环：要么前所未有的增税，要么压倒性的赤字，要么联邦和州预算的严厉削减。
So to say it as plainly as I can, health care is the single most important thing we can do for America's long-term fiscal health. That is a fact. That's a fact. 所以让我尽可能直白地说，医疗保健是我们能为美国长期财政健康所做的最重要的事情。这是事实。这就是事实。
It's a fact, and the truth is most people know that it's a fact. And yet, as clear as it is that our system badly needs reform, reform is not inevitable. There's a sense out there among some, and perhaps some members who are gathered here today of the AMA, that as bad as our current system may be -- and it's pretty bad -- the devil we know is better than the devil we don't. There's a fear of change -- a worry that we may lose what works about our health care system while trying to fix what doesn't. 这是事实，而且大多数人都知道这是事实。然而，尽管我们的系统迫切需要改革，改革并不是必然的。有些人中存在一种感觉，也许今天聚集在这里的AMA的一些成员也有这种感觉，即无论我们当前的系统多么糟糕——确实相当糟糕——我们知道的魔鬼比我们不知道的魔鬼好。人们对变革有一种恐惧——担心我们在尝试修复不工作的部分时，可能会失去医疗保健系统中有效的部分。
I'm here to tell you I understand that fear. And I understand the cynicism. They're scars left over from past efforts at reform. After all, Presidents have called for health care reform for nearly a century. Teddy Roosevelt called for it. Harry Truman called for it. Richard Nixon called for it. Jimmy Carter called for it. Bill Clinton called for it. But while significant individual reforms have been made -- such as Medicare, Medicaid, and the Children's Health Insurance Program -- efforts at comprehensive reform that covers everyone and brings down costs have largely failed. 我在这里告诉你们，我理解这种恐惧。我也理解这种冷漠。它们是过去改革努力留下的伤疤。毕竟，近一个世纪以来，总统们一直在呼吁医疗保健改革。泰迪·罗斯福呼吁过。哈里·杜鲁门呼吁过。理查德·尼克松呼吁过。吉米·卡特呼吁过。比尔·克林顿呼吁过。虽然我们取得了一些重大的个别改革——比如医疗保险、医疗补助和儿童健康保险计划——但覆盖所有人并降低成本的综合改革努力大多失败了。
Part of the reason is because the different groups involved -- doctors, insurance companies, businesses, workers, and others -- simply couldn't agree on the need for reform or what shape it would take. And if we're honest, another part of the reason has been the fierce opposition fueled by some interest groups and lobbyists -- opposition that has used fear tactics to paint any effort to achieve reform as an attempt to, yes, socialize medicine. 部分原因是，相关的不同群体——医生、保险公司、企业、工人和其他人——根本无法就改革的必要性或改革的形式达成一致。如果我们诚实的话，另一个原因是一些利益集团和游说团体推动的激烈反对——这种反对使用恐惧策略，将任何实现改革的努力描绘成，是的，社会化医疗。
And despite this long history of failure, I'm standing here because I think we're in a different time. One sign that things are different is that just this past week, the Senate passed a bill that will protect children from the dangers of smoking, a reform the AMA has long championed -- this organization long championed; it went nowhere when it was proposed a decade ago -- I'm going to sign this into law. 尽管有这样的失败历史，我站在这里是因为我认为我们正处在一个不同的时代。表明情况有所不同的一个迹象是，就在上周，参议院通过了一项保护儿童免受吸烟危害的法案，这是AMA长期以来一直倡导的一项改革——本组织长期以来一直倡导；十年前提出时没有任何进展——我将签署这项法案成为法律。
Now, what makes this moment different is that this time -- for the first time -- key stakeholders are aligning not against, but in favor of reform. They're coming out -- they're coming together out of a recognition that while reform will take everyone in our health care community to do their part -- everybody is going to have to pitch in -- ultimately, everybody will benefit. 现在，让这一刻不同的是，这一次——第一次——关键的利益相关者正在联合起来，不是反对改革，而是支持改革。他们正在站出来——他们正在聚在一起，因为他们认识到，虽然改革需要我们医疗保健界的每一个人都尽自己的一份力量——每个人都必须出力——但最终，每个人都会受益。
And I want to commend the AMA, in particular, for offering to do your part to curb costs and achieve reform. Just a week ago, you joined together with hospitals, labor unions, insurers, medical device manufacturers and drug companies to do something that would have been unthinkable just a few years ago -- you promised to work together to cut national health care spending by $2 trillion over the next decade, relative to what it would have otherwise been. And that will bring down costs; that will bring down premiums. 我尤其要赞扬AMA，主动提出要为削减成本和实现改革尽自己的一份力量。就在一周前，你们与医院、工会、保险公司、医疗器械制造商和制药公司联合起来，做了几年前不可思议的事情——你们承诺共同努力，在未来十年中将国家医疗保健支出减少2万亿美元，与原本的水平相比。这将降低成本；这将降低保险费。
That's exactly the kind of cooperation we need, and we appreciate that very much. Thank you. 这正是我们需要的那种合作，我们对此非常感谢。谢谢你们。
Now, the question is how do we finish the job? How do we permanently bring down costs and make quality, affordable health care available to every single American? That's what I've come to talk about today. We know the moment is right for health care reform. We know this is a historic opportunity we've never seen before and may not see again. 那么，问题是我们如何完成这项工作？如何永久降低成本，让每个美国人都能获得优质、负担得起的医疗保健？这就是我今天来谈论的内容。我们知道现在是医疗保健改革的正确时机。我们知道这是一个我们从未见过、可能再也不会出现的历史性机会。
But we also know that there are those who will try and scuttle this opportunity no matter what -- who will use the same scare tactics and fear-mongering that's worked in the past; who will give warnings about socialized medicine and government takeovers, long lines and rationed care, decisions made by bureaucrats and not doctors. We have heard this all before. And because these fear tactics have worked, things have kept getting worse. 但我们也知道，有些人会不惜一切代价破坏这个机会——他们会使用过去奏效的同样的恐吓策略和恐惧贩卖；他们会警告社会化医疗和政府接管、漫长的排队和配给式护理、由官僚而非医生做决定。我们以前都听过这些。正因为这些恐惧策略奏效了，情况才一直在恶化。
So let me begin by saying this to you and to the American people: I know that there are millions of Americans who are content with their health care coverage -- they like their plan and, most importantly, they value their relationship with their doctor. They trust you. And that means that no matter how we reform health care, we will keep this promise to the American people: If you like your doctor, you will be able to keep your doctor, period. If you like your health care plan, you'll be able to keep your health care plan, period. No one will take it away, no matter what. 所以让我首先对你们和美国人民说：我知道有数百万美国人对他们的医疗保健Coverage很满意——他们喜欢他们的计划，而且最重要的是，他们重视与医生的关系。他们信任你们。这意味着无论我们如何改革医疗保健，我们都将向美国人民许下这个承诺：如果你喜欢你的医生，你可以继续看你的医生，就这么简单。如果你喜欢你的医保计划，你可以继续保持你的计划，就这么简单。没有人会把它拿走，无论发生什么。
My view is that health care reform should be guided by a simple principle: Fix what's broken and build on what works. And that's what we intend to do. 我的观点是，医疗保健改革应该遵循一个简单的原则：修复坏掉的部分，在有效的基础上继续建设。这就是我们打算做的。
If we do that, we can build a health care system that allows you to be physicians instead of administrators and accountants; a system that gives Americans -- a system that gives Americans the best care at the lowest cost; a system that eases up the pressure on businesses and unleashes the promise of our economy, creating hundreds of thousands of jobs, making take-home wages thousands of dollars higher, and growing our economy by tens of billions of dollars more every year. 如果我们这样做，我们可以建立一个让你们成为医生而不是行政管理人员和会计的医疗保健系统；一个给美国人——一个给美国人提供最好的护理、以最低的成本的系统；一个减轻企业压力、释放我们经济潜力的系统，创造数十万就业机会，让实际工资每年提高数千美元，推动我们经济每年增长数百亿美元。
That's how we'll stop spending tax dollars to prop up an unsustainable system, and start investing those dollars in innovations and advances that will make our health care system and our economy stronger. 这就是我们将如何停止用纳税人的钱支撑一个不可持续的系统，而开始把这些钱投资到创新和进步中，这些创新和进步将使我们的医疗保健系统和我们的经济更强大。
That's what we can do with this opportunity. And that's what we must do with this moment. 这就是我们能用这个机会做的事情。这就是我们必须用这个时刻做的事情。
Now, the good news is that in some instances, there's already widespread agreement on the steps necessary to make our health care system work better. 现在，好消息是，在某些情况下，对于让我们的医疗保健系统更好运转所必需的步骤，已经存在广泛的共识。
First, we need to upgrade our medical records by switching from a paper to an electronic system of record keeping. And we've already begun to do this with an investment we made as part of our Recovery Act. 首先，我们需要通过从纸质记录转向电子记录系统来升级我们的病历。我们已经通过《复苏法案》中的投资开始了这项工作。
It simply doesn't make sense that patients in the 21st century are still filling out forms with pens on papers that have to be stored away somewhere. As Newt Gingrich has rightly pointed out -- and I don't quote Newt Gingrich that often -- we do a better job tracking a FedEx package in this country than we do tracking patients' health records. 21世纪的病人仍然在用笔在纸上填表，然后这些表格必须被存放在某个地方，这根本没有道理。正如纽特·金里奇正确指出的那样——我不常引用纽特·金里奇的话——我们在这个国家追踪一个联邦快递包裹的工作做得比追踪病人的健康记录还要好。
You shouldn't have to tell every new doctor you see about your medical history or what prescriptions you're taking. You shouldn't have to repeat costly tests. All that information should be stored securely in a private medical record so that your information can be tracked from one doctor to another -- even if you change jobs, even if you move, even if you have to see a number of different specialists. That's just common sense. 你不应该每次看新医生时都要告诉他们你的病史或你正在服用的处方。你不应该重复昂贵的检查。所有这些信息都应该安全地存储在一个私人医疗记录中，这样你的信息就可以从一个医生追踪到另一个医生——即使你换了工作，即使你搬家了，即使你需要看多个不同的专科医生。这只是常识。
And that will not only mean less paper-pushing and lower administrative costs, saving taxpayers billions of dollars; it will also mean all of you physicians will have an easier time doing your jobs. It will tell you, the doctors, what drugs a patient is taking so you can avoid prescribing a medication that could cause a harmful interaction. It will prevent the wrong dosages from going to a patient. It will reduce medical errors, it's estimated, that lead to 100,000 lives lost unnecessarily in our hospitals every year. 这不仅意味着更少的文书工作和更低的管理成本，为纳税人节省数十亿美元；还意味着你们所有的医生都会更容易地做好你们的工作。它会告诉医生病人正在服用什么药物，这样你就可以避免开可能导致有害相互作用的药物。它会防止给病人错误的剂量。据估计，它将减少每年在我们医院中不必要地失去10万人生命的医疗错误。
So there shouldn't be an argument there. And we want to make sure that we're helping providers computerize so that we can get this system up and running. 所以这不应该有争议。我们希望确保我们正在帮助提供者实现计算机化，这样我们才能让这个系统启动并运行起来。
The second step that we can all agree on is to invest more in preventive care so we can avoid illness and disease in the first place. That starts with each of us taking more responsibility for our health and for the health of our children. It means quitting smoking. It means going in for that mammogram or colon cancer screening. It means going for a run or hitting the gym, and raising our children to step away from the video games and spend more time playing outside. 我们都同意的第二步是在预防性护理上投入更多资金，这样我们就能首先避免疾病。这始于我们每个人为自己的健康和孩子的健康承担更多责任。这意味着戒烟。这意味着去做乳房X光检查或结肠癌筛查。这意味着去跑步或去健身房，并且教育我们的孩子远离视频游戏，多花时间在户外玩耍。
It also means cutting down on all the junk food that's fueling an epidemic of obesity -- which puts far too many Americans, young and old, at greater risk of costly, chronic conditions. That's a lesson Michelle and I have tried to instill in our daughters. As some of you know, we started a White House vegetable garden. I say "we" generously, because Michelle has done most of the work. That's a lesson that we should work with local school districts to incorporate into their school lunch programs. 这也意味着减少所有助长肥胖流行病的垃圾食品——这使太多美国人，无论老少，都面临患上昂贵的慢性病的更大风险。这是米歇尔和我努力灌输给我们女儿的一个教训。正如你们中有些人知道的，我们开办了白宫蔬菜园。我慷慨地说"我们"，因为米歇尔做了大部分工作。这是一个我们应该与当地学区合作，将其纳入学校午餐计划的教训。
Building a health care system that promotes prevention rather than just managing diseases will require all of us to do our parts. It will take doctors telling us what risk factors we should avoid and what preventive measures we should pursue. It will take employers following the example of places like Safeway that is rewarding workers for taking better care of their health while reducing health care costs in the process. 建立一个促进预防而不是仅仅管理疾病的医疗保健系统，需要我们所有人都尽自己的一份力量。这需要医生告诉我们应该避免哪些风险因素，应该追求哪些预防措施。这需要雇主效仿Safeway等地方的例子，奖励员工更好地照顾自己的健康，同时在此过程中降低医疗保健成本。
If you're one of three-quarters of Safeway workers enrolled in their "Healthy Measures" program, you can get screened for problems like high cholesterol or high blood pressure. And if you score well, you can pay lower premiums; you get more money in your paycheck. It's a program that has helped Safeway cut health care spending by 13 percent, and workers save over 20 percent on their premiums. And we're open to doing more to help employers adopt and expand programs like this one. 如果你是参加Safeway"健康措施"计划的四分之三的工人之一，你可以接受高胆固醇或高血压等问题的筛查。如果你得分很高，你可以支付更低的保险费；你的工资袋里会有更多的钱。这个计划帮助Safeway将医疗保健支出削减了13%，工人在保险费上节省了超过20%。我们愿意做更多的事情来帮助雇主采用和扩展这样的计划。
Our federal government also has to step up its efforts to advance the cause of healthy living. Five of the costliest illnesses and conditions -- cancer, cardiovascular disease, diabetes, lung disease, and strokes -- can be prevented. And yet only a fraction of every health care dollar goes to prevention or public health. And that's starting to change with an investment we're making in prevention and wellness programs that can help us avoid disease that harm our health and the health of our economy. 我们联邦政府也必须加大努力推进健康生活的事业。五种最昂贵的疾病和病症——癌症、心血管疾病、糖尿病、肺病和中风——是可以预防的。然而，每花一美元医疗保健费用中只有一小部分用于预防或公共卫生。这种情况正在开始改变，因为我们正在投资于预防和健康项目，这些项目可以帮助我们避免损害我们健康和经济的疾病。
But as important as they are, investments in electronic records and preventive care, all the things that I've just mentioned, they're just preliminary steps. They will only make a dent in the epidemic of rising costs in this country. 但尽管它们很重要，电子病历和预防性护理的投资，以及我刚才提到的所有事情，都只是初步步骤。它们只会对遏制本国人在上升的成本流行病产生有限的影响。
Despite what some have suggested, the reason we have these spiraling costs is not simply because we've got an aging population; demographics do account for part of rising costs because older, sicker societies pay more on health care than younger, healthier ones, and there's nothing intrinsically wrong in us taking better care of ourselves. 尽管有人认为，我们这些螺旋式上升的成本不仅仅是因为我们的人口老龄化；人口结构确实是成本上升的部分原因，因为更老、更病弱的社会在医疗保健上的支出比更年轻、更健康的社会多，而且我们更好地照顾自己并没有什么内在的错误。
But what accounts for the bulk of our costs is the nature of our health care delivery system itself -- a system where we spend vast amounts of money on things that aren't necessarily making our people any healthier; a system that automatically equates more expensive care with better care. 但造成我们成本大部分的原因是我们的医疗保健提供系统本身的性质——一个我们在不一定让人们更健康的事情上花费大量资金的系统；一个自动将更昂贵的护理等同于更好的护理的系统。
Now, a recent article in the New Yorker, for example, showed how McAllen, Texas, is spending twice as much as El Paso County -- twice as much -- not because people in McAllen, Texas, are sicker than they are in El Paso; not because they're getting better care or getting better outcomes. It's simply because they're using more treatments -- treatments that, in some cases, they don't really need; treatments that, in some cases, can actually do people harm by raising the risk of infection or medical error. 例如，最近《纽约客》上的一篇文章显示，德克萨斯州的麦卡伦市的支出是埃尔帕索县的两倍——两倍——不是因为麦卡伦的人比埃尔帕索的人更病；不是因为他们得到了更好的护理或更好的结果。这只是因为他们使用了更多的治疗方法——在某些情况下，他们并不真正需要的治疗方法；在某些情况下，实际上可能通过增加感染或医疗错误的风险而伤害人们的治疗方法。
And the problem is this pattern is repeating itself across America. One Dartmouth study shows that you're less likely -- you're no less likely to die from a heart attack and other ailments in a higher-spending area than in a lower-spending one. 问题在于，这种模式正在全美国重复。达特茅斯的一项研究表明，在高支出地区，你死于心脏病发作和其他疾病的可能性并不比低支出地区低。
There are two main reasons for this. The first is a system of incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I'm talking about. It's a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can't spend much time with each, and gives you every incentive to order that extra MRI or EKG, even if it's not necessary. It's a model that has taken the pursuit of medicine from a profession -- a calling -- to a business. 这有两个主要原因。首先是激励机制系统，其中提供的检查和服务越多，我们支付的钱就越多。这个房间里的很多人都知道我在说什么。这是一个奖励护理数量而不是护理质量的模式；它推动你，医生，去看越来越多的病人，即使你不能花太多时间与每个病人在一起，并激励你安排那个额外的MRI或EKG，即使这不是必要的。这是一个将医学职业从一个专业——一个使命——变成了一门生意的模式。
That's not why you became doctors. That's not why you put in all those hours in the Anatomy Suite or the O.R. That's not what brings you back to a patient's bedside to check in, or makes you call a loved one of a patient to say it will be fine. You didn't enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers. And that's what our health care system should let you be. That's what this health care system should let you be. 这不是你们成为医生的原因。这不是你们在解剖室或手术室里花那么多时间的原因。这不是让你回到病人床边检查，或让你给病人的家属打电话说一切都会好起来的原因。你们进入这个行业不是为了成为记账员和文书。你们进入这个行业是为了成为治疗者。这就是我们的医疗保健系统应该让你们成为的。这就是这个医疗保健系统应该让你们成为的。
Now, that starts with reforming the way we compensate our providers -- doctors and hospitals. We need to bundle payments so you aren't paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead paid well for how you treat the overall disease. We need to create incentives for physicians to team up, because we know that when that happens, it results in a healthier patient. We need to give doctors bonuses for good health outcomes, so we're not promoting just more treatment, but better care. 现在，这始于改革我们补偿提供者——医生和医院——的方式。我们需要捆绑支付，这样你就不会因为为糖尿病等慢性病患者提供的每一项治疗而获得报酬，而是因为你如何治疗整体疾病而获得良好的报酬。我们需要为医生创造激励，让他们组成团队，因为我们知道当这种情况发生时，病人会更健康。我们需要给医生提供良好健康结果的奖金，这样我们就不仅仅是在推广更多的治疗，而是更好的护理。
And we need to rethink the cost of a medical education, and do more to reward medical students who choose a career as a primary care physician -- who choose to work in underserved areas instead of the more lucrative paths. That's why we're making a substantial investment in the National Health Service Corps that will make medical training more affordable for primary care doctors and nurse practitioners so they aren't drowning in debt when they enter the workforce. Somebody back there is drowning in debt. 我们需要重新思考医学教育的成本，并做更多的事情来奖励那些选择成为初级保健医生的医学生——那些选择在服务不足地区工作而不是走更赚钱的道路的人。这就是为什么我们正在为国家卫生服务团做出大量投资，这将使初级保健医生和执业护士的医学培训更实惠，这样他们进入职场时就不会被债务淹没。那边有人正被债务淹没。
The second structural reform we need to make is to improve the quality of medical information making its way to doctors and patients. We have the best medical schools, the most sophisticated labs, the most advanced training of any nation on the globe. Yet we're not doing a very good job harnessing our collective knowledge and experience on behalf of better medicine. 我们需要进行的第二个结构性改革是改善传递给医生和病人的医疗信息的质量。我们拥有世界上最好的医学院、最复杂的实验室和最先进的培训。然而，我们在利用我们的集体知识和经验来促进更好的医学方面做得并不好。
Less than 1 percent of our health care spending goes to examining what treatments are most effective -- less than 1 percent. And even when that information finds its way into journals, it can take up to 17 years to find its way to an exam room or operating table. As a result, too many doctors and patients are making decisions without the benefit of the latest research. 我们的医疗保健支出中只有不到1%用于研究哪种治疗方法最有效——不到1%。即使这些信息发表在期刊上，也可能需要长达17年才能进入诊室或手术室。因此，太多的医生和病人在没有最新研究支持的情况下做出决定。
A recent study, for example, found that only half of all cardiac guidelines are based on scientific evidence -- half. That means doctors may be doing a bypass operation when placing a stent is equally effective; or placing a stent when adjusting a patient's drug and medical management is equally effective -- all of which drives up costs without improving a patient's health. 例如，最近的一项研究发现，只有一半的心脏病诊疗指南是基于科学证据的——一半。这意味着医生可能在做搭桥手术，而放置支架同样有效；或者放置支架，而调整病人的药物和医疗管理同样有效——所有这些都会推高成本而不会改善病人的健康。
So one thing we need to do is to figure out what works, and encourage rapid implementation of what works into your practices. That's why we're making a major investment in research to identify the best treatments for a variety of ailments and conditions. 所以我们需要做的一件事就是找出什么有效，并鼓励将有效的方法迅速应用到你的实践中。这就是为什么我们正在为研究做出重大投资，以确定各种疾病和病症的最佳治疗方法。
Now, let me be clear -- I just want to clear something up here -- identifying what works is not about dictating what kind of care should be provided. It's about providing patients and doctors with the information they need to make the best medical decisions. See, I have the assumption that if you have good information about what makes your patients well, that's what you're going to do. I have confidence in that. We're not going to need to force you to do it. We just need to make sure you've got the best information available. 现在，让我说清楚——我只是想在这里澄清一些事情——确定什么有效不是在规定应该提供什么样的护理。而是为病人和医生提供他们做出最佳医疗决策所需的信息。看，我有一个假设，如果你有关于什么能让你的病人康复的良好信息，那就是你要做的。我对此有信心。我们不需要强迫你去做。我们只需要确保你能获得最好的信息。
Still, even when we do know what works, we are often not making the most of it. And that's why we need to build on the examples of outstanding medicine at places like the Cincinnati Children's Hospital, where the quality of care for cystic fibrosis patients shot up after the hospital began incorporating suggestions from parents. And places like Tallahassee Memorial Health Care, where deaths were dramatically reduced with rapid response teams that monitored patients' conditions, and "multidisciplinary rounds" with everyone from physicians to pharmacists. 尽管如此，即使我们确实知道什么有效，我们往往也没有充分利用它。这就是为什么我们需要在辛辛那提儿童医院等地方建立杰出医学的例子，那里在医院开始采纳父母的建议后，囊性纤维化患者的护理质量大幅提升。还有塔拉哈西 memorial 医疗中心，那里通过监测病人状况的快速反应团队和从医生到药剂师所有人的"多学科查房"，死亡率大幅降低。
And places like Geisinger Health System in rural Pennsylvania, and Intermountain Health in Salt Lake City, where high-quality care is being provided at a cost well below the national average. These are all islands of excellence that we need to make the standard in our health care system. 还有宾夕法尼亚州农村的盖辛格卫生系统和盐湖城的山间卫生，那里正在以远低于全国平均水平的成本提供高质量的护理。这些都是我们需要成为医疗保健系统标准的卓越岛屿。
So replicating best practices, incentivizing excellence, closing cost disparities -- any legislation sent to my desk that does not these -- does not achieve these goals in my mind does not earn the title of reform. 因此，复制最佳实践、激励卓越、缩小成本差距——任何送到我桌上的法案如果不实现这些目标，在我看来就不配称为改革。
But my signature on a bill is not enough. I need your help, doctors, because to most Americans you are the health care system. The fact is Americans -- and I include myself and Michelle and our kids in this -- we just do what you tell us to do. That's what we do. We listen to you, we trust you. And that's why I will listen to you and work with you to pursue reform that works for you. 但我在法案上的签名还不够。我需要你们的帮助，医生们，因为对大多数美国人来说，你们就是医疗保健系统。事实是美国人——我自己、米歇尔和我们的孩子也包括在内——我们只做你们告诉我们的事情。这就是我们做的。我们听你们的，我们信任你们。这就是为什么我会听你们的，与你们合作，追求对你们有效的改革。
Together, if we take all these steps, I am convinced we can bring spending down, bring quality up; we can save hundreds of billions of dollars on health care costs while making our health care system work better for patients and doctors alike. And when we align the interests of patients and doctors, then we're going to be in a good place. 如果我们共同采取所有这些步骤，我相信我们可以降低支出，提高质量；我们可以在医疗保健成本上节省数千亿美元，同时让我们的医疗保健系统为病人和医生更好地运转。当我们调整病人和医生的利益时，我们就会处于一个好的境地。
Now, I recognize that it will be hard to make some of these changes if doctors feel like they're constantly looking over their shoulders for fear of lawsuits. I recognize that. Don't get too excited yet. Now, I understand some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That's a real issue. Now, just hold on to your horses here, guys. I want to be honest with you. I'm not advocating caps on malpractice awards -- which I personally believe can be unfair to people who've been wrongfully harmed. 现在，我认识到，如果医生觉得他们不得不不断回头害怕被起诉，那么做出其中一些改变会很困难。我认识到这一点。别太激动。现在，我理解一些医生可能觉得有必要安排更多的检查和治疗，以避免在法律上受到攻击。这是一个真正的问题。现在，请大家耐心听我说。我想对你们诚实。我不主张对医疗事故赔偿设定上限——我个人认为这可能对那些被错误伤害的人不公平。
But I do think we need to explore a range of ideas about how to put patient safety first; how to let doctors focus on practicing medicine; how to encourage broader use of evidence-based guidelines. I want to work with the AMA so we can scale back the excessive defensive medicine that reinforces our current system, and shift to a system where we are providing better care, simply -- rather than simply more treatment. 但我确实认为，我们需要探索一系列关于如何将病人安全放在首位的想法；如何让医生专注于行医；如何鼓励更广泛地使用基于证据的指南。我想与AMA合作，这样我们就可以缩减强化当前系统的过度防御性医疗，转向一个我们提供更好护理的系统——而不是仅仅提供更多治疗。
So this is going to be a priority for me. And I know, based on your responses, it's a priority for you. And I look forward to working with you. And it's going to be difficult. But all this stuff is going to be difficult. All of it's going to be important. 所以这将是我的一个优先事项。我知道，根据你们的反应，这也是你们的优先事项。我期待着与你们合作。这会很困难。但所有这些事情都会很困难。所有这些都将是重要的。
Now, I know this has been a long speech, but we got more to do. The changes that I have already spoken about, all that is going to need to go hand-in-hand with other reforms. Because our health care system is so complex and medicine is always evolving, we need a way to continually evaluate how we can eliminate waste, reduce costs, and improve quality. 现在，我知道这是一个很长的演讲，但我们还有更多要做的。我已经谈到的这些变化，所有这些都需要与其他改革齐头并进。因为我们的医疗保健系统是如此复杂，医学一直在发展，我们需要一种方法来持续评估如何消除浪费、降低成本和提高质量。
That's why I'm open to expanding the role of a commission created by a Republican Congress called the Medicare Payment Advisory Commission, which happens to include a number of physicians on the commission. In recent years, this commission proposed roughly $200 billion in savings that never made it into law. 这就是为什么我愿意扩大由共和党国会创建的一个委员会——医疗保险咨询委员会——的作用，该委员会恰好包括一些医生成员。近年来，该委员会提出了大约2000亿美元的储蓄建议，但从未成为法律。
These recommendations have now been incorporated into our broader reform agenda, but we need to fast-track their proposals, the commission's proposals, in the future so that we don't miss another opportunity to save billions of dollars, as we gain more information about what works and what doesn't work in our health care system. 这些建议现在已被纳入我们更广泛的改革议程，但我们需要加快委员会提案的进度，这样当我们获得更多关于什么在我们的医疗保健系统中有效、什么无效的信息时，我们就不会错过另一个节省数十亿美元的机会。
And as we seek to contain the cost of health care, we also have to ensure that every American can get coverage they can afford. We must do so in part because it's in all of our economic interests. Each time an uninsured American steps foot into an emergency room with no way to reimburse the hospital for care, the cost is handed over to every American family as a bill of about $1,000 that's reflected in higher taxes, higher premiums, and higher health care costs. It's a hidden tax, a hidden bill that will be cut as we insure all Americans. 当我们寻求控制医疗保健成本时，我们也必须确保每个美国人都能获得他们负担得起的保险。我们必须部分这样做，因为这符合我们所有的经济利益。每次一个没有保险的美国人走进急诊室，无法偿还医院的护理费用，这笔费用就以大约1000美元的账单形式转嫁给每个美国家庭，反映在更高的税收、更高的保险费和更高的医疗保健成本中。这是一种隐藏的税收，一种隐藏的账单，当我们为所有美国人提供保险时就会被削减。
And as we insure every young and healthy American, it will spread out risk for insurance companies, further reducing costs for everyone. 当我们为每个年轻健康的美国人提供保险时，它将为保险公司分散风险，进一步降低每个人的成本。
But alongside these economic arguments, there's another, more powerful one. And it is simply this: We are not a nation that accepts nearly 46 million uninsured men, women and children. We are not a nation that lets hardworking families go without coverage, or turns its back on those in need. We're a nation that cares for its citizens. We look out for one another. That's what makes us the United States of America. We need to get this done. 但除了这些经济论点之外，还有另一个更有力的论点。那就是：我们不是一个接受近4600万无保险男女和儿童的国家。我们不是一个让努力工作的家庭得不到保险，或对有需要的人置之不理的国家。我们是一个关心其公民的国家。我们互相照顾。这就是使我们成为美利坚合众国的原因。我们需要完成这件事。
So we need to do a few things to provide affordable health insurance to every single American. The first thing we need to do is to protect what's working in our health care system. So just in case you didn't catch it the first time, let me repeat: If you like your health care system and your doctor, the only thing reform will mean to you is your health care will cost less. If anyone says otherwise, they are either trying to mislead you or don't have their facts straight. 所以我们需要做几件事来为每个美国人提供负担得起的医疗保险。我们需要做的第一件事是保护我们医疗保健系统中有效的部分。所以如果你第一次没听清，让我重复一下：如果你喜欢你的医疗保健系统和你的医生，改革对你来说唯一的意义就是你的医疗保健费用会降低。如果有人说不是这样，他们要么试图误导你，要么没有搞清楚事实。
Now, if you don't like your health care coverage or you don't have any insurance at all, you'll have a chance, under what we've proposed, to take part in what we're calling a Health Insurance Exchange. This exchange will allow you to one-stop shop for a health care plan, compare benefits and prices, and choose a plan that's best for you and your family -- the same way, by the way, that federal employees can do, from a postal worker to a member of Congress. 现在，如果你不喜欢你的医疗保险范围，或者你根本没有任何保险，在我们提出的方案下，你将有机会参加我们所谓的健康保险交易所。这个交易所将允许你一站式比较医疗保险计划，比较福利和价格，选择最适合你和你家人的计划——顺便说一下，这与联邦雇员能做的方式相同，从邮递员到国会议员。
You will have your choice of a number of plans that offer a few different packages, but every plan would offer an affordable, basic package. 你将可以从多个提供不同套餐的计划中选择，但每个计划都将提供负担得起的基本套餐。
Again, this is for people who aren't happy with their current plan. If you like what you're getting, keep it. Nobody is forcing you to shift. But if you're not, this gives you some new options. And I believe one of these options needs to be a public option that will give people a broader range of choices -- and inject competition into the health care market so that force -- so that we can force waste out of the system and keep the insurance companies honest. 同样，这是为那些对当前计划不满意的人。如果你喜欢你得到的，就保留它。没有人强迫你更换。但如果你不满意，这会给你一些新的选择。我相信其中一个选择需要是一个公共选项，它将给人们更广泛的选择——并将竞争注入医疗保健市场，这样我们就可以把浪费赶出系统，让保险公司保持诚实。
Now, I know that there's some concern about a public option. Even within this organization there's healthy debate about it. In particular, I understand that you're concerned that today's Medicare rates, which many of you already feel are too low, will be applied broadly in a way that means our cost savings are coming off your backs. 现在，我知道人们对公共选项有一些担忧。即使在这个组织内部也有关于它的健康辩论。特别是，我理解你担心的是，你们许多人已经觉得太低的医疗保险费率，将被广泛应用，这意味着我们的成本节约将从你们的口袋里出。
And these are legitimate concerns, but they're ones, I believe, that can be overcome. As I stated earlier, the reforms we propose to reimbursement are to reward best practices, focus on patient care, not on the current piecework reimbursements. What we seek is more stability and a health care system that's on a sounder financial footing. 这些都是合理的担忧，但我相信它们是可以克服的。正如我之前所说，我们提议的报销改革是奖励最佳实践，关注病人护理，而不是当前的计件报销。我们寻求的是更多的稳定性和一个在更坚实的财政基础上的医疗保健系统。
And the fact is these reforms need to take place regardless of whether there's a public option or not. With reform, we will ensure that you are being reimbursed in a thoughtful way that's tied to patient outcomes, instead of relying on yearly negotiations about the Sustainable Growth Rate formula that's based on politics and the immediate state of the federal budget in any given year. 事实上，无论是否有公共选项，这些改革都需要进行。通过改革，我们将确保你以一种与病人结果挂钩的深思熟虑的方式获得报销，而不是依赖于每年关于可持续增长率公式的谈判，该公式基于政治和联邦预算的即时状态。
And I just want to point out the alternative to such reform is a world where health care costs grow at an unsustainable rate. And if you don't think that's going to threaten your reimbursements and the stability of our health care system, you haven't been paying attention. 我只想指出，这种改革的替代方案是一个医疗保健成本以不可持续的速度增长的世界。如果你认为这不会威胁到你的报销和我们医疗保健系统的稳定性，那你就没有注意。
So the public option is not your enemy; it is your friend, I believe. 所以公共选项不是你的敌人；我相信，它是你的朋友。
Let me also say that -- let me also address a illegitimate concern that's being put forward by those who are claiming that a public option is somehow a Trojan horse for a single-payer system. I'll be honest; there are countries where a single-payer system works pretty well. But I believe -- and I've taken some flak from members of my own party for this belief -- that it's important for our reform efforts to build on our traditions here in the United States. So when you hear the naysayers claim that I'm trying to bring about government-run health care, know this: They're not telling the truth. 让我也说一下——让我也回应一个由那些声称公共选项某种程度上是单一支付者系统特洛伊木马的人提出的不合法担忧。我说实话；有些国家的单一支付者系统运作得相当好。但我相信——我因为这个信念从我自己政党的成员那里受到了一些批评——我们的改革努力建立在美国的传统之上是很重要的。所以当你听到反对者声称我试图引入政府运营的医疗保健时，请知道：他们没有说实话。
What I am trying to do -- and what a public option will help do -- is put affordable health care within reach for millions of Americans. And to help ensure that everyone can afford the cost of a health care option in our exchange, we need to provide assistance to families who need it. That way, there will be no reason at all for anyone to remain uninsured. 我试图做的——以及公共选项将帮助做的——是为数百万美国人提供负担得起的医疗保健。为了帮助确保每个人都能负担得起我们交易所中的医疗保健选项的费用，我们需要为需要的家庭提供援助。这样，就不会有任何人没有保险的理由了。
Indeed, it's because I'm confident in our ability to give people the ability to get insurance at an affordable rate that I'm open to a system where every American bears responsibility for owning health insurance -- so long as we provide a hardship waiver for those who still can't afford it as we move towards this system. 事实上，正是因为我相信我们有能力让人们以负担得起的费率获得保险，我才支持每个美国人承担拥有医疗保险的责任的制度——只要我们为那些在我们迈向这个制度时仍然负担不起的人提供困难豁免。
The same is true for employers. While I believe every business has a responsibility to provide health insurance for its workers, small businesses that can't afford it should receive an exemption. And small business workers and their families will be able to seek coverage in the exchange if their employer is not able to provide it. 雇主也是如此。虽然我相信每个企业都有为其员工提供医疗保险的责任，但负担不起的小企业应该获得豁免。小企业的工人及其家人如果雇主无法提供保险，将能够在交易所寻求保险。
Now, here's some good news. Insurance companies have expressed support for the idea of covering the uninsured and they certainly are in favor of a mandate. I welcome their willingness to engage constructively in the reform debate. I'm glad they're at the table. But what I refuse to do is simply create a system where insurance companies suddenly have a whole bunch of more customers on Uncle Sam's dime, but still fail to meet their responsibilities. We're not going to do that. 现在，这里有一些好消息。保险公司已经表达了对覆盖无保险者的支持，他们当然也支持强制投保。我欢迎他们愿意建设性地参与改革辩论。我很高兴他们在谈判桌上。但我拒绝做的是简单地创造一个系统，让保险公司突然在山姆大叔的 dime 上拥有更多客户，但仍然不履行他们的责任。我们不会那样做。
Let me give you an example of what I'm talking about. We need to end the practice of denying coverage on the basis of preexisting conditions. The days of cherry-picking who to cover and who to deny, those days are over. I know you see it in your practices, and how incredibly painful and frustrating it is -- you want to give somebody care and you find out that the insurance companies are wiggling out of paying. 让我给你一个我所说的例子。我们需要结束根据既往病症拒绝保险的做法。挑选和选择覆盖谁、拒绝谁的日子已经过去了。我知道你在你的实践中看到了这一点，这是多么痛苦和令人沮丧——你想给某人提供护理，却发现保险公司在逃避支付。
This is personal for me also. I've told this story before. I'll never forget watching my own mother, as she fought cancer in her final days, spending time worrying about whether her insurer would claim her illness was a preexisting condition so it could get out of providing coverage. Changing the current approach to preexisting conditions is the least we can do -- for my mother and for every other mother, father, son, and daughter, who has suffered under this practice, who've been paying premiums and don't get care. We need to put health care within the reach for millions of Americans. 这对我来说也是个人的。我以前讲过这个故事。我永远不会忘记看着我自己的母亲，在她与癌症作斗争的最后日子里，花时间担心她的保险公司是否会声称她的疾病是既往病症，以便逃避提供保险。改变目前对既往病症的做法是我们至少能做的——为了我的母亲和每一个其他母亲、父亲、儿子和女儿，他们在这种做法下受苦，他们一直在交保费却得不到护理。我们需要把医疗保健带给数百万美国人。
Now, even if we accept all of the economic and moral reasons for providing affordable coverage to all Americans, there is no denying that expanding coverage will come at a cost, at least in the short run. But it is a cost that will not -- I repeat -- will not add to our deficits. I've set down a rule for my staff, for my team -- and I've said this to Congress -- health care reform must be, and will be, deficit-neutral in the next decade. 现在，即使我们接受了为所有美国人提供负担得起的保险的所有经济和道德理由，不可否认的是，扩大覆盖范围会带来成本，至少在短期内是这样。但这是一笔不会——我重复——不会增加我们赤字的成本。我为我的工作人员、我的团队设定了一条规则——我已经对国会说过——医疗保健改革必须在未来十年内做到赤字中性。
Now, there are already voices saying the numbers don't add up. They're wrong. Here's why. Making health care affordable for all Americans will cost somewhere on the order of $1 trillion over the next 10 years. That's real money, even in Washington. But remember, that's less than we are projected to have spent on the war in Iraq. And also remember, failing to reform our health care system in a way that genuinely reduces cost growth will cost us trillions of dollars more in lost economic growth and lower wages. 现在，已经有声音说数字加不起来。他们错了。原因如下。为所有美国人提供负担得起的医疗保健将在未来10年中花费大约1万亿美元。这是真金白银，即使在华盛顿也是如此。但请记住，这比我们预计在伊拉克战争上的支出要少。还要记住，未能以真正降低成本增长的方式改革我们的医疗保健系统，将使我们在经济增长损失和工资降低方面损失数万亿美元。
That said, let me explain how we will cover the price tag. First, as part of the budget that was passed a few months ago, we put aside $635 billion over 10 years in what we're calling a Health Reserve Fund. Over half of that amount -- more than $300 billion -- will come from raising revenue by doing things like modestly limiting the tax deductions the wealthiest Americans can take to the same level that it was at the end of the Reagan years -- same level that it was under Ronald Reagan. 话虽如此，让我解释一下我们将如何支付这笔费用。首先，作为几个月前通过的预算的一部分，我们在所谓的医疗储备基金中，在10年内留出了6350亿美元。其中一半以上——超过3000亿美元——将通过提高收入来筹集，例如将最富有的美国人可以获得的税收减免适度限制在里根执政末期的水平——与罗纳德·里根时期的水平相同。
Some are concerned that this will dramatically reduce charitable giving, for example, but statistics show that's not true. And the best thing for our charities is the stronger economy that we will build with health care reform. 有人担心这会大幅减少慈善捐赠，例如，但统计数据显示并非如此。对我们的慈善机构最好的事情是我们将通过医疗改革建立的更强大的经济。
But we can't just raise revenues. We're also going to have to make spending cuts, in part by examining inefficiencies in our current Medicare program. There are going to be robust debates about where these cuts should be made, and I welcome that debate. But here's where I think these cuts should be made. 但我们不能只是增加收入。我们还必须削减支出，部分是通过检查我们当前医疗保险计划中的低效。关于这些削减应该在哪里进行，将会有激烈的辩论，我欢迎这场辩论。但我认为这些削减应该在这里进行。
First, we should end overpayments to Medicare Advantage. Today, we're paying Medicare Advantage plans much more than we pay for traditional Medicare services. Now, this is a good deal for insurance companies. It's a subsidy to insurance companies. It's not a good deal for you. It's not a good deal for the American people. And by the way, it doesn't follow free market principles, for those who are always talking about free market principles. 首先，我们应该结束对医疗保险优势计划的过度支付。今天，我们向医疗保险优势计划支付的费用远高于传统医疗保险服务的费用。现在，这对保险公司来说是个好交易。这是对保险公司的补贴。这对你们来说不是好交易。这对美国人民来说不是好交易。顺便说一句，这不符合自由市场原则，对于那些总是谈论自由市场原则的人来说。
That's why we need to introduce competitive bidding into the Medicare Advantage program, a program under which private insurance companies are offering Medicare coverage. That alone will save $177 billion over the next decade, just that one step. 这就是为什么我们需要在医疗保险优势计划中引入竞争性竞标，这是一个私人保险公司提供医疗保险覆盖的计划。仅这一步就将在未来十年内节省1770亿美元。
Second, we need to use Medicare reimbursements to reduce preventable hospital readmissions. Right now, almost 20 percent of Medicare patients discharged from hospitals are readmitted within a month, often because they're not getting the comprehensive care that they need. This puts people at risk; it drives up cost. By changing how Medicare reimburses hospitals, we can discourage them from acting in a way that boosts profits but drives up costs for everyone else. That will save us $25 billion over the next decade. 第二，我们需要使用医疗保险报销来减少可预防的医院再入院。目前，几乎20%的出院医疗保险病人在一个月内再次入院，通常是因为他们没有得到所需的全面护理。这使人们处于风险之中；它推高了成本。通过改变医疗保险报销医院的方式，我们可以阻止他们做出提升利润却推高其他所有人成本的行为。这将在未来十年内为我们节省250亿美元。
Third, we need to introduce generic biologic drugs into the marketplace.These are drugs used to treat illnesses like anemia. But right now, there is no pathway at the FDA for approving generic versions of these drugs. Creating such a pathway will save us billions of dollars. We can save another roughly $30 billion by getting a better deal for our poorer seniors while asking our well-off seniors to pay a little more for their drugs. 第三，我们需要将通用生物药物引入市场。这些是用于治疗贫血等疾病的药物。但目前，FDA没有批准这些药物的通用版本的途径。创建这样的途径将为我们节省数十亿美元。我们可以通过为较贫困的老年患者争取更好的交易，同时要求我们富裕的老年患者为他们的药物多付一点，再节省大约300亿美元。
So that's the bulk of what's in the Health Reserve Fund. I've also proposed saving another $313 billion in Medicare and Medicaid spending in several other ways. One way is by adjusting Medicare payments to reflect new advances and productivity gains in our economy. Right now, Medicare payments are rising each year by more than they should. These adjustments will create incentives for providers to deliver care more efficiently, and save us roughly $109 billion in the process. 所以这就是医疗储备基金中的大部分内容。我还提议通过其他几种方式在医疗保险和医疗补助上再节省3130亿美元。一种方式是调整医疗保险支付，以反映我们经济中的新进展和生产力收益。目前，医疗保险支付每年的增长幅度超过应有的水平。这些调整将为提供者创造更有效提供护理的激励，并在此过程中为我们节省约1090亿美元。
Another way we can achieve savings is by reducing payments to hospitals for treating uninsured people. I know hospitals rely on these payments now, legitimately, because of the large number of uninsured patients that they treat. But if we put in a system where people have coverage and the number of uninsured people goes down with our reforms, the amount we pay hospitals to treat uninsured people should go down, as well. Reducing these payments gradually, as more and more people have coverage, will save us over $106 billion. 我们可以实现储蓄的另一种方式是减少医院治疗无保险者的支付。我知道医院现在合法地依赖这些支付，因为他们治疗了大量的无保险患者。但如果我们建立了一个人们有保险的系统，随着我们的改革，无保险人数下降，我们付给医院治疗无保险者的费用也应该下降。随着越来越多的人获得保险，逐步减少这些支付将为我们节省超过1060亿美元。
And we'll make sure the difference goes to the hospitals that need it most. 我们将确保差额流向最需要它的医院。
We can also save about $75 billion through more efficient purchasing of prescription drugs. And we can save about $1 billion more by rooting out waste, abuse, fraud throughout our health care system so that no one is charging more for a service than it's worth or charging a dime for a service that they don't provide. 我们还可以通过更高效地购买处方药节省约750亿美元。我们还可以通过根除整个医疗保健系统中的浪费、滥用和欺诈再节省约10亿美元，这样就没有人会为一种服务收取超过其价值的费用，或为他们没有提供的服务收取一分钱。
Let me be clear: I'm committed to making these cuts in a way that protects our senior citizens. In fact, these proposals will actually extend the life of the Medicare Trust Fund by seven years, and reduce premiums for Medicare beneficiaries by roughly $43 billion over the next 10 years. And I'm working with AARP to uphold that commitment. 让我说清楚：我承诺以保护我们的老年公民的方式进行这些削减。事实上，这些提议实际上将使医疗保险信托基金的寿命延长七年，并在未来10年内为医疗保险受益人减少约430亿美元的保费。我正在与AARP合作维护这一承诺。
Now, for those of you who took out your pencil and paper -- altogether, these savings mean that we've put about $950 billion on the table -- and that doesn't count some of the long-term savings that we think will come about from reform -- from medical IT, for example, or increased investment in prevention. So that stuff in congressional jargon is not scorable; the Congressional Budget Office won't count that as savings, so we're setting that aside. 现在，对于那些拿出纸笔的人——总的来说，这些储蓄意味着我们已经拿出了大约9500亿美元——这还不包括我们认为将从改革中产生的一些长期储蓄——例如来自医疗信息化，或对预防的更多投资。所以那些在国会术语中不是"可计分"的东西；国会预算办公室不会将其计为储蓄，所以我们将其搁置一旁。
We think that's going to come, but even separate and far from that, we've put $950 billion on the table, taking us almost all the way to covering the full cost of health care reform. 我们认为这将会到来，但即使撇开这些，我们已经拿出了9500亿美元，几乎涵盖了医疗保健改革的全部成本。
In the weeks and months ahead, I look forward to working with Congress to make up the difference so that health care reform is fully paid for -- in a real, accountable way. And let me add that this does not count longer-term savings. I just want to repeat that. 在未来的几周和几个月里，我期待着与国会合作，弥补差额，使医疗保健改革以真实、负责任的方式全额支付。让我补充一点，这还不包括较长期的储蓄。我只是想重复这一点。
By insisting that the reforms that we're introducing are deficit-neutral over the next decade, and by making the reforms that will help slow the growth rate of health care costs over the coming decades -- bending the curve -- we can look forward to faster economic growth, higher living standards, and falling, instead of rising, budget deficits. 通过坚持我们正在引入的改革在未来十年内做到赤字中性，并通过做出将有助于减缓未来几十年医疗保健成本增长速度的改革——弯曲曲线——我们可以期待更快的经济增长、更高的生活水平，以及下降而不是上升的预算赤字。
Now, let me just wrap up by saying this. I know people are cynical whether we can do this or not. I know there will be disagreements about how to proceed in the days ahead. There's probably healthy debate within the AMA. That's good. I also know this: We can't let this moment pass us by. 现在，让我总结一下。我知道人们对我们能否做到这一点持怀疑态度。我知道在未来的日子里，关于如何推进将会有分歧。AMA内部可能有健康的辩论。这很好。我也知道这一点：我们不能让这一刻从我们身边溜走。
You know, the other day, a friend of mine, Congressman Earl Blumenauer, handed me a magazine with a special issue titled, "The Crisis in American Medicine." One article notes "soaring charges." Another warns about the "volume of utilization of services." Another asks if we can find a "better way than fee-for-service for paying for medical care." It speaks to many of the challenges we face today. The thing is, this special issue was published by Harper's Magazine in October of 1960 -- before I was born. 你知道，前几天，我的朋友、国会众议员厄尔·布卢门瑙尔递给我一本杂志，上面有一个特别专题，标题是《美国医学的危机》。一篇文章提到了"飙升的收费"。另一篇警告了"服务使用量"的问题。另一篇问我们能否找到一种"比按服务付费更好的方式来支付医疗保健"。它谈到了我们今天面临的许多挑战。问题是，这个特别专题是哈珀杂志1960年10月出版的——在我出生之前。
Members of the American Medical Association, and my fellow Americans, I'm here today because I don't want our children and their children to still be speaking of a crisis in American medicine 50 years from now. I don't want them to still be suffering from spiraling costs that we did not stem, or sicknesses that we did not cure. I don't want them to be burdened with massive deficits we did not curb or a worsening economy that we did not rebuild. 美国医学会的成员们，我的美国同胞们，我今天站在这里是因为我不希望我们的孩子和他们的孩子在50年后仍然在谈论美国医学的危机。我不希望他们仍然在遭受我们未能遏制的螺旋式成本，或我们未能治愈的疾病。我不希望他们背负我们未能控制的大规模赤字或我们未能重建的恶化的经济。
I want them to benefit from a health care system that works for all of us; where families can open a doctor's bill without dreading what's inside; where parents are talking to their kids and getting them to get regular checkups, and testing themselves for preventable ailments; where parents are feeding their kids healthier food and kids are exercising more; where patients are spending more time with their doctors, and doctors can pull up on a computer all the medical information and latest research they'll ever want to know to meet patients' needs; 我希望他们能从一个为所有人服务的医疗保健系统中受益；家庭可以打开医生的账单而不必害怕里面是什么；父母正在与他们的孩子交谈，让他们定期检查，并为可预防的疾病进行检测；父母给孩子喂更健康的食物，孩子们多锻炼；病人花更多的时间与医生在一起，医生可以在电脑上调阅他们 Meet patients' needs 所需的所有医疗信息和最新研究；
where orthopedists and nephrologists and oncologists are all working together to treat a single human being; where what's best about America's health care system has become the hallmark of America's health care system. 骨科医生、肾病学家和肿瘤学家都在一起治疗一个人；美国医疗保健系统中最好的方面已成为美国医疗保健系统的标志。
That's the health care system we can build. That's the future I'm convinced is within our reach. And if we're willing to come together and bring about that future, then we will not only make Americans healthier, we will not only unleash America's economic potential, but we will reaffirm the ideals that led you into this noble profession and we'll build a health care system that lets all Americans heal. 这就是我们可以建设的医疗保健系统。这就是我相信在我们力所能及的范围内的未来。如果我们愿意走到一起，实现那个未来，那么我们不仅会让美国人更健康，不仅会释放美国的经济潜力，还会重申引导你们进入这个崇高职业的理想，我们将建设一个让所有美国人都能康复的医疗保健系统。
Thank you very much, AMA. Appreciate it, thank you. 非常感谢，AMA。谢谢你们。