President Obama: Good morning! 奥巴马总统：早上好！
Ms. Kliff: Good morning. 克里夫女士：早上好。
Mr. Klein: Thank you for being here. 克莱因先生：感谢您能来。
President Obama: It is great to be here. And thank you so much for all the good reporting you guys have been doing on this important issue. 奥巴马总统：很高兴来到这里。非常感谢你们在这个重要议题上所做的所有出色报道。
Mr. Klein: Thank you. 克莱因先生：谢谢您。
Ms. Kliff: So we will get started. So there was an expectation that was shared among many of your staff, many congressional Democrats, that as the Affordable Care Act rolled out, as it delivered benefits to millions of people, that it would become more popular. It would be safe from repeal or even substantial reform. And it appears at this point that doesn’t seem to be quite true. What do you think that theory got wrong? Why didn’t the health care law become more popular? 克里夫女士：那我们就开始吧。很多您的幕僚、很多国会民主党人都有过这样的预期：随着《平价医疗法案》的推行，随着它向数百万人提供福利，它会变得越来越受欢迎。它将安全到不会被废除，甚至不会被重大改革。但现在看来，这似乎并不完全正确。您认为那个理论错在哪里？为什么医保法没有变得更受欢迎？
President Obama: Well, let’s back up and say from the start there’s a reason why for a hundred years no President could get expansion of health care coverage beyond the work that had been done for Medicare and Medicaid, targeting primarily seniors. And the reason was that this is hard. The health care system is big; it is very personal. Families I think recognize the need for health insurance, but it's not something that they think about except when things go wrong -- when you have an accident or you're sick. 奥巴马总统：好吧，让我们退一步说，从一开始，一百年来没有哪位总统能在联邦医疗保险和医疗补助（主要针对老年人）的基础上进一步扩大医保覆盖范围，这是有原因的。原因就是这太难了。医疗体系很庞大；它非常个人化。我认为家庭都认识到医保的必要性，但除非出了问题——比如出了事故或者生病了——否则人们不会去想它。
And so any costs, particularly at a time when families are feeling stressed economically, any added costs, higher premiums, higher co-pays, all that ends up having real impacts on families. 所以任何费用，尤其是在家庭感到经济压力的时候，任何额外的成本、更高的保费、更高的自付额，所有这些最终都会对家庭产生实际影响。
And so the challenge of getting it passed was always the fact that, unlike other advanced countries, we didn’t start with a system in which everybody was covered, and we have a very complicated marketplace, and we have third-party insurers. And what that meant was that even after we got the law passed anything that dissatisfied people about the health care system could be attributed to -- quote, unquote -- “Obamacare,” even if it had nothing to do with Obamacare. And that was something that we recognized even when we were trying to get the law passed. 因此，通过这项法案的挑战一直在于，与其他发达国家不同，我们不是从一个人人都有医保的体系起步的，我们有一个非常复杂的市场，还有第三方保险公司。这意味着，即使在我们通过法案之后，人们对医疗体系的任何不满都可以归咎于——所谓的——"奥巴马医改"，即便那和奥巴马医改毫无关系。这一点我们在努力推动法案通过时就认识到了。
The other thing is the fact that the unwillingness of Republicans in Congress and around the country, including some governors, to, after the fight was over, say, all right, let’s try to make this work -- the way Democrats did during the time when President Bush tried to expand the prescription drug program, Part D -- meant that the public never heard from those who had originally been opposed any concession that, you know what, this is actually doing some good. And that ends up affecting public opinion. 另一个原因是，国会和全国各地的共和党人，包括一些州长，在斗争结束后不愿意说，好吧，让我们试着让它发挥作用——就像民主党人在布什总统试图扩大处方药计划（联邦医疗保险D部分）时所做的那样——这意味着公众从未从那些最初反对的人那里听到任何让步，比如，你知道吗，这实际上确实带来了一些好处。而这最终影响了公众舆论。
And the third thing is that whenever you look at polls that say 40-something percent are supportive of the law and 40-something percent are dissatisfied -- in the dissatisfied column are a whole bunch of Bernie Sanders supporters who wanted a single-payer plan. And so the problem is not that they think Obamacare is a failure; the problem is that they don't think it went far enough and that it left too many people still uncovered, that the subsidies that people were getting weren’t as rich as they should have been, 第三点是，每当你看到民调说百分之四十几的人支持这项法律，百分之四十几的人不满意——在不满意的那一栏里，有一大堆伯尼·桑德斯的支持者，他们想要的是单一支付者制度。所以问题不在于他们认为奥巴马医改是失败的；问题在于他们认为它做得还不够，它仍然让太多人没有医保，人们得到的补贴还不够多，
that there’s a way of dealing with prescription drug makers in a way that drives down those costs. And so all those things meant that even after the law was passed there was going to still be a lot tough politics. 还有，应该有办法对付制药商来压低那些成本。所以所有这些都意味着，即使在法案通过后，仍然会有很多艰难的政治斗争。
Having said all that, the thing that I've been most proud of is the fact that not only have we gotten 20 million people covered, not only have we been able to reduce the pace at which health care costs have been going up -- ever since the law was passed, basically health care inflation has been as low as it's been in 50 years, which has saved the federal government hundreds of billions of dollars, extended the Medicare trust fund by 11 years -- 说了这么多，我最引以为豪的是，我们不仅让2000万人获得了医保，不仅成功减缓了医疗费用上涨的速度——自从法案通过以来，基本上医疗通胀率达到了50年来的最低水平，这为联邦政府节省了数千亿美元，将联邦医疗保险信托基金的寿命延长了11年——
but most importantly, for the people who have gotten insurance through the exchanges, there’s been pretty high satisfaction rates, as surveys have shown. 但最重要的是，对于那些通过保险市场获得保险的人来说，满意度相当高，正如调查所显示的。
So rather than look at public opinion as a whole, the thing I've been most interested in is, how is this affecting the people who have gotten benefits? These are real families who have gotten real coverage. And I get letters every single day from people who say, this has saved my life, or this has saved my bank account, or this has made sure that my son who got hooked on some sort of opioid was able to get treatment, or I was able to get a mammogram that caught a cancer in time. And that ultimately is the measure of the success of the law. 所以，与其看整体的公众舆论，我最感兴趣的是，这对那些获得了福利的人产生了怎样的影响。这些都是真实的家庭，获得了真实的医保。我每天都会收到人们的来信，说这救了我的命，或者这保住了我的银行存款，或者这确保了我染上阿片类药物成瘾的儿子能够得到治疗，又或者我终于做上了及时发现癌症的乳房X光检查。而这最终才是衡量法案成功与否的标准。
Mr. Klein: So do you think this dynamic where when you reform the health care system, you own it goes the other way? Republicans are beginning with the repeal-and-delay strategy. President-elect Trump has said that he does want to repeal Obamacare, but he also wants to replace it with something that covers as many people -- or he said that at least at certain points. 克莱因先生：那么您是否认为，当你改革医疗体系时，你就"拥有"了它——这种动态也会反过来起作用？共和党人正从"先废除再拖延"的策略开始。当选总统特朗普表示他确实想废除奥巴马医改，但他也想用某种覆盖同样多人的方案来取代——至少他在某些时候这么说过。
Do you think that the dynamic in which you became responsible for what people didn’t like is going to hamper Republican movement in their efforts to change a system that maybe they don’t like but does have a lot of people relying on it? 您是否认为，那种您要为人们不喜欢的东西负责的动态，将会阻碍共和党人改变一个他们可能不喜欢、但确实有很多人依赖的体系的努力？
President Obama: Well, let me start from a very simple premise: If it works, I’m for it. If something can cover all Americans, make sure that if they have a preexisting condition they can still get coverage, make sure that prescription drugs are affordable, encourage preventive measures to keep people healthy, that makes sure that in rural communities people have access to substance abuse care or mental health care, that Medicare and Medicaid continue to function effectively -- 奥巴马总统：让我从一个非常简单的前提出发：如果它有效，我就支持。如果有什么东西能覆盖所有美国人，确保有既往病史的人仍然能获得保险，确保处方药是负担得起的，鼓励预防措施让人们保持健康，确保农村社区的人们能够获得药物滥用治疗或心理健康护理，确保联邦医疗保险和医疗补助继续有效运作——
if you can do all that cheaper than we talked about, cheaper than Obamacare achieves and with better quality and it’s just terrific, I’m for it. 如果你能以比我们说的更低的成本做到这一切，比奥巴马医改实现的成本更低，而且质量更高，那就太棒了，我支持。
I think that part of the challenge in this whole debate. And this is true, dating back to 2009, back to 2010, is this idea that somehow we had a fixed way of trying to fix the health care system, that we were rigid and stubborn and wouldn’t welcome Republican ideas, and if we only had, they had all these great solutions. In fact, if you look at how this law evolved -- and I’ve said this publicly before, if I was starting from scratch, I probably would have supported a single-payer system because it’s just easier for people to understand and manage. 我认为这场辩论的部分挑战在于——这可以追溯到2009年，追溯到2010年——就是这样一种观念，不知何故我们有一套固定的方式来修复医疗体系，我们很僵化、很固执，不愿接受共和党的想法，如果我们愿意的话，他们有一大堆很好的解决方案。事实上，如果你看看这项法案是如何演变的——我之前也公开说过，如果我从零开始，我可能会支持单一支付者制度，因为它更容易让人们理解和管理。
And that’s essentially what Medicare is, is a single-payer system for people of a certain age. And people are very satisfied with it and it’s not that complicated to understand or to access services. But that wasn’t available; we weren’t starting from scratch. 而这本质上就是联邦医疗保险——针对特定年龄人群的单一支付者制度。人们对它非常满意，而且理解或获取服务也不是那么复杂。但那行不通；我们不是从零开始。
So what did I then do? I said, well, where is a system out there that seems to be providing coverage for everybody that politically we could actually get through a Congress and where we could get Republican support. And lo and behold, in Massachusetts there was a plan that had been designed on a bipartisan basis -- including by a Republican governor who ultimately became the nominee for the Republican Party -- that came close to providing universal coverage. 那我后来做了什么？我说，好吧，有没有哪个体系似乎能为所有人提供保障，而且在政治上我们能在国会通过，还能获得共和党的支持。你瞧，在马萨诸塞州有一个计划，是在两党基础上设计的——包括由一位共和党州长设计，他后来还成了共和党的总统提名人——那个计划接近实现全民覆盖。
And I would have thought since this was an idea that had previously gotten a lot of Republican support that it would continue to get a lot of Republican support. And yet, somehow, magically, the minute we said this is a great idea and it’s working, Republicans said this is terrible and we don’t want to do this. 我本以为，既然这个想法之前获得了很多共和党人的支持，它会继续获得很多支持。然而，不知何故，神奇地，当我们一说这是个好主意而且它正在起作用时，共和党人就说这太糟糕了，我们不想这么做。
So I say all this, Ezra, simply to make something very clear. From the very start, in the earliest negotiations in 2009, 2010, I made clear to Republicans that, if they had ideas that they could show would work better than the ideas that we had thought of, I would be happy to incorporate them into the law. And rather than offer ideas, what we got was a big no, we just don’t want to do this. 所以我说这些，埃兹拉，只是想把一件事说清楚。从一开始，在2009年、2010年的最早谈判中，我就向共和党人明确表示，如果他们有想法，并且能证明比我们想到的想法更有效，我很乐意将它们纳入法案。而我们得到的不是想法，而是一个大大的"不"，我们就是不想这么做。
After the law passed, for the last six, seven years, there has been the argument that we can provide a great replacement that will be much better for everybody than what the Affordable Care Act is providing. And yet, over the last six, seven years, there has been no actual replacement law that any credible health care policy experts have said would work better. In fact, many of them would result in millions of people losing coverage and the coverage being worse for those who kept it. 法案通过后，过去六七年里，一直有一种说法，说我们可以提供一个很棒的替代方案，比《平价医疗法案》提供的对每个人都好得多。然而，在过去六七年里，没有任何可信的医疗政策专家说过有哪个实际的替代法案会更有效。事实上，其中很多会导致数百万人失去保险，而那些保留保险的人的保障也会更差。
And so now is the time when Republicans, I think, have to go ahead and show their cards. If, in fact, they have a program that would genuinely work better and they want to call it whatever they want -- they can call it Trumpcare, they can call it McConnellcare, or Ryancare. If it actually works, I will be the first one to say, great, you should have told me that back in 2009. I asked. I suspect that will not happen. 所以现在是时候了，我认为共和党人必须亮出他们的底牌。如果他们真的有一个确实能更好运作的计划，他们想叫什么都行——可以叫特朗普医改，可以叫麦康奈尔医改，也可以叫瑞安医改。如果它真的有效，我会第一个说，好极了，你2009年就该告诉我。我问过的。我怀疑那不会发生。
And the reason it will not happen is because if you want to provide coverage to people, then there are certain baseline things that you got to do. Number one, health care is not cheap. And for people who can't afford health care or don’t get it through the job, that means the government has got to pay some money. 而它不会发生的原因是，如果你想为人们提供保障，你就必须做一些基本的事情。第一，医疗保健不便宜。对于那些负担不起医保或者没有通过工作获得医保的人来说，这意味着政府必须支付一些钱。
Number two, all those provisions that the Republicans say they want to keep and that they like -- for example, making sure that people can get health care even if they have a preexisting condition -- well, it turns out that the only way to meet that guarantee is to either make sure that everybody has some modest obligation to get health care so that they're not gaming the system, or you've got to be willing to provide huge subsidies to the insurance companies so that they're taking in people who are already sick. 第二，所有那些共和党人说他们想保留和喜欢的条款——比如，确保人们即使有既往病史也能获得医保——嗯，事实证明，实现这一保证的唯一方法是，要么确保每个人都有适度的参保义务，这样他们就不会钻制度的空子，要么你就得愿意向保险公司提供巨额补贴，这样他们才愿意接收已经生病的人。
And I think what you're going to see now that you have a Republican President-elect, you have Republicans who control both chambers in Congress -- is that all the promises they made about how they can do it better, cheaper, everybody is going to be satisfied, are going to be really hard to meet. 我认为你们现在会看到的是，既然有了一位共和党当选总统，既然共和党人控制着国会参众两院——那么他们所有关于如何能做得更好、更便宜、每个人都会满意的承诺，都将变得非常难以兑现。
And this is why the strategy of repeal first and replace later is just a huge disservice to the American people, and is something that I think, whether you're a Republican or a Democrat, you should be opposed to. These are real lives at stake. 这就是为什么"先废除后替代"的策略对美国人民是极大的伤害，而且我认为，无论你是共和党人还是民主党人，你都应该反对。这些都是真实的生命，危在旦夕。
I'm getting letters right now from people who say, I am terrified because my son's or daughter's insurance -- their ability to get lifesaving drugs, their ability to get drug treatment, their ability to get mental health services are entirely dependent on us being able to afford and keep our insurance. 我现在就收到人们的来信，说我很害怕，因为我儿子或女儿的保险——他们获得救命药物的能力、获得药物治疗的能力、获得心理健康服务的能力——完全取决于我们能否负担得起并保住我们的保险。
And if, in fact, there's going to be a massive undoing of what's one-sixth of our economy, then the Republicans need to put forward very specific ideas about how they're going to do it. People need to be able to debate it, they need to be able to study it the same way they did when we passed the Affordable Care Act. And let the American people gauge is this going to result in something better than what Obamacare has produced. 如果真的要大规模撤销占我们经济六分之一的东西，那么共和党人需要提出非常具体的想法来说明他们将如何做。人们需要能够辩论它，他们需要能够像我们通过《平价医疗法案》时那样研究它。让美国人民来判断这是否会带来比奥巴马医改更好的结果。
And if they're so convinced that they can do it better, they shouldn’t be afraid to make that presentation. It is really interesting to try to figure out why is it that they're trying to rush the repeal so quick. What is it that they're afraid of? Why wouldn’t they want to say, here's our plan, and show, side by side, here's why our plan is better than what Obamacare has produced? Because they have said, absolutely, adamantly, that they can do it better. 如果他们那么确信自己能做得更好，他们就不应该害怕展示出来。弄清楚他们为什么这么着急要废除，这真的很有意思。他们在害怕什么？他们为什么不想说，这是我们的计划，然后并排展示，说明为什么我们的计划比奥巴马医改的成果更好？因为他们一直绝对地、坚定地说他们能做得更好。
I am saying to every Republican right now, if you, in fact, can put a plan together that is demonstrably better than what Obamacare is doing, I will publicly support repealing Obamacare and replacing it with your plan. But I want to see it first. I want to see it first. And I want third-party, objective people -- whether it's the Congressional Budget Office or health care experts across the ideological spectrum, or Vox, or whoever -- 我现在对每一位共和党人说，如果你们真的能拿出一个明显比奥巴马医改做得更好的计划，我会公开支持废除奥巴马医改，用你们的计划取而代之。但我想先看看。我想先看看。我希望第三方、客观的人士——无论是国会预算办公室，还是各个意识形态阵营的医疗保健专家，或者Vox，或者任何人——
Mr. Klein: We'd be happy to, yes. 克莱因先生：我们很乐意，是的。
President Obama: -- to just evaluate it. And the public will not have to take my word for it. They can -- we can designate some referees. And if they can show that they can do it better, cheaper, more effective, provide better coverage, why wouldn’t I be for it? Why wouldn’t I be for it? 奥巴马总统：——来评估它。公众不必听信我的话。我们可以指定一些裁判。如果他们能证明他们能做得更好、更便宜、更有效、提供更好的保障，我为什么不支持呢？我为什么不支持呢？
This idea that somehow, oh, this is about Obama preserving his legacy -- keep in mind, I'm not the one who named it Obamacare. They were the ones who named it Obamacare, because what they wanted to do was personalize this and feed on antipathy towards me in their party as an organizing tool, as politics. 那种"哦，这是奥巴马在维护他的遗产"的想法——别忘了，不是我把它命名为奥巴马医改的。是他们把它命名为奥巴马医改的，因为他们想做的是把这件事个人化，利用他们党内对我的反感作为组织工具，作为政治手段。
But I don’t have a pride of authorship on this thing. If they can come up with something better, I'm for it. But you have to show -- and I would advise every Democrat to be for it -- but you have to show that it's better. And that's not too much to ask. And that's the challenge. 但我对这件事没有作者的骄傲。如果他们能想出更好的办法，我支持。但你得证明——而且我会建议每一位民主党人都支持——但你得证明它更好。这要求并不过分。而这就是挑战。
And the question right now for Paul Ryan and Mitch McConnell is, why is it that you feel obliged to repeal it before you show what it is that is going to replace? 现在对保罗·瑞安和米奇·麦康奈尔的问题是，为什么你们觉得有必要在展示替代方案之前就废除它？
Because the majority of Americans have been very clear that they think that's a bad idea. You now have Republican governors, some Republican senators, who have said, we don’t think that's a good idea. And there's been no real explanation to why you would actually try to do this before the new President is even inaugurated. What exactly is this rush? Particularly if you're going to delay the actual repeal. 因为大多数美国人已经非常明确地表示他们认为这是个坏主意。现在有共和党州长，一些共和党参议员，已经表示，我们认为这不是个好主意。而且至今没有真正解释为什么你要在新总统甚至还没就职就试着这么做。到底在急什么？尤其是如果你还要推迟实际废除的话。
If they were making the argument that this is so disastrous that we actually think we have to repeal it completely today because it's just terrible, well, I would disagree, but at least I could understand it. But here you're saying, we're going to vote to repeal, but then were going to delay its effects for a couple of years. Well, why, if it's so bad? 如果他们的论点是，这太灾难性了，我们实际上认为今天就得完全废除它，因为它太糟糕了，好吧，我不同意，但至少我能理解。但现在你们说，我们要投票废除，但然后把生效时间推迟几年。好吧，如果它那么糟糕，为什么要推迟？
And if the answer is, well, it would be disruptive and we don't want to take people’s insurance away right away, well, then that means you have time to show us and, more importantly, show the American people who need health insurance what exactly you're replacing it with. 如果答案是，嗯，这会造成混乱，我们不想马上夺走人们的保险，好吧，那这意味着你有时间向我们展示，更重要的是，向需要医保的美国人民展示你到底要用什么来取代它。
In that sense -- Ezra, I know that was a long answer but in that sense, the answer is the Republicans, yes, will own the problems with the health care system if they choose to repeal something that is providing health insurance to a lot of people, and providing benefits to every American who has health insurance even if they’re getting it through the job, and they haven't shown us what it is that they’re going to do. Then they do own it. Because that is irresponsible. And even members of their own party, even those who are opposed to me, have said that that is an irresponsible thing to do. 从这个意义上说——埃兹拉，我知道这是个很长的答案，但从这个意义上说，答案是肯定的，如果共和党人选择废除一个为很多人提供医保、为每个有医保的美国人提供福利（即使他们是通过工作获得的）的东西，而他们又没有告诉我们他们打算怎么做，那么他们就要为医疗体系的问题负责。他们确实要负责。因为那是不负责任的。甚至他们自己党内的人，甚至那些反对我的人，都说那样做是不负责任的。
Ms. Kliff: Let me follow up a little bit on the congressional fight. So we saw yesterday President-elect Donald Trump, he said yesterday on Twitter, “It's time for Republicans and Democrats to get together and come up with a health care plan that really works” -- which is something -- I remember you saying similar things in 2009, 2010, when I was covering this debate. 克里夫女士：让我就国会的斗争追问一下。我们昨天看到当选总统唐纳德·特朗普，他昨天在推特上说，"现在是共和党人和民主党人聚在一起，拿出一个真正有效的医疗计划的时候了"——这听起来——我记得你在2009年、2010年也说过类似的话，当时我在报道这场辩论。
Knowing what you know now about partisanship, a President who has tried to do this, was, like you said, unable to get Republican votes -- what three pieces of advice would you give someone trying to attempt to pass a bipartisan health care law? 以你现在对党派之争的了解，作为一位曾尝试过此事的总统，就像你说的，未能获得共和党选票——你会给试图通过两党医保法的人哪三条建议？
President Obama: Well, look, I think I sort of gave the advice just now, which is, if, in fact, this is not about politics but this is about providing the best possible health care system for the American people, then my advice would be to say what precisely is it about Obamacare that you think doesn’t work. Because you’ve already said that there are some things you think do work. 奥巴马总统：你看，我想我刚才已经给出了建议，那就是，如果这真的不是关于政治，而是关于为美国人民提供最好的医疗体系，那么我的建议就是，具体说清楚你认为奥巴马医改哪里行不通。因为你已经说过有些地方你认为是行得通的。
The Republicans keep on saying, well, we want to keep the things that people like and that are working well. So they think that it's a good idea that Obamacare says your kids can stay on your health insurance plan until they’re 26. They think that's a good idea. They think it's a good idea that if you’ve got a preexisting condition you can still get health insurance. I assume they think it's a good idea that seniors have gotten discounts on their prescription drugs -- we closed the doughnut hole during the course of Obamacare. 共和党人一直在说，嗯，我们想保留人们喜欢的、运作良好的那些部分。所以他们认为奥巴马医改规定孩子可以在父母的医保计划上待到26岁是个好主意。他们认为那是个好主意。他们认为有既往病史的人仍然可以获得医保是个好主意。我猜他们认为老年人在处方药上得到了折扣是件好事——我们在奥巴马医改期间填补了"甜甜圈洞"（处方药保险缺口）。
They approve of some of the changes we've made to encourage a health care system that rewards quality rather than just the number of procedures involved, and how we pay providers. 他们赞成我们为鼓励医疗体系奖励质量而非仅仅是程序数量所做的一些改变，以及我们如何支付医疗服务提供者。
So we could make a list of all the things that, as terrible as Obamacare is, actually they think works, according to them. All right, well, let’s make, then, a list of the things they don't like or the American people are concerned about. 所以我们可以列出所有这些东西——尽管奥巴马医改很可怕，但据他们说，实际上这些东西是有效的。好吧，那我们就来列一下他们不喜欢的或者美国人民担心的事情。
Well, what we know is that people would always like lower costs on their premiums and their out-of-pocket expenses. And although the Affordable Care Act provides a lot of subsidies to a lot of people so they can afford health insurance, what is absolutely true is we would love to see even higher subsidies to relieve the costs even more. But that costs money. 嗯，我们知道的是，人们总是希望保费和自付费用更低。虽然《平价医疗法案》为很多人提供了大量补贴，让他们能负担得起医保，但绝对真实的是，我们很乐意看到更高的补贴来进一步减轻负担。但那需要钱。
What we also know is that where we've seen problems in the implementation of the Affordable Care Act, it has been in certain areas, particularly more rural areas, less densely populated areas, where we're not seeing as many insurers so there’s not as much competition. Well, one way that we've suggested we could solve that problem is to say that if, in fact, there aren't enough insurers to drive competition and reduce costs and give people enough choices, then we should have a public option that's available. 我们还知道的是，在《平价医疗法案》实施过程中出现问题的地方，是在某些地区，特别是更多的农村地区、人口不太稠密的地区，那里的保险公司不多，所以竞争不够充分。嗯，我们提出的解决这个问题的一个方法是，如果事实上没有足够的保险公司来推动竞争、降低成本并给人们足够的选择，那么我们应该提供一个公共选项。
So if you look at the things that people are frustrated about with Obamacare, the Affordable Care Act, the big things are the subsidies aren't as high as they’d like and they don't have as many options as they’d like. And I'm happy to provide both those things. I'd sign on to a Republican plan that said we're going to give more subsidies to people to make it even cheaper, and we're going to have a public option where there isn't an option. 所以，如果你看看人们对奥巴马医改、对《平价医疗法案》感到沮丧的地方，主要是补贴不够高，选择不够多。而我很乐意提供这两样东西。我会签署一项共和党计划，只要它说我们要给人们更多补贴，让它更便宜，而且在没有选择的地方要有公共选项。
Here’s the problem. I don't think that's the thing that they want to do. 问题就在这里。我认为那不是他们想做的事。
Ms. Kliff: I don't think so, no. 克里夫女士：我也不这么认为。
President Obama: But I guess my point is this, that it is possible for people of goodwill to try to come up with significant improvements to the law that we already have, but it does require to be specific about what it is that you think needs to be changed. And that, so far, has not happened. 奥巴马总统：但我想我的观点是，善意的人们是有可能对我们已有的法律提出重大改进的，但这确实需要具体说明你认为需要改变什么。而到目前为止，这还没有发生。
And my advice to the President-elect -- in fact, we talked about this when I met with him for an hour and a half right after he got elected -- I said make your team and make the Republican members of Congress come up with things that they can show will actually make this work better for people. And if they’re convincing, I think you would find that there are a lot of Democrats out there -- including me -- that would be prepared to support it. But so far, at least, that's not what’s happened. 我给当选总统的建议——事实上，他当选后我和他见了一个半小时，我们谈过这个——我说，让你的团队和国会的共和党成员拿出他们能证明确实能让这件事更好地为人民服务的东西。如果他们有说服力，我想你会发现有很多民主党人——包括我——会准备支持它。但至少到目前为止，这还没有发生。
Mr. Klein: I think Obamacare has exposed an interesting tension between controlling costs in the system and controlling economic pain for individuals. So the law has, until now, come in under budget. But part of the ways it's done that are higher deductibles than people expected, higher co-pays now in networks. In a couple of years, if it doesn’t change, the excise tax on high-value insurance will come into play, the individual mandate. 克莱因先生：我认为奥巴马医改暴露了一个有趣的矛盾，就是在控制体系成本和控制个人经济痛苦之间的矛盾。所以到目前为止，这项法案的支出低于预算。但它做到这一点的部分方式是，免赔额比人们预期的更高，网络内的自付额也更高。再过几年，如果不改变的话，针对高价值保险的消费税将会生效，还有个人强制参保。
And these things -- individual people -- while they keep the usage of health care down and they keep the cost of health care down, they make health care feel more expensive. They make health care feel unusable. 而这些东西——它们虽然抑制了医疗使用量，压低了医疗成本，但也让人们觉得医疗更贵了。让人们觉得医保用不起了。
Do you think the Affordable Care Act got the balance right on controlling system-wide costs versus insulating individuals from their health expenses? 您认为《平价医疗法案》在控制全系统成本与保护个人免受医疗费用冲击之间取得了恰当的平衡吗？
President Obama: Well, let me make a couple distinctions. First of all, part of what happened at the beginning of the marketplaces -- and for those who aren't wonks -- I was teasing Ezra and Sarah, I said this is like a Wonkapalooza. This is some serious policy detail, here. 奥巴马总统：让我做几个区分。首先，保险市场初期发生的部分情况——对于那些不是政策狂热爱好者的人来说——我刚才还在跟埃兹拉和萨拉开玩笑，我说这就像个"政策狂人大会"。这里讨论的都是些严肃的政策细节。
But so the marketplaces are basically just those places where insurers put up, here’s the insurance package we're offering, and you can choose from a variety of different packages, and then once you’ve chosen you can figure out the subsidies that you're qualified for and that will give you a sense of what your out-of-pocket costs are. 保险市场基本上就是保险公司在那里展示，这是我们提供的保险套餐，你可以从各种不同的套餐中选择，选好之后你就能算出你有资格获得多少补贴，这样你就知道自付费用是多少了。
And what we discovered was that a lot of insurers underpriced early on, because they had done surveys and -- look, people who are purchasing health insurance are like people who are purchasing everything else, they like to get the best deal for the lowest price. What makes health care tricky is, when you buy a TV you can kind of see what the picture looks like; when you're buying health insurance it's tempting to initially buy the cheapest thing -- 我们发现的是，很多保险公司一开始定价过低，因为他们做了调查——你看，买医保的人和买其他东西的人一样，都喜欢以最低的价格获得最好的交易。医保的棘手之处在于，你买电视的时候可以大概看看画质怎么样；而买医保的时候，一开始你很容易就买最便宜的——
until, heaven forbid, you get sick and it turns out, gosh, I can't see the doctor I want or the specialist I want, or this is more inconvenient than I expected. 直到，但愿不要发生，你生病了，然后才发现，天哪，我不能看我想看的医生或专科医生，或者这比我预想的更不方便。
So what ended up happening was people bought, oftentimes, the cheapest insurance that they could. Insurance companies, wanting to get as much market share as possible, ended up creating very low-cost plans, but those are going to have restrictions on them. And that's not just if you're buying health insurance in Obamacare, that's generally how it is even when employers buy health insurance for their employees. 所以最终的结果是，人们常常买他们能买到的最便宜的保险。保险公司想要尽可能多的市场份额，结果就推出了非常低成本的计划，但这些计划是有限制的。这不只是你在奥巴马医改上买医保才会这样，即便雇主为员工购买医保通常也是如此。
Now, I think that what we're seeing is insurers now making adjustments, saying, okay, we need to charge more. And that is something that, the good news is, appears to -- may have stabilized and might be kind of a one-time thing, and now we're in a position to be able to do an evaluation of have we gotten this balance right, as you say. 现在，我认为我们看到的是保险公司正在做出调整，说，好吧，我们需要多收费。而好消息是，这似乎——可能已经稳定下来了，可能是一次性的调整，现在我们可以评估一下，正如你所说，我们是否取得了恰当的平衡。
We can't get health care for free. You're going to have to pay for it one way or another. Either the government is going to pay more so that people don't have as many out-of-pocket costs -- and that means, in some fashion, higher taxes for somebody -- or individuals are going to have to pay more out of pocket in one way or another. 我们不能免费获得医疗保健。你总得以某种方式为之付费。要么政府多付钱，这样人们就不用有那么多自付费用——而这意味着，以某种方式，对某些人提高税收——要么个人就得以这样或那样的方式自付更多。
The same is true for employers. Either employers pay more for a really good health care package, but that takes something out of the employer’s bottom line, or they’re putting more costs onto workers in the form of higher deductibles and higher co-pays. 雇主也是一样。要么雇主为一个非常好的医保套餐多付钱，但这会影响雇主的利润，要么他们就把更多成本以更高免赔额和更高自付额的形式转嫁给工人。
And I think that a lot of the good work that can be done in lowering costs had to do not with cost shifting, but with actually making the system work better. And we've done a lot of work on that. What I referred to earlier, incentivizing a system that instead of ordering five tests because doctors and providers are getting paid for the test, you now have a system where you're going to get reimbursed if the person gets healthy quicker and is not returned to the hospital. Well, it turns out that that can, over time, be a real cost reduction. 我认为，在降低成本方面可以做的很多好工作，与成本转移无关，而是与真正让体系运转得更好有关。我们在这方面做了很多工作。我之前提到的，激励一个体系，不再是因为医生和医疗提供者按检查次数收费就让你做五项检查，而是变成，如果病人康复得更快、不再回到医院，你就能获得报销。嗯，事实证明，随着时间的推移，这可以带来真正的成本降低。
Those are the kinds of things that we're implementing in the system as a consequence of Obamacare. The more we do that kind of stuff the less we're going to see this cost shifting. But the intention has never been to say let’s make it more expensive for people to get health care so they’re going to access the system more. And I think the proof of that is, is that even though per-person costs have not gone up a lot, the overall spending on health care has gone up because more people have come into the system. 这些都是我们正在体系中实施的东西，是奥巴马医改的结果。我们越多做这类事情，我们就越少看到这种成本转移。但我们的意图从来不是说，让人们看病更贵，这样他们就会更多地使用这个体系。我认为证据就是，尽管人均费用没有上涨多少，但整体医疗支出却增加了，因为更多的人进入了这个体系。
We want people to use the health care system. We just don't want them to use it in the emergency room. We want them to use it to stay healthy -- and smoking cessation plans, and making sure that they’re getting regular checkups and mammograms, those are the things that are ultimately going to save us as much money as we can. 我们希望人们使用医疗体系。我们只是不希望他们在急诊室里使用。我们希望他们用它来保持健康——戒烟计划，确保他们定期体检和做乳房X光检查，这些才是最终能为我们节省尽可能多钱的东西。
Ms. Kliff: I have a wonky follow-up question. 克里夫女士：我有一个很"技术宅"的追问。
President Obama: There you go. 奥巴马总统：来就来。
Ms. Kliff: What about controlling prices? We have some of the highest health care prices in the world in the United States. Most other developed countries, they regulate how much you can charge for an MRI, for an emergency room visit, for an appendectomy. That seems like it's really at the core of this tension, the fact that we have these very high prices. Americans don't go to the doctor more, we just pay a lot more when we go to the doctor. That is something the health care law did not tackle. 克里夫女士：控制价格方面呢？美国的医疗价格是世界上最高的。大多数其他发达国家都会监管做一次核磁共振、一次急诊、一次阑尾切除术能收多少钱。这似乎真的是这个矛盾的核心，就是我们有这么高的价格。美国人并没有更频繁地去看医生，我们只是在看医生的时候付得多得多。这是医保法没有解决的问题。
And I'm curious to hear you reflect on that and what you would think about the role of price controls in American medicine. 我很想听听您对此的反思，以及您对价格管制在美国医疗中的作用有何看法。
President Obama: Well, look, this is the irony of this whole debate, is the things that people are most dissatisfied with about Obamacare, about the Affordable Care Act, are things that essentially in other countries are solved by more government control, not less. And so Republicans are pointing at these things to stir up dissatisfaction, but when it comes to, all right, what’s the solution for it, their answer is less government regulation and letting folks charge even more and doing whatever they want and letting the marketplace work its will. 奥巴马总统：你看，这就是整场辩论的讽刺之处，人们对奥巴马医改、对《平价医疗法案》最不满意的事情，恰恰是在其他国家通过更多政府控制而不是更少来解决的问题。所以共和党人指着这些事情来煽动不满，但当说到，好吧，那解决方案是什么呢，他们的答案却是更少政府监管，让人们收更多费，想怎么做就怎么做，让市场自己发挥作用。
I think that there are strengths to our system because we have a more market-based system. Our health care system is more innovative. Prescription drugs is probably the best example of this. It is true that we essentially come up with the new drugs in this country because our drug companies are fat and wealthy enough that they can invest in the research and development. They make bigger profits, which they can, then, plow back into drug development. And essentially we have a lot of other countries that are free riders on that system. 我认为我们的体系有其优势，因为我们有一个更市场化的体系。我们的医疗体系更具创新性。处方药可能是最好的例子。的确，我们基本上是在这个国家发明新药的，因为我们的制药公司足够富裕，有足够的钱投资于研发。他们赚取更高的利润，然后可以再投入到药物开发中。基本上，其他很多国家都在这个体系上搭便车。
So they can negotiate with the drug companies and force much lower prices, but they generally don't have a drug industry that develops new drugs. 所以他们可以和制药公司谈判，迫使价格低得多，但他们通常没有一个开发新药的制药业。
That's true. This is an example where you probably do want some balance to maintain innovation, but to have some tougher negotiations around the system as a whole. And we are trying to use Medicare as the place where, since there’s no health care provider or stakeholder in the health care industry that doesn’t in some ways want to get Medicare business, we're trying to use Medicare as a lever to get better deals for consumers and better prices for consumers -- not just those in Medicare, but also people throughout the system. 这是事实。这是一个你可能确实需要某种平衡来维持创新的例子，但也要围绕整个体系进行更艰难的谈判。我们正试图将联邦医疗保险作为一个杠杆点，因为没有哪个医疗服务提供者或医疗行业利益相关者不在某种程度上想要获得联邦医疗保险的业务，我们正试图利用联邦医疗保险为消费者争取更好的交易和更低的价格——不仅仅是联邦医疗保险的参保者，也包括整个体系中的人们。
But as I said, the irony is, is that when we tried to do that the people who are most resistant are the very Republican members of Congress who are criticizing us -- or at least telling the American people that you should want lower prices on various procedures. 但正如我所说，讽刺的是，当我们试图这样做时，最抵制的正是那些批评我们的共和党国会议员——或者至少是告诉美国人民你们应该希望各种程序价格更低的那些人。
If we want to control prices for consumers more, then the marketplace by itself will not do that. And the reason is because health care is not exactly like other products. It's not like buying a flat-screen TV. If you're sick, or if your kid is sick, most of the time you're not in a position to negotiate right there and then. You can't walk out of the store and say, well, I'm going to see if I can get a better deal. You're trying to figure out -- like when Sasha got meningitis when she was four months old -- make my child better, and that's all -- and I'll worry about the costs later. 如果我们想更多地为消费者控制价格，市场本身是做不到的。原因是医疗保健不像其他产品。它不像买一台平板电视。如果你生病了，或者你的孩子生病了，大多数时候你根本没有谈判的立场。你不能走出商店说，好吧，我去看看能不能找到更便宜的。你满脑子想的都是——就像萨沙四个月大时得了脑膜炎那次——让我的孩子好起来，别的都——费用以后再说。
And that's the mentality that most people have when it comes to health care. 而这就是大多数人面对医疗保健时的心态。
So the traditional models of the marketplace don't work perfectly in the health care system. There are areas where we can increase marketplace competition. There are areas in which we can make it work better. But ultimately, if we want to really get at some of these costs, there has to be some more expensive regulation in certain areas than we currently have. 所以传统的市场模式在医疗体系中不能完美运作。有些领域我们可以增加市场竞争。有些领域我们可以让它运转得更好。但归根结底，如果我们真的想解决其中一些成本问题，在某些领域必须要有比目前更多的监管。
Ms. Kliff: So I recently took a trip to an area of Kentucky -- on a slightly different topic -- I saw some huge coverage gains under the health care law, but also voted overwhelmingly for President-elect Trump. And one of the people I met there was Kathy Oller, who’s here with us today. She is an Obamacare enrollment worker who has signed up more than a thousand people for coverage. She supported you in 2008 and 2012, but voted for President-elect Trump in 2016, and expects him to improve on the Affordable Care Act. And she would like to ask you a question about that. 克里夫女士：我最近去了肯塔基州的一个地区——换个稍微不同的话题——我看到医保法带来了巨大的参保率提升，但那里也以压倒性多数投票给了当选总统特朗普。我在那里遇到的一个人叫凯西·奥勒，她今天也和我们在一起。她是一名奥巴马医改的登记工作人员，已经为一千多人登记了保险。她在2008年和2012年支持您，但在2016年投票给了当选总统特朗普，并且期望他能改进《平价医疗法案》。她想问您一个关于这方面的问题。
President Obama: Go ahead, Kathy. 奥巴马总统：来吧，凯西。
Question: Hello, President Obama. I'm so excited to meet you. 提问：您好，奥巴马总统。见到您我太激动了。
President Obama: It's good to see you. 奥巴马总统：很高兴见到你。
Question: Thanks. I'm a little bit nervous, as you can see. But over the years, I've enrolled and talked to numerous Kentuckians, and I've signed up some the first time -- so it was working -- in the Affordable Care Act. And also we've been, going over the years, and I've talked to people. But recently we found out that there was fewer choices in our area, and the increase in the premiums and deductibles, and our facilities aren’t even taking some of them. And many Kentuckians now are looking at the Affordable Care as unaffordable and unusable. 提问：谢谢。您看得出来，我有点紧张。但这些年来，我为肯塔基州的很多人登记过，也和他们聊过，我第一次为一些人登记了——所以它是有效的——《平价医疗法案》的保险。这些年来，我们一直在做，我也和人们交谈。但最近我们发现我们地区的选择更少了，保费和免赔额都上涨了，我们的医院甚至都不接受其中一些保险了。现在很多肯塔基人觉得平价医疗法案既负担不起又用不了。
And I have the opportunity to ask you a few questions that you have probably went over, but how do you think this happened? How can we fix it? Do we start all over again? What do you think we should do? 我有机会问您几个问题，您可能已经讨论过了，您认为这是怎么发生的？我们该怎么修复？我们要从头开始吗？您认为我们应该怎么做？
President Obama: Well, first of all, Kathy, I want to thank you for being out there enrolling people. 奥巴马总统：首先，凯西，我要感谢你一直在那里帮人们登记。
Question: Thank you. 提问：谢谢您。
President Obama: That’s been hugely important. 奥巴马总统：那一直非常重要。
The second point I would make is that Kentucky is a place where this has really worked, and it’s worked for two reasons. One is Kentucky expanded Medicaid. And we haven’t talked a lot about that, but a big chunk of Obamacare was just making Medicaid accessible to more people. And those states that expanded Medicaid have seen a much bigger drop in the uninsured than those states who didn’t. 我要说的第二点是，肯塔基州是一个这项法案真正奏效的地方，它奏效有两个原因。一是肯塔基州扩大了医疗补助。我们还没有怎么谈过这个，但奥巴马医改很大一部分就是让更多人能够获得医疗补助。那些扩大了医疗补助的州，没有参保的人数下降幅度比没有扩大的州大得多。
And by the way, those states that didn’t, they didn’t do so just out of politics -- I’ll just be very blunt -- because the federal government was going to pay for this Medicaid expansion. And there are some states, because they had all this uncompensated care, ended up making money by providing more health insurance to your people. It was a hard bargain -- a hard deal to turn down, and yet you got a number of states that turned it down mainly because Republican governors and Republican state legislatures didn’t want to make it work. 顺便说一句，那些没有扩大的州，他们不这么做不只是出于政治原因——我就直说了——因为联邦政府本来会为医疗补助扩大买单。有些州，因为有这么多无偿医疗，通过为人民提供更多医保反而赚钱了。这是一个很难拒绝的——很难拒绝的交易，然而有很多州拒绝了，主要是因为共和党州长和共和党州议会不想让它成功。
Kentucky, under Steve Beshear, was one of those people that did expand Medicaid, had a really active program. Because I don’t poll that well in Kentucky, they didn’t call it Obamacare, they called it Connect -- Kentucky Connect, right? 在史蒂夫·贝希尔领导下的肯塔基州，是那些确实扩大了医疗补助的州之一，有一个非常积极的项目。因为我在肯塔基州的民调不是那么好，他们没叫它奥巴马医改，他们叫它"连接"——肯塔基连接，对吧？
And so there were a whole lot of people who said, well, we don’t like Obamacare but I like this program and we’ll signed you up, right? You signed people up, you didn’t tell them it was Obamacare all the time. And it’s actually worked. Right? 所以有很多人说，嗯，我们不喜欢奥巴马医改，但我喜欢这个计划，我们会报名参加，对吧？你帮人们登记，你不会总告诉他们这是奥巴马医改。而它实际上奏效了。对吧？
Now, what is true in Kentucky, though, is true in some other states. You had a governor who ran explicitly on the idea of rolling back Obamacare even though it was working. And so the state marketplace, the state exchange he dismantled, which means we had to shift everything onto the federal exchange. Most people got shifted, but it indicated a lack of interest and effort on his part in making the thing work. He promised to roll back Medicaid, but he started realizing that wasn’t as good politics as he thought it was when he was running, so he hasn’t done that. 然而，肯塔基州的真实情况，在其他一些州也是如此。你们有一位州长明确以撤销奥巴马医改为竞选纲领，尽管它是有效的。所以州市场、州交易所被他解散了，这意味着我们不得不把一切都转移到联邦交易所。大多数人都转过去了，但这表明了他对让这件事奏效缺乏兴趣和努力。他承诺撤销医疗补助，但他开始意识到这不像他竞选时想的那么好做政治文章，所以他还没有那么做。
But what is also true is -- and this is my main criticism of Obamacare, of the Affordable Care Act -- is that the subsidies aren’t as high as they probably should be for a lot of working people. If you don’t qualify for Medicaid where you don’t have to pay, for the most part, for your coverage, and instead you’re buying health insurance on the marketplace -- so you’re a working person but you don’t have a lot of money, and particularly if you are older, where you use the health care system more and you need a better benefit package than somebody 18 or 20 might, 但同样真实的是——这也是我对奥巴马医改、对《平价医疗法案》的主要批评——对于很多工薪阶层来说，补贴可能不够高。如果你不符合医疗补助的资格（医疗补助大部分是免费的），而是在市场上购买医保——那么你是一个工薪阶层但钱不多的人，尤其是如果你年纪更大，使用医疗体系更多，需要比18岁或20岁的人更好的福利套餐，
then there are families where the premiums are still too high. 那么有些家庭的保费还是太高了。
And as I said earlier, there are some parts of the country where there are only a handful of hospitals and a few doctors, and where you don’t have a lot of competition, and the insurers are looking and they’re saying, we’re not going to make a lot of money there, so you don’t end up having a lot of insurance plans in those areas. 正如我之前所说，这个国家有些地区只有少数几家医院和几名医生，没有太多竞争，保险公司看了之后说，我们在那里赚不了多少钱，所以那些地区最终没有很多保险计划。
So the two things that we could do that would really make it work even better for people in Kentucky would be, number one, provide more subsidies to folks who are working hard every day but still find the premiums even with the subsidies hard to meet, and have the public option for those communities where they’re not getting a lot of competition and insurers aren’t coming in. 所以我们可以做的、能让肯塔基州的人们觉得更有效的两件事是，第一，为那些每天努力工作但即使有补贴仍然觉得保费难以承担的人们提供更多补贴，第二，为那些没有很多竞争、保险公司不愿进入的社区提供公共选项。
The problem is, is that that's not what's being proposed by Mitch McConnell, the senator from Kentucky. Instead what he's proposing, I gather, is you're going to repeal the law, then you're going to come up with something, except you will have taken away all the -- the way we pay for the subsidies for working people is we're taxing wealthier folks at a little bit higher. So he wants to cut those taxes, and that money would be gone right away. 问题是，这不是肯塔基州参议员米奇·麦康奈尔提出的东西。相反，我猜想他提议的是，你要废除这项法律，然后你会想出点什么，只不过你会拿走所有——我们为工薪阶层提供补贴的方式是对富人多征一点税。所以他想削减那些税收，那笔钱马上就没了。
And then he's going to promise you, or those people who you've been signing up, better health care, except there's not going to be any money to pay for it. And nobody has explained to me yet how that's going to work. 然后他会向你承诺，或者向你一直在登记的那些人承诺更好的医保，只不过不会有任何钱来支付它。至今没有人向我解释这怎么行得通。
And so I think this takes me back to the point I made earlier. If, in fact, the people you've been signing up, the folks in your communities, are not fully satisfied with the benefits that they're getting now and are hopeful for something better, then at the very least you should be putting pressure on your members of Congress to say, show us exactly what the deal is going to be for us before you take away the deal that we got. Because the people you sign up, they may not be as happy as they'd like, but -- tell me if I'm wrong -- they like it better than not having any insurance at all. 所以我想这又回到了我之前提出的观点。如果事实上，你一直在登记的那些人，你社区里的人们，对他们现在获得的福利不完全满意，并且期望得到更好的东西，那么至少你应该向你的国会议员施压，说，在你夺走我们现有的东西之前，先告诉我们你到底要给我们什么。因为你登记的那些人，他们可能不像他们希望的那么满意，但——告诉我我是不是错了——但他们总比完全没有保险强。
Ms. Kliff: And some didn’t even have insurance. 克里夫女士：有些人甚至根本没有过保险。
President Obama: And some people didn’t have insurance. Because I get letters from folks who say, for the first time in my life -- I have had a bad hip for 15 years and I've been pain-free for the first time because I finally got insurance. So the answer is not for them not to have insurance. And if we go back to a system where they've got to buy it on their own, they're not going to buy it because they'll have even less subsidy. 奥巴马总统：有些人根本没有过保险。因为我收到人们的来信说，我这辈子第一次——我髋关节不好已经15年了，第一次不再疼痛了，因为我终于有了保险。所以答案不是让他们没有保险。如果我们回到一个他们必须自己购买的体系，他们是不会买的，因为他们的补贴会更少。
How much time do we got? 我们还有多少时间？
Mr. Klein: I think we're quite low. 克莱因先生：我想时间不多了。
President Obama: We got low time? Because I got all kinds of more stuff. 奥巴马总统：时间不多了？我还有好多话要说呢。
Mr. Klein: Well, it's your schedule. We're happy to keep you as long as you'd like. 克莱因先生：这是您的日程。您想待多久我们都乐意。
President Obama: Well, there are a couple points I want to make in closing -- 奥巴马总统：嗯，最后我想讲几点——
Mr. Klein: Excellent. 克莱因先生：好极了。
President Obama: -- but why don’t you ask some questions. 奥巴马总统：——不过你还是先问几个问题吧。
Mr. Klein: So one thing we haven’t touched on yet in much detail is the delivery system of follow-ups, which are a big part of the law. So what is a policy or experiment or change in that space that has over-performed your expectations? And what's one that has maybe not panned out as you’d liked or hoped? 克莱因先生：有一件事我们还没有详细讨论过，就是医疗服务递送体系改革，这是法案的重要组成部分。那么在那个领域，有没有哪项政策或实验或变革超出了您的预期？有没有哪项可能没有达到您的期望或希望？
President Obama: You know, I think a good example of something that's worked better than we expected, or at least worked as well as we expected is the issue of hospital readmissions. Now, it turns out that a lot of times you go to the hospital -- let's say, you get your appendix taken out, and then you go home and then there's a complication, and then you have to go back into the hospital. That's obviously inconvenient for you and it's expensive for the system as a whole. And it turns out that there are just a few things that you can do that help reduce people being readmitted. 奥巴马总统：我认为一个比我们预期效果更好的例子，或者至少和我们预期一样好的例子，是医院再入院问题。事实证明，很多时候你去医院——比如说，你做了阑尾切除手术，然后你回家了，然后出现了并发症，然后你又得回医院。这对你来说显然很不方便，对整个体系来说也很昂贵。而事实证明，你只需要做几件事就能帮助减少病人再入院。
First of all, making sure that the first procedure goes well, but, secondly, making sure that there's good follow-up. So it might be that a hospital or a health care system pays for, when you do go home, you just getting some phone calls to remind you to take the medicine that you got to take to make sure you heal properly -- because they may have done a study and it turns out that people forget to do what they're supposed to do, they don’t follow exactly their doctor's instructions, and they can't afford to have a nurse in their house who's doing it for them. 首先，确保第一次手术做得好，其次，确保有良好的后续跟进。可能是医院或医疗体系付费，在你回家后，给你打几个电话提醒你按时吃药，确保你正确康复——因为他们可能做过研究，结果发现人们会忘记做他们该做的事，他们不完全遵守医生的指示，他们也负担不起请个护士到家里来帮他们做这些。
Well, maybe there are just a few things that can be done to help make sure that they do what they are supposed to do, and that way they don’t have complications. 嗯，也许只需要做几件事就能帮助确保他们做他们该做的事，这样他们就不会出现并发症。
What we've seen is a significant reduction in hospital readmissions over the course of this law just by doing some smart incentivizing, just saying to the hospitals we'll reimburse you or we'll give you some other benefit for doing smart follow-up. That's an area where I think we've made some real progress. 我们看到的是，在这项法案实施期间，仅仅通过一些聪明的激励措施——比如对医院说，我们会给你报销或者给你一些其他福利，只要你做好后续跟进——医院再入院率就显著下降了。我认为这是我们取得了一些真正进展的领域。
The other place -- and this is connected -- where I think we've got some good bipartisan support is just encouraging what's called -- shifting from what's called fee-for-service payments, where you get paid by the procedure, which means that you may end up getting five tests instead of getting one test that's emailed to five providers who are treating you. And we've started to see some real movement when we say to the system as a whole we're going to pay you for outcomes -- did the patient do well. And that has been helpful. 另一个领域——这是相关的——我认为我们得到了一些很好的两党支持的，就是鼓励所谓的——从按服务收费转向按结果付费，按服务收费就是你做多少程序拿多少钱，这意味着你可能最后做了五项检查，而不是做一项检查然后电邮给五位治疗你的医生。我们已经开始看到一些真正的转变，当我们对整个体系说，我们会为结果付费——病人是否康复得好。这是有帮助的。
In terms of areas where I think we haven’t seen as much improvement as I'd like, it's probably -- one thing that comes to mind is on the electronic medical records. If you think about how wired and plugged in everybody is now -- I mean, you can basically do everything off your phone. The fact that there are still just mountains of paperwork, and you don’t understand what these bills are that still get sent to your house, and nobody -- and the doctors still have to input stuff, and the nurses are spending all their time on all this administrative work -- 至于我认为改进没有我希望的那么多的领域，大概是——我想到的一件事是电子病历。如果你想想现在每个人有多电子化、多联网——我的意思是，你基本上可以用手机做任何事情。然而，仍然有成堆的文书工作，你看不懂那些寄到你家里的账单，而且没有人——医生仍然需要输入信息，护士把所有时间都花在行政工作上——
we put a big slug of money into trying to encourage everybody to digitalize, catch up with the rest of the world here. 我们投入了大量资金来鼓励每个人数字化，赶上世界其他地方的步伐。
And it's proven to be harder than we expected, partly because everybody has different systems, they don’t all talk to each other. It requires retraining people in how to use them effectively. And I'm optimistic that over time it's inevitable that it's going to get better, because every other part of our lives, it's become paperless. But it's been a lot slower than I would have expected. 但事实证明这比我们预期的要难，部分原因是每个人都有不同的系统，它们之间不能互相通信。这需要重新培训人们如何有效使用它们。我很乐观，随着时间的推移，它不可避免地会变得更好，因为我们生活的其他方面都已经无纸化了。但它比我预期的要慢得多。
And some of it has to do with the fact that, as I said, it's decentralized and everybody has different systems. In some cases, you have sort of economic incentives that are pushing against making the system work better. For example, there are service providers -- people make money on keeping people's medical records, so making it easier for everybody to access each other's medical records means that there are some folks who could lose business. And that has turned out to be a little more complicated than I expected. 部分原因在于，正如我所说，它是分散的，每个人都有不同的系统。在某些情况下，还有一些经济激励在阻碍体系更好地运转。例如，有些服务提供商——人们靠保管人们的医疗记录赚钱，所以让每个人更容易获取彼此的医疗记录意味着有些人可能会失去生意。这比我预期的要复杂一点。
Ms. Kliff: Do you have any closing remarks? And one thing I'm interested in is kind of what you see your role in this debate we're gearing up for. 克里夫女士：您有什么结束语吗？还有一件事我很感兴趣，就是您认为在这场我们即将展开的辩论中，您将扮演什么角色？
President Obama: Well, let me make a couple of closing remarks. Number one, I think it is important to remember that just because people campaigned on repealing this law, it is a much more complicated process to repeal this law than I think was being presented on the campaign trail, as my Republican friends are discovering. 奥巴马总统：让我做几点总结。第一，我认为重要的是要记住，仅仅因为人们在竞选时承诺废除这项法律，真正废除这项法律的过程要比竞选活动中呈现的复杂得多，正如我的共和党朋友们正在发现的那样。
The way this process is going to work, there's this rushed vote that's taking place this week, next week to -- quote, unquote -- "repeal Obamacare." But really all that is, is it's a resolution that is then instructing these committees in Congress to start actually drafting a law that specifically would say what's being repealed and what's not. Then, after that, they'd have to make a decision about what's going to replace it and how long is that going to take. And that stretches the process out further. 这个过程的运作方式是，这周、下周会有一个仓促的投票来——所谓的——"废除奥巴马医改"。但实际上那只是一个决议，指示国会的这些委员会开始真正起草一项法律，具体说明哪些被废除，哪些没有。然后，在那之后，他们必须决定用什么来取代它，以及需要多长时间。这会把过程拉得更长。
And so I think, whether you originally supported Obamacare or you didn’t, whether you like me or you don’t, the one thing I would just ask all the American people to do is adopt the slogan of the great state of Missouri -- "Show me." Show me. Do not rush this process. 所以我认为，无论你最初是否支持奥巴马医改，无论你是否喜欢我，我只想请求所有美国人民做一件事，那就是采用伟大的密苏里州的口号——"拿给我看"。拿给我看。不要仓促行事。
And to Republicans, I would say: What are you scared of? If you are absolutely convinced, as you have been adamant about for the last seven years, that you can come up with something better, go ahead and come up with it. And I'll even cut you some slack for the fact that you've been saying you can come up with something better for seven years and I've never seen it. But we'll restart the clock. 我要对共和党人说：你们在怕什么？如果你们像过去七年一直坚称的那样，绝对相信你们能想出更好的东西，那就去想出来吧。我甚至可以给你们一些宽限，尽管你们七年来一直说你们能想出更好的东西，而我从来没见过。但我们可以重新计时。
It's interesting that we're here in the Blair House because this is a place where I met, in front of the American people, with Republicans who had already indicated their adamant opposition to health care. And I sat with them for a couple hours -- how long was it? 很有意思，我们现在在布莱尔宫，因为就是在这里，我当着美国人民的面，与那些已经明确表示坚决反对医改的共和党人会面。我和他们坐了几个小时——有多久来着？
Secretary Sebelius: Eight. 塞贝利厄斯部长：八小时。
President Obama: Eight hours. Kathleen Sebelius, who is my Secretary of Health and Human Services, remembers -- for eight hours, on live TV, to talk about here's why we're trying to do what we're doing here, and challenging them to come up with better answers than the ones we had come up with. And we spent a year of really significant debate. 奥巴马总统：八小时。凯瑟琳·塞贝利厄斯，我的卫生与公众服务部部长，记得——八个小时，电视直播，讨论我们为什么要做我们在这里试图做的事情，并挑战他们拿出比我们想出的更好的答案。我们花了一年时间进行真正重要的辩论。
And I would think that given that we now have proof that 20 million people do have health insurance, that we're at the lowest rate of uninsured in our history, that health care costs, rather than spiking way up, have actually gone up slower than they have in 50 years; given that the vast majority of people who get health insurance through Obamacare have said they're satisfied with their care and that they're better off than when they didn’t have care; 我认为，既然我们现在有证据表明2000万人确实有了医保，我们的无保率处于历史最低水平，医疗费用没有飙升，实际上其上涨速度是50年来最慢的；既然绝大多数通过奥巴马医改获得医保的人都说他们对自己的医疗服务感到满意，他们比没有医保时过得更好；
given that even though a lot of people don’t know it, even if you're not getting health insurance through Obamacare, you've benefitted, because if you get health insurance on the job, it now doesn’t have a lifetime limit, it doesn’t have fine print that could end up costing you a lot of money -- given all those things, I would think that you'd at least want to explain to the American people what it is that you want to do. 既然尽管很多人不知道，但即使你不是通过奥巴马医改获得医保，你也受益了，因为如果你是通过工作获得医保，它现在没有终身赔付限额了，没有那些可能最终让你花很多钱的小字条款了——既然有了所有这些，我认为你至少应该想向美国人民解释你想做什么。
And that, I think, is a minimum expectation out of this Congress and out of the President-elect. 而这，我认为，是对本届国会和当选总统的最低期望。
I'm make a second point, and that is that we just worked, on a bipartisan basis, to sign something called the Cures Bill that included two really important bipartisan priorities. One was Joe Biden's Cancer Moonshot initiative -- because we're seeing so many medical breakthroughs in so many areas that we have an opportunity to make a real dent in how we deal with cancer, which affects everybody in some fashion -- somebody has been touched in your family with this terrible disease. 我要讲第二点，那就是我们刚刚在两党基础上合作签署了一项名为《治愈法案》的东西，其中包含两项真正重要的两党优先事项。一项是乔·拜登的"癌症登月计划"——因为我们在很多领域看到了如此多的医学突破，我们有机会真正在应对癌症方面取得重大进展，癌症以某种方式影响着每个人——你的家人中总有人被这种可怕的疾病触动过。
So we got a lot more money for research in that, and the bill also contained a big investment in the opioid challenge. 所以我们为此获得了更多研究资金，该法案还包含了对阿片类药物挑战的大量投资。
As many of you know, you’re seeing more and more communities that are being ravaged by, initially, prescription drugs; then that ends up being a gateway into heroin, some of which, like synthetic heroin being produced called Fentanyl, just has terrible rates of overdose deaths. And this is not an inner-city problem, per se, but this is reaching every community. In some ways, it’s worse in a lot of rural communities. 你们中很多人都知道，越来越多的社区正在遭受摧残，最初是处方药；然后那变成了通往海洛因的门户，其中一些，比如被称为芬太尼的合成海洛因，有着可怕的过量死亡率。这不是一个市中心的问题，严格来说，但它正在蔓延到每个社区。在某些方面，很多农村社区情况更糟。
So there was a bipartisan effort for us to put some more money into that. But here’s the thing. If we just put money into cancer research, and we just put money into dealing with the opioid crisis, and now we’re taking away money that is providing drug treatment services in those very same communities by repealing Obamacare, and taking away the ability to access a doctor to get new cancer treatments, then we’re not really helping anybody. So that’s a second point I want to make. 所以我们为此投入更多资金是两党共同的努力。但问题是，如果我们只把钱投入癌症研究，只把钱投入应对阿片类药物危机，而现在我们又通过废除奥巴马医改拿走了在这些同样社区提供药物治疗服务的钱，拿走了获得医生和新癌症治疗的机会，那我们其实没有帮助任何人。这是我想讲的第二点。
A third point I want to make is that I would encourage local communities to get involved in this process. And I think part of the problem with this whole law has been that the people who benefit aren’t out there making noise, and the people who ideologically have opposed it have been really loud. Well, now is the time for people who have benefitted or seen their families benefit to tell their stories. 我想讲的第三点是，我会鼓励地方社区参与到这个过程中来。我认为这项法律的部分问题在于，受益的人没有站出来发声，而那些在意识形态上反对它的人却一直非常大声。现在，是时候让那些受益或看到家人受益的人们讲述他们的故事了。
Because, ultimately, this is not a political game. This is really something that affects people in the most personal ways. My friend, Natoma Canfield, is here in the front row. Some of you heard Natoma’s story before, where -- a cancer survivor who, because she had now a preexisting condition, was faced with either keeping her health insurance at such a high rate -- the only way she could get health insurance with a preexisting condition was to basically pay so much that she could no longer afford to pay the mortgage on her house. 因为，归根结底，这不是一场政治游戏。这真的是以最个人的方式影响人们的事情。我的朋友纳托玛·坎菲尔德就在前排。你们有些人以前听过纳托玛的故事，她——一位癌症幸存者，因为她现在有了既往病史，面临着要么以如此高的费率继续保留医保——她有既往病史还能获得医保的唯一办法就是付那么多钱，多到她再也付不起房子的抵押贷款。
And I remember her writing to me, and I thought, that could be my mom. That could be yours. And that’s not a choice that people should have to make. And when most people, even if they’re not Obama supporters, hear Natoma’s story or the stories of other people who have been helped, they know it’s wrong to just take away their health care. And it becomes less about who’s winning here in Washington. It becomes about how are we doing right by our fellow Americans. 我记得她给我写信，我当时想，那可能是我妈妈。那可能是你们的妈妈。那不是人们应该被迫做出的选择。而当大多数人，即使不是奥巴马的支持者，听到纳托玛的故事或其他得到帮助的人的故事时，他们知道就这样夺走他们的医保是不对的。这变得不再是谁在华盛顿赢了的问题。而是我们如何善待我们的美国同胞的问题。
But those stories have to be heard. And I would just encourage people to start telling their stories. And tell their stories -- you’re not always going to get a lot of attention here in Washington because they want to know this vote and this insult that was hurled back-and-forth between whoever. But you know what, tell that story in your local newspapers. Talk to your local reporters. Congregations that are involved in caring for those in need, make sure that you’re telling stories in church and in services so that people know. 但这些故事必须被听到。我只是鼓励人们开始讲述他们的故事。讲述他们的故事——你在华盛顿不一定总能得到很多关注，因为他们想知道这次投票和那次对骂，谁和谁吵了一架。但你知道吗，在你们当地的报纸上讲那个故事。和你们当地的记者谈谈。参与关爱有需要之人的教会团体，确保你们在教堂和礼拜仪式上讲故事，让人们知道。
Because the one thing that I’m convinced about is the American people want to do the right thing. They just -- it’s hard to get good information, and unless you’re reading Vox every day, which is hard to do -- 因为我深信一件事，美国人民想做正确的事。他们只是——很难获得好的信息，而且除非你每天都读Vox，这很难做到——
Mr. Klein: It’s not that hard to do. 克莱因先生：没那么难。
President Obama: -- getting the details of all this policy is hard. It’s complicated. You don’t know what’s true; you don’t know what’s not true. 奥巴马总统：——搞清楚所有这些政策细节是很难的。太复杂了。你不知道什么是真的；你不知道什么不是真的。
I mean, those folks in Kentucky that you’ve signed up -- there are a lot of people who voted for not just a President, but also for a member of Congress who said, explicitly, we’re going to eliminate this. Well, I understand why people might think, okay, well, he’s going to eliminate it, but he will give us something better. But this is hard. And what you don’t want is a situation where they make a promise that they can’t keep. 我的意思是，你在肯塔基州登记的那些人——很多人投票不仅给一位总统，也给一位国会议员，那位议员明确说，我们要废除它。嗯，我理解为什么人们可能会想，好吧，他要废除它，但他会给我们更好的东西。但这很难。你不想要的是一种他们许下无法兑现的承诺的局面。
And I’ve worked on this a long time. If we had had a better way to do this, we would have done it. It would have been in my interest to do it, because I knew I was going to be judged on whether or not it worked. And those areas that don’t work had to do with there not being enough money in the system and not having a public option. And I’m more than happy to put those fixes in place, anytime, anyplace. But that’s not, so far, what the Republicans are proposing. You deserve to know what it is that they’re doing. 我在这上面工作了很长时间。如果我们有更好的办法，我们早就做了。那么做符合我的利益，因为我知道我会因它是否有效而被评判。而那些行不通的领域，是因为体系中没有足够的资金，也没有公共选项。我非常乐意在任何时间、任何地点实施这些修复。但至少到目前为止，这不是共和党人提出的东西。你们有权知道他们在做什么。
So, anyway, I appreciate you guys taking the time to tell the story. 所以，不管怎样，感谢你们花时间讲述这个故事。
Mr. Klein: Real quick, Sarah had asked about your role going forward. 克莱因先生：快问一下，莎拉之前问过您接下来的角色。
President Obama: Oh, my role going forward? Well, look, I mean, I do deserve a little sleep. And I’ve got to take Michelle on a vacation. But I’ve said consistently that the most important office in a democracy is the office of citizen. And I will be a citizen who still remembers what it was like when his mom died of cancer younger than I am now, and who didn’t have all the insurance and disability insurance and support, and wasn’t using the health care system enough to have early detection that might have prevented her from passing away. 奥巴马总统：哦，我接下来的角色？你看，我确实该好好睡一觉了。我还要带米歇尔去度个假。但我一直说，民主制度中最重要的职位是公民的职位。我会作为一个公民，仍然记得他的母亲在比我现在还年轻的时候死于癌症，没有足够的保险和伤残保险及支持，也没有充分利用医疗体系进行早期检测，那本可以防止她去世。
You know, Michelle’s dad had multiple sclerosis -- MS -- but was part of that generation that just didn’t have a lot of expectations about health care and so just kind of suffered for years. I mean, those are our stories. So it’s not like I’m going to suddenly fade away on this. I will be a part of the work of our fellow citizens in trying to make sure that the wealthiest country on Earth is able to do the same thing that every other advanced country is able to do. 你知道，米歇尔的爸爸患有多发性硬化症——MS——但他属于那一代人，对医疗保健没有太多期望，所以就那么忍受了很多年。我的意思是，这些都是我们的故事。所以我不会在这件事上突然消失。我会成为我们同胞努力的一份子，确保地球上最富有的国家能够做到其他每一个发达国家都能做到的事情。
I mean, it’s not as if this has never been done before. If you’re in Canada, you got health care, no matter who you are. If you’re in France, you got health care. If you’re in England, you got health care. If you’re in Australia, you got health care. If you’re in New Zealand, you got health care. 我的意思是，这又不是什么从未做过的事。如果你在加拿大，无论你是谁，你都有医保。如果你在法国，你有医保。如果你在英国，你有医保。如果你在澳大利亚，你有医保。如果你在新西兰，你有医保。
I remember talking to my friend, John Key, who was the Prime Minister of New Zealand. He is part of the Conservative Party in New Zealand. And he said to me in the middle of this health care debate, he said, boy, if I proposed that we took away people’s health care, that we repealed it, I’d be run out of office by my own party. Because it was just assumed that, in a country this wealthy that this is one of the basic rights, not privileges, of citizenship in a well-to-do country like ours. 我记得和我的朋友约翰·基谈过，他是新西兰前总理。他是新西兰保守党的。他在医保辩论最激烈的时候对我说，他说，如果我提议夺走人们的医保，我们要废除它，我会被我自己的党赶下台的。因为大家都认为，在一个这么富裕的国家，这是公民的基本权利之一，而不是特权，在我们这样富裕的国家。
So I’ll be working with all of you. But my voice is going to be less important than the voices of people who are directly affected. And so I would urge everybody to make your voice heard. Now is the time to do it. 所以我会和你们所有人一起努力。但我的声音不如那些直接受影响的人的声音重要。所以我会敦促每个人都发出你们的声音。现在是时候了。
The people who have opposed this were opposing it not based on facts, but were opposing it based on sort of an ideological concern about expansion on the state, and taxes on wealthier people that are helping people who don’t have as much money. And I respect their role in the democracy. They’ve been really fighting hard. Well, folks here got to fight just as hard. 那些反对这件事的人不是基于事实反对的，而是基于一种意识形态上的担忧，即国家的扩张，以及对帮助不那么富裕的人的富人征税。我尊重他们在民主中的角色。他们一直非常努力地战斗。那么，这里的人们也必须同样努力地战斗。
My final piece of advice would be to the news media, which is, generally speaking, when Obamacare has worked well it wasn’t attributed to Obamacare, and when there were problems they got front-page headlines. And I think that, hopefully, now is a time where people can be a little -- this doesn’t apply to Vox, by the way. But I think it would be a good time for people to be a little more measured and take a look at what are the facts of this thing. Because the stakes are high. 我给新闻媒体的最后一条建议是，一般来说，当奥巴马医改运作良好时，功劳不会归于奥巴马医改，而当出现问题时，它们却上了头版头条。我认为，希望现在是时候让人们能够更——顺便说一句，这不包括Vox。但我认为现在是人们更审慎一点、看看这件事的事实是什么的好时机。因为事关重大。
Even on this whole premium issue -- increase issue that happened right before the election, it is true, as I said, that insurers adjusted and hiked premiums. But I kept on trying to explain, number one, if you’re getting a tax subsidy, this wasn’t going to affect your out-of-pocket costs because the tax credit would just go up. But nobody kind of heard that. 即使在整个保费问题上——选举前发生的上涨问题，确实，正如我所说，保险公司进行了调整并提高了保费。但我一直试图解释，第一，如果你获得税收补贴，这不会影响你的自付费用，因为税收抵免会跟着上涨。但没人听进去。
And number two, these increases in premiums only applied to people who were buying health insurance on the exchanges. In fact, 85 percent of the people don’t get health insurance through Obamacare. And for you, your health care premiums actually have gone up a lot less since Obamacare was passed than they did before Obamacare was passed. The average family has probably saved about $3,000 in lower health care premiums than if you had seen those same health care cost trends increase at the pace that they did before the law was passed. 第二，这些保费上涨只适用于那些在保险市场上购买医保的人。事实上，85%的人不是通过奥巴马医改获得医保的。而对你们来说，你们的医保保费在奥巴马医改通过后的上涨幅度，实际上比奥巴马医改通过之前要小得多。普通家庭可能已经节省了大约3000美元的医保保费，如果医疗成本趋势以法案通过前的速度上涨的话。
But I didn’t see a lot of headlines about that -- which I understand, I mean because it’s not controversial enough, or it’s a little bit too complicated to get in a sound bite. 但我没看到多少关于这个的头条新闻——我理解，因为这不够有争议性，或者在一句话新闻里有点太复杂了。
So that’s why the individual voice is so important. And that’s why I’m so appreciative of journalists who actually know what they’re talking about. 所以这就是为什么个人的声音如此重要。这就是为什么我如此感激那些真正知道自己在说什么的记者。
Mr. Klein: Thank you, Mr. President. 克莱因先生：谢谢您，总统先生。