特朗普要失望了 奥巴马医改法不会“迅速灭亡”

新任美国总统唐纳德·特朗普喜欢说，他会让前任奥巴马打造的医改法案“爆炸”（或者先内爆，然后外爆）。但根据国际评级机构标准普尔新近公布的一份报告，奥巴马医改的市场实际上日趋稳定，一些投保人享受的投保受益能持续到2018年。

特朗普坚称奥巴马执政时通过的《患者保护与平价医疗法案》（ACA）会迅速灭亡，根据是该法案传出的一些坏消息。去年医疗保险公司宣布，大幅上调ACA医保市场的个人医保计划保费（但其中不少增加的费用都可以通过联邦政府补贴抵消），Humana等保险公司宣布退出ACA市场，称医保计划导致亏损，而且法案存在不确定性。批评人士预计，种种事件将造成奥巴马医改的保费越来越昂贵，无法持续，从而陷入“死亡循环”最终崩盘。

标准普尔上述报告深入分析了美国个人保险市场支柱、奥巴马医改法的市场骨干——医疗保险公司Blue Cross Blue Shield（BCBS）旗下医保计划，发现“BCBS大多数投保人2016年的投保收益较往年明显提升。”标准普尔的分析师写道：“我们分析2016年的业绩和2017年迄今为止的保险申请数据，显示ACA个人医保市场并没有陷入‘死亡循环’。”

标准普尔还认为，ACA市场里不少保险公司可能今年会止住亏损势头，有些企业甚至明年有可能扭亏为盈。

“展望未来，我们预计，保险公司今年（ACA医保）基本能接近盈亏平衡，”报告的作者写道，“如果市场不受影响，（ACA）只做少数修正而非全面整改，我们预计2018年，即ACA个人医保市场在运作第五年会逐步好转，更多保险公司财报会略有盈余（虽然盈利只是低个位数）。”

考虑到个人医保市场诸多复杂因素，呈现逐步好转意义重大。奥巴马医改出现以前，该市场俨然蛮荒之地，不过是医疗保险领域的一小块。和企业投保的医疗保险不同，个人医保市场鲜有规范管理收益、医疗核保和避免歧视病患的法规，也几乎没有机构跟进市场动向，了解最新盈亏状况。

因此，当保险公司遵循奥巴马医改的新监管规定首次设定保费时，实质上是在玩一场庞大的猜谜游戏，投保人健康状况如何？多少人会投保？最终要赔付多少？客户会不会年复一年留在市场里？

要回答这些问题并相应调整还需要相当一段时间，以及诸多修正，比如2017年就出现保费大增。标准普尔认为进展相对稳定，随着进一步了解市场，多项早年奥巴马医改计划到期，保险公司正逐渐调整以稳定市场。

但乐观预期并不意味着市场会形势大好。对参与奥巴马医改法的保险企业来说，不确定性是最大的威胁，因为特朗普和国会正在设法推翻奥巴马医改，一旦得手仍然可能严重影响ACA。

标准普尔也承认这是当前首要风险。其分析师写道：“假如个人保险市场出现重大变化，或者（政府为帮助客户减少投入而给予保险公司的补贴）彻底失效，市场只能按照新规定从头再来。”（财富中文网）

译者：Pessy

审稿：夏林

President Donald Trump is fond of saying that he will simply let Obamacare "explode" (or implode, then explode). But the health law's marketplaces are actually becoming more stable and may even churn out profits for some participating health insurers by 2018, according to a new Standard & Poor's report.

Trump's insistence that Affordable Care Act (ACA) markets are exploding is based on some legitimately bad news for Obamacare. Health insurers announced substantial premium increases for individual plans sold through the law's exchanges last year (although many of these increases are counteracted by federal subsidies), and insurance companies like Humana have been announcing their departure from the marketplaces, citing losses and general uncertainty surrounding the law. Critics have predicted that this combination of events will lead to a so-called "death spiral" in which Obamacare becomes increasingly expensive and unsustainable, eventually causing a market collapse.

But S&P's dive into the operating performance of Blue Cross Blue Shield plans—which make up the backbone of the individual insurance market and the bulk of the Obamacare exchanges—finds that "2016 was a marked improvement" over previous years for most BCBS insurers. "Our analysis of 2016 results and the market enrollment so far in 2017 shows that the ACA individual market is not in a 'death spiral,'" wrote the S&P analysts.

S&P also believes that many insurers in the marketplaces are likely to stop bleeding money this year—and may even start making some in the next.

"Looking forward, we expect insurers, on average, to get close to break-even margins in this segment in 2017," wrote the report authors. "If the market continues unaffected, with a few fixes rather than an overhaul, we expect 2018, or Year 5 of the ACA individual market, to be one of gradual improvement with more insurers reporting positive (albeit low single-digit) margins."

The gradual improvement makes sense considering the multiple complexities of the individual market. Before Obamacare's enactment, this market, which is just a sliver of the overall health insurance sector, was essentially the wild west. There were very few rules governing benefits, medical underwriting, or discrimination against the sick; unlike in employer-sponsored health insurance, there were few entities keeping track of the market and its finances.

So when insurers set their premiums for the first time under Obamacare's new regulations, they were essentially playing a huge guessing game. How sick would enrollees be? How many would sign up? How much would it cost to cover them? And would customers remain in the market year after year?

It takes a fair bit of time—and plenty of corrections, such as the steep 2017 premium increases—to both answer these questions and then makes changed to fit the market reality. That's finally beginning to happen, according to S&P, as insurers gain a more nuanced understanding of the exchanges and adjust to the expiration of several early-year Obamacare programs meant to stabilize the markets.

But none of that means that the markets will be fine and dandy going forward. Uncertainty is the single biggest threat to insurance company participation in Obamacare, meaning President Trump and Congress' ongoing efforts to dismantle the law could still wreak havoc on the ACA if ultimately successful.

That's a fact that S&P acknowledges right up top. "[I]f there are significant changes to the individual market, or if [subsidies to insurers that help reduce customers' out-of-pocket costs] are made null and void, the market essentially has to restart with a new set of rules," the analysts wrote.