Evan Fowler 方禮倫
LSE倫敦政經學院歷史系畢業，不屬單一種族、國籍，土生土長香港人。
2012-10-11 11:55:02
（英文原文，下附中譯。)
"Everyones been talking about it. But I can't hear a word they say. Only the echoes of my mind."
The lyrics seem appropriate. Last week for a good few days news channels seemed transfixed by the first US Presidential debate between Barack Obama and Mitt Romney. Note I have called it the US Presidential debate. Not the Presidential debate. Whilst an important man, sometimes we need reminding that he is, in fact, not our president. Though perhaps the thought of President Hu taking part in a public debate that may decide the transition of leadership in China seems, at this time, more than a little far fetched.
But first the debate. Obama's performance did lack lustre. The ready charm that won the hearts of so many voters has certainly waned over his term in office. Mr. Romney certainly had the energy of a man eager for the position. But frankly are we surprised? Running Bain Capital is certainly easier than Capitol hill.
But lets just think what Mr. Romney actually said. Take one example. Mr. Obama, he implied, had neglected the economy in his desire to push for reform of the medical aid. He should be helping small businesses instead by lowering tax. What I find surprising is that Mitt seems to overlook the fact that the state of US medical aid is, according to the most recent edition of The Economist, the biggest worry facing small businesses in America today. Yes, more than taxes and regulation. With private health care costs in the US spiraling, from 1.8% of GDP to a projected 60% by the end of this century, affordable medical care is a middle class and small business issue. At a projection of 60% of GDP it should be a serious national issue.
How can private medical care be this expensive? There is, in my mind, a fundamental conflict of interest at play. Modern insurance began with the need to level the risk involved in maritime trade. A ship is expensive, especially laden with cargo. Insurance serves an important role when costs are large and static, and there is choice. You can choose to gamble your savings on a trade. It is wrong to feel one must gamble your savings to be in good health.
The other increases have mirrored the rise in private medical costs: the cost of private medical insurance and the number of people who have purchased such a policy. They are all related. Higher medical costs creates more of an incentive to take out a policy, and also inflates the cost of the policy itself. To make money it is in the interest of medical insurers that medical care becomes dearer and public options are limited. As in finance, it is not so much that people in the industry are openly attempting to work against the interests of society, but that the very nature of the business, and often how they are rewarded, provides an incentive that compromises them in doing a job.
Last week my mother phoned me. She was worried. She had been advised by her doctor that she needed an MRI scan. She has been suffering headaches of increasing intensity for many years now. My initial reaction shocked me. Before feelings of worry for my mothers well being, I first questioned whether the scan was necessary. I would never have questioned a doctor's judgement if it was not for an experience a few year back I had with my family in the US.
On arrival my mother had a sore throat, and was advised by friends and relatives to visit a private clinic to have it checked. Upon hearing that he was dealing with a sore throat the doctor advised my mother to check-in to a private hospital and to see a throat specialist. The throat specialist then proceeded to advise my mother to have a series of scans. Rather than make a judgement as to what was most likely the problem, the doctor recommended test be done to rule out what it was not. At each stage, each referral, each test or scan performed, the doctor took a kick-back. Not directly, but in gifts.
Your insurance will cover you, he seemed happy to say. We all win. But no. The costs is still a cost, and must be paid, if not this time but by higher insurance premiums in future. Not only is this irresponsible, it had, I realised when receiving my mothers call last week, affected the trust I had always had growing up in Hong Kong for doctors. As Sandel highlighted in his recent book, markets can and often do redefine our relationship with the service and the service provider.
So Mr Romney, what should be of concern is not that Mr Obama attempted to tackle the problem of affordable health care for the majority of working and middle class Americans over the economy, but the fact that you do not seem to see a problem at all.
Everyone has indeed been talking positively about Mr. Romney's performance in the first debate. But I'm sorry, I can't hear a word they say. Only an echo of my mind.
（主場中譯全文）
羅姆尼看不透的醫療困境
"Everyones been talking about it. But I can't hear a word they say. Only the echoes of my mind."
這幾句歌詞真應景。過去一周，各大媒體都被奧巴馬和羅姆尼的首次美國總統大選辯論嚇傻了眼。嗯，留意，我說的是美國總統大選，「美國」這個因素很重要。雖然當選的人將會對全世界都有重大影響，但我們要提醒自己，他不是我們的總統。幻想一下中國最高領導的更替也有選舉、也會辯論，我們的「總統」濤哥在辯場上雄辯滔滔的樣子……也太牽強了吧。
說回這次選舉辯論。奧巴馬的表現失色，那份胸有成竹的神采曾贏得無數美國人的心，但在過去四年確實是被磨光了。反觀羅姆尼帶著對總統之位的野心，顯得活力十足。不過老實說，這是可以預期的，畢竟執掌一個國家比一家投資公司累得多。
醫療開支急升才是核心問題
不過，羅姆尼在辯論中的言論值得細看。比如，他暗示奧巴馬為了推行醫療改革，忽略了經濟困局，他本應透過減稅來支持小型企業才對云云。我覺得很驚訝，他竟然無視了一個現實︰根據最新一期的《經濟學人》，美國的小型企業最憂慮的，正正就是現時的醫療方案，而不是稅項與各種規限。美國國內的私營醫療收費急升，本來只佔GDP 1.8%，長此下去，預期會上升至GDP的60%──醫療費用過高本就是中產與小型企業面對的一大困難，遲早會成為全國性的問題。
醫療服務點解要咁貴？個人覺得，業內有私相授受之嫌。今時今日惡晒的保險業，當年是靠保障海上物流起家的。一隻商船造價很高，連同船上貨物，成本總值就更可觀：如果不買保險，每次出海都會是一場豪賭，保險公司的存在對商人來說，很重要。做生意嘅，要賭咪賭囉；可恨的是，現時普通人唔買保險，就隨時為健康輸清光副身家，成件事錯曬。私營醫療服務收費上升，連帶私營醫療保險價格與其投保人數也會跟著上揚，藤㨢瓜瓜㨢藤：去睇私家醫生貴咗，大眾就越想買保險，投保價格就越貴。保險公司要賺錢，保費當然越高越好，大眾選擇少就仲好。就正如金融業一樣，從事的人其實並沒有跟大眾利益對著幹的意圖：那根本就是金融工作的本質，也是從業員獲利的主要方法、他們投入工作的動力。
醫生做掃描會收佣
上個禮拜，我媽媽打電話俾我，聲音中充滿憂慮。她長年頭痛，情況越發嚴重，醫生讓她去做磁力共振掃瞄。我的第一反應，連我自己都嚇親：我沒有第一時間關心她的身體狀況，反而問她做掃瞄有冇必要。我竟然會質疑一個醫生的決定，完全是因為幾年前在美國的親身經歷。
當時我媽媽喉嚨痛，親友提議她去私營診所檢查，那個私家醫生一聽到症狀是喉嚨痛，就叫我媽媽入住私家醫院，接受耳鼻喉科專家的診治。那位專家替我媽媽做了各式各樣的掃瞄。專家逐樣逐樣掃瞄做，是為了剔除不同的可能病症，而不是直接診斷我媽媽患有什麼病症。每一次轉介、每一次測試、每一次掃瞄，啲醫生專家都有回佣收，唔係錢嘅，收下禮囉。
你保險會包埋㗎啦，對大家都好呀，呀專家講得幾口響！唔係囉！診症的費用現在不用我們付，但最終，保險公司會收番，連本帶利嗰隻。這種行為不只不負責任；我在香港成長，一直信任醫生，但這份信任已被破壞。Michael Sandel新書有講，市場經濟會重新定義我們與服務提供者的關係，以及我們對該服務的觀感。
呀羅姆尼先生，奧巴馬著手解決困局，為中產及勞工階層提供可負擔的健康保障，而怠慢了低迷的經濟，並不值得你咁高度關注。你不如俾啲時間，反省下點解你唔覺得咁樣有問題。
很多人都對羅姆尼首次辯論的表現，有正面評價，但對唔住，我真係一個字都聽唔入耳，我憶起很多可怕的回憶。
