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1AC
Advantage (1) is the economy

Two Internal links---first is coverage:

US is locked into slow growth crisis now -- upward trends are short-
term
John Ross 17, Senior Fellow at Chongyang Institute for Financial Studies, Renmin University
of China, former Professor at Shanghai Jiao Tong University, 6/12/2017, “Why the US economy
remains locked in slow growth,”
http://ablog.typepad.com/keytrendsinglobalisation/2017/06/why-the-us-economy-remains-
locked-in-slow-growth.html
The latest US economic data confirms the US remains locked in a prolonged period of slow
growth with major consequences for geopolitics and destabilising consequences for US domestic politics. ¶
The latest US economic growth data¶ Almost no international issue is more crucial for economic and
geopolitical strategy than economic trends within the US. It is therefore crucial to have an accurate analysis of
these. Regarding such a serious issue and such powerful forces there is no merit in ‘pessimism’, underestimating US growth, and no
merit in ‘optimism’, overestimating US growth – there is only a virtue in realism.¶ This article therefore analyses the latest US GDP
data. The conclusion is clear. The data
confirms the US fundamentally remains in a period of
medium/long term slow growth which will last for at least a minimum of several years.¶ Strikingly, taking a period
of 15 years after the beginning of the international financial crisis, average US growth will be
slower than after the beginning of the Great Depression in 1929. Analyses which appear in parts of
the media claiming the US is entering a significant new period of rapid growth are fundamentally in
error – for reasons analysed in detail blow.¶ Such slow US growth necessarily has major geopolitical
consequences and provides a backdrop for continuing instability and turns in US politics. The
recent period within US politics has already seen:¶ Trump selected as Republican Party Presidential candidate against the wishes of
that Party’s establishment, and elected President against the opposition of the overwhelming major of the US mass media.¶ Since
Trump’s election sharp clashes have continued within the US political establishment with leaks against the President by the US
security services, the President’s sacking of the FBI head, investigations by the US Congress and US police of close aides to the
President, and open campaigns to force the President to change policies or to remove him from office by major US media such as the
New York Times and CNN.¶ Within the Democratic Party a serious challenge mounted to the Party establishment’s candidate
Clinton by the first figure declaring themselves to be a socialist to receive major US public support for almost a century – Sanders.¶
As US medium/long term slow economic growth will continue sharp turns and tensions in US politics will not disappear but are
likely to continue.¶ The consequences for US relations with China flowing from this situation, and geopolitical tensions between the
US and its traditional allies such as Germany shown for example at the recent G7 summit, are analysed at the end of this article. The
conclusion is that China’s constructive approach to the Trump administration is clearly correct but that the risk of sharp turns in the
situation must be taken into account due to the tensions within the US created by its historically low growth.¶ This prolonged period
of slow growth in the US, and in the advanced economies in general, combines with China’s own transition to ‘moderate prosperity’,
and then to a ‘high income’ economy by World Bank international standards, to create under Xi Jinping a qualitatively new period in
China’s development.¶ The Great Stagnation¶ Starting with the global background to the latest US economic data, a
defining
feature of the present overall international situation is extremely slow growth in the advanced
Western economies.¶ In nine years since the 2008 international financial crisis average growth in the advanced Western
economies is already almost as slow as during the ‘Great Depression’ of the 1930s and by the end of 2017 it will be
significantly slower. By 2016, total GDP growth in the advanced economies in the years since 2007 was only 10.1% and by the
end of 2017, on IMF projections, the growth in the advanced economies after 2007 will be lower than in the same period after 1929 –
total growth of 12.3% in the 10 years after 2007 compared to 15.1% in the 10 years after 1929.¶ Even more strikingly IMF
data
projects that future growth in the advanced Western economies, following the international
financial crisis, will be far slower than in the same period after 1929. IMF projections are that by 2021,
fourteen years after 2007, total growth in the advanced economies will be less than half that in the 14 years after 1929 – average
annual growth of only 1.3% compared to 2.9%, and total growth of 20.6% compared to 49.8%.¶ This data is shown in Figure 1. An
aim of this article is instead to carry out the necessary factual checks that the latest US data does not represent a break with long-
term trends.¶ US GDP growth¶ In the 1st quarter of 2017 US GDP was 2.0% higher than in the first quarter of 2016.[1] To evaluate
this 2.0% growth, given that a market economy inherently displays business cycles, it is necessary to separate purely cyclical trends
from medium/long term ones. Failure to do so leads to false analysis/statistical trickery – comparing a peak of the business cycle
with the trough will exaggerate growth, while comparing the trough of the business cycle with the peak will understate growth. Such
cyclical effects may be removed by using a sufficiently long term moving average that cyclical fluctuations become averaged out and
the long term structural growth rate is shown. Figure 2 therefore shows annual average US GDP growth using a 20-year moving
average – a comparison to shorter term periods is given below.¶ Figure 2 clearly shows that the fundamental trend of the US
economy is long-term slowdown. Annual average US growth fell from 4.4% in 1969, to 4.1% in 1978, to 3.2% in 2002, to 2.2% by 1st
quarter 2017. That is, the most fundamental long term growth trend in the US economy is that it has been slowing for half a century.
The latest US GDP growth of 2.0% clearly does not represent a break with this long term US economic slowdown but is in line with
it.¶ Per capita¶ US per capita GDP growth follows the same falling trend. Figure 3 shows a 20-year moving average for US per capita
GDP growth. Annual average US per capita GDP growth fell from 2.8% in 1969, to 2.7% in 1977, to 2.4% in 2002, to 1.2% by the first
quarter of 2017. The latest US data shows no break with this trend of long term slowdown - it is in line with it and continues these
long term trends.¶ This data
shows clearly claims the US economy is currently ‘dynamic’ driven by a
‘wave of innovation’ are therefore factually false – a pure propaganda myth repeated by US media such as
Bloomberg with no connection with factual trends. US per capita growth has in fact fallen to a low
level.¶ This fall of US per capita GDP growth to a low level clearly has major political implications within the US and underlies recent
domestic political events. Very low US per capital growth, accompanied by increasing economic inequality, has resulted in US
median wages remaining below their 1999 level – this prolonged stagnation of US incomes explaining recent intense political
disturbances in the US around the sweeping aside of the Republican Party establishment by Trump, the strong support given to a
candidate for president declaring himself to be a socialist Sanders, current sharp clashes among the US political establishment etc.¶
Cycle and trend¶ Turning from long term trends to analysis of the current US business cycle it may be noted that a 5-year moving
average of annual US GDP growth is 2.0%, a 7-year moving average 2.1% and the 20-year moving average 2.2%. Leaving aside a 10-
year moving average, which is greatly statistically affected by the severe recession of 2009 and therefore yields a result out of line
with other measures of average annual growth of only 1.4%, US average annual GDP growth may therefore be taken as around 2% or
slightly above. That is, fundamental structural factors in the US economy create a medium/long term growth rate of 2.0% or slightly
above. Business cycle fluctuations then take purely short term growth above or below this average. To analyse accurately the present
situation of the US business cycle therefore recent growth must be compared with this long-term trend.¶ Figure 4 therefore shows
the 20-year moving average for US GDP growth together with the year on year US growth rate. This shows that in 2016 US GDP
growth was severely depressed – GDP growth in the whole year 2016 was only 1.6% and year on year growth fell to 1.3% in the
second quarter. By the 1st quarter of 2017 US year on year GDP growth had only risen to 2.0% - in line with a 5-year moving average
but still below the 20-year moving average.¶ As
US economic growth in 2016 was substantially below
average a process of ‘reversion to the mean’, that is a tendency to correct exceptionally slow or
exceptionally rapid growth in one period by upward or downward adjustments to growth in
succeeding periods, would be expected to lead to a short-term increase in US growth compared to
low points in 2016. This would be purely for statistical reasons and not represent any increase in underlying or medium/long US
term growth. This normal statistical process is confirmed by the acceleration in US GDP growth
since the low point of 1.3% in the 2nd quarter 2016 – growth accelerating to 1.7% in 3rd quarter
2016 and 2.0% in 4th quarter 2016 and 1st quarter 2017.¶ President Trump’s administration may of course
claim ‘credit’ for the likely short term acceleration in US growth in 2017 but any such short-term shift is merely a
normal statistical process and would not represent any acceleration in underlying US growth. Only if growth
continued sufficiently strongly and for a sufficiently long period to raise the medium/long term rate
average could it be considered that any substantial increase in US economic growth was
occurring. The latest US growth data, 2.0% year on year, however does not represent any acceleration in US growth compared to
longer term averages and is therefore in line with the pattern of US slow growth and does not represent a break with it.

Increasing coverage is key to faster growth –it solves workforce

productivity, job lock, and bankruptcies
Liam Malloy 16, Ph.D. in Economics from the University of Maryland, Assistant Professor in
the Economics Department at the University of Rhode Island, et al., 2016, “State Sponsored
Health Insurance and State Economic and Employment Growth,”
http://digitalcommons.uri.edu/cgi/viewcontent.cgi?article=1004&context=ecn_facpubs

We find that in both panels increased health insurance coverage is associated with faster economic
growth . In the United States, we find evidence that Medicaid coverage increases both macroeconomic growth and employment
growth. However, our results also suggest that in their efforts to capitalize on the economic benefits of expanding health insurance,
legislators would be wise to implement policies that control per-enrollee costs. To the extent that the economic implications of
increased state-supported health care coverage are a key aspect of the ongoing debate in the health insurance policy arena, our
findings could inform future reforms.¶ Social Policy and Economic Growth¶ Previous
studies of the relationship
between social policies and state economic growth find inconsistent effects (see e.g., Blair and Premus
1987; Crain and Lee 1999; Dye 1980; Erickson 1987; Fisher 1997; Helms 1985; Jiwattanakulpaisarn et al. 2009; Jones 1990; Jones
and Vedlitz 1988; Newman 1983; Schneider 1987). Some find positive relationships between spending and economic growth, others
a negative relationship, and still others find no relationship at all.2 Work on the specific relationship between health spending and
economic growth is very limited. For example, a report issued by the Department of Health and Human Services (2008, 47)
reviewing the literature on government health spending and economic growth concluded that “[g]iven that most
of the
literature in this area is based on anecdotal reports or descriptive evidence, there is significant
scope for improving the current methods by using longitudinal data and more rigorous
empirical analysis.” Their own empirical tests using a panel dataset including 13 years of state spending data suggested
a positive relationship between government expenditures on health and state economic growth, a result contrary to that found in
Jones (1990).¶ Because health problems worsen when unaddressed, cities paying for emergency care of uninsured populations may
pay significantly more for the health problems that result from putting off care than places that pay upfront for preventative care
(Baicker and Chandra 2006 Baker, Fisher, and Wennberg 2008; Bamezai and Melnick 2006). In fact, Baicker and Chandra (2004,
184) find that spending and health outcomes are inversely related perhaps because “the use of intensive, costly care…crowds out the
use of more effective care.” Scholarship on the relationship between health care spending in health outcomes suggests a complex
relationship. Fisher and others (2007) find that additional spending on Medicare patients tends to be associated with higher
numbers of procedures rather than improved health outcomes. Other research suggests that health care spending does produce
improved outcomes but only in particular populations (i.e., infants due to a decrease in infant mortality) (Gallet and Doucouliagos
2015). While the relationship between health care spending and health outcomes is complex, the relationship between spending on
health insurance and health care outcomes may be more straightforward. Health insurance may lead to more desirable health care
outcomes directly (through care which addresses extant diseases/infirmities) and indirectly (through preventative care), and
healthcare spending is not a simple proxy for the prevalence of health care insurance (see Anderson and Frogner 2008; Anderson
and Poullier 1999).¶ Over the last decade, there has been an increase in attention to assessing social programs to see if they “work.”
In the health care policy arena, these assessments tend to focus on one of two primary criteria: (1) health outcomes, or (2) fiscal
efficiency. If health insurance is supposed to make people healthier, we can evaluate Medicaid (for example) based on the health
related outcomes of program participants (e.g., Baiker et al. 2013). But states (and politicians) also have to weigh if a program is
“worth the cost” given that there are other calls on the public purse. These assessments focus more on if a program saves more
money than it spends over time or leads to economic growth that helps the state recoup its costs (in terms of making up lost or
increasing tax revenue for example) or an increase in employment growth that makes the state economy stronger. If providing public
health insurance strengthens the economy and reduces the net cost of the program, it should enjoy broader support. Policy experts
disagree about the net costs of existing state-sponsored health insurance programs, the focal point of this article. Below, we review
these arguments. ¶ Pro: Expanding State Sponsored Health Insurance is Worth the Cost¶ First, increasing
access to health
insurance could positively affect labor supply and demand . Access to health insurance
increases the ability of people to remain in the workforce because it keeps them healthier and
increases the likelihood that they will be available for work. While this can increase overall lifetime
earnings and decrease employee turnover, it also could reduce the number of people reliant on
other government social programs such as social security, food stamps, housing assistance, etc.
Moreover, access to health insurance, particularly through the government may eliminate
“job lock ” and encourage entrepreneurial activities such as starting a new business or investing
in research that could create more jobs for others (see e.g., Sterret, Bender, and Palmer 2014). ¶ Likewise, larger
government sponsored programs could alleviate some inequalities in the system (Sterret, Bender, and Palmer 2014). For example,
under an employee-sponsored health insurance regime, firms with more elderly or disabled employees, pregnant women, and so on,
pay more for health care than firms who have employees that are cheaper to cover. The financial incentives generated by this
insurance regime may encourage firms to either discriminate against certain workers (American Civil Liberties Union 2002),
decrease wages (Gruber 1994) and investments, or decrease hiring additional workers (especially new full time workers) (Baicker
and Chandra 2006) as health care costs become a larger percentage of labor costs. For these reasons, increasing government
sponsored health insurance could increase employment and economic growth by increasing the labor supply and eliminating market
inefficiencies. ¶ Looking specifically at Medicaid, some evidence suggests that expanding Medicaid coverage could increase economic
and employment growth. Baiker and others (2013) harnessed he unique “experimental” expansion of Medicaid in Oregon to test how
Medicaid coverage affected individual health outcome and economic security. While Medicaid access did not improve all health
outcomes, “Medicaid coverage decreased the probability of a positive screening for depression, increased the use of many preventive
services, and nearly eliminated catastrophic out-of-pocket medical expenditures” (Baiker et al. 2013). A related study demonstrated
that those participating in the Medicaid expansion had “lower out-of-pocket medical expenditures and medical debt (including fewer
bills sent to collection), and better self-reported physical and mental health than the control group” (Finkelstein et al. 2012).3¶
State-sponsored health insurance may boost economic growth through other means as well.
Providing lower income individuals with state health insurance can increase tax revenues by
keeping families and individuals out of debt that would otherwise keep them from paying their
taxes. For example, as the cost of health care has increased in the United States, lack of health insurance has
become the largest driver of bankruptcy (Himmelstein et al. 2009). Expenses associated with
significant health issues also decrease the ability of families to invest in activities that would increase
their economic position and thus increase taxable income. For example, a study by Collins and others (2012)
found that 36 percent of young adults had medical debt, and of those 31 percent had put off education and career plans, 28 percent
were unable to meet their basic financial obligations because of medical bills, and 32 percent could not make their student loan or
tuition payments. ¶ Athird mechanism through which state sponsored health insurance could bolster economic growth is as
a direct economic stimulus (see e.g., Pauly 2003): expenditures on health care increase both
wages and the number of jobs in the health care sector. To the extent that expenditures on health care lead to
new treatments and cures that decrease morbidity and infirmity, spending can result in a large financial gain for
the country. (Aaron 2003; Murphy and Topel 2006).z

Coverage gaps threaten economic decline – stabilizing insurance

markets is key
Sara Rosenbaum 10, JD from Boston University, Jonathan Gruber, Buying Health Care,
the Individual Mandate, and the Constitution, The New England Journal of Medicine,
http://www.nejm.org/doi/pdf/10.1056/NEJMp1005897
From an economics standpoint, pose of the ACA is to regulate how Americans buy health care, which is clearly economic conduct.
Above all, the ACA’s fundamental goal is to stabilize the vast U.S. market for health care services — which accounts for 17.5% of the
gross domestic product, according to Congress — along with the health insurance system on which nonelderly Americans rely as a
principal means for financing their health care. The law’s goal is revealed through extensive legislative findings that are set forth in
the ACA. Thegoal also can be seen in the act’s provisions that collectively are aimed at making the
insurance market work for millions of Americans who, because of their income, health status, or
both, have been locked out of affordable, accessible, and stable coverage and must therefore try
to pay for care at the point of service.¶ The existing system has broad economic
implications for both the insured and the uninsured. Far from being passive and noneconomic, the
uninsured consume more than $50 billion in uncompensated care, the costs of which are passed
through health care institutions to insured Americans. Moreover, medical expenses not covered by
insurance are one of the leading causes of bankruptcy in the United States, and the costs of
resolving those bankruptcies are borne throughout the U.S. economy. In addition, the lack of
health insurance leads to poorer health, which can, in turn, reduce workplace productivity. Even
the possibility of losing health insurance makes many workers afraid to leave their jobs for more
productive positions elsewhere, so the current system reduces the over all productivity of the
U.S. labor force.¶ The changes made by the ACA to stabilize the insurance market are fundamentally economic. The
legislation’s core is its mandate to end pervasive discriminatory insurance practices while making care affordable. But such
change is not possible without an individual mandate. If people who are in better health can opt
out of the market and effectively gamble that they can pay for whatever health care they need at
the point of service, prices rise for those who are in poorer health, leading to an “adverse
selection” spiral that raises insurance prices for all. This is not an idle conjecture . Five states
have tried to undertake reforms of the nongroup insurance market like those in the ACA without enacting an individual mandate;
those five states are now among the eight states with the most expensive nongroup health insurance.¶ In the end, the
ACA is all
about altering individual economic conduct, and its importance lies in the way it changes the
when and how of health care purchasing. By ensuring access to affordable coverage for most
Americans, the law seeks to rationalize our economic behavior while providing the regulatory
and subsidization tools to make this rationalization possible. To characterize the ACA as a law aimed at
anything other than individual economic conduct is to fundamentally miss the point of the legislation.
Second is small businesses:
Uncertainty and poor ACA implementation threatens job lock and
crush small businesses – they’re key to the economy
Jeanne Shaheen 17, MA in Political Science from the University of Mississippi, 6/29/2017,
Small businesses are collateral damage in healthcare chaos, http://www.nhbr.com/July-7-
2017/Small-businesses-are-collateral-damage-in-healthcare-chaos/
The Republican plan to overhaul our healthcare system is causing anxiety for millions of Americans
and uncertainty for small businesses and entrepreneurs who are the backbone of our
economy.¶ The Senate bill was drafted in secret by Republican senators with no input from the public, no testimony from doctors
or hospitals and no public hearings. This backroom maneuvering follows passage of the House Republican healthcare plan, which
even President Trump has called “mean.”¶ These bills roll back protections for people with pre-existing conditions, raise out-of-
pocket costs and strip coverage from millions of people. They also slash Medicaid — our nation’s program for insuring children,
people with disabilities, seniors in nursing homes, and people with substance use disorders — by nearly half.¶ I recognize that the
A ffordable C are A ct needs changes. I believe we should focus on improving the law, keeping what
works and fixing what’s not working, while helping to level the playing field for small businesses.¶ But
instead of fixing it, the Trump administration is systematically undermining the ACA by cutting
outreach and enrollment efforts, suggesting it won’t enforce the law and refusing to commit to
making cost sharing reduction payments essential to the ACA-created health insurance
marketplaces for more than a month at a time. President Trump has made clear his desire to see the system fail,
saying: “The best thing we can do politically speaking is let Obamacare explode.”¶ That’s irresponsible, and treats small businesses
as collateral damage.¶ While some small businesses buy health insurance in the small group market, many entrepreneurs, sole
proprietors and people working for small firms purchase their insurance on the individual market through an ACA marketplace.¶
According to the nonpartisan Congressional Budget Office, the
chaotic, incoherent and secretive process in
Washington is creating “substantial uncertainty about how the new law would be implemented
[and] could lead insurers to withdraw from or not enter the non-group [individual] market” for
insurance purchased individually on ACA marketplaces.¶ In 2014, one in five individuals who purchased
healthcare on an ACA marketplace was a small business owner, self-employed, or both. Before passage of the ACA, small businesses
paid an average 18 percent more for coverage than large businesses.¶ Data from the Centers for Medicare and Medicaid Services says
the average yearly premium increase in the small group market was 10.4 percent between 2008 and 2010 (pre-ACA), but dropped by
half between 2011 and 2015. The number of uninsured small business employees (those working at firms with fewer than 50
workers) dropped by more than four million between 2013 and 2015.¶ The
ACA also enabled many Americans to
consider entrepreneurship by ending the disincentive known as “job lock,” which kept many
Americans in jobs they didn’t want because they feared losing their health insurance.¶ David Lucier,
owner of Claremont Spice & Dry Goods in Claremont, said: “Before the ACA, insurance costs were more than a third of my business
expenses. Now, they’re less than an eighth. The ACA made it possible for me to go out on my own and realize my dream of starting a
small business.Ӧ Citing
the uncertainty and the general unpredictability of the legislative process in
Washington, insurers are departing the exchanges. This is especially damaging for sole
proprietors and small businesses that rely on the ACA and its affordable insurance options.¶
Without the ACA, millions of Americans will lose their insurance, and small businesses will face
the prospect of closing or shifting health costs to employees.¶ New Hampshire is a small business state.
Small businesses employ more than half our private workforce and are a job creating
engine . They need certainty so they can make prudent decisions about payroll, budgets and
product development.¶ Running a small business is hard enough. The current chaos in Washington makes it
that much more difficult.¶ Instead of tearing down the ACA and taking health coverage away from
people and small businesses, we should be building on the gains and achievements of healthcare
reform and work together on a bipartisan basis to fix what’s not working.¶ The ACA has had a positive
impact all across America, but it needs commonsense repairs and strengthening . My message to Republican
leaders in Congress and President Trump is: stop undermining the ACA, and let’s work together to improve America’s healthcare
system.
Small businesses are key to reverse economic stagnation – solves
weak job growth and labor outflows
Boyd Nash-Stacey 16, Economist at BBVA Compas, MA in Economics from the University
of Houston, 6/22/2016, Running on fumes: remaining gap in Beveridge Curve a matter of
structural forces, https://www.bbvaresearch.com/wp-
content/uploads/2016/06/160622_US_EW_RunningOnFumes.pdf
As the U.S. economy enters its 28th consecutive quarter of expansion (4th longest since the
great depression), there is ongoing debate as to whether labor markets, and for that matter, the
broader economy is nearing the end of the expansion cycle. While there is evidence that expansions do not die
of old age, there are signs that the labor market recovery is nearing retirement, similar to a growing
share of the labor force. 1 For example, a recent report from the BLS suggested that job growth
was the lowest in six and half years. Moreover, the auspicious signs of strong flows back into the
labor force reversed course dramatically. While these measures can be volatile, there are many signs that
cyclical recovery is nearing its peak at a moment when conditions remain below the economy’s
pre-crisis potential.¶ That being said, a broad view of the labor market suggests that conditions could not be better. The
economy has added an average of 226K jobs per month since 2014, and the unemployment rate now stands at 4.7%—the lowest rate
in nine years. In addition, the number of people choosing to re-enter the labor force and begin work was at an all-time high in April,
pushing up the labor force participation rate, a trend that had coincided with wage gains and tighter labor market conditions. ¶ To
assess if there is remaining slack in the labor market or if the remaining headwinds are structural in nature, we exploit the empirical
relationship between the unemployment rate and jobs vacancies, known as the Beveridge Curve (BC), and a time-series derivation of
the gap in the BC referred to as the “curve shifter.” Theory suggests that higher levels of unemployment (larger pool of job seekers) is
associated with a lower number of vacancies given that a higher supply of job seekers and greater demand for employees will
increase the likelihood of employers finding a match for their vacant positions. As a result, traditional business cycles produce
movements along the curve. However, during
the recession and recovery, there has been a persistent
outward shift in the curve, which is unlikely to be explained by normal cyclical forces.¶ To put
this into perspective relative to the pre-crisis, for any given job vacancy rate, there was a 2pp
higher unemployment rate (UR). For sectors most acutely impacted by the crisis, such as
construction and transportation and utility, the gaps were 5.1pp and 2.3pp larger, respectively.
Although there have been some indications of improvements, based on a derivation of this gap
or shift in the BC, there appear to be remaining frictions.¶ Using this reduced form representation of the
curve shifter, we confirm previously established relationships between productivity (Lubik 2012), uncertainty (Liu & Leduc 2015),
and secular shifts in labor force activity a la Bova et al (2016). However, we find that access to credit, in addition to significant fiscal
policy tightening, are the key elements in the breakdown of labor market matching. Moreover, we find heterogeneous impacts across
firm size and age, and industries. In fact, the reduced form representation of the factors that can “shift the curve” a la Pissarides
(2000) and Liu & Leduc (2015) shows that despite a handful of cyclical indicators suggesting vast improvements in the labor market,
there remain significant structural forces at play.¶ Usual suspects explain remaining gap in labor market¶ After controlling for
changes in unemployment benefits (extension of unemployment insurance claims) due to the financial crisis, we found that there
were three key factors that explain the significant and persistent outward shift in the BC: labor force outflows of those 55 and older,
cyclical fiscal policy tightening and credit availability. In fact, over a four year cycle, increased willingness of banks to lend in the
commercial and industrial (C&I) and commercial real estate loans (CRE) spaces explains 35% of the shift, while cyclical fiscal policy
shocks explain 31% of the movement, productivity explains 15%, and retiree outflows from the labor force explain an additional 13%.
Unlike Liu & Leduc (2015), we find that policy uncertainty explains only a small portion of the shift (3.0%). On a short time horizon
(four quarters), however, productivity plays a more important role in matching, explaining nearly 50% of the shift, with labor force
outflows explaining an additional 17%.¶ These results
imply that factors that are cyclical by nature can have
lasting effects on broader labor market activity. A process sometimes referred to as hysteresis. For example, fiscal
policy shocks and credit availability tend to ebb and flow with the business cycles, leading to predictable movements along the BC.
However, without offsetting shocks to other determining factors, e.g. lower uncertainty or higher productivity, the impact can persist
for years, and in some cases never fully recover. In addition, to the extent that credit and fiscal policy have experienced a permanent
shift, and the fact that monetary policy is becoming a less effective tool, it will be hard to envisage any significant reduction in the
gap in the medium-term. ¶ In addition, we tested the impact hiring rates have on BC across firm age, size and industry. In the short
run, large and incumbent firms have the largest impact on the BC. However, after six quarters, the
impact that startups
and small firms have on the BC is more significant and persistent. In fact, at 16 quarters, the impact that
startup hiring has on BC compared to old firms is 10 times greater; for small firms, in a
similar vein, the impact is 250% greater at 16 quarters versus four quarters from the initial
shock. With this in mind, creating an environment that encourages small business formation and risk
taking could counteract headwinds plaguing the labor market. ¶ Firms at all levels are susceptible to credit
cycles and cash flow volatility. However, these factors are amplified for new entrants or small firms, imparting a larger influence on
the broader labor market, particularly in keystone sectors such as retail, real estate and construction. In other words, hiring
slowdowns in these sectors have the largest and most persistent effect on the BC shifter. For instance, a one standard deviation drop
in the hiring rates in these sectors would shift the BC outwards by approximately 10%. To put this into perspective, in the aftermath
of the crisis, the BC shifter increased by 30% from peak-trough. Moreover, unlike other industries that are more apt at weathering
cycles and have greater access to credit such as manufacturing, these industries are generally slow to respond and as a result,
accumulate losses over a longer time period, and in some cases, never recover.¶ This
finding has substantial
implication for the health of the broader economy given the fact that small and new firms are
the dominant force in net job creation in the U.S.; whereas, larger (500+ employees) and older (11+ years)
firms are historically net job destroyers. Moreover, startups and small businesses hire at a rate between 1 to
2.5 times higher than older and larger firms. Labor-intensive service sectors such as retail also have persistently
higher levels of hiring, in some cases 50-75bp higher than other sectors. More specifically, startup hiring rates in industries such as
finance and insurance, manufacturing and information are 380%, 330% and 270% higher, respectively, than their industry peers.
Small and young firms in arts and entertainment, agriculture and accommodation hire at rates 200%-400% higher than the national
average. Research
has also shown that only 3% of businesses can be classified as “high growth
businesses,” but they are responsible for a disproportionate share of growth. Moreover, small
businesses are essential parts of U.S. supply chains given that can lower logistical costs, are
nimble problem solvers and are better equipped to partner on joint innovations. ¶ There is
additional upside to targeting small businesses and startups given that as outflows from the
labor market intensify, there could be adverse effects for aggregate productivity as new entrants
take time to develop skills. As a result, focusing on new business hires could help to accelerate the
demographic transition.

Small businesses solves competitiveness – reverses offshoring

Karen Mills 13, MBA from Harvard Business School, SBA’s Karen Mills: U.S. competitiveness
hinges on the strength of small business suppliers, The Washington Post,
https://www.washingtonpost.com/business/on-small-business/sbas-karen-mills-us-
competitiveness-hinges-on-the-strength-of-small-business-suppliers/2013/05/06/03f517b8-
b412-11e2-9a98-4be1688d7d84_story.html?utm_term=.86664a9b8ab1
¶However, according to Gary Pisano and Willy Shih of Harvard Business School, for decades, companies operating in
the United States were steadily outsourcing development and manufacturing work to specialists
abroad and cutting their spending here at home. Over time, this outsourcing moved up from low
value tasks to more sophisticated engineering and manufacturing.¶ ¶ This has hurt America’s
competitiveness and our ability to innovate .¶ ¶ Economy & Business Alerts¶ Breaking news about economic
and business issues.¶ Sign up¶ But the trend is shifting, and across the Obama administration, we have put in place
programs that attract more production, more investment and more jobs back to our shores.¶ ¶ Caterpillar, GE and Ford, for example,
are among those that have recently announced they are shifting some manufacturing operations back to the United States. ¶ ¶ The
reasons are clear. In an article about onshoring GE’s appliance manufacturing to Kentucky, CEO Jeff Immelt wrote that
“engineering and manufacturing are hands-on and iterative, and our most innovative appliance-
design work is done in the United States. At a time when speed to market is everything,
separating design and development from manufacturing didn’t make sense.”¶ ¶ This trend is
likely to continue as companies recognize higher U.S. worker productivity, rising labor and
energy costs abroad and logistical advantages here at home. Couple that with global demand for high quality
American-made products, and it is hard not to be bullish about America’s long-term opportunities.¶ ¶ The key now is
building capacity and investing in our country’s small business supplier base so that these firms
can better support global manufacturers and help bring more jobs back to the United States —
and both the government and the private sector have a role to play in making this possible.¶ The
United States has some of the world’s most innovative small suppliers and entrepreneurs. We
have the types of small businesses that, with the right support, can go toe-to-toe with China
(particularly on the higher end of the value chain) or with Germany’s famed Middlestand companies.¶
Businesses around the world are taking notice. Foreign companies like Lenovo, Ikea, Nissan,
Airbus, Siemens are starting or growing U.S. operations, and they are looking for networks of
U.S.-based suppliers to support them.¶ So how do we build on this momentum?¶ Related: How to land contracts with
corporate clients¶ Today, U.S.-based, forward-thinking companies are looking at their supply chains
very differently. They are working together to co-innovate, they are helping supply the capital
and skills their small suppliers need, and they are operating as partners.¶ At the U.S. Small Business
Administration, we are leading a government-wide effort called the American Supplier Initiative to support small suppliers.¶
Between 250,000 and 750,000 U.S. businesses are part of commercial and government supply chains. We are using our experience
and the best practices we have developed overseeing the federal government’s $100 billion small business contracting program to
help more small firms be successful commercial suppliers. Here’s how:¶ Making connections: We are connecting small and large
businesses together through matchmaking activities and through public private partnerships like IBM’s Supplier Connection, a
portal that makes it easier for small businesses to connect to supply chain opportunities.¶ Access and opportunity: The Washington
Post highlighted a recent Massachusetts Institute of Technology (MIT) report that concluded that the “future of manufacturing will
consist of smaller firms that may not always have enough money to train workers, commercialize new products and procure
financing on their own.Ӧ Our agency has a $100 billion loan portfolio to help get capital to these businesses. We also train and
counsel more than a million business owners each year. And, as I highlighted in the second blog in this series, the president’s budget
proposes $40 million for intensive entrepreneurial training to support established firms that are well positioned for growth. The
training is tailored to ensure that entrepreneurs get the skills, resources, counseling and long-term business planning advice they
need to be part of corporate supply chains.¶ Creating ecosystems: A key component of a thriving manufacturing base is a network of
nimble suppliers. At the SBA, we launched the first official federal government cluster initiative in 2010; today, the federal
government is invested in more than 50 clusters across the country.¶ The goal of these clusters is to leverage, integrate and better
align all of a region’s assets (local industries, skill base of local workforce, economic development agencies, universities and
community colleges). These ecosystems are a proven tool for attracting and strengthening regional manufacturing and for boosting
exports.¶ In addition, as part of the American Supplier Initiative, the SBA is supporting efforts to fund supply chain mapping
techniques.¶ This is only the beginning. All across the country there
are small suppliers ready, able and willing to
make America’s corporations more productive, more innovative and more globally competitive.
As those supplier networks grow and connect, they will serve as a magnet to bring more
manufacturing and more jobs back to our shores.¶ That’s how we can accelerate economic
growth, strengthen the middle class and make America more globally competitive.

Strengthening US growth key to solve global conflicts

Richard N. Haass 13, President of the Council on Foreign Relations, 4/30/13, “The World
Without America,” http://www.project-syndicate.org/commentary/repairing-the-roots-of-
american-power-by-richard-n--haass
Let me posit a radical idea: The most critical threat facing the United States now and for the foreseeable future is not a rising China, a reckless North
the biggest
Korea, a nuclear Iran, modern terrorism, or climate change. Although all of these constitute potential or actual threats,
challenges facing the US are its burgeoning debt, crumbling infrastructure, second-rate primary and secondary schools, outdated
immigration system, and slow economic growth – in short, the domestic foundations of American power.
Readers in other countries may be tempted to react to this judgment with a dose of schadenfreude, finding more than a little satisfaction in America’s
difficulties. Such a response should not be surprising. The US and those representing it have been guilty of hubris (the US may often be the
indispensable nation, but it would be better if others pointed this out), and examples of inconsistency between America’s practices and its principles
understandably provoke charges of hypocrisy. When America does not adhere to the principles that it preaches to others, it breeds resentment. But, like
most temptations, the urge to gloat at America’s imperfections and struggles ought to be resisted. People around the globe should be careful what they
wish for. America’s failure to deal with its internal challenges would come at a steep price. Indeed, the
rest of the world’s stake in American success is nearly as large as that of the US itself. Part of the reason
is economic. The US economy still accounts for about one-quarter of global output. If US growth
accelerates, America’s capacity to consume other countries’ goods and services will increase,
thereby boosting growth around the world. At a time when Europe is drifting and Asia is slowing,
only the US (or, more broadly, North America) has the potential to drive global economic recovery.
The US remains a unique source of innovation. Most of the world’s citizens communicate with mobile devices based on
technology developed in Silicon Valley; likewise, the Internet was made in America. More recently, new technologies developed in the US greatly
increase the ability to extract oil and natural gas from underground formations. This technology is now making its way around the globe, allowing other
societies to increase their energy production and decrease both their reliance on costly imports and their carbon emissions. The US is also an invaluable
source of ideas. Its world-class universities educate a significant percentage of future world leaders. More fundamentally, the US has long been a
leading example of what market economies anddemocratic politics can accomplish. People and governments around the world
are far more likely to become more open if the American model is perceived to be succeeding.
Finally, the world faces many serious challenges, ranging from the need to halt the spread of

weapons of mass destruction, fight climate change, and maintain a functioning world economic order
that promotes trade and investment to regulating practices incyberspace, improving global health, and preventing armed
conflicts. These problems will not simply go away or sort themselves out. While Adam Smith’s “invisible
hand” may ensure the success of free markets, it ispowerless in the world of geopolitics. Order requires the visible hand of
leadership to formulate and realize global responses to global challenges. Don’t get me wrong: None of this is
meant to suggest that the US can deal effectively with the world’s problems on its own. Unilateralism rarely works. It is not just that the US lacks the
means; the very nature of contemporary global problems suggests that only collective responses stand a good chance of succeeding. But
multilateralism is much easier to advocate than to design and implement. Right now there is
only one candidate for this role: the US. No other country has the necessary combination of
capability and outlook. This brings me back to the argument that the US must put its house in order –
economically, physically, socially, and politically – if it is to have the resources needed to promote order in the
world. Everyone should hope that it does: The alternative to a world led by the US is not a world led by China, Europe,
Russia, Japan, India, or any other country, but rather a world that is not led at all. Such a world would almost
certainly be characterized by chronic crisis and conflict. That would be bad not just for Americans, but for
the vast majority of the planet’s inhabitants.
Continued slow growth causes diversionary conflict with China
John Ross 17, Senior Fellow at Chongyang Institute for Financial Studies, Renmin University
of China, former Professor at Shanghai Jiao Tong University, 7/10/2017, “Trump's economy -
cyclical upturn and long term slow growth”,
http://ablog.typepad.com/keytrendsinglobalisation/2017/07/trumps-economy-cyclical-upturn-
and-long-term-slow-growth.html

It is crucial for both economic and geopolitical perspectives to have an accurate analysis of trends
in the US economy. The publication of the latest revised US GDP figures is therefore important as it provides the latest
opportunity to verify these developments. This data confirms the fundamental trends in the US economy under Trump:¶ The US
remains locked in very slow medium and long-term growth – particularly in terms of per capita GDP growth.¶
Due to extremely weak growth of the US economy in 2016 a purely short-term cyclical upturn is likely in 2017 -
but any such short-term cyclical upturn will be far too weak to break out of this fundamental
medium and long-term trend of US slow growth.¶ This article analyses these economic trends in detail, considers
some of their geopolitical consequences, and their impact on domestic US politics.¶ US GDP and per capita GDP growth¶ In the 1st
quarter of 2017 US GDP was 2.1% higher than in the first quarter of 2016. Making an international comparison to other major
economic centres:¶ US total GDP growth of 2.1% was the same as the EU’s 2.1%.¶ Making a comparison to the largest developing
economies, US 2.1% growth was far lower than China’s 6.9% or India’s 6.2%.¶ This data is shown in Figure 1¶ However, in terms of
per capita GDP growth the US was the worst performing of the major international economic centres, because the US has faster
population growth than any of these except India. US annual population growth is 0.7%, compared to 0.6% in China and 0.4% in the
EU – India’s is 1.3%. The result therefore, as Figure 2 shows, is that US per capita GDP growth in the year to the 1st quarter of 2017
was only 1.3% compared to the EU’s 1.7%, India’s 4.9% and China’s 6.3%.¶ In summary US per capita GDP growth is very weak –
only slightly above 1%.¶ Figure 1¶ image¶ Figure 2¶ image¶ ¶ Business cycle¶ In order to accurately evaluate the significance of this
latest US data it is necessary to separate purely business cycle trends from medium/long term ones – as market economies are
cyclical in nature failure to separate cyclical trends from long term ones may result in seriously distorted assessments. Purely cyclical
effects may be removed by using a sufficiently long term moving average that cyclical fluctuations become averaged out and the long
term structural growth rate is shown. Figure 3 therefore shows annual average US GDP growth using a 20-year moving average – a
comparison to shorter term periods is given below.¶ Figure 3 clearly shows that the fundamental trend of the US economy is long-
term slowdown. Annual average US growth fell from 4.4% in 1969, to 4.1% in 1978, to 3.2% in 2002, to 2.2% by 1st quarter 2017. The
latest US GDP growth of 2.1% clearly does not represent a break with this long-term US economic slowdown but is in line with it.¶
Figure 3¶ image¶ ¶ Cycle and trend¶ Turning from long term trends to analysis of the current US business cycle, it may be noted that
a 5-year moving average of annual US GDP growth is 2.0%, a 7-year moving average 2.1% and the 20-year moving average 2.2%.
Leaving aside a 10-year moving average, which is greatly statistically affected by the severe recession of 2009 and therefore yields a
result out of line with other measures of average annual growth of only 1.4%, US average annual GDP growth may therefore be taken
as around 2% or slightly above. That is, fundamental structural factors in the US economy create a medium/long term growth rate of
2.0% or slightly above. Business cycle fluctuations then take purely short-term growth above or below this average. To analyse
accurately the present situation of the US business cycle therefore recent growth must be compared with this long-term trend.¶
Figure 4 therefore shows the 20-year moving average for US GDP growth together with the year on year US growth rate. This shows
that in 2016 US GDP growth was severely depressed – GDP growth in the whole year 2016 was only 1.6% and year on year growth
fell to 1.3% in the second quarter. By the 1st quarter of 2017 US year on year GDP growth had only risen to 2.1% - still below the 20-
year moving average.¶ As
US economic growth in 2016 was substantially below average a process of
‘reversion to the mean’, that is a tendency to correct exceptionally slow or exceptionally rapid
growth in one period by upward or downward adjustments to growth in succeeding periods,
would be expected to lead to a short-term increase in US growth compared to low points in
2016. This would be purely for statistical reasons and not represent any increase in underlying
or medium/long US term growth. This normal statistical process is confirmed by the acceleration in US GDP growth
since the low point of 1.3% in the 2nd quarter 2016 – growth accelerating to 1.7% in 3rd quarter 2016, 2.0% in 4th quarter 2016 and
2.1% in 1st quarter 2017.¶ Given the very depressed situation of the US economy in 2016 therefore some increase in speed of growth
may be expected in 2017 for purely statistical reasons connected to the business cycle.¶ Figure 4¶ The economic and domestic US
political conclusions of the trends shown in the latest US data are therefore clear¶ US
economic growth in 2016 at 1.6%
was so depressed below even its long term average that some moderate upturn in 2017 is likely.
President Trump’s administration may of course claim ‘credit’ for the likely short-term acceleration in US growth in 2017 but any
such short-term shift is merely a normal statistical process and would not represent any acceleration in underlying US growth.
Only if growth continued sufficiently strongly and for a sufficiently long period to raise the
medium/long term rate average could it be considered that any substantial increase in
underlying US economic growth was occurring.¶ This fall of US per capita GDP growth to a low
level clearly has major political implications within the US and underlies recent domestic political events. Very
low US per capita growth, accompanied by increasing economic inequality, has resulted in US median wages remaining below their
1999 level – this prolonged stagnation of US incomes explaining recent intense political disturbances in the US around the sweeping
aside of the Republican Party establishment by Trump, the strong support given to a candidate for president declaring himself to be
a socialist Sanders, current sharp clashes among the US political establishment etc.¶ Even a short-term cyclical upturn in the US
economy, however, is likely to be translated into increased economic confidence by US voters. This may give some protection to
Trump despite current sharp political clashes in the US with numerous Congressional investigations of President related issues and
virtually open campaigns by mass media such as the New York Times and CNN to remove the President. The latest opinion poll for
the Wall Street Journal showed that men believed the economy had improved since the Presidential election by 74% to 25%, while
women believed by 49% to 48% that the economic situation had not improved.¶ In terms of geopolitical consequences affecting
China:¶ The short term moderate cyclical upturn in the US economy which is likely in 2017 will aid China’s short term economic
growth – particularly as it is likely to by synchronised with a moderate cyclical upturn in the EU. Both trends aid China’s exports ¶
Nevertheless, due
to the very low medium and long-term US growth rate the US will not be able to
play the role of economic locomotive of the G20. In addition to economic fundamentals IMF projections are
that in the next five years China’s contribution to world growth will be substantially higher than the US. It is therefore crucial China
continues to push for economic progress via the G20 and China has the objective possibility to play a leading role in this.¶ Very
slow growth in the US in the medium and longer term creates a permanent temptation to the US
political establishment to attempt to divert attention from this by reckless military action or
‘China bashing’ . China’s foreign policy initiatives to seek the best possible relations with the US are extremely correct but
the risks from such negative trends in the US situation, and therefore of sharp turns in US foreign
policy, must also be assessed.

US-China tensions rising now – aggressive actions escalate to nuke

war
Polina Tikhonova 17, Reporter, MA from Oxford University, citing Bruce G. Blair, the
National Bureau of Asian Research, and Union of Concerned Scientists, 7/27/2017, “If Trump
Orders A Nuclear Strike On China, Here’s What Happens”,
https://www.valuewalk.com/2017/07/trump-orders-nuclear-strike-china/
The fact that Trump now has the obedience of the U.S. Pacific Fleet chief in the hypothetical, yet
possible, decision to launch nuclear strikes against Beijing makes the whole let’s-nuke-China
scenario even faster and easier to execute.¶ Less than five minutes. This is the approximate
time that would elapse from President Trump’s decision to launch a nuclear strike against China
to shooting intercontinental ballistic missiles out of their silos, according to Bloomberg
estimations. The publication, citing former Minuteman missile-launch officer Bruce G. Blair, also estimates that it
would take about 15 minutes to fire submarine missiles from their tubes.¶ While the expert predicts that there might be
some minor hiccups in the let’s-nuke-China scenario – like some of the top brass trying to talk Trump out of launching a nuclear
strike – it appears that it
would be easier for the President to nuke an enemy than expected now that
he has the public support from the commander of the U.S. Navy’s Pacific Fleet.¶ US vs China Tensions
Rising, But Is Nuclear War Imminent?¶ The mere thought of a nuclear war between the U.S. and China – the world’s two biggest
militaries – sounds intimidating. Amid
strained relations between Washington and Beijing, and with
Trump recently giving U.S. Navy more freedom in South China Sea, the territory that China
considers vital to its national and security interests, the possibility of the two nations going to a
nuclear war cannot be ruled out anymore.¶ With Trump pledging to rein in China’s aggressive
territorial expansion in the South China Sea during his presidential campaign, the Trump administration has
made quite a few moves that could be pushing the two nations to the point of no return . In
May, Trump ordered the U.S. Navy to conduct a freedom-of-navigation operation in the
disputed area, which Beijing claims in its entirety despite the Philippines, Malaysia, Brunei,
Vietnam and Taiwan also claiming parts of the disputed region.¶ Earlier this month, the Trump
administration sent an even scarier war message to Beijing to challenge its military buildup on
the artificial islands in the South China Sea. A U.S. destroyer passed through the international flashpoint in the
South China Sea, a move that prompted a furious response from Chinese President Xi Jinping, who warned his American
counterpart of “negative factors” in U.S.-China relations. The Chinese Foreign Ministry lambasted the incident as a “serious political
and military provocation.”¶ US vs China War Would Be ‘Disastrous For Both’¶ Just last week, Trump approved the Pentagon’s plan
to challenge Chinese claims in the South China Sea, where Beijing has been actively building reefs into artificial islands capable of
hosting military planes. Breitbart News’s Kristina Wong exclusively reported that the President approved the plan to check China
over its ongoing militarization of and actions in the South China Sea, a move that will most likely further stain U.S.-China relations.¶
The latest heated exchange of hostile gestures between Beijing and Washington cannot but make
experts wonder: what would happen if the U.S. and China went to war? That would be
“disastrous for both sides – politically, economically, and militarily,” according to VICE citing
senior vice president for political and security affairs at the National Bureau of Asian Research,
Abraham Denmark.¶ While the two nations continue working together to prevent a potential
nuclear threat from China’s neighbor – North Korea – it seems like an even bigger nuclear
conflict is brewing between Washington and Beijing .¶ ‘Increased’ Possibility of Nuclear War¶ In
ValueWalk’s recent comparison of the U.S., Chinese and Russian militaries, it was concluded that the outcome of any war involving
the U.S. and China is quite impossible to predict, as there’s no telling what would be the scope and duration of the military
confrontation and if nuclear weapons would be used.¶ It’s also unclear if Russia would join forces with its arguably one of the biggest
allies – China. If it did, China’s chances of winning a war against Washington would considerably soar. After all, there are plenty of
potential flashpoints in the relations between Washington and Beijing, notably Taiwan and the South China Sea. The U.S. has in its
possession about 6,800 nuclear warheads – the world’s second largest nuclear arsenal after Russia – while China has only 270
nukes, according to recent estimations by the Arms Control Association.¶ According to a report by the Union of
Concerned Scientists, published last year, the U.S. going to “nuclear war with China is not
inevitable – but the possibility that it could occur has increased.” However, with Washington and Beijing not
being able to find common ground on such a vital issue for China’s national and security interests as the South China Sea, and with
Trump ordering more actions that further strain U.S.-China relations, the risk of nuclear war
between the world’s two biggest militaries could skyrocket.
The US-led liberal order is key to solve global conflict – econ key
Robert Kagan 17, Senior Fellow in Foreign Policy, Project on International Order and
Strategy, Brookings Institution, “The twilight of the liberal world order,” 1/24/17,
https://www.brookings.edu/research/the-twilight-of-the-liberal-world-order/
However, it is the two great powers, China
and Russia, that pose the greatest challenge to the relatively
peaceful and prosperous international order created and sustained by the United States.
If they were to accomplish their aims of establishing hegemony in their desired spheres of influence, the
world would return to the condition it was in at the end of the 19th century , with
competing great powers clashing over inevitably intersecting and overlapping spheres of
interest. These were the unsettled, disordered conditions that produced the fertile ground for the two
destructive world wars of the first half of the 20th century. The collapse of the British-dominated world
order on the oceans, the disruption of the uneasy balance of power on the European continent due to the rise of a powerful unified
Germany, combined with the rise of Japanese power in East Asia all contributed to a highly competitive international environment
in which dissatisfied
great powers took the opportunity to pursue their ambitions in the absence of
any power or group of powers to unite in checking them. The result was an unprecedented global
calamity. It has been the great accomplishment of the U.S.-led world order in the 70 years since the end of the Second World
War that this kind of competition has been held in check and great power conflicts have been avoided.

The role of the United States, however, has been critical. Until recently, the dissatisfied great and medium-size powers
have faced considerable and indeed almost insuperable obstacles to achieving their objectives. The chief obstacle has been the power
and coherence of the order itself and of its principal promoter and defender. The
American-led system of political
and military alliances, especially in the two critical regions of Europe and East Asia, has presented China and
Russia with what Dean Acheson once referred to as “situations of strength” in their regions that have
required them to pursue their ambitions cautiously and in most respects to defer serious efforts
to disrupt the international system. The system has served as a check on their ambitions in both positive and negative
ways. They have been participants in and for the most part beneficiaries of the open international economic system the United States
created and helped sustain and, so long as that system was functioning, have had more to gain by playing in it than by challenging
and overturning it. The same cannot be said of the political and strategic aspects of the order, both of which have worked to their
detriment. The growth and vibrancy of democratic government in the two decades following the collapse of Soviet communism have
posed a continual threat to the ability of rulers in Beijing and Moscow to maintain control, and since the end of the Cold War they
have regarded every advance of democratic institutions, including especially the geographical advance close to their borders, as an
existential threat—and with reason. The continual threat to the basis of their rule posed by the U.S.-supported order has made them
hostile both to the order and to the United States. However, it has also been a source of weakness and vulnerability. Chinese rulers in
particular have had to worry about what an unsuccessful confrontation with the United States might do to their sources of legitimacy
at home. And although Vladimir Putin has to some extent used a calculated foreign adventurism to maintain his hold on domestic
power, he has taken a more cautious approach when met with determined U.S. and European opposition, as in the case of Ukraine,
and pushed forward, as in Syria, only when invited to do so by U.S. and Western passivity. Autocratic rulers in a liberal democratic
world have had to be careful.

The greatest check on Chinese and Russian ambitions, however, has come from the combined military power of the United States
and its allies in Europe and Asia. China, although increasingly powerful itself, has had to contemplate facing the combined military
strength of the world’s superpower and some very formidable regional powers linked by alliance or common strategic interest,
including Japan, India, and South Korea, as well as smaller but still potent nations like Vietnam and Australia. Russia has had to
face the United States and its NATO allies. When united, these military powers present a daunting challenge to a revisionist power
that can call on no allies of its own for assistance. Even were the Chinese to score an early victory in a conflict, they would have to
contend over time with the combined industrial productive capacities of some of the world’s richest and most technologically
advanced nations. A weaker Russia would face an even greater challenge.

Faced with these obstacles, the

two great powers, as well as the lesser dissatisfied powers, have had to hope for or if
possible engineer a
weakening of the U.S.-supported world order from within. This could come about
either by separating the United States from its allies, raising doubts about the U.S.
commitment to defend its allies militarily in the event of a conflict, or by various means wooing American allies out from
within the liberal world order’s strategic structure. For most of the past decade, the reaction of American allies to greater
aggressiveness on the part of China and Russia in their respective regions, and to Iran in the Middle East, has been to seek more
reassurance from the United States. Russian actions in Georgia, Ukraine, and Syria; Chinese actions in the East and South China
seas; Iranian actions in Syria, Iraq, and along the littoral of the Persian Gulf—all have led to calls by American allies and partners for
a greater commitment. In this respect, the system has worked as it was supposed to. What the political scientist William Wohlforth
once described as the inherent stability of the unipolar order reflected this dynamic—as
dissatisfied regional powers
sought to challenge the status quo, their alarmed neighbors turned to the distant American
superpower to contain their ambitions.

The system has depended, however, on will, capacity, and coherence at the heart of the
liberal world order. The United States had to be willing and able to play its part as the principal
guarantor of the order, especially in the military and strategic realm. The order’s ideological and
economic core —the democracies of Europe and East Asia and the Pacific—had to remain relatively healthy
and relatively confident. In such circumstances, the combined political, economic, and military power of the liberal
world would be too great to be seriously challenged by the great powers, much less by the smaller dissatisfied powers.

Cost and certainty on the individual exchanges is key to solve job lock
– studies
Bradley T. Heim 17, Professor in the School of Public and Environmental Affairs at Indiana
University, PhD in Economics from Northwestern University, Lang Kate Yang, 4/272017, The
impact of the Affordable Care Act on self-employment, Health Economics, accessed via Wiley
Online Library
It is well known that the cost and availability (or lack thereof) of health insurance has the potential to
impact self-employment decisions, since leaving a wage and salary job often entails the loss of
employer sponsored health insurance. Further, surveys performed by the National Federation of
Independent Business find that the rising cost of health insurance is perennially a top
concern among small business owners. 1 As a result, laws that reform the health insurance market,
particularly for those who are self-employed, may impact the level of self-employment in the
United States. In this paper, we use data from the Current Population Survey to provide evidence on whether the most recent of such reforms, the Affordable Care Act (ACA), has impacted the
level of self-employment in the United States.¶ ¶ Self-employed individuals who do not receive an offer of employer-sponsored or government insurance 2 (either directly or through a spouse) and who wish to
purchase insurance generally must do so in the nongroup health insurance market. Prior to the ACA, even healthy insurance seekers on the private nongroup market often faced high premiums due to adverse
selection in the market, and those with poor health or preexisting conditions generally faced even higher risk-rated premiums or were unable to purchase a policy altogether.¶ ¶ The ACA makes several federal-
level changes to regulations in the private nongroup health insurance market. 3 For health insurance policies that begin in January 2014, it implements modified community rating regulations, which limit the
extent to which insurance companies may charge different premiums based on health status, and guaranteed issue regulations, which prevent insurance companies from excluding anyone based on preexisting
conditions. In addition, it contains subsidies for low-income taxpayers with family income up to 400% of the federal poverty level (FPL) to purchase health insurance and for small firms to provide health
insurance for their employees. Beginning on October 1, 2013, these insurance policies were offered on health insurance exchanges, some of which were operated by individual states and some of which were
operated by the federal government.¶ ¶ The first year of exchange operation was marred by numerous well-publicized difficulties in the function of the federal exchange and many state exchanges, but the second
year of exchange operation went more smoothly. 4 However, numerous state and federal lawmakers have called for repeal of the ACA. In addition, a number of markets have recently experienced decreased
participation by insurers as some large insurers have pulled out of participating in the exchanges, 5 and a number of state cooperative insurers have become insolvent, 6 which may call into question the long-term

Thus, for an individual contemplating self-employment and securing coverage

viability of the exchanges.¶ ¶

through an exchange policy, the availability of guaranteed issue and community rated insurance
in the nongroup market would be expected to make health insurance coverage more accessible
and affordable, increasing the attractiveness of self-employment. However, the poor
functioning of the exchanges in the first year of operation, combined with uncertainty surrounding whether the law will remain in
effect and whether the exchanges will continue to be viable over the long term, would tend to temper such effects. Further, it may take time for individuals to switch from wage and salary

employment to self-employment, which may delay any effect.¶ ¶ In this study, we analyze data from the 2010 to 2015 Current

Population Survey (CPS) to provide evidence on the impact of the ACA on the level of self-
employment. The CPS is a nationally representative survey of U.S. households and is
administered every month. Its timeliness and inclusion of labor force participation information
make CPS an appropriate data source for analyzing changes in self-employment upon the
implementation of the ACA.¶ ¶ We pursue two identification strategies. In the first, we utilize the fact that the pre-ACA individual health insurance environment differed across
states regarding community rating and guaranteed issue regulations. To identify the impact of the ACA on self-employment, we compare the change in self-employment rates pre- and post-ACA implementation in
states that had no such regulations (or had a subset of these regulations) and for which the ACA is a substantial change in policy, to states that had regulations similar to the ACA regulations and for which the ACA
is a smaller change in policy. The former group constitutes the treatment states, while the latter the comparison states. ¶ ¶ In the second identification strategy, we utilize differences across individuals in whether
they had employer-sponsored health insurance (ESI) prior to 2014, and examine, among those who had such insurance, whether having a characteristic (spousal coverage, older age, or a large family) that would
make them more (less) likely to be insurable if they left their job is associated with higher (lower) levels of transitions to self-employment. Such a relationship has previously been interpreted as evidence of
entrepreneurship lock. 7 We test this difference-in-differences analysis in the pre-ACA period (from November 2010 to December 2013) and the results confirm the expected impact of the aforementioned
individual characteristics on entrepreneurship lock. We then adopt a triple-differences strategy with pre- and post-ACA implementation as the third level of difference to investigate whether the estimated
prevalence of entrepreneurship lock has declined following the implementation of the ACA.¶ ¶ Our results suggest that the implementation of the nongroup market reforms and establishment of health insurance
exchanges due to the ACA in 2014 did not lead to an overall increase in self-employment in states that lacked similar provisions in their individual health insurance markets prior to 2014. We also do not find that
the ACA differentially increased self-employment among individuals who may have been likely to face entrepreneurship-lock in the pre-ACA period. We do, however, find statistically significant positive impacts in
states that lacked the ACA nongroup market provisions in the second year of implementation (when exchanges functioned properly and people had sufficient time to adjust their employment status) among

results suggest that the ACA led to increased self-employment

individuals eligible for insurance subsidies. Taken together, these

only in cases in which the uncertainty surrounding the exchanges was sufficiently reduced (due to the
exchanges functioning properly), the cost of insurance was sufficiently low (among low- and moderate-income individuals who qualified for subsidies), and
individuals had time to adjust.

Strengthening the mandate is key to make insurance markets

financially viable
Paul Demko 16, Healthcare Reporter for Political, former Washington Bureau Chief for
Modern Healthcare, 7/13/2016, Obamacare’s sinking safety net,
http://www.politico.com/agenda/story/2016/07/obamacare-exchanges-states-north-carolina-
000162
Even so, many of those insurers
lost tens of millions of dollars on their Obamacare policies last year —
and now they're seeking big rate hikes.¶ The ACA’s strength and its weakness is that it was built
atop America's private insurance system: rather than creating new government health plans, it depends on
competition among companies to offer affordable insurance to people who need it. In a nation dominated by private-sector health
care players, this made it politically possible–but it
also means the system works only if insurers find
Obamacare to be a desirable business. What has happened instead in North Carolina and many other states is that
insurers are finding the Obamacare business to be a swamp.¶ Nationwide, an analysis by
McKinsey found that insurers lost $2.7 billion on individual customers in 2014, the only year since
Obamacare coverage expansion for which full numbers are available–with 70 percent of carriers sustaining losses.
Those losses are after government payments intended to help plans with high-cost customers.
Preliminary data from 2015 suggest the rate of losses likely doubled, according to McKinsey.¶ The red ink
has led to the collapse of two-thirds of 23 new nonprofit health plans that were
established with federal loan dollars to increase competition in the state exchanges where
customers shop for policies. And UnitedHealth Group is largely getting out of the Obamacare
business because of anticipated losses of $650 million this year. “The individual market is a
mess ,” Brian Webb, health policy manager for the National Association of Insurance
Commissioners, told a recent briefing on Capitol Hill.¶ As Obamacare approaches its fourth season of
enrollment, and prepares to enter the post-Obama era, it's hitting an inflection point—and, in states like North Carolina,
that point could become a crisis. Millions are now being covered through the law, but
they're older, sicker and more expensive to insure than anyone anticipated. To compensate,
health plans are raising premiums, in some cases by a lot—the largest insurer in Texas wants to jack up rates
for individual plans by an eye-popping 60 percent next year.¶ A close look at what's really keeping the exchanges underwater
suggests that some of the problems are self-inflicted wounds by Obama and his administration; others are the handiwork of
Republican saboteurs, who undercut the safeguards intended to help companies weather the uncertainty of the new law. And overall,
the system has been weighed down by one big miscalculation: Health
insurance amounts to a guess about how
much customers’ health care is going to cost in the long run, and in many states Obamacare
health insurers guessed wrong.¶ None of the problems are insurmountable, but if they aren’t fixed, the
law could find itself in a mounting crisis—what observers call a “death spiral”— in
which competition vanishes, costs skyrocket, and a dwindling pool of insurers offer policies so expensive that health insurance is as
out of reach as it ever was.¶ Politically, the repair job isn’t trivial: It requires a bipartisan decision to stabilize the Obamacare
markets, a consensus that has been unattainable in the politically toxic atmosphere on Capitol Hill since the law was passed six years
ago without a single Republican vote. With this year’s enrollment season set to open just one week before Election Day, the
turbulence in the exchanges could be a wildcard in the presidential contest–and threaten Obama’s signature domestic achievement.¶
The gulf between Obamacare's success covering citizens and its failures on the insurance front
isn't just an accidental side effect: It's a direct result of the key selling point of the law, that
coverage is now accessible to all Americans. Health care finance experts point to a handful of policy changes that
could bolster the exchanges and ensure that people in states like North Carolina can still buy health insurance five and 10 years from
now. That would require an honest reckoning with what’s gone wrong–and the legislative resolve to enact fixes. “There’s plenty
to be worried about,” said Don Taylor, a health policy expert at Duke University who has tracked Obamacare in his home
state of North Carolina and across the country. “The answer is more policy—not doing nothing.” ¶ So
just what is that new policy supposed to look like?¶ ANY LAW AS ambitious and complex as the ACA is going to be a work in
progress. Almost from the moment Medicare passed in 1965, Congress has been revising it, and even now it undergoes changes
every year. Most insurance companies say they remain committed to offering Obamacare plans, and as long as they stay in the
business, the exchanges are unlikely to implode.¶ In some states, such as California and Washington, the system is working fine.
More than 9 in 10 health plans made money selling Obamacare policies to individuals during the first year of enrollments, according
to McKinsey’s analysis. But in states like North Carolina, it's becoming increasingly clear that the assumptions the law was built on
just haven't held up. “The pool is far less healthy than we forecast,” said Brad Wilson, CEO of Blue Cross Blue Shield of North
Carolina, in an interview with POLITICO. “We need more healthy people.”¶ North Carolina’s Obamacare story started out just as the
administration hoped it would: More than 350,000 people signed up for insurance the first year it was offered. Just two insurance
companies were offering polices through the state's "insurance exchange"—the marketplace that lets individuals without workplace
coverage buy their own coverage–but in 2015 they were joined by a third carrier, UnitedHealth Group. Sign-ups that year surged
above 550,000. This year, the state saw another 10 percent bump, topping 600,000.¶ But as those customers demanded health care,
costs started to mount. In 2014, medical claims in the individual market for both Blue Cross Blue Shield of North Carolina and Aetna
exceeded 90 percent of premiums paid, according to financial filings. Last year, those costs soared above 100 percent of premiums
for all three carriers competing in North Carolina. Altogether,
medical claims hit $3.2 billion–nearly $100
million more than premiums the insurers collected. Throw in administrative costs on top of that,
and it becomes clear that the insurers lost tens of millions of dollars on their individual market
business, most of it coming through the exchange. This year, all three insurers stopped paying
commissions to brokers for selling individual plans, hoping to suppress enrollments and limit
their losses.¶ The companies are still analyzing how and why their initial estimates for setting their rates and writing policies
were so off the mark. The largest insurer, the nonprofit Blue Cross Blue Shield of North Carolina, has repeatedly stated it can’t
continue to sustain the losses it endured during the first two years of Obamacare enrollment, and it is currently weighing whether it
will continue competing on the exchange at all for 2017. Though the insurer has submitted plans to do business again in every
county in the state, it plans to hike rates nearly 20 percent on average. A final decision on 2017 participation won’t be made until
August.¶ “All options are on the table,” Wilson said—even getting out of the Obamacare business.¶ If Blue Cross Blue Shield does
decide to abandon the North Carolina exchange— which most observers believe is unlikely this year—it would potentially leave just
two companies, Aetna and Cigna, offering Obamacare policies in the state. And neither of those companies intend to compete
statewide in 2017, instead offering policies in select counties. The worst-case scenario is that residents of some North Carolina
counties would be left with just one–or even zero–insurers. Nobody knows precisely what that would mean for consumers at this
point, but at the very least exchange shoppers would have fewer choices and higher prices.¶ “That would be very scary for lots of
people,” said Ciara Zachary, health policy analyst at the North Carolina Justice Center, a liberal advocacy group.¶ The troubles in
North Carolina’s exchanges are not unique. POLITICO’S analysis of financial filings for exchange carriers in a dozen states shows
continued struggles in 2015. Health plans competing on the exchanges in Colorado and Oregon, for
example, collectively paid out at least 20 percent more in medical costs on their individual
customers than they received in premiums, leaving insurers tens of millions of dollars in the
red.¶ In New York, most plans are losing money, including the much ballyhooed startup insurer Oscar, which has attracted
hundreds of millions in venture capital funding by promising to shake up the insurance market with tech-savvy innovations. But
Oscar sustained medical claims of $180 million on its roughly 50,000 New York customers last year. That’s nearly $1.50 paid out in
medical claims for every $1 collected in premiums–a burn rate that is clearly unsustainable.¶ Not all exchange markets have proven
to be financial quagmires. The exchange market in Florida, for example, appears to be on a path toward financial stability. Fewer
than half of competing carriers operated in the black in 2014, according to McKinsey’s analysis. But of the nine competing plans for
which 2015 data were available, just one–UnitedHealth–had medical claims that exceeded premiums on its individual market
business. Among the remaining plans, medical claims accounted for 86 percent of premiums. That’s right where insurers need to be
to at least break even.¶ There are no simple explanations for the huge difference in financial performance for Obamacare insurers
competing in different states. Though it's a national law, health insurance varies widely from state to state: the populations are
different, the medical cultures are different, and each state has its own business landscape. The local political responses have been
different, too, but that's not always the main story: both Florida and North Carolina enrolled a lot of people despite having a state
government that strongly opposed the health law.¶ One likely factor is the amount of competition among hospitals, doctors and
other health care providers, which determines their ability to dictate reimbursement rates. In southeastern Minnesota, for example,
where the Mayo Clinic is the dominant provider, the cheapest midlevel plan available to a 40-year-old through the state’s exchange
this year was $329 per month. That’s roughly 20 percent higher than in the rest of the state.¶ “The more competition you have, the
better the pricing,” said Mario Molina, CEO of Molina Healthcare, which is selling exchange plans in nine states. “In some markets
where there’s very little competition it’s difficult to get the prices that health plans need.”¶ But looming over the whole conversation
is the blunt question of just who signs up for Obamacare in each state, and how sick they are. In the dry language of insurance
companies, customers are called their “risk pool”—and when it comes to Obamacare, the pool is way riskier than they wanted.¶ SO
WHAT WENT wrong? Like all insurance, Obamacare is built on the idea of shared risk: A small number of customers with big
medical bills needs to be offset by a much wider group who pay monthly premiums but rarely access care. Theoretically, they balance
 The biggest problem plaguing the exchanges is that for many
out, and insurers collect their profits off the top.¶
states, the balance has turned out to be way off. Fewer individuals signed up for coverage than
projected, and they’ve proven sicker and more expensive than insurers had expected.¶ Before the
ACA, there were a handful of ways insurers could balance their risk pool. One big tactic was just to avoid covering sick people,
filtering out individual customers who appear likely to need lots of expensive medical care. But Obamacare made that type of
discrimination illegal: One big selling point of the law was that everyone would be eligible to sign up.¶ In
the new insurance
landscape, where carriers must take all comers, no matter how sick and costly, the simplest way
to ensure a viable risk pool is to make it as large and diverse as possible.¶ For Obamacare, that has turned
out to be a bigger problem than anyone anticipated. Three years ago, the Congressional Budget Office projected that 24 million
Americans would be enrolled in exchange plans in 2016. The reality: barely half that number signed up this year–and that number is
certain to erode as people stop paying their insurance bills or find jobs that include coverage. The Obama administration’s stated
goal is now just 10 million enrollments by the end of 2016.¶ Why so low? In part, it's because fewer people got kicked off their work
plans than expected. Initially, the architects of the plan thought many employers would stop offering insurance and let people buy
their own on the Obamacare market. That didn't happen. “Employers have not ‘dumped’ employees to the extent that some people
feared and predicted,” said Ceci Connolly, CEO of the Alliance of Community Health Plans. It was good news for those workers, but
not so good for the exchanges’ actuarial health.¶ And in part the small size of the Obamacare pool is because of a self-inflicted wound
by Obama himself. For years, in selling the ACA, Obama had been repeating a talking point: "If you like your health care plan, you
can keep it." But in late 2013, as the first open-enrollment season loomed, millions of Americans received notices that their plans
were being canceled because they didn’t meet the coverage requirements of the health care law. Republicans relentlessly mocked the
president’s failure to keep his pledge. PolitiFact called it the 2013 “Lie of the Year.”¶ In response to the blowback, the administration
decided that those old plans didn’t have to be canceled after all–people could keep them through 2017, even if they didn’t comply
with the new rules. That move may have quelled the political uproar, but it also cut off a potential flow of millions of customers who
may otherwise have signed up for new plans in the fledgling Obamacare exchange markets.¶ Not all states extended those plans, and
some insurers phased them out on their own. But McKinsey estimates that heading into the 2016 enrollment season, 3.7 million
Americans were still in those old individual plans. And it’s likely that an awful lot of them are quite healthy, given that they were able
to obtain coverage even when health plans were free to discriminate against people with pre-existing conditions.¶ A viable risk pool
also needs healthy customers. The most desirable customers are young, from 18 to 34—the so-called young invincibles—who might
not want to sign up at all, because they don't think they'll need health care.¶ To
encourage all Americans to sign up,
Obamacare includes a cudgel: You have to pay a tax penalty if you aren't covered in a qualified
health plan. In reality, there are numerous exemptions–and the penalty has proven too low to
induce younger Americans to buy insurance. The fine maxed out this year at $695, or 2.5
percent of income, whichever is higher. Healthy, younger people (some of whom may be eligible
for subsidies but not realize it) often figure it’s cheaper to pay the fine than shell out money on
health insurance that they don’t think they’ll need. That may or may not make financial sense for them as
individuals, but it's hurting the broader system. For markets to be sustainable financially, experts estimate
that 35 percent of customers should be between the ages of 18 and 34. In reality, right now, just
28 percent of customers fall in that group.¶ Obamacare also includes a restriction on timing: Exchange customers are
supposed to sign up only during the annual open-enrollment period. That’s designed to prevent people from gaming the system and
getting insurance only when they need medical care. But there are exceptions to the timing rule--you can sign up for Obamacare
when you've switched jobs and lose your work coverage, for instance. And insurers complain that these exceptions are far too
numerous and easy to game. Most troubling to insurers, there’s been no rigorous verification process to corroborate that Obamacare
customers are truly eligible for special enrollment periods—that they really did change jobs, that they weren’t just claiming to have
done so because they had just gotten a scary diagnosis or banged up their knee and now wanted health care. Many health plans have
found that customers who come in through special enrollments run up bigger medical bills than other people. Pennsylvania’s
Independence Blue Cross, for example, says people who enroll outside the standard window have 30 percent more medical
expenses.
 1AC
Advantage (2) Is Medical Tourism

Weak ACA implementation is driving growth in medical tourism –

strengthening the mandate key
Renee-Marie Stephano 12, JD in Health Law, Villanova University School of Law, 7/9/2012,
US HealthCare Reform’s Effect on the US Medical Tourism Marketplace,
http://medicaltourismassociation.com/en/us-healthcare-reform-s-affect-on-the-us-medical-
tourism-marketplace-white-paper.html
The United States has been in a healthcare crisis for years. It is estimated that more than 50
million Americans and growing are without health insurance and over 120 million are without dental
insurance. A common misperception is that the average American without health insurance does not have the financial means to
purchase health insurance, but it is estimated the average American without health insurance makes approximately $50,000 dollars
per year. Those Americans who do not have the financial means to purchase health insurance are typically provided coverage, called
Medicaid, by the state and federal government. The definition of an uninsured American varies and has become a political debate as
different political parties argue different definitions and numbers.¶ At
the end of March 2010, the Patient
Protection and Affordable Care Act (PPACA) and the reconciliation bill were passed into law. US
Healthcare Reform should have a very positive impact on the growth of outbound medical tourism leaving the United States while
having no impact on the continued growth of both foreign patients coming into the US for healthcare treatment (inbound medical
tourism), or on American healthcare consumers who travel regionally throughout the US for healthcare treatment (Domestic
medical tourism).¶ Healthcare Reform will most likely drive up the costs of health insurance in the US to
an unsustainable level. It is estimated that in 2020, health insurance costs for a family could range from $30,000 to
$40,000 per year. Under Healthcare Reform, these health insurance costs should be higher. While Healthcare Reform’s
intention is to insure more Americans, it may have the opposite effect of creating more
uninsured due to high health insurance costs. Healthcare Reform is pushing more employers,
insurers and health insurance agents to examine implementing medical tourism. With health
insurance and healthcare costs in the US rising at a much faster pace under Healthcare Reform,
the medical tourism industry is expected to see growth in 2013 and very strong growth
occurring in 2014, as the major parts and mandates of Healthcare Reform are implemented and
health insurance cost increases are felt more clearly.¶ The passage of Healthcare Reform has made sweeping
changes and has changed healthcare as we know it in America. Very few people in the US, including government officials, employers
and insurance companies, understand its true impact or have even read the entire Healthcare Reform legislation. Unfortunately,
even after reading the Healthcare Reform bill, there are many unanswered questions because the bill creates new governmental
entities whose duties will be to create new regulations, rules and guidelines of how Healthcare Reform will work and what the actual
defined benefit levels will be. It will take several years for industry participants to fully understand the full effect Healthcare Reform
will have on their business.¶ To complicate the matter of the lack of understanding of Healthcare Reform’s true effect, one must
understand the law, and the cost of understanding and complying with the law and the layers of government involvement within it.
The Healthcare Reform Law is almost 3,000 pages, and there are almost 13,000 pages of regulations. In drafting regulations and
interpretations the IRS, Health and Human Services, and many other agencies have not really even gotten started yet on creating
those regulations, rules and interpretations. There are approximately 180 government committees, bureaus, commissions, boards,
within the different agencies involved in providing the rules, regulations, interpretations and enforcement of the law. One can only
imagine how many years and the amount of analysis and education it will take for employers, insurance companies and individual
healthcare consumers to fully understand the law and its impact.¶ Healthcare Reform did not create a public option or a government
plan, so the insurance marketplace will still be run by private industry, specifically the fully insured and self-funded health plans.
Some of the major changes in Healthcare Reform will be the waiving of pre-existing conditions, the elimination of annual and
lifetime limits, the expanding of dependant coverage to age 26 (Caterpillar Inc, when the law was first passed in 2010, estimated that
expanding the dependant age to 26 will cost the company $20 million per year more), providing level or equal premiums for those
who are sick or healthy, the creation of “essential benefits,” the creation of health insurance exchanges (where Americans can
purchase health insurance) and mandating the purchase of health insurance by Americans or a penalty must be paid. Healthcare
Reform also lowers the insurance premiums for elderly Americans artificially and raises it for younger Americans, specifically at a
three to one ratio, where elderly Americans cannot be charged more than 3 times that of a younger American even though actuarially
they should be charged five to six times the price of a younger American.¶ Preventative Services¶ Healthcare Reform required that
preventative services be included for newly enrolled insured plans by the fall of 2010 or within six months of enactment of the bill
for existing health insurance plans. Specifically, the following benefits must be included:¶ ¶ Evidence-based items or services with a
rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;¶ Immunizations
recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect
to the individual involved;¶ For infants, children and adolescents, evidence-informed preventive care and screenings provided for in
the comprehensive guidelines supported by the Health Resources and Services Administration;¶ For women, additional preventive
care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration;¶ For
women, the recommendations issued by the United States Preventive Service Task Force regarding breast cancer screening,
mammography and prevention shall be considered the most current other than those issued in or around November 2009.¶ For
those qualified health plans that will be required to provide this preventative coverage without cost-sharing for preventive services
that are rated ‘A’ or ‘B’ by the U.S. Preventive Services Task Force, these services could be recommended immunizations, preventive
care for infants, children and adolescents and additional preventive care and screenings for women.¶ Pre-Existing Conditions¶ The
waiving of pre-existing conditions will have both positive and negative effects on the health insurance industry. The waiving of pre-
existing conditions clauses, which started in 2010 for children and will begin in 2014 for adults, will drive up the costs of health
insurance in the US. For those who are sick and have health conditions this can be a positive step forward, because there are many
Americans who were previously denied health insurance because of a pre-existing condition or who could not afford to purchase
health insurance because of the high premiums. For many of these Americans that health insurance and health care were
inaccessible for, they could not afford to receive the proper medical care, which resulted in the worsening of their health conditions
and, later in life, much higher medical expenses. Also, many of these Americans did not have access to preventative services to catch
serious health conditions at an early stage, due to lack of access to proper or affordable health care. For
these Americans,
the waiving of the pre-existing conditions clauses and the lowering of health insurance
premiums, which will be subsidized by healthy Americans that will have their insurance rates
increased, will provide them access to more affordable healthcare for the first time.¶
Unfortunately there are also some negative side effects to this. Even though pre-existing
conditions clauses will be waived starting in 2014, with the costs of a family health insurance
plan rising to $30,000 to $40,000 a year by 2020 or earlier, many of these sick Americans with
pre-existing conditions may not be able to afford to pay the health insurance premiums. Also,
insurance premiums for individuals who are healthy will increase in order to subsidize sicker Americans who have pre-existing
conditions. This is because the law requires healthy and sick people to pay the same health insurance premiums. The only variations
Healthcare
allowed in the charging of health insurance premiums are for age, tobacco use and geographic location.¶
Reform does not properly incentivize Americans to purchase health insurance.
The fines for not purchasing health insurance in 2014 start at $95, and increase each year. Compared to
rising health insurance costs in the next 10 years, the fines, which were originally meant to force
the majority of Americans to buy health insurance, are small and will fall short of their intended
goal. This would mean many Americans can make the decision to not purchase health
insurance, not engage in healthy lifestyles or behaviors or focus on preventative medicine and
instead wait until they are sick and then purchase guaranteed-issue health insurance with no
pre-existing conditions clauses at a “fair price subsidized by the healthy.” This penalizes Americans who
have engaged in healthy behavior and lifestyles and who have planned and paid for health insurance every month in anticipation of
one day possibly becoming ill or sick. People who have always paid for health insurance and maintained a healthy lifestyle are in
actuality being penalized in the form of their health insurance premiums increasing. An example of this is as follows:¶ In 2014, Joe,
who is 45 and whose health insurance costs $1,200 a month makes a decision to not pay for health insurance and instead to pay the
$95 fine for the year. He chooses not to buy health insurance because he knows when he does get sick with a major health condition
he can purchase health insurance at any time and immediately be covered. Joe smokes a pack of cigarettes per day, drinks alcohol
each day, eats fast food for meals and does not exercise.¶ Jane is 45, healthy and her health insurance costs in 2014 would be $1,200
a month. She pays her premiums each month. She exercises five times per week, eats healthy food and does not drink or smoke.
Under Healthcare Reform, Jane and Joe’s health insurance premiums must cost the same. Joe will eventually develop serious health
conditions because of his lifestyle and when he buys health insurance later in life it will automatically cover everything at the same
price as Jane. Starting in 2014, Jane’s insurance premiums will have to increase significantly for the eventuality and potential of
people like Joe waiting until they are very sick and need health insurance to purchase it.¶ The
rise of health insurance
premiums will have a very positive effect on the medical tourism industry. Because of
the potential for skyrocketing health insurance costs, many employers and insurance companies
will start to implement medical tourism as one of the only means to lower healthcare
costs. The waiving of pre-existing conditions and requiring sick and healthy Americans to pay
the same price for health insurance destroys the underwriting process and can put an employer
or insurance company in a difficult position of potentially losing a significant amount of money,
meaning medical claims incurred by the insurance carrier or employer exceed insurance
premiums collected. Medical tourism provides a “hedge”/protection against this because if an
insured utilizes the medical tourism benefit it will lower medical claims costs.

Medical tourism threatens international medical apartheid –

exporting care undermines public health systems in South East Asia
specifically
Glenn Cohen 11, Assistance Professor and Co-Director of the Center for Health Law Policy,
Biotechnology and Bioethics, Harvard Law School, JD from Harvard Law, Medical Tourism,
Access to Health Care, and Global Justice, Virgina Journal of International Law, Vol 52(1),
http://www.vjil.org/assets/pdfs/vol52/issue1/Cohen_Final.pdf
Medical tourism — the travel of patients who are residents of one country (the “home country”)
to another country for medical treatment (the “destination country”) — represents a growing and
important business. For example, by one estimate, in 2004, more than 150,000 foreigners sought medical
treatment in India, a number that is projected to increase by fifteen percent annually for the
next several years.1 Malaysia saw 130,000 foreign patients in the same year.2 In 2005,
Bumrungrad International Hospital in Bangkok, Thailand, alone saw 400,000 foreign patients, 55,000 of
whom were American (although these numbers are contested).3 By offering surgeries such as hip and heart valve
replacements at savings of more than eighty percent from that which one would pay out of
pocket in the United States, medical tourism has enabled underinsured and uninsured
Americans to secure otherwise unaffordable health care.4 The title of a recent Senate hearing — “The
Globalization of Health Care: Can Medical Tourism Reduce Health Care Costs?” — captures the promise of medical tourism.5 U.S.
insurers and self-insured businesses have also made attempts to build medical tourism into
health insurance plans offered in the United States, and states like West Virginia have
considered incentivizing their public employees to use medical tourism.6 There have even been calls for
Medicaid and Medicare to incentivize medical tourism for their covered populations.7¶ Although hardly new, in recent years, the
dramatic increase in the scope of the industry and the increasing involvement of U.S. citizens as
medical tourists to developing countries have made pressing a number of legal and ethical issues.8
While the growth of medical tourism has represented a boon (although not an unqualified one9) for U.S. patients, what about
the interests of those in the destination countries ? From their perspective,
medical tourism presents a host of cruel ironies . Vast medico-industrial complexes
replete with the newest expensive technologies to provide comparatively wealthy medical
tourists hip replacements and facelifts coexist with large swaths of the population dying from
malaria, AIDS, and lack of basic sanitation and clean water. A recent New York Times article entitled “Royal
Care for Some of India’s Patients, Neglect for Others,” for example, begins by describing the care given at Wockhardt Hospital in
India to “Mr. Steeles, 60, a car dealer from Daphne, Ala., [who] had flown halfway around the world last month to save his heart
[through a mitral valve repair] at a price he could pay.”10 The article describes in great detail the dietician who selects Mr. Steele’s
meals, the dermatologist who comes as soon as he mentions an itch, and Mr. Steeles’s “Royal Suite” with “cable TV, a computer,
[and] a mini-refrigerator, where an attendant that afternoon stashed some ice cream, for when he felt hungry later.”11 This
treatment contrasts with the care given to a group of “day laborers who laid bricks and mixed cement for Bangalore’s construction
boom,” many of whom “fell ill after drinking illegally brewed whisky; 150 died that day.”12 “Not for them [was] the care of India’s
best private hospitals,” writes the article’s author; “[t]hey had been wheeled in by wives and brothers to the overstretched
government-run Bowring Hospital, on the other side of town,” a hospital with “no intensive care unit, no ventilators, no dialysis
machine,” where “[d]inner was a stack of white bread, on which a healthy cockroach crawled.”13¶ These kinds of stark
disparities have prompted intuitive discomfort and critiques in the academic and policy
literatures. For example, David Benavides, a Senior Economic Affairs Officer working on trade for
the United Nations, has noted that developed and developing countries’ attempts at exporting
health services sometimes come “at the expense of the national health system , and the
local population has suffered instead of benefiting from those exports.”14 Rupa Chanda, an
Indian professor of business, writes in the World Health Organization Bulletin that medical tourism
threatens to “result in a dual market structure, by creating a higher-quality, expensive
segment that caters to wealthy nationals and foreigners, and a much lower-quality, resource-
constrained segment catering to the poor.”15 While the “[a]vailability of services, including
physicians and other trained personnel, as well as the availability of beds may rise in the higher-
standard centres,” it may come “at the expense of the public sector, resulting in a
crowding out of the local population.” 16 FOOTNOTE 16 BEGINS… 16. Id.; see also MILICA Z. BOOKMAN &
KARLA K. BOOKMAN, MEDICAL TOURISM IN DEVELOPING COUNTRIES 176 (2007) (“Medical Tourism can thus create a dual
market structure in which one segment is of higher quality and caters to the wealthy foreigners (and
local high-income patients) while a lower quality segment caters to the poor . . . [such that]
health for the local population is crowded out as the best doctors, machines, beds, and hospitals
are lured away from the local poor.”). FOOTNOTE 16 ENDS… Similarly, Professor Leigh Turner suggests that “ the
greatest risk for inhabitants of destination countries is that increased volume of
international patients will have adverse effects upon local patients, health care
facilities and economies.” 17 He explains that the kinds of investments destination-country
governments must make to compete are in “specialized medical centres and advanced
biotechnologies” unlikely to be accessed by “most citizens of a country [who] lack access to basic
health care and social services.”18 Furthermore, higher wages for health care professionals resulting
from medical tourism may crowd out access by the domestic poor.19 Thus, “[i]nstead of contributing to
broad social and economic development, the provision of care to patients from other countries might
exacerbate existing inequalities and further polarize the richest and poorest members” of the destination country.20¶
The same point has also been made in several regional discussions: Janjaroen and Supakankuti argue that
in Thailand, medical tourism threatens to both disrupt the ratio of health personnel to the
domestic population and “create a two-tier system with the better quality services reserved for
foreign clients with a higher ability to pay.”21 Similarly, the Bookmans’ claim that in Cuba, “only one-fourth
of the beds in CIREN (the international Center for Neurological Restoration in Havana) are
filled by Cubans, and . . . so-called dollar pharmacies provide a broader range of medicines to
Westerners who pay in foreign currency.”22 They describe a medical system so distorted by the
effects of medical tourism as “medical apartheid, because it makes health care available
to foreigners that is not available to locals.” 23 Numerous authors have made similar
claims about medical tourism in India.24 Similar concerns have even been raised as to medical tourism in developed
countries. For example, an investigation by the Israeli newspaper Haaretz concluded, “medical tourists enjoy conditions Israelis can
only dream of, including very short waiting times for procedures, the right to choose their own doctor and private rooms . . . [a]nd
these benefits may well be coming at the expense of Israeli patients’ care,” and suggested that allowing medical tourists to move to
the front of the line on waiting lists for services meant that “waiting times for ordinary Israelis will inevitably lengthen — especially
in the departments most frequented by medical tourists, which include the cancer, cardiac and in vitro fertilization units.”25

Market is nascent – further growth key – especially in Asia --

underinsurance drives demand
GMT 16, Globla Medical Tourism, magazine known as the “voice” of the medical tourism
industry, 10/6/2016, http://global-mtm.com/global-medical-tourism-market-to-witness-
increasing-influx-of-medical-tourists-in-asian-countries/
The increasing number of people travelling abroad to seek medical treatment comprises a rising
global trend. The exponentially rising healthcare cost in developed regions, coupled with the availability of
advanced yet cost-effective medical services in developing countries, is encouraging people to travel abroad for
treatment purposes that may also incorporate an extended holiday. This trend is called medical tourism and has been
showcasing definitive growth around the world over the past few years .¶ Demand for Advanced
and Cost-effective Medical Services Boosts Global Medical Tourism Market¶ Medical tourism may include sophisticated treatments
such as neurosurgery, cardiac surgery, orthopedics, elective treatments such as cosmetic surgeries and dental care, or routine health
check-ups. The
visibly rising cost of healthcare services in developed countries is the prime
factor bolstering the market for medical tourism. According to a report published by Transparency Market
Research, approximately 50 million people in the U.S. alone are uninsured , while 139 million
Americans do not have dental insurance.¶ An estimated 1.6 million Americans opted for medical tourism in 2012, since the
treatment for the same disease in developing nations costs 20% to 30% less than that in developed countries. This helps patients and
their families save a substantial share of the cost even after accounting for the travel expenses.¶ The
global medical
tourism market, therefore, sees lucrative opportunities in the forthcoming years with an
increasing number of people making it their preferred choice. Transparency Market Research, in its
latest report, pegs the overall value of the global medical tourism market at US$10.5 bn in 2012, and it is expected to reach US$32.5
bn by the end of 2019. If the figures hold true, the global medical tourism market will exhibit an impressive CAGR of 17.9% between
2013 and 2018.¶ Asian
Countries Witness Highest Influx of Medical Tourists¶ With high-quality
infrastructure and low costs, Asian countries have emerged as the most prominent players
in the market for medical tourism over the past few years. Asia attracted over 5.6 million foreign patients in
2012, generating a revenue of a whopping US$6.4 bn from medical tourism. The presence of popular tourist destinations in this
region has also contributed to attracting an increasing number of people from abroad.¶ India,
Thailand, Malaysia,
Singapore, South Korea, and Taiwan are among the Asian countries that witness the highest
number of people travelling from abroad to seek medical services. For instance, Thailand has emerged as
the most popular destination for medical tourists from Western Europe for cosmetic surgeries. In 2012, Thailand received over 2.5
million foreign patients that accounts for almost 45% of the total number of foreign arrivals in Asia. Likewise, India and Singapore
specialize in complex procedures such as cardiac surgeries. In the meantime, Malaysia also has been attracting a large number of
medical tourists due to the presence of a modern healthcare infrastructure.¶ Favorable Government Policies May Boost Global
Medical Tourism Market¶ The medical tourism market is still in a nascent stage and requires substantial
coordination among healthcare providers, insurers, and governments to enjoy sustainable growth in the near future. With favorable
government policies, the organizations operating in the market can enjoy a competitive advantage. Some of the most prominent
names operating in this industry include Bumrungrad Hospital, Apollo Enterprise Ltd, Bangkok Medical Center, Prince Court
Medical Center, Raffles Medical Group, and others.

Public health inequality causes East Asian instability

James R Campbell 12, Professor at the College of Security Studies, Asia-Pacific Center for
Security Studies, 2012, Human Health Threats and Implications for Regional Security in
Southeast Asia*, in Human Security: Securing East Asia's Future,
https://link.springer.com/content/pdf/10.1007%2F978-94-007-1799-2_9.pdf
According to the World Health Organization (WHO), health is not only the absence of infi rmity and disease but also a state of
physical, mental and social well-being (WHO 1946 : 100). As
disease incidence (the number of new cases of a
particular disease within a population over time) increases, the burden on individuals, local
health care systems and other government agencies increases. New or re-emerging infectious
diseases, particularly diseases contracted from exposure to infected animals (zoonotic disease)
such as SARS, Nipah virus and avian infl uenza spread quickly within a region, creating new,
unpredictable crises for national public health systems. For biological and epidemiological reasons not fully
understood, most of the new influenza viruses that spread globally each year originate in the
Southeast Asian region. Yet treatments may not be equitably shared between countries, and international relations can
quickly deteriorate. When Indonesia sought guarantees from the WHO that any vaccine against H5N1 infl uenza that was based on
Indonesian strains of the virus would subsequently be made available to Indonesia at an affordable price, the WHO was unable or
unwilling to convince the large pharmaceutical companies to provide such a guarantee (Current Concerns 2009 ) . As a result
Indonesia withheld critical virus strains from vaccine research and development, putting itself and the region at risk, for which it
was rebuked by much of the international health community. ¶ In 2005 the WHO updated and re-issued its International Health
Regulations (IHR), which specifi es mandatory infectious disease outbreak reporting requirements for the 194 state parties to the
agreement. However the fi nancial and technological burdens of increased disease surveillance inhibited compliance with the
regulations among many of the low and middle income nations in the region. In future outbreaks, under authority of
the IHR, the WHO may enter a country with regionally-placed teams of experts and supplement
that nation’s resources in order to protect global public health (WHO 2005 ) . While the benefi ts of such a
policy for regional and global public health are obvious, potential disputes involving state sovereignty create
emerging threats to regional security. Diseases with pandemic potential are especially
problematic to health security, with the additional potential to cause political unrest and civil
disorder, deplete military forces, destabilize nations and contribute to state failure. These
diseases also affect regional health security indirectly, through strategic impacts on important Asian
neighbors like China. The most populous nation on Earth, China earned the enmity of the entire international health
community for its dilatory response to the global outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003 (Maclean 2008 :
475). Because of the tremendous disparity between countries in planning and response capabilities for dealing with pandemics, in
any global pandemic such as the H5N1 avian infl uenza outbreak developing
countries in Southeast Asia will likely
experience proportionately more morbidity and mortality than developed nations, due to limited
access to any vaccines and anti-viral medications like oseltamivir (Tamifl u). Ill-will generated by such
health inequity and perceived injustice could potentially damage international relations and
impact regional stability . ¶ In 2004 the Global Fund offered $100 million in grants to fi ght tuberculosis, malaria and
HIV/AIDS in Myanmar. However in 2005, because of serious concerns about governance in that country and the unwillingness of
the ruling military junta to respect the project’s safeguards and performance-based grant implementation the funds were rescinded
(Global Fund 2005 ) . As a result these highly infectious diseases rampant in Myanmar have returned as imminent health security
threats to neighboring countries. Border regions within Myanmar populated by ethnic minorities and marked by ongoing civil confl
ict suffer the highest national incidences of malaria. The ramifi cations for transnational health security are obvious, because regions
within India, Bangladesh, Laos, Thailand and China that border Myanmar all have signifi cantly higher incidences of malaria,
tuberculosis and HIV/AIDS than other regions of those countries (Beyrer and Lee 2008 : 2). Myanmar has one of the largest AIDS
epidemics in Asia, and this can be as destabilizing as war. The age demographic affected most directly by AIDS includes the most
productive segments of society, such as military and civil servants, business owners, teachers and parents. Higher
mortality
in these sub-populations results in an increased proportion of the young and the old, creating a
less stable and more fragile social situation. By framing infectious diseases as a matter of national security with
regional implications, governments and their people will be better prepared to handle sudden outbreaks that endanger
human lives and threaten the existence and survival of nation-states (Caballero-Anthony 2005
) . ¶ Another factor that destabilizes regional human security is the large number of the world’s poorest people
residing in Southeast Asia who lack access to essential medicines to treat these diseases, which argues
strongly for health programs that emphasize prevention of disease. Besides the expense factor, this lack of access is also due to poor
infrastructure, lack of technical assistance and uncertain quality of pharmaceuticals (International Dispensary Association 2009 ) .
The production, distribution and use of counterfeit medicines represent a thriving transnational crime in Southeast Asia. These fake
drugs, either less than full strength or containing no drug at all, also are an increasing public health problem for the region, often
with tragic results (Fernandez et al. 2008 : 585, Newton et al. 2008 : e32). Under-strength drugs are particularly insidious because
they contain enough of the active compound to foil screening tests yet not enough to treat the disease, while at the same time the
reduced potency accelerates the evolution of drug resistant strains of dangerous human pathogens.

Instability escalates – domestic pressures are a key determinant of

conflict
Michael Auslin 17, PhD in History from the University of Illinois at Urbana-Champaign,
former associate professor of History at Yale The End of the Asian Century: War, Stagnation,
and the Risks to the World’s Most Dynamic Region, January 2017, accessed via Kindle for
Windows - no page numbers available
The regional demographics that we explored in chapter 3 spill over directly into domestic politics. Next to the failure of economic
reform, the political challenges facing Indo-Pacific nations are perhaps the largest risk area the region faces. How
well its
leaders deal with the demands of their populaces, be they modernized or developing, may be the
most important factor determining the future of the Indo-Pacific. ¶ The real risk from
domestic politics in Asia can be boiled down to one idea: ever since the final Qing ruler
abandoned his ivory-inlaid throne, Asia’s political history has been one of unfinished revolution.
From armed uprisings in Japan in 1867 and in China in 1911 and 1949, through decolonization
in India in 1947 and in Southeast Asia in the 1950s, to peaceful popular revolutions in the
Philippines in 1986 and in South Korea 1987, Asian politics has been one of constant struggle.¶ It
sounds odd to claim that Asia’s future is still threatened by political revolution. After all, Japan
seems an entirely stable mature democracy, and the Vietnamese and Chinese Communist
Parties maintain an iron grip on power. But economic and social pressures inside all of Asia’s
countries threaten domestic political consequences. ¶ Equally, to turn a popular advertising slogan on its head,
what happens inside a country does not always stay there. An Asia whose political systems fail to provide
stability, legitimacy, and growth is an Asia that will become increasingly troubled. The region’s history
is full of examples of domestic failure leading to wider dislocation. 2 At the same time, embattled
regimes have regularly sought to defuse tensions at home by exporting instability abroad,
even to the point of invading neighboring countries.¶ In looking at the trends in domestic politics
throughout the Indo-Pacific region, this chapter will chart the challenges to democracy and authoritarianism alike. Few
Westerners pay more than passing attention to Asia’s politics. It sometimes may get a minute or
two on the network newscasts, as when Thailand’s military launched a coup in May 2014 or after
the victory of Nobel Peace Prize winner Aung San Suu Kyi’s democratic opposition party in Burma’s
November 2015 election. Yet precisely because so many are not paying sufficient attention, we should be far
more sensitive to the hidden risks that roil domestic politics in the Indo-Pacific. ¶ The question of domestic
political stability leads to the larger issue of the future of politics throughout the region. Americans, whose nation originated in a war
of independence from a European colonial empire, see the spread of democracy as a natural condition. They believe that, given the
choice of self-determination or servitude, any people would prefer to choose their destiny. 3 Economic freedom and opportunity are
believed to follow naturally from and be guaranteed by political freedom. The collapse of the Soviet Union and the rapid
democratization of eastern Europe in the 1990s only reinforced the American belief in the ultimate victory of democracy. 4 While
most Americans understand that political development is not that simple, the moral superiority of democratic governance remains
an article of faith. Even in the face of frequent domestic political gridlock and economic crises, Americans still assume democracy is
a universal good toward which most peoples on earth aspire. To acknowledge this ideological predisposition is not automatically to
deny its validity.¶ Yet the Indo-Pacific continues to confound American understanding of the natural path of political development.
From totalitarian North Korea to authoritarian China on one side of the spectrum and from India’s dizzying democracy to Japan’s
often sclerotic politics on the other, Asia incorporates nearly every type of government known to humanity. Freedom and despotism
continue to battle for Asia’s political soul in another facet of unfinished revolution. ¶ It
is on this battleground that the
future of the Asia-Pacific will take shape. If democracy proves successful at dealing with its
domestic troubles, it will save its legitimacy, gain adherents, and more likely ensure that it
becomes the norm throughout the region. But if smaller states waver in their commitment to
democracy, the triumph of illiberal political regimes may be assured, and the influence of
power politics correspondingly will grow.

Nuke war
Michael Auslin 17, PhD in History from the University of Illinois at Urbana-Champaign,
former associate professor of History at Yale The End of the Asian Century: War, Stagnation,
and the Risks to the World’s Most Dynamic Region, January 2017, accessed via Kindle for
Windows - no page numbers available
How close is Asia to seeing conflict erupt, and where? Not every dispute threatens peace, but today, the
Indo-Pacific region
is regressing to a nineteenth-century style of power politics in which might makes right. With
the world’s largest and most advanced militaries other than the United States, and including
four nuclear powers, a conflict in Asia could truly destabilize the global economy and spark a
conflagration that might spiral out of control.¶ If you are lucky, you might be near Pearl Harbor in Hawaii
when one of America’s aircraft carriers is in port. One afternoon not long ago, I watched the USS Ronald Reagan slowly steam out of
Pearl Harbor into the vastness of the Pacific Ocean. The Ronald Reagan is an apt symbol of how security risk has been managed in
Asia: the United States has underwritten regional stability since 1945. Today,
however, the post– World War II
order instituted by the United States is increasingly stressed, at the very time when Washington
is finding it difficult to respond to crises in Europe and the Middle East. The economic and political risks discussed
here are not isolated from these security trends.¶ The immediate cause of rising insecurity is simple: as China has grown stronger, it
has become more assertive, even coercive. Beijing has embraced the role of a revisionist power, seeking to define new regional rules
of behavior and confronting those neighbors with which it has disagreements. Japan and Taiwan, along with many countries in
Southeast Asia, fear a risingChina, as does India, though to a lesser degree. That fear, fueled by numerous unresolved
territorial disputes in the East and South China Seas and by growing concern over maintaining
vital trade routes and control of natural resources, is causing an arms race in Asia. The region’s
waters have become the scene of regular paramilitary confrontations. ¶ These fears and responses are
triggering more assertive policies on the part of all states in the region, which only raises tensions further. At the same time,
governments feel pressured at home to demonize neighbors, encroach on territory, and refuse to
negotiate on security disputes. This is clearly what has happened in recent years in the Sino-Japanese relationship. We
have already gone through two turns of a “risk cycle”: uncertainty and insecurity, driven over the past
decade by China’s growing power and increasingly assertive and coercive behavior, and by the emergence of a de facto nuclear North
Korea. A third turn, to instability , could cause conflict and even war .¶ The “Asian Century”
thus may not turn out to be an era when Asia imposes a peaceful order on the world, when
freedom continues to expand, or when the region remains the engine of global economic growth. What it imposes may
instead be conflict and instability. The nations of the Indo-Pacific and the world must prepare for the
possibility of economic stagnation, social and political unrest, and even armed conflict . The
emergence of those would mark the end of the Asian Century.

Failing to invest in public health crushes Indian economy

T Sundararaman 16, Dean of the School of Health System Studies, Tata Institute of Social
Sciences, et al, 4/16/2016, No Respite for Public Health, Economic and Political Weekly Vol
51(16), http://www.epw.in/journal/2016/16/budget-2016%E2%80%9317/no-respite-public-
health.html?0=ip_login_no_cache%3D9366610247f77ea97304b0bae8cb5184
The second argument is the rationale advanced for routing public investments through the private sector, based on a claim that the
latter makes more efficient use of resources. There is little evidence to support such a claim, and much evidence that contradicts it.
But even if it were to be true, there
are many vital roles that relate to health as a public good—disease
surveillance and epidemic preparedness, for example, or the prevention of the rising tide of non-
communicable disease—where the private sector cannot substitute for an effective public health
system.¶ As a result, despite a huge growth in the private sector-based health services, age-
standardised mortality rates for non-communicable diseases are now far higher in India than in
any developed nation and there is still no universal primary healthcare programme in the public
sector that addresses this rising tide. Nor is there any effort to expand the very selective
packages of care that fund-constrained district health systems are providing currently. The National
Health Policy draft admits that current district and sub-district health services address less than 15% of
all morbidities, and this, more than any other single factor, forces the public to seek care either
in the private sector or in the overcrowded mega public health hospitals .¶ One of the
lessons that nations need to learn from the Ebola crisis of Western Africa is that when nations
fail to invest in public health systems , they lay themselves open to deadly epidemics that
could threaten the health security and economy of a nation. The Ebola crisis ravaged precisely
those nations in Africa which had seen a decade of structural adjustment-driven reforms which had left their
public systems understaffed and dysfunctional.¶ The damage to industry and growth rates
that such an epidemic would do is mind-boggling. The finance ministry is apparently responsive only to the needs
of the industry, defence and economic growth rates. Without sounding alarmist, it would be useful to remind the ministry that
chronic and sustained under-financing of public health systems over the last four years has now
reached such critical levels , that there is a serious threat to health security of the nation as well as to
its economic growth—not only in the long run, but also in the immediate—not only for the poor, but
for everyone.

and clean cooking but also for livelihood activities.

Growth solves Indo-pak war

Marshall M. Bouton 10, Adjunct Professor of Political Science at Northwestern University,
President – Chicago Council on Global Affairs, July 2010, America’s Interests in India, CNAS
Working Paper,
http://www.cnas.org/files/documents/publications/CNAS_USInterestsinIndia_ Bouton.pdf
In South Asia, the most immediately compelling U.S. interest is preventing terrorist attacks on
the U.S. homeland originating in or facilitated by actors in South Asia, particularly in
Afghanistan and Pakistan. To avert that possibility, the United States also has an interest in the
stability and development of both countries. At the same time, the United States has a vital
interest in preventing conflict between Pakistan and India, immediately because such a conflict
would do great damage to U.S. efforts in Afghanistan and Pakistan (such as the diversion of
Pakistani military attention away from the insurgency) and because it would pose the severe risk
of nuclear escalation. Finally, the United States has an interest in peace and stability in
South Asia as a whole. Instability and violence in nearly every one of India’s neighbors, not to
mention in India itself, could, if unchecked, undermine economic and political progress,
potentially destabilizing the entire region. At present, a South Asia dominated by a politically
stable and economically dynamic India is a hugely important counterweight to the
prevalent instability and conflict all around India’s periphery. Imagining the counterfactual
scenario, a South Asian region, including India, that is failing economically and stumbling
politically, is to imagine instability on a scale that would have global consequences, including
damage to the global economy, huge dislocations of people and humanitarian crisis, increasing
extremism and terrorism, and much greater potential for unchecked interstate and civil
conflict

That escalates
Russ Wellen 14, editor of Foreign Policy In Focus’ ‘Focal Points’ blog for the Institute of
Policy Studies, 12/19/2014, “The Threshold for Nuclear War Between Pakistan and India Keeps
Dropping,” http://fpif.org/threshold-nuclear-war-pakistan-india-keeps-dropping/
Most people think that, since the end of the Cold War, chances that a nuclear war will break out are slim to none.
Though some nervousness has surfaced since the Ukraine crisis, it’s true that, barring an accident, the United States and Russia are unlikely to attack each other with nuclear
weapons. Southeast Asia is another matter, as Gregory Koblentz warns in a report for the Council of Foreign Relations titled Strategic Stability in the Second Nuclear Age.
Interviewed about the report by Deutsche Welle, Koblentz pointed out: “The only four countries currently expanding their nuclear arsenals are China, India, Pakistan and North
Korea.” China, for example, is developing mobile intercontinental ballistic missiles to prevent its stationery ICBMs from becoming sitting ducks, as well as submarines capable of

by 2020, Pakistan could have enough nuclear material to build 200

launching ballistic missiles. Meanwhile,

nuclear weapons, about as many as Great Britain currently has. Koblentz told Deutsche Welle: Altogether, Pakistan has deployed or is
developing eleven different nuclear delivery systems including ballistic missiles, cruise missiles, and

aircraft. As if terrorism, such as the Mumbai attacks of 2008, and territorial disputes , such as over
Jammu and Kashmir, don’t make relations between Pakistan and India volatile enough, a new element

has been introduced. Pakistan is now seeking to develop low-yield tactical nuclear weapons (as
opposed to strategic ― the big ones) to compensate for its inferiority to India in conventional weapons and numbers of
armed forces. Koblentz told Deutsche Welle: Since the conventional military imbalance between India and Pakistan is expected to grow thanks to India’s larger economy and

Pakistan’s reliance on nuclear weapons to compensate for its

higher gross domestic product (GDP) growth rate,

conventional inferiority will likely be an enduring feature of the nuclear balance in South Asia.
What makes tactical weapons so dangerous is that, by blurring the distinction between
nuclear and conventional weapons, they turn nuclear weapons from unthinkable to
thinkable. Equally as dangerous, Koblentz explains: The introduction of t actical n uclear w eapon s may lead Pakistan to loosen its
highly centralized command and control practices. Due to their short-ranges (the Nasr/Hatf-IX has a range of about 60
kilometers), these types of weapons need to be deployed close to the front-lines and ready for use at short-notice. Thus are lower-ranking officers

granted “greater authority and capability to arm and launch nuclear weapons” which “raises
the risk of unauthorized actions during a crisis.” Another risk … is inadvertent escalation.
There is the potential for a conventional conflict to escalate to the nuclear level if the
commander of a forward-deployed, nuclear-armed unit finds himself in a ‘use it or lose it’
situation and launches the nuclear weapons under his control before his unit is overrun.” It’s all too
vertiginous for words. Some in the United States might think that’s not our problem. Pakistan and India are digging their own grave ― let them lie in it.” But, of course,

nuclear war in Southeast Asia has the potential to turn the entire world into a grave . To wit:
Summary of Consequences of Regional nuclear war between India and Pakistan (from studies done at
Rutgers, the University of Colorado-Boulder and UCLA) If … • War is fought with 100 Hiroshima-size weapons (currently available in India-Pakistan arsenals), which have half

20 million people die

of 1 percent (0.05%) of the total explosive power of all currently operational and deployed U.S.-Russian nuclear weapons •

from the direct effects of the weapons , which is equal to nearly half the number of people killed
during World War II • Weapons detonated in the largest cities of India and Pakistan create
massive firestorms which produce millions of tons of smoke • 1 to 5 million tons of smoke quickly
rise 50 km above cloud level into the stratosphere • The smoke spreads around the world,
forming a stratospheric smoke layer that blocks sunlight from reaching the surface of Earth •
Within 10 days following the explosions, temperatures in the Northern Hemisphere would
become colder than those experienced during the pre-industrial Little Ice Age … This cold weather would
also cause a 10% decline in average global rainfall and a large reduction in the Asian summer monsoon. • 25-40% of the protective ozone layer

would be destroyed at the mid-latitudes, and 50-70% would be destroyed at northern high
latitudes.Massive increases of harmful UV light would result, with significantly negative
effects on human, animal and plant life. • These changes in global climate would cause
significantly shortened growing seasons in the Northern Hemisphere for at least years. It would be too cold to grow wheat in most of Canada. •
World grain stocks, which already are at historically low levels, would be completely depleted. Grain exporting nations would likely cease
exports in order to meet their own food needs. • Some medical experts predict that ensuing food shortages would cause hundreds of

millions of already hungry people, who now depend upon food imports, to starve to death during the years following the nuclear
conflict. When it comes to nuclear weapons, we truly are all in it together. Many claim that whatever leadership the United
States and the West might demonstrate in disarmament would be lost on Asian nuclear-weapon states. But they fail to take into account how disarmament is becoming a norm
all over the world including in Asia.
 Plan
The United States federal government should:
- significantly increase penalties for the requirement to maintain
minimum essential health coverage
- appropriate out-of-pocket financial assistance for the Health
Insurance Marketplace
- expand premium financial assistance on the Health Insurance
Marketplace
- commit enforcement and outreach resources to these actions.
 1AC---Solvency
The plan solves – strengthening the mandate, funding cost-sharing
and increasing subsidies is key to a balanced risk pool, higher
enrollement, competition, and lower premiums– working through
the ACA framework is key to stability
Cori Uccello 17, Senior Health Fellow at the American Academy of Actuaries, MA in Public
Policy from Georgetown University, Deep Banerjee, Director at Standard & Poor, 5/5/2017, The
Individual Market at a Crossroads Transcript, http://www.allhealthpolicy.org/the-individual-
market-at-a-crossroads-5/
Let’s talk about the future a little bit. So, I’m
going to talk about two kinds of forecasts. One is business as usual.
What we mean by that is, everything stays with obviously some changes, but no big overhaul to the rules
of the marketplace. If that is the case, what do we expect? Well, we expect 2017 to be a year when more
insurance companies get to break even margin. So, break even, zero percent, so no loss, break even
margin. And then continued improvement in 2018 where they get to small, single digit margins in this
line of business. It is still a very fragile market and it needs time to stabilize.

Probably the
more important discussion is business unusual or business interrupted forecast. So,
there is obviously a lot of pricing and insurer participation issues in the marketplace today,
going into 2018. One of the biggest things that we look at, is the CSR, which there is some
uncertainty about the future funding of that. The reason the CSR is important — it’s not because just
the dollar amount that goes towards it, but more importantly it is paid to the insurance
companies after the fact. So, the insurance company on day one, accepts members who are CSR
eligible and stop paying out claims based on the fact that they will receive a CSR. The only
receive the federal government funding for the CSR later on. So, insurance companies don’t want
to be in the situation where they find out six months into the year, hey, guess what, you don’t get
that money anymore. What we expect to happen are two options available to insurance companies. One, they would price with what we are
calling an uncertainty buffer. So, let’s say they were expecting to price high single digit premium increases for next year. They will probably tack on a
little bit of this uncertainty buffer, because they don’t know what is going to happen. They can load the silver plan with the CSR that they are not going
to get. So, you will see the silver plan premiums go up. The second option, which is probably a little more drastic, is they get more selective about
participating. If
there is greater amount of uncertainty, they could decide to pull out of certain
counties or certain states. And the third one, which is probably important to mention too, that the marketplace has a set of rules. If the
rules are changed after you are already playing the game, it becomes harder to adjust. So, rules
like the individual mandate or the special enrollment periods, enforcement of that will also be critical for the
future stabilization of the marketplace. Perhaps we will talk about (indiscernible) later on, when questions come up.
SARAH DASH: Thank you so much, Deep, and let me turn it over to Cori Uccello. Thanks.

CORI UCCELLO: First I would like to thank Sarah and the Alliance for inviting me to participate today.

As others have already pointed out, we are in a different situation today then maybe we were a couple days ago, but I am going to still focus my remarks
at a fairly general level and discuss the kinds of actions that are needed to improve the stability and sustainability of the individual market. Before
getting to those potential improvements, I think it’s important for us to know what the goals are.

So first, I will talk about what

is necessary in order to have a stable and sustainable market. First, we
need enrollment levels that are high enough to reduce random fluctuations and a balanced risk
pool. In other words, we need enough healthy people so we can spread the cost of the high cost people
over a broader pool. Second, we need a stable regulatory environment that facilitates fair
competition. And that includes not only a level playing field, but also consistent rules that are
known in advance. Third, we need enough insurers participating to have insurer competition and
consumer choice. And as Karen mentioned this, the correct – -the optimal number of insurers probably varies by area. Last, but no least,
because most premiums go toward paying medical claims, it’s important not to overlook the need for continuing to control healthcare spending and
improve quality of care.

So, how is the market doing compared to these criteria? Well, the ACA dramatically reduced uninsured rates and
participation in enrollment in the individual market increased. Nevertheless, in general, enrollment in the individual market was
lower than initially expected, and the risk pool was less healthy than expected. Now, in the market,
competing rules do generally face the same rules. There is pretty much a level playing field. But, the uncertain and changing
legislative and regulatory environment have contributed to adverse experience among insurers.
This has led to a decrease in the number of participating insurers both in 2016 and 2017 and
there is an indication there will be a further reduction of insurers in 2018. Continued uncertainty
could lead to more insurer withdrawals, leaving consumers with fewer plan choices or
potentially none at all. And as Deep has alluded to, insurer experience has stabilized, but the market itself is still
fragile .

This leads me to the actions that should be taken to improve the market. I feel like I’m piling on here, but
first and foremost is the need to fund the cautionary reductions. Not paying for these reductions or even
uncertainty about whether they will be funded, could lead to higher premiums. As Karen said,
the Kaiser Family Foundation has estimated that on average, not paying for those CSRs could result in premium increases of nearly 20%. That’s on top
of the premium increases that will already occur due to medical inflation and other factors.

Second, the individual mandate needs to be enforced. The mandate is intended to increase
enrollment and encourage even healthy people to enroll. That’s what’s needed for a balanced risk pool. As Karen
mentioned, the mandate itself is already fairly weak, because the financial penalty is low, many people are exempt
from the penalty and enforcement itself is weak. But further weakening it, would make it less effective and would lead to higher premiums.
Strengthening it could improve the risk profile and put downward pressure on premiums. But
enforcement itself isn’t enough. I think there are a lot of people out there who don’t even realize the mandate is still in play. And so, it also needs to be
publicized in order to be effective. Alternatives
to the mandate are being explored, such as the continuous
coverage requirements that were in the house passed bill. But it’s difficult to structure those
kinds of mechanisms, so that they encourage healthy people to enroll sooner rather than later, while
still providing protections to people with preexisting conditions.
So, if the mandate is the stick to encourage enrollment, premium subsidies are the carrots. More external funding in the form of
higher premium subsidies, or funding that will offset the cost of high cost enrollees, such a
through high risk pools or these invisible high risk pools, or reinsurance, could help improve the
pool. It’s important to note that there are many — we use the word “high risk pools” a lot, but there are actually several different ways that high risk
pools can be structured. In your packets, there is a paper from the academy that talks about the different ways that that could be done. Like I said, they
could be done in terms of the traditional high risk pools that were in place prior to the ACA, they could be invisible risk pools so that the person
enrolling in the private market stays in that plan, but their claims are paid through this external funding, and that could be their eligibility for those risk
pools, could be based on either having certain conditions or having spending that exceeds a particular threshold.

Finally, it’s
important to not only take actions to improve the market, but also avoid actions that
could make things worse. So, for instance, allowing the sales of insurance across state lines, or
expanding the availability of association health plans, could actually lead to market
fragmentation and higher premiums. So, with that, I will turn things over to Brian.

A stronger mandate is key – induces millions to enroll in individual

exchanges
Oliver Wyman 9, international management consulting firm , 10/14/2009, Insurance
Reforms Must Include a Strong Individual Mandate and Other Key Provisions to Ensure
Affordability, http://www.oliverwyman.de/content/dam/oliver-
wyman/global/en/files/archive/2011/Importance_of_Strong_Individual_Mandates_-
_Public_Memo.pdf
2. Without a strong mandate, premiums for purchasers in the new marketplace will increase
significantly: ¶ We estimate that without strong individual mandates, average annual medical claims in the
reformed individual market five years after reform are expected to be 50 percent higher
compared to today, not including the impact of medical inflation.¶ This would translate into premium
increases of approximately $1,500 for single coverage for a year and $3,300 for family coverage in today’s dollars for people
purchasing new policies. Subsidies will entirely or partially offset these premium increases for some individuals. Eight million
current individual market members and 25 million uninsured earn between 100 and 400 percent of the federal poverty level and will
have access to subsidies through the exchange.¶ ƒ Adequate
subsidies help participation, but are
insufficient to drive effective coverage levels—both a strong personal responsibility
requirement and subsidies are needed. Over 18 million people, including both currently uninsured and existing
individual market members, are ineligible for subsidies based on the Senate Finance Committee proposed subsidy schedules. For the
very low income, below 200% of the federal poverty level (FPL), we believe a
large percentage of the uninsured will
purchase insurance because of the generous subsidies. However, take up rates will be much
lower for those above 200% FPL without a meaningful penalty, since subsidies decline at higher income
levels.¶ ƒ Weak mandates result in more uninsured. Requiring insurers to guarantee issue coverage
regardless of preexisting conditions—without an effective mandate—means that people can wait
to purchase coverage until they need it, causing premiums to increase for most new purchasers.
We estimate that 12.6 million people will forego coverage, relative to an effective mandate. ¶ 3. The impact of reform on the
individual market will vary significantly by geography. The vast majority of States have not enacted the reforms proposed in Federal
bills. The states where twothirds of the United States population reside will experience the highest premium increases. In these
states, the reformed individual market claims are estimated to be up to 60-73%1 higher than today with a weak individual mandate.¶
4. People with existing individual coverage may not see significant impact from rating and benefit changes. The bills “grandfather”
existing coverage, so that people can keep their current coverage. These “grandfathered” policies will not be impacted by the rating
changes described above. However, individuals with “grandfathered” policies will not be eligible for the new subsidies. We estimate
that as many as 4.6 million people will stay in the “grandfathered” blocks after 5 years. However, these individuals would still be
subject to premium increases as a result of insurer fees included in the Senate Finance Committee bill.¶ Key Findings: Small Group
Market¶ Under reform, small group employers (2-50 employees) will experience rating changes similar to those proposed for the
individual market. Key findings include:¶ 1. Average premiums for small employers will increase: Under reform, small employers
will experience premium increases as a result of rating rule changes and minimum benefit requirements. We estimate that small
employers purchasing new policies in the reformed market, with an ineffective mandate, will experience premiums that are up to 19
percent higher in Year 5 of reform, not including the impact of medical inflation. About 9.5 million small group employees who have
coverage today will stay covered under the “grandfathered” block in the initial post-reform years, but will face premium increases
when the grandfathering phases-out.¶ 2. Overall, the number of small employers offering coverage will decline: Under reform and
after accounting for small employer tax credits, premium increases will lead to fewer small employers offering coverage. We estimate
2.5 million fewer members will be insured through small employer policies. ¶ Overview of Modeling Approach and Methodology¶
Oliver Wyman has developed a comprehensive model to study the impact of different health insurance reform proposals on the
individual and small employer health insurance markets.¶ The
model is based on a database of actual claims,
premium and underwriting information from over 375,000 small groups, representing 4.2 million covered lives, and
1.24 million individual policies, representing 1.6 million covered lives. The database includes blinded information on approximately
1-in-10 purchasers in the individual and small employer markets today. These data are representative of states across the country
and reflect the varying rating rules that are used today. This allows the model to provide insight into the impact of reform at the state
level.¶ The
model differs from other models currently in use because it allows for the analysis of
how insurance reforms will impact actual insurance policies. This is critical because most of the
rating reform impact is felt at the “ends of the distributions.” For example, the medical claims for the
healthiest 10 percent of members are typically less than a quarter of the average claims, and the
sickest 10 percent are often four to seven times more than the average. With actual insurance policy data,
we can see how much premiums will shift, and therefore how enrollment is likely to shift, across the full distribution of policies.¶
Other analyses generally use synthetic health insurance units developed from survey data to
evaluate the impact of reform. Because of this, other models may underestimate the real-world
impact of rating changes, in particular, because they do not evaluate the impact on a distribution of actual
policies.¶ Actuarial analysis is used to determine the premium impact of changes in rating regulations and the differential impact
across geographic regions. The model estimates premium changes and migration among coverage categories over a five year period
after reform is implemented. This multi-year view allows us to capture the impact of adverse selection, which can drive up average
prices in an environment with no or weak mandates. Adverse
selection theory holds that healthier individuals
are more likely to drop or switch coverage when faced with cost increases, leaving the remaining
pool more expensive to insure.¶ Our model estimates the costs of different coverage choices available in the market under
a given reform scenario, determines market reaction, and shifts between different potential sources of coverage (e.g., the individual
market, small employer market, large group market, government programs) and the uninsured. To evaluate the market reaction to
different reform scenarios, we
apply elasticities of demand for employers, employees, and consumers
that are consistent with the academic literature and ranges used by the Congressional Budget Office and other
models.¶ The elasticities, combined with the estimated cost changes to the employer or individual, allow us to determine how many
members will enter or exit the market. We are able to track the membership inflow and outflow based on the health status and
income levels of individuals. In addition to the rating changes, we also account for the savings individuals realize from subsidies and
the cost of declining coverage if an individual mandate penalty is in place. Stated more simply, we are able to estimate the number of
people that will be insured and their expected medical costs for any given reform scenario. ¶ Results Consistent with Actual Market
Experience¶ The results we see in the output of the model are consistent with the experience
observed in the market. Among the trends that are readily validated by actual market experience are:¶ ƒ Less healthy
individuals are more likely to take up coverage and less likely to drop coverage when costs
change.¶ ƒ Healthy individuals are more cost sensitive. They are more likely to exit the market
if costs increase and require stronger inducements to take up coverage if they are uninsured.¶ ƒ
Premiums will increase at a rate higher than average medical inflation if the pool enters a risk
spiral , which occurs when the percentage of healthy members in the pool declines.¶ Key Model Variables¶ Our analysis includes
the major elements of the Senate Finance Committee’s proposal, the “America’s Healthy Future Act of 2009” or AHFA, that will
impact the cost of insurance in the individual and small employer health insurance market. These key elements include the
following: ¶ [Table Omitted] ¶ The AHFA also includes changes to the insurance market that were not explicitly evaluated in our
model. These include optional risk corridors, which could protect certain plans from losses in the early years of reform, and the
inclusion of a “young invincibles” product that could have higher cost-sharing than permitted for other products. We do not expect
these policy provisions to have a substantial impact on average prices for new purchasers of health insurance coverage. ¶ The AHFA
also includes a number of fees and taxes on the health industry to help finance the proposal. These include a $6.7 billion annual
assessment on insurers, assessments on drug and medical device manufacturers, and other assessments that are likely to impact
premiums in the individual and small group health insurance market. The AHFA also imposed an excise tax on high cost benefit
plans offered in the employer marketplace. The analysis for this report does not include the impact of these fees and taxes on cost
and coverage in the individual and small employer markets. The excise tax on high cost benefit plans does not apply to the individual
market and we estimate the impact on small group policies to be negligible.¶ We have not explicitly modeled the impact of health
insurance exchanges. However, Oliver Wyman issued a report in 2008 on this subject that found that exchanges were unlikely to
reduce health insurance premiums for individuals and small employers2 . The Congressional Budget Office's analysis of the Senate
Finance Committee proposal indicates that exchanges could reduce premiums by 4-5 percent in the individual health insurance
market3.¶ We evaluated the impact of health insurance reforms with and without including underlying medical cost inflation. The
results of this report are presented in the absence of medical trend to isolate the cost impact of specific reforms. While the Senate
Finance Proposal includes provisions that are intended to bend the cost curve over the long-term, the inclusion of medical trend
would have increased our projected cost increases over the five-year period we examined.¶ Additional Methodology Detail—
Estimated Medical Costs for the Uninsured Once They Become Insured¶ It is important to have an estimate of the expected
utilization of healthcare services of the uninsured after they become insured. There are a handful of academic studies that have
examined this issue, and the Congressional Budget Office has also estimated the potential cost of the uninsured.¶ Our analysis is
generally consistent with the approach used by CBO. We estimate that the morbidity of the uninsured will be about 85 percent of the
level of the current insured market - meaning the uninsured are generally healthier than the current insured market. However, the
insured market is comprised mostly of members from the employer market. It is well known that the current individual market is
generally healthier than the employer market in the majority of the U.S.¶ We estimate that the average uninsured will have average
medical utilization about 20 percent higher than the current individual market. Given that many of the uninsured are likely to seek
coverage in the reformed individual market, we expect that the average claims in the risk pool of the reformed market will increase
as a result. ¶ The uninsured are expected to have higher medical costs than the current Individual market Expected Claims Cost
(Indexed relative to current Individual Market) 100 120 Current Individual Market Current Uninsured On average, uninsured are
estimated to have 20% more medical claims than current Individual market once they become covered Based on our review of
available information, we estimate that the morbidity of the uninsured if given access to insurance would be essentially 85% of the
currently insured. We note that this assumption is roughly consistent with assumptions that the CBO used in its evaluation of the
available data4 . Using premium, claims, and other available information we estimate that the morbidity of those insured through
the individual market is roughly 70% of the morbidity of the entire universe of people insured through the individual, small group,
and large group markets (including self-insured). This 70% factor is the result of the fact that people insured through the individual
market, in most states, are medically underwritten5 . Combining these two estimates, the uninsured will have morbidity that is
roughly 20% greater than those currently covered in the Individual market. ¶ We also used the distribution of claims expenses in the
individual market to estimate the distribution of expected costs for the uninsured. We assume that the sickest 10 percent of the
uninsured are estimated to have claims that are four to six times higher than the average in the current individual market, which
translates to annual claims of $9,000 to $10,000. This amount is similar to the typical range observed in states’ high risk insurance
pools. ¶ Impact of Insurance Reform on Today’s Market ¶ In most parts of the country today, insurers in the individual market are
permitted to underwrite and design benefit plans with a variety of price points. This flexibility enables a stable, competitive
insurance market. Perhaps most importantly, it offers the greatest affordability to attract younger and healthier members and helps
encourage wider enrollment in health insurance. ¶ The proposed insurance
reforms will increase claims costs
significantly in the individual insurance market. We estimate the average medical claims for the uninsured are 20
percent higher than claims in the current individual market. This is because some have not been receiving regular medical care and
some have been unable to obtain coverage at an affordable price as a result of having chronic conditions. ¶ In addition, certain
segments with high medical utilization who are now insured through other arrangements will
enter the individual market as a result of guaranteed issue and modified community rating
requirements. This includes people enrolled in state high risk pools, people on COBRA through their former employers’
coverage and other group conversion policies.¶ Our model assumes that people will generally act in their economic self-interest.
Although individuals and families cannot predict their health care needs precisely, they often
have a relatively good idea of their short term needs. Insurance reforms will tend to lower
barriers and create stronger financial incentives for unhealthy people to become insured. As
individuals work to optimize the costs and benefits of different coverage options, the market will become more prone
to adverse selection that will increase costs over successive years, especially if insurance reforms
are not coupled with an effective individual mandate.¶ Collectively, these factors will lead to a less
healthy “risk pool” in the individual market which ultimately leads to higher average premiums.
The rating reforms significantly alter the cost-to-value ratio that consumers will experience, and younger members will bear a
greater burden of subsidizing premiums for older members. The high degree of cross-subsidization in the
reformed market makes it imperative to have high levels of participation among young people to
subsidize the older population.¶ Impact of Age Bands¶ Eliminating medical underwriting, requiring guaranteed issue and
requiring minimum benefit packages with 65 percent actuarial value will increase premiums significantly for the youngest,
healthiest 30 percent of members in the market today. Based on our analysis of actual polices, the premium increases will be greater
than 50 percent for this cohort in most of the country in the first year of reform.¶ Forty-two states permit health plans to vary
premiums based on age by 5:1 or more, with most of these allowing rates to be based on actuarial justification. The Senate Finance
Committee proposal to limit variations based on age of 4:1 is more restrictive than all but 8 states today. This would create a strong
disincentive for the young and healthy to participate even under the 4:1 age band in the AHFA.¶ In a previous analysis, Oliver
Wyman, Inc. estimated that in most states, premiums for the youngest one-third of the population would increase by 69 percent
under a 2:1 age band called for in the House and Senate HELP Committee bills, and by 35 percent under a 3:1 age band (being
discussed as a compromise) relative to 5:1 age band. While these tighter age bands will reduce premiums for older purchasers, at
least initially, most people under the age of 50 will see their rates increase significantly under tighter age bands.¶ The effect of tighter
age bands on premiums compounds over time, and it becomes increasingly difficult to attract younger members into the insurance
market. Without an effective mandate with meaningful penalties, people with higher expected
utilization of medical services will be much more likely to purchase coverage, driving up
premiums and reducing the number of people who would be covered. On the other hand, the
young and healthy will have little incentive to maintain coverage as they know they can get
insurance when they anticipate a need6 . As a result, the risk pool will deteriorate and premiums
will rise without adequate cross-subsidies. This situation is not conducive to a viable
insurance market.¶ Impact of Benefit Changes¶ The bills before Congress would also require that new purchasers buy
health insurance products that meet certain minimum benefit requirements. The Senate Finance Committee proposal requires
insurers in the individual and small group markets to offer “Gold” and “Silver” policies, which have an actuarial value (AV) of 80
percent and 70 percent respectively. The lowest actuarial value product that insurers could offer in this market would be the
“Bronze” package, with an AV of 65 percent.7¶ In addition to the minimum actuarial value of benefit, the bill also includes a range of
other changes that will impact the cost of benefit packages, including requirements to cover certain services (maternity, mental
health services, etc.), unlimited annual and lifetime maximums, and other limitations that will increase costs. These changes do not
directly affect the actuarial value of the plan, as described in the legislation, but will add to the actual cost of the products.¶ Oliver
Wyman, Inc. reviewed current benefit offerings in the individual and small group markets to understand how the requirements
proposed by the Senate Finance Committee legislation compare to benefit offerings today, and to assess the likely impact of the bill’s
requirements on premiums. The average actuarial value of coverage purchased in the individual health insurance market today is
close to 65 percent, similar to what the Congressional Budget Office has estimated, however, onehalf of individual market policies
are significantly below the proposed requirement. For the small group market, we estimate that the actuarial value of products
currently purchased is 75 percent, with about 20 percent of small groups having products with actuarial values below the Senate
Finance Committee minimum of 65 percent.¶ We estimate that compliance with the benefit requirements in the Senate Finance
Package would cause premiums for new purchasers to increase by approximately 10 percent in the individual market and 3 percent
in the small employer market nationwide.¶ Reform Scenario Results—Impact of Strong Individual Mandates¶ Each of the
major bills before Congress require individuals to purchase insurance coverage or face potential
penalties. The bills generally also include requirements for large employers to purchase insurance or face a financial penalty. In
general, the bills exempt the smallest employers from this requirement. In the case of the Senate Finance Committee bill, firms with
fewer than 50 employees would be exempt from the requirement to provide coverage.¶ An amendment accepted during mark-up of
the Chairman’s Mark in the Finance Committee substantially weakened the bill’s individual mandate. This amendment eliminated
Modest
penalties for not maintaining insurance entirely in the first year insurance reforms become effective (2013).
penalties are phased in , reaching a maximum of $750 per adult in 2017. This maximum
penalty is likely to be only about 15 percent of an average premium in 2017, assuming current rates
of medical cost inflation. The amendment also exempted individuals whose premiums exceed 8 percent of their adjusted gross
income. In 33 states, the average cost of health insurance exceeds eight percent of median state income.8¶ Mandates
with
meaningful penalites are highly effective in encouraging a broad cross-section of the uninsured
to purchase coverage when combined with subsidies. For example, the RAND Corporation’s COMPARE model
found that an individual mandate would have the greatest impact on increasing insurance
coverage.9 By itself, an individual mandate with a penalty of 80 percent of premiums could
increase the number of people with insurance by up to 34 million, a 75 percent reduction in the
uninsured. However, RAND estimates the net newly insured would increase by only 8.7 million if there were no penalties and
subsidies up to 200 percent of the federal poverty level.10¶ A recent survey designed by Professor Joel C. Huber of Duke University,
conducted by Knowledge Networks, and funded by the Blue Cross and Blue Shield Association found that fewer
than one
third of the uninsured seeking individual coverage and making between 200 percent and 300
percent of the federal poverty level are likely to purchase coverage given the maximum penalty
of $750 per year in 2017 under the Senate Finance Committee proposal, even after subsidies are provided .
Approximately one in five uninsured making over 300 percent of poverty are likely to purchase
unsubsidized individual coverage with a penalty of $750 per year, according to the survey.¶ To further
evaluate the need for a strong individual mandate, we modeled two reform scenarios with different levels of
penalties for the mandate. The “High Mandate” and “Low Mandate” scenarios illustrate the effect
of individual mandates on affordability and total number of uninsured. The number of uninsured is
estimated to be approximately 12.6 million people higher with the weakened mandate.¶ Further, with weak mandates, the
risk pool of the individual market will be less healthy, have much lower participation among
younger members, and experience much higher premium increases. The average medical claims
of members in the reformed individual market will be 50 percent higher than the average in the market
today (not including medical inflation). This would translate into premium increases of approximately $1,500 for single coverage
and $3,300for family coverage in today’s dollars.11¶ Younger, healthier members are particularly vulnerable to rating reform. They
will experience premium increases greater than 50 percent relative to the current market in most of the U.S.
With weak
mandate penalties coupled with guaranteed issue, it will be less expensive for many people to choose to
buy insurance only when needed. Strong mandates will draw nearly 3 million more young
and healthy members into the reformed individual market. The healthier insurance pool will result in
premiums lower than reform with weak mandates.¶ Mandates serve to complement subsidies. Subsidies will be most
effective for individuals with low income levels. For the uninsured earning 100-200 percent FPL, we estimate that
more than 60 percent of them will purchase insurance because of subsidies. However, more than 60 percent of the current
individual market and about 20 percent of the uninsured have incomes above 300 percent FPL and will realize limited or no subsidy
support. Over 18 million uninsured and existing individual market members are ineligible for subsidies based on the proposed
structures. Higher
income uninsured individuals are not likely to take up coverage without a
meaningful penalty .

Millions are paying the penalty now – strengthening the mandate

changes the incentive structure
Steve Walker 16, JD from George Washington University, former Vice President of the
Healthcare Investment Banking Division of Merril Lynch, 10/28/2016, Millions choose to pay
Obamacare fines rather than enroll; Simple solution–higher fines or…, Monday Morning,
http://mondaymorning.com/2016/10/28/millions-choose-to-pay-obamacare-fines-rather-
than-enroll-simple-solution-higher-fines-or/
The architects of the Affordable Care Act thought they had a blunt instrument to force people–
even the young and invincible–to buy insurance through the law’s online marketplaces: a tax
penalty for those who remain uninsured. It hasn’t worked all that well, according to The New York Times,
and that is at least partly to blame for soaring premiums next year on some of the health law’s
insurance exchanges. The full weight of the penalty will not be felt until next April, says The Times,
when those who have avoided buying insurance will face penalties in the neighborhood of $700 a person. But even that
might be insufficient: For the young and healthy who are desperately needed to make the
exchanges work, it sometimes makes more sense for them to pay the Internal Revenue Service
than an insurance company charging large premiums, with huge deductibles. “In my experience, the
penalty has not been large enough to motivate people to sign up for insurance ,” said
Christine Speidel, a tax lawyer at Vermont Legal Aid. Some do sign up, especially those with low incomes who receive the most
generous subsidies, Ms. Speidel said. But others, she said, find that they cannot afford insurance, even with subsidies, so “they
grudgingly take the penalty.” The IRS says
that 8.1 million returns included penalty payments for people
who went without insurance in 2014, the first year in which most people were required to have coverage. A preliminary
report on the latest tax-filing season, tabulating data through April, said that 5.6 million returns included penalties averaging $442 a
return for people uninsured in 2015. With the health law’s fourth open-enrollment season beginning next Tuesday, Nov. 1,
consumers are fretfully weighing their options, says The Times. When Congress was drafting the Affordable Care Act in 2009 and
2010, lawmakers tried to adopt a carrot or stick approach: subsidies to induce people to buy insurance and tax penalties “to ensure
compliance,” in the words of the Senate Finance Committee. But the requirement for people to carry insurance is one of the most
unpopular provisions of the health law, and the Obama administration has been cautious about enforcing it. The IRS portrays the
decision to go without insurance as a permissible option, not as a violation of federal law. The law “requires you and each member of
your family to have qualifying healthcare coverage (called minimum essential coverage), qualify for a coverage exemption, or make
an individual shared responsibility payment when you file your federal income tax return,” the IRS says at its website. Some
consumers who buy insurance on the exchanges still feel vulnerable. Deductibles are so high, they say, that the insurance seems
useless. So some think that whether they send hundreds of dollars to the IRS or thousands to an insurance company, they are
essentially paying something for nothing, The Times points out. Obama administration officials say that perception is wrong. Even
people with high deductibles have protection against catastrophic costs, they say, and many insurance plans cover common health
care services before consumers meet their deductibles. In addition, even when consumers pay most or all of a hospital bill, they often
get the benefit of discounts negotiated by their insurers. The health law authorized certain exemptions from the coverage
requirement, and the Obama administration has expanded that list through rules and policy directives. More than 12 million
taxpayers claimed one or more coverage exemptions last year because, for instance, they were homeless, had received a shut-off
notice from a utility company or were experiencing other hardships. “Thepenalty for violating the individual
mandate has not been very effective,” said Joseph J. Thorndike, the director of the tax history project at Tax Analysts, a
nonprofit publisher of tax information. “If it were effective, we would have higher enrollment, and the
population buying policies in the insurance exchange would be healthier and younger.” “If you
make the penalties tougher, you need to make financial assistance broader and
deeper ,” said Michael Miller, the policy director of Community Catalyst, a consumer group seeking health care for all. Steve’s
Take: With the exception of the “repeal and replace” camp, practically everyone agrees that insurance companies
are a necessary ingredient in the exchanges for the ACA to function the way it was intended. And,
for insurance companies to remain in the exchange, they need more healthy people, fewer sick
people or a combination of the two. Both sides of the aisle agree that insurance companies
should not be able to reject people with pre-existing conditions, which means sick people in
need of care will remain, according to Forbes. That means a stronger mandate is required
to get healthy people into the insurance pools . Unfortunately, neither party seems to be discussing this
possibility.

Now is key -- insurers have to commit to selling plans by September

27th
Eric Levitz 9/7, Political Reporter at New York Magazine, former Visiting Lecturer at Johns
Hopkins University in writing, 9/7/2017, The GOP Must Make Obamacare Sabotage-Proof by
Month’s End, http://nymag.com/daily/intelligencer/2017/09/the-gop-must-make-obamacare-
sabotage-proof-by-months-end.html
Republicans can’t blame Donald Trump for their failure to repeal Obamacare. The president didn’t force the GOP to adopt heinously
unpopular priorities for health-care policy, or spend years lying to their voters about what those priorities were; nor did the mogul
force his party to attach draconian Medicaid cuts to their (sloppily drafted) Obamacare-replacement bills, or to reduce insurance
subsidies in a manner that disproportionately harmed parts of the Republican base.¶ But Republicans
can blame Trump
for sabotaging the Affordable Care Act so shamelessly that their party must now pass legislation
strengthening the law, by the end of this month, or else suffer political blowback from
soaring premiums.¶ Under Obamacare, participating insurers are required to keep deductibles and co-payments
affordable for low-income people. In practice, this means that insurers must underprice the risk of covering such individuals, and,
thus, accept a financial loss. To make that proposition more appealing to these for-profit companies, Obamacare provides them with
“cost-sharing reductions” — subsidies that defray the insurers’ losses.¶ But for complicated reasons relating to a lawsuit that House
Republicans brought against the Obama administration, Donald Trump can cancel those subsidies at will. And he
has threatened to do just that, over and over again , for months.¶ This was disconcerting to insurance
providers. In mid-April, several of them descended on Washington, in hopes of securing the White
House’s assurance that Trump’s rhetoric about withholding the subsidies was just a bluff. Seema
Verma, Trump’s head of Medicare and Medicaid Services, informed the insurers that it could be a bluff — if
they agreed to publicly support the president’s health-care bill. The insurers refused to play ball.
And the president has kept a gun pointed at his hostage ever since.¶ So long as that remains the case,
insurers will need to proceed on the assumption that Trump is going to pull the trigger .
Which is to say: They will need to either pull out of the Obamacare exchanges, or else raise
premiums high enough to offset the costs of covering low-income enrollees without Uncle Sam’s help.¶
This week, two insurers passed through door number No. 1, as Vox’s Dylan Scott notes:¶ First, Optima Health announced it would
stop selling Obamacare plans in some Virginia counties in 2018, citing in part uncertainty around the health care law’s cost-sharing
reduction payments…Optima’s exit is expected to leave tens of thousands of Obamacare customers without insurance options, unless
a new carrier steps in.¶ …Then on Thursday, it was reported that Anthem would leave Maine’s marketplaces if the cost-sharing
reduction payments were not guaranteed for 2018. According to Vox’s tally, that would not leave any counties bare, but it would
reduce the number of plans that customers in the state could choose from.¶ Meanwhile, the Trump administration has decided to
slash advertising for Obamacare open enrollment by 90 percent, and funding for “navigators” who help people sign up by 40 percent
— even as Health and Human Services has spent public funds on advertisements effectively discouraging participation in the law. ¶
These actions exacerbate the risk of a premium hike. Sick people will seek out health insurance,
whether or not they’re exposed to advertising that encourages them to do so. But many healthy
people will not — especially when the administration has publicly suggested that it will not enforce Obamacare’s individual
mandate. And without a critical mass of healthy individuals purchasing coverage on the exchanges,
insurers will need to raise premiums to offset the costs of covering a disproportionately sick
population.¶ All of which is to say: If Congress doesn’t at least take the gun out of Trump’s hand — and
pass legislation guaranteeing that the cost-sharing reductions will be paid — health care is
going to become considerably more expensive next year. And all available polling suggests that swing voters will
blame the ruling party for that development.¶ The good news for the congressional GOP is that Republican senator Lamar Alexander
and Democratic senator Patty Murray have been working on a bill that appropriates those cost-sharing reductions. The bad news is
that, in
order to avoid a spike in premiums, they’re going to need to pass that bill by September
27 — the deadline for insurers to commit to selling plans through Obamacare in 2018.

Future terror attacks trigger accidental US-Russia nuclear war---

extinction
Anthony Barrett 13, PhD in Engineering and Public Policy from Carnegie Mellon, Director of
Research @ the Global Catastrophic Risk Institute (GCRI), Fellow @ the RAND Stanton Nuclear
Security Fellows Program, and Seth Baum, PhD in Geography from Pennsylvania State
University, Executive Director @ the GCRI, Research Scientist @ the Blue Marble Space
Institute of Science, and Kelly Hostetler, Research Assistant @ the GCRI, “Analyzing and
Reducing the Risks of Inadvertent Nuclear War Between the United States and Russia,” Science
and Global Security 21(2): 106-133, online
War involving significant fractions of the U.S. and Russian nuclear arsenals, which are by far the largest
of any nations, could have globally catastrophic effects such as severely reducing food production for
years, 1,2,3,4,5,6 potentially leading to collapse of modern civilization worldwide and even the
extinction of humanity . 7,8,9,10 Nuclear war between the US and Russia could occur by
various routes, including accidental or unauthorized launch; deliberate first attack by one nation; and
inadvertent attack. In an accidental or unauthorized launch or detonation, system safeguards or procedures to maintain
control over nuclear weapons fail in such a way that a nuclear weapon or missile launches or explodes without direction from
leaders. In a deliberate first attack, the attacking nation decides to attack based on accurate information about the state of affairs.
In an inadvertent attack, the attacking nation mistakenly concludes that it is under attack
and launches nuclear weapons in what it believes is a counterattack. 11,12 (Brinkmanship
strategies incorporate elements of all of the above, in that they involve deliberate manipulation
of the risk of otherwise unauthorized or inadvertent attack as part of coercive threats that “leave
something to chance,” i.e., “taking steps that raise the risk that the crisis will go out of control
and end in a general nuclear exchange.” 13,14 ) Over the years, nuclear strategy was aimed primarily at
minimizing risks of intentional attack through development of deterrence capabilities, though numerous measures were also taken
to reduce probabilities of accidents, unauthorized attack, and inadvertent war. 15,16,17 For purposes of deterrence, both U.S. and
Soviet/Russian forces have maintained significant capabilities to have some forces survive a first attack by the other side and to
launch a subsequent counter-attack. However, concerns about the extreme disruptions that a first attack would cause in the other
side’s forces and command-and-control capabilities led to both sides’development of capabilities to detect a first attack and launch a
counter-attack before suffering damage from the first attack. 18,19,20 Many people believe that with the end of the Cold War and
with improved relations between the United States and Russia, the risk of East-West nuclear war was significantly reduced. 21,22
However, it has also been argued that inadvertent nuclear war between the United States and Russia has
continued to present a substantial risk . 23,24,25,26,27,28,29,30,31,32,33 While the United States
and Russia are not actively threatening each other with war, they have remained ready to launch
nuclear missiles in response to indications of attack. 34,35,36,37,38 False indicators of nuclear
attack could be caused in several ways. First, a wide range of events have already been mistakenly
interpreted as indicators of attack, including weather phenomena, a faulty computer chip, wild animal activity, and control-
room training tapes loaded at the wrong time. 39 Second, terrorist groups or other actors might cause attacks on
either the United States or Russia that resemble some kind of nuclear attack by the other nation
by actions such as exploding a stolen or improvised nuclear bomb, 40,41,42 especially if such an event
occurs during a crisis between the United States and Russia. 43 A variety of nuclear terrorism scenarios are possible. 44 Al
Qaeda has sought to obtain or construct nuclear weapons and to use them against the United
States. 45,46,47 Other methods could involve attempts to circumvent nuclear weapon launch control safeguards or exploit holes
in their security. 48,49 It has long been argued that the probability of inadvertent nuclear war is
significantly higher during U.S.-Russian crisis conditions, 50,51,52,53 with the Cuban Missile Crisis
being a prime historical example of such a crisis. 54,55,56,57,58 It is possible that U.S.-Russian
relations will significantly deteriorate in the future, increasing nuclear tensions. 59 There are a
variety of ways for a third party to raise tensions between the United States and Russia, making
one or both nations more likely to misinterpret events as attacks. 60,61,62,63
2AC
MT
 2AC – India A/O
Failing to invest in public health crushes Indian economy
T Sundararaman 16, Dean of the School of Health System Studies, Tata Institute of Social
Sciences, et al, 4/16/2016, No Respite for Public Health, Economic and Political Weekly Vol
51(16), http://www.epw.in/journal/2016/16/budget-2016%E2%80%9317/no-respite-public-
health.html?0=ip_login_no_cache%3D9366610247f77ea97304b0bae8cb5184
The second argument is the rationale advanced for routing public investments through the private sector, based on a claim that the
latter makes more efficient use of resources. There is little evidence to support such a claim, and much evidence that contradicts it.
But even if it were to be true, there
are many vital roles that relate to health as a public good—disease
surveillance and epidemic preparedness, for example, or the prevention of the rising tide of non-
communicable disease—where the private sector cannot substitute for an effective public health
system.¶ As a result, despite a huge growth in the private sector-based health services, age-
standardised mortality rates for non-communicable diseases are now far higher in India than in
any developed nation and there is still no universal primary healthcare programme in the public
sector that addresses this rising tide. Nor is there any effort to expand the very selective
packages of care that fund-constrained district health systems are providing currently. The National
Health Policy draft admits that current district and sub-district health services address less than 15% of
all morbidities, and this, more than any other single factor, forces the public to seek care either
in the private sector or in the overcrowded mega public health hospitals .¶ One of the
lessons that nations need to learn from the Ebola crisis of Western Africa is that when nations
fail to invest in public health systems , they lay themselves open to deadly epidemics that
could threaten the health security and economy of a nation. The Ebola crisis ravaged precisely
those nations in Africa which had seen a decade of structural adjustment-driven reforms which had left their
public systems understaffed and dysfunctional.¶ The damage to industry and growth rates
that such an epidemic would do is mind-boggling. The finance ministry is apparently responsive only to the needs
of the industry, defence and economic growth rates. Without sounding alarmist, it would be useful to remind the ministry that
chronic and sustained under-financing of public health systems over the last four years has now
reached such critical levels , that there is a serious threat to health security of the nation as well as to
its economic growth—not only in the long run, but also in the immediate—not only for the poor, but
for everyone.

and clean cooking but also for livelihood activities.

Growth solves Indo-pak war

Marshall M. Bouton 10, Adjunct Professor of Political Science at Northwestern University,
President – Chicago Council on Global Affairs, July 2010, America’s Interests in India, CNAS
Working Paper,
http://www.cnas.org/files/documents/publications/CNAS_USInterestsinIndia_ Bouton.pdf
In South Asia, the most immediately compelling U.S. interest is preventing terrorist attacks on
the U.S. homeland originating in or facilitated by actors in South Asia, particularly in
Afghanistan and Pakistan. To avert that possibility, the United States also has an interest in the
stability and development of both countries. At the same time, the United States has a vital
interest in preventing conflict between Pakistan and India, immediately because such a conflict
would do great damage to U.S. efforts in Afghanistan and Pakistan (such as the diversion of
Pakistani military attention away from the insurgency) and because it would pose the severe risk
of nuclear escalation. Finally, the United States has an interest in peace and stability in
South Asia as a whole. Instability and violence in nearly every one of India’s neighbors, not to
mention in India itself, could, if unchecked, undermine economic and political progress,
potentially destabilizing the entire region. At present, a South Asia dominated by a politically
stable and economically dynamic India is a hugely important counterweight to the
prevalent instability and conflict all around India’s periphery. Imagining the counterfactual
scenario, a South Asian region, including India, that is failing economically and stumbling
politically, is to imagine instability on a scale that would have global consequences, including
damage to the global economy, huge dislocations of people and humanitarian crisis, increasing
extremism and terrorism, and much greater potential for unchecked interstate and civil
conflict
 Vagueness
Counter-interpretation – we only have to specify up to the resolution
– solves their ground arguments

Any other interp is infinitely regressive – their focus trades off with
topic education

Solvency evidence specifies as much as possible

CX checks
Topicality
 2AC – T Public
We meet---the ACA mandates people get insurance

Counterinterpretation – NHI requires two things – a legal

requirement for insurance and universality – the ACA currently fails
this test but the plan makes it NHI
Thomas Bodenheimer 16, MD, MPH, Founding Director of the Center for Excellence in
Primary Care, University of California-San Francisco; and Kevin Grumbach, MD, Founding
Director of the Center for Excellence in Primary Care, University of California-San Francisco,
2016, Understanding Health Policy: A Clinical Approach, Seventh Edition, p. 185-196

n ational h ealth i nsurance program, a government guarantee that every

For more than 100 years, reformers in the United States argued for the passage of a

person is covered for basic health care. Finally in 2010, the United States took a major, though incomplete, step
forward toward universal health insurance.¶ The subject of national health insurance has seen six periods of intense activity, alternating with times of political
inattention. From 1912 to 1916, 1946 to 1949, 1963 to 1965, 1970 to 1974, 1991 to 1994, and 2009 to 2015 it was the topic of major national debate. In 1916, 1949, 1974, and 1994, national health insurance was
defeated and temporarily consigned to the nation’s back burner. Guaranteed health coverage for two groups—the elderly and some of the poor—was enacted in 1965 through Medicare and Medicaid. In 2010,

with the passage of the Patient Protection and Affordable Care Act, also known as the Affordable Care Act (ACA) or “Obamacare,” the stage was set for the
expansion of coverage to millions of uninsured people. National health insurance means the
guarantee of health insurance for all the nation’s residents —what is commonly referred to as
“universal coverage .” Much of the focus, as well as the political contentiousness, of national health insurance proposals concern how to pay for universal coverage. N ational
h ealth i nsurance proposals may also address provider payment and cost containment .¶ The controversies that
erupt over universal health care coverage become simpler to understand if one returns to the four basic modes of health care financing

outlined in Chapter 2: out-of-pocket payment, individual private insurance, employment-based private insurance, and

government financing. There is general agreement that out-of-pocket payment does not work as a sole
financing method for costly contemporary health care. National health insurance involves the replacement of
out-of-pocket payments by one, or a mixture, of the other three financing modes .¶
Under government-financed national health insurance plans, funds are collected by a government or quasigovernmental fund,
which in turn pays hospitals, physicians, health maintenance organizations (HMOs), and other health care providers. Under private individual or
employment-based n ational h ealth i nsurance, funds are collected by private insurance companies, which then
pay providers of care.¶ Historically, health care financing in the United States began with out-of-pocket payment and progressed through individual private insurance, then employment-based
insurance, and finally government financing for Medicare and Medicaid (see Chapter 2). In the history of US national health insurance, the chronologic sequence is reversed. Early attempts at national health
insurance legislation proposed government programs; private employment-based national health insurance was not seriously entertained until 1971, and individually purchased universal coverage was not
suggested until the 1980s (Table 15-1). Following this historical progression, we shall first discuss government-financed national health insurance, followed by private employment-based and then individually

The ACA represents a pluralistic approach that draws on all three of these financing models: government
purchased coverage.

financing, employment-based private insurance, and individually purchased private insurance.¶ GOVERNMENT-FINANCED
NATIONAL HEALTH INSURANCE¶ The American Association for Labor Legislation Plan¶ In the early 1900s, 25 to 40% of people who became sick did not receive any medical care. In 1915, the American
Association for Labor Legislation (AALL) published a national health insurance proposal to provide medical care, sick pay, and funeral expenses to lower-paid workers—those earning less than $1,200 a year—and
to their dependents. The program would be run by states rather than the federal government and would be financed by a payroll tax–like contribution from employers and employees, perhaps with an additional
contribution from state governments. Government-controlled regional funds would pay physicians and hospitals. Thus, the first national health insurance proposal in the United States was a government-financed
program (Starr, 1982).¶ In 1910, Edgar Peoples worked as a clerk for Standard Oil, earning $800 a year. He lived with his wife and three sons. Under the AALL proposal, Standard Oil and Mr. Peoples would each
pay $13 per year into the regional fund, with the state government contributing $6. The total of $32 (4% of wages) would cover the Peoples family.¶ The AALL’s road to national health insurance followed the
example of European nations, which often began their programs with lower-paid workers and gradually extended coverage to other groups in the population. Key to the financing of national health insurance was
its compulsory nature; mandatory payments were to be made on behalf of every eligible person, ensuring sufficient funds to pay for people who fell sick.¶ The AALL proposal initially had the support of the
American Medical Association (AMA) leadership. However, the AMA reversed its position and the conservative branch of labor, the American Federation of Labor, along with business interests, opposed the plan
(Starr, 1982). The first attempt at national health insurance failed.¶ The Wagner–Murray–Dingell Bill¶ In 1943, Democratic Senators Robert Wagner of New York and James Murray of Montana, and
Representative John Dingell of Michigan introduced a health insurance plan based on the social security system enacted in 1935. Employer and employee contributions to cover physician and hospital care would
be paid to the federal social insurance trust fund, which would in turn pay health providers. The Wagner–Murray–Dingell bill had its lineage in the New Deal reforms enacted during the administration of
President Franklin Delano Roosevelt.¶ In the 1940s, Edgar Peoples’ daughter Elena worked in a General Motors plant manufacturing trucks to be used in World War II. Elena earned $3,500 per year. Under the
1943 Wagner–Murray–Dingell bill, General Motors would pay 6% of her wages up to $3,000 into the social insurance trust fund for retirement, disability, unemployment, and health insurance. An identical 6%
would be taken out of Elena’s check for the same purpose. One-fourth of this total amount ($90) would be dedicated to the health insurance portion of social security. If Elena or her children became sick, the
social insurance trust fund would reimburse their physician and hospital.¶ Edgar Peoples, in his seventies, would also receive health insurance under the Wagner–Murray–Dingell bill, because he was a social
security beneficiary.¶ Elena’s younger brother Marvin was permanently disabled and unable to work. Under the Wagner–Murray–Dingell bill he would not have received government health insurance unless his

government-financed health insurance can be divided into

state added unemployed people to the program.¶ As discussed in Chapter 2,

two categories. Under the social insurance model, only those who pay into the program, usually through social
security contributions, are eligible for the program’s benefits. Under the public assistance (welfare) model, eligibility
is based on a means test; those below a certain income may receive assistance. In the welfare model, those who benefit
may not contribute, and those who contribute (usually through taxes) may not benefit (Bodenheimer & Grumbach, 1992). The Wagner–Murray–Dingell bill, like the AALL proposal, was a social insurance
proposal. Working people and their dependents were eligible because they made social security contributions, and retired people receiving social security benefits were eligible because they paid into social security
prior to their retirement. The permanently unemployed were not eligible.¶ In 1945, President Truman, embracing the general principles of the Wagner–Murray–Dingell legislation, became the first US president
to strongly champion national health insurance. After Truman’s surprise election in 1948, the AMA succeeded in a massive campaign to defeat the Wagner–Murray–Dingell bill. In 1950, national health insurance
returned to obscurity (Starr, 1982).¶ Medicare and Medicaid¶ In the late 1950s, less than 15% of the elderly had health insurance (see Chapter 2) and a strong social movement clamored for the federal government
to come up with a solution. The Medicare law of 1965 took the Wagner–Murray–Dingell approach to national health insurance, narrowing it to people 65 years and older. Medicare was financed through social
security contributions, federal income taxes, and individual premiums. Congress also enacted the Medicaid program in 1965, a public assistance or “welfare” model of government insurance that covered a portion
of the low-income population. Medicaid was paid for by federal and state taxes.¶ In 1966, at age 66, Elena Peoples was automatically enrolled in the federal government’s Medicare Part A hospital insurance plan,
and she chose to sign up for the Medicare Part B physician insurance plan by paying a $3 monthly premium to the Social Security Administration. Elena’s son, Tom, and Tom’s employer helped to finance
Medicare Part A; each paid 0.5% of wages (up to a wage level of $6,600 per year) into a Medicare trust fund within the social security system. Elena’s Part B coverage was financed in part by federal income taxes
and in part by Elena’s monthly premiums. In case of illness, Medicare would pay for most of Elena’s hospital and physician bills.¶ Elena’s disabled younger brother, Marvin, age 60, was too young to qualify for
Medicare in 1966. Marvin instead became a recipient of Medicaid, the federal–state program for certain groups of low-income people. When Marvin required medical care, the state Medicaid program paid the

Medicare is a social insurance program,

hospital, physician, and pharmacy, and a substantial portion of the state’s costs were picked up by the federal government.¶

requiring individuals or families to have made social security contributions to gain eligibility to the
plan. Medicaid, in contrast, is a public assistance program that does not require recipients to make
contributions but instead is financed from general tax revenues. Because of the rapid increase in Medicare costs, the social security
contribution has risen substantially. In 1966, Medicare took 1% of wages, up to a $6,600 wage level (0.5% each from employer and employee); in 2015, the payments had risen to 2.9% of all wages, higher for

Many
wealthy people. The Part B premium has jumped from $3 per month in 1966 to $104.90 per month in 2015, higher for wealthy people.¶ The 1970 Kennedy Bill and the Single-Payer Plan of the 1990s¶

people believed that Medicare and Medicaid were a first step toward universal health insurance. European
nations started their national health insurance programs by covering a portion of the population and later extending coverage to more people. Medicare and Medicaid seemed to fit that tradition. Shortly after
Medicare and Medicaid became law, the labor movement, Senator Edward Kennedy of Massachusetts, and Representative Martha Griffiths of Michigan drafted legislation to cover the entire population through a
national health insurance program. The 1970 Kennedy–Griffiths Health Security Act followed in the footsteps of the Wagner–Murray–Dingell bill, calling for a single federally operated health insurance system
that would replace all public and private health insurance plans.¶ Under the Kennedy–Griffiths 1970 Health Security Program, Tom Peoples, who worked for Great Books, a small book publisher, would continue
to see his family physician as before. Rather than receiving payment from Tom’s private insurance company, his physician would be paid by the federal government. Tom’s employer would no longer make a social
security contribution to Medicare (which would be folded into the Health Security Program) and would instead make a larger contribution of 3% of wages up to a wage level of $15,000 for each employee. Tom’s
employee contribution was set at 1% up to a wage level of $15,000. These social insurance contributions would pay for approximately 60% of the program; federal income taxes would pay for the other 40%. ¶
Tom’s Uncle Marvin, on Medicaid since 1966, would be included in the Health Security Program, as would all residents of the United States. Medicaid would be phased out as a separate public assistance
program.¶ The Health Security Act went one step further than the AALL and Wagner–Murray–Dingell proposals: It combined the social insurance and public assistance approaches into one unified program. In
part because of the staunch opposition of the AMA and the private insurance industry, the legislation went the way of its predecessors: political defeat.¶ In 1989, Physicians for a National Health Program offered a

government-financed national health insurance proposal. The plan came to be known as the “ single-
new

payer ” program, because it would establish a single government fund within each state to pay
hospitals, physicians, and other health care providers, replacing the multipayer system of
private insurance companies (Himmelstein & Woolhandler, 1989). Several versions of the single-payer plan were introduced into Congress in the 1990s, each bringing the entire
population together into one health care financing system, merging the social insurance and public assistance approaches (Table 15-2). The California Legislature, with the backing of the California Nurses

Association, passed a single-payer plan in 2006 and 2008, but the proposals were vetoed by the Governor.¶ THE EMPLOYER-MANDATE MODEL OF
NATIONAL HEALTH INSURANCE ¶ In response to Democratic Senator Kennedy’s introduction of the 1970 Health Security Act, President Nixon, a
Republican, countered with a plan of his own, the nation’s first employment-based, privately administered national health insurance proposal. For 3 years, the Nixon and Kennedy approaches competed in the
congressional battleground; however, because most of the population was covered under private insurance, Medicare, or Medicaid, there was relatively little public pressure on Congress. In 1974, the momentum

The essence of the Nixon proposal was the employer mandate, under
for national health insurance collapsed, not to be seriously revived until the 1990s.

which the federal government requires (or mandates) employers to purchase private health insurance for
their employees.¶ Tom Peoples’ cousin Blanche was a receptionist in a physician’s office in 1971. The physician did not provide health insurance to his employees. Under Nixon’s 1971 plan,
Blanche’s employer would be required to pay 75% of the private health insurance premium for his employees; the employees would pay the other 25%.¶ Blanche’s boyfriend, Al, had been laid off from his job in

No longer
1970 and was receiving unemployment benefits. He had no health insurance. Under Nixon’s proposal, the federal government would pay a portion of Al’s health insurance premium.¶

was national health insurance equated with government financing. Employer mandate plans
preserve and enlarge the role of the private health insurance industry rather than
replacing it with tax-financed government-administered plans. The Nixon proposal changed the entire political landscape of
national health insurance, moving it toward the private sector.¶ During the 1980s and 1990s, the number of people in the United States without any health insurance rose from 25 million to more than 40 million

Clinton
(see Chapter 3). Approximately three-quarters of the uninsured were employed or dependents of employed persons. In response to this crisis in health care access, President

submitted legislation to Congress in 1993 calling for universal health insurance through an
employer mandate . Like the Nixon proposal, the essence of the Clinton plan was the requirement that employers pay for
most of their employees’ private insurance premiums. The proposal failed.¶ A variation on the employer mandate type
of n ational h ealth i nsurance is the voluntary approach. Rather than requiring employers to purchase health insurance for employees, employers are

given incentives such as tax credits to cover employees voluntarily. The attempt of some states to implement this type of
voluntary approach has failed to significantly reduce the numbers of uninsured workers.¶ THE INDIVIDUAL-MANDATE MODEL OF

NATIONAL HEALTH INSURANCE¶ In 1989, a new species of national health insurance appeared, sponsored by the conservative Heritage Foundation: the
individual mandate. Just as many states require motor vehicle drivers to purchase automobile insurance, the Heritage plan called for the federal government to

require all US residents to purchase individual health insurance policies. Tax credits would be
made available on a sliding scale to individuals and families too poor to afford health insurance premiums (Butler,
1991). Under the most ambitious versions of the individual mandate, employer-sponsored insurance and

government-administered insurance would be dismantled and replaced by a universal,

individual mandate program. Ironically, the individual insurance mandate shares at least one feature with the single-payer, government-financed approach to universal coverage:
Both would sever the connection between employment and health insurance, allowing portability and continuity of coverage as workers moved from one employer to another or became self-employed.¶ Tom
Peoples received health insurance through his employer, Great Books. Under an individual mandate plan, Tom would be legally required to purchase health insurance for his family. Great Books could offer a
health plan to Tom and his coworkers but would not be required to contribute anything to the premium. If Tom purchased private health insurance for his family at a cost of $10,000 per year, he would receive a

With
tax credit of $4,000 (i.e., he would pay $4,000 less in income taxes). Tom’s Uncle Marvin, formerly on Medicaid, would be given a voucher to purchase a private health insurance policy.¶

individual mandate health insurance, the tax credits may vary widely in their amount depending on
characteristics such as household income and how much of a subsidy the architects of individual mandate proposals build into the plan. In a generous case, a family might receive a $10,000 tax credit, subsidizing
much of its health insurance premium. Another version of individual health insurance expansion is the voluntary concept, supported by President George W. Bush during his presidency. Uninsured individuals
would not be required to purchase individual insurance but would receive a tax credit if they chose to purchase insurance. The tax credits in the Bush plan were small compared to the cost of most health insurance
policies, with the result that these voluntary approaches if enacted would have induced few uninsured people to purchase coverage.¶ The Massachusetts Individual Mandate Plan of 2006¶ Nearly 20 years after the

The Massachusetts
Heritage Foundation’s individual mandate proposal, Massachusetts enacted a state-level health coverage bill implementing the nation’s first individual mandate.

plan, enacted under Republican Governor Mitt Romney, mandated that every state resident must have health insurance
meeting a minimum standard set by the state or pay a penalty. The law provided state subsidies for purchase of private health insurance
coverage to individuals with incomes below 300% of the federal poverty level if they are not covered by Medicaid or through employment-based insurance. The law did not eliminate

existing employer-based or government insurance programs for those already covered by those
mechanisms.¶ Following enactment of the Massachusetts Plan, the uninsurance rate among nonelderly adults in the state dropped from 14% in 2006 to 3.7% in 2014 (Skopec and Long, 2015). Some residents of
Massachusetts continued to have trouble affording private insurance even with some degree of state subsidy, and the high levels of cost sharing allowed under the minimum benefit standards left many insured
individuals with substantial out-of-pocket payments. The Massachusetts Plan set the stage for a national plan enacted under the sponsorship of Barack Obama after his election as President in 2008.¶ THE
PLURALISTIC REFORM MODEL: THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010¶ Following a year-long bitter debate, the Democrat-controlled House of Representatives and Senate
passed the Affordable Care Act (ACA) without a single Republican vote in favor. President Obama, on March 23, 2010, signed the most significant health legislation since Medicare and Medicaid in 1965 (Morone,
2010). Although the ACA was attacked as “socialized medicine” and a “government takeover of health care,” its policy pedigree derives much more from the proposals of a Republican President (Nixon), a

The
Republican Governor (Romney), and a conservative think tank (the Heritage Foundation) than from the single-payer national health insurance tradition of Democratic Presidents Roosevelt and Truman.

pluralistic financing model of the ACA includes individual and employer mandates for private insurance and
an expansion of the publicly financed Medicaid program.¶ In 2013, Mandy Must, a single mother of 2 children working for a small shipping company in Houston that did not offer
health insurance benefits, was uninsured. In 2014, Mandy earned $35,000 per year and was required by the ACA to obtain private insurance coverage. She received a federal subsidy of about $1,400 toward her
purchase of an individual insurance policy with an annual premium cost of $5,000 of which she paid $3,600.¶ Mandy’s older sister Dorothy Woent was a self-employed accountant with no dependents living in
Dallas and earning $48,000 a year. She did not have health insurance, and at her income level was not eligible for a federal subsidy to purchase an individual insurance policy. She would have to pay at least
$4,900 to purchase a qualifying health plan that included a $5,000 annual deductible. Dorothy was in good health and having trouble paying the mortgage on her house. She decided not to enroll in a health
insurance plan in 2014 and instead paid a $695 fine to the federal government for not complying with the ACA’s individual mandate.¶ In 2013, Walter Groop worked full-time as a salesperson for a large
department store in Miami which did not offer health insurance benefits to its workers. In 2014, he began to apply for an individual policy to meet the requirements of the ACA, but his employer informed him that
the department store would start contributing toward group health insurance coverage for its employees to avoid paying penalties under the ACA.¶ In 2013, Job Knaught had been an unemployed construction
worker in Chicago for over 18 months and, aside from an occasional odd job, had no regular source of income. Because he was not disabled, he did not qualify for Medicaid prior to the ACA despite being poor. In

If the ACA were implemented in its entirety as written into law, it is estimated
2014, Job became eligible for Illinois’ Medicaid program.¶

that32 million uninsured Americans would receive insurance coverage—about half through Medicaid
expansion and half through the individual mandate. None of the coverage expansion measures
would benefit undocumented immigrants.¶ The ACA has four main components to its reform of health care financing
(Kaiser Family Foundation, 2013).¶ Individual mandate : As discussed in Chapter 2, the ACA requires virtually all US citizens and legal residents to have insurance coverage meeting
a federally determined “essential benefits” standard. This standard would allow high-deductible plans to qualify, with out-of-pocket cost-sharing in 2015 capped at $6,600 per individual and $13,200 per family.
Those who fail to purchase insurance and do not have employer-sponsored insurance, or do not qualify for Medicaid, Medicare, or veteran’s health care benefits, must pay a tax penalty which would be gradually
phased in. In 2016, the penalty would equal the greater of $695 per year for an individual or 2.5% of household income (up to $2,085 for a family). Individuals and families below 400% of the Federal Policy Level
are eligible for income-based sliding-scale federal subsidies to help them purchase the required health insurance.¶ The ACA established federal and state-based insurance exchanges to function as clearing houses
to assist people seeking coverage under the individual mandate to shop for insurance plans meeting the federal standards. The benefit packages offered by plans in the exchanges vary depending on whether

individuals purchase a low-premium bronze plan with high out-of-pocket costs, a high-premium platinum plan with lower out-of-pocket costs, or the intermediate silver or gold plans.¶ Employer
mandate : Beginning in 2015, employers with 50 or more full-time employees face a financial penalty if: (1) their employees are not enrolled in an employer-sponsored health plan meeting the
essential benefit standard and (2) any of their employees apply for federal subsidies for individually purchased insurance. While this measure does not technically mandate large employers to provide health

benefits to their full-time workers, it penalizes employers who do not provide insurance benefits and leave their employees to fend for themselves in the individual market.¶ Medicaid
eligibility expansion : As discussed in Chapter 2, to qualify for Medicaid required not only low income, but also meeting “categorical” eligibility criteria such as being a young child,
parent, pregnant, elderly, or disabled, leaving out nondisabled, nonpregnant adults without dependent children. The ACA eliminated the categorical eligibility requirement and required that states make all US
citizens and legal residents below 138% of the Federal Poverty Level eligible for their Medicaid programs. In 2015, 138% of the Federal Poverty Level was $15,654 for a single person and $32,252 for a family of
four. The federal government would pay states 100% of Medicaid costs for beneficiaries qualifying under the expanded eligibility criteria for 2014 through 2016, with states contributing 10% after 2016. A 2012
Supreme Court allowed states to opt out of the Medicaid expansion, and as of July 2015, 21 states, mostly those with Republican governors and legislatures, had declined to expand Medicaid and continue using the
traditional income and eligibility requirements, thereby denying several million people health insurance. In those states, people below 100% of poverty who are ineligible for Medicaid are also not eligible to receive

subsidized insurance from the health insurance exchanges. Thus many of the nation’s poorest citizens remain uninsured. ¶ Insurance market regulation : The ACA also
imposes new rules on private insurance. Private health insurance plans are required to include young adults up to age 26 under their parents’ policies. The ACA also eliminates caps on total insurance benefits
payouts, prohibits denial of coverage based on preexisting conditions, and limits the extent of experience rating to a maximum ratio of three-to-one between a plan’s highest and lowest premium charge for the
same benefit package. These regulatory measures were deemed by many to be essential to the feasibility and fairness of an individual mandate. For example, mandates cannot work if insurers may deny coverage
to individuals with preexisting conditions or steeply experience-rate premiums. The insurance industry, for its part, balks at these types of market reforms in the absence of a mandate, fearing adverse
disproportionate enrollment of high-risk individuals when coverage is voluntary. The mandate brings young, healthy individuals and families into the private insurance market; because they utilize far less health
care, their premiums help subsidize those with high health care costs.¶ The ACA’s cost to the federal government includes Medicaid expansion outlays and individual health insurance subsidies. The law is
financed by a combination of new taxes and fees and by cost savings in the Medicare and Medicaid programs. Individuals with earnings over $200,000 and married couples with earnings over $250,000 pay more
for Medicare Part A. Health insurance companies, pharmaceutical firms, and medical device manufacturers pay yearly fees. Medicare Advantage insurance plans and hospitals receive less payment from the
Medicare program (Table 15-3).¶ The Stormy Roll-out of the ACA¶ The ACA has weathered recurring storms since its enactment. The presidential election of 2012 featured many attacks on the ACA, which the
reelection of Barack Obama was not able to quiet. From 2011 to 2015, the Republican-controlled House of Representatives voted 60 times to repeal the law. The opening of the health insurance exchanges was
marked by technical glitches in the federally run exchange, Healthcare.gov, and in some state exchanges, problems that were subsequently largely solved. In multiple public opinion polls, the majority of
respondents were opposed to the ACA, though by 2015 public opinion was shifting gradually to favor the law.¶ Two critical Supreme Court rulings dominated the years following the ACA’s passage in 2010. Many

the Supreme Court to declare the law unconstitutional in its 2012 decision; although the 5–4 vote supported the constitutionality of the individual mandate, it greatly
expected

weakened the Medicaid expansion by making state participation voluntary. The second Supreme Court case was a
challenge to the individual mandate provision that allowed millions of people to obtain low-cost health insurance with government subsidies through the health insurance exchanges. The case was inspired by the
seemingly unending, glaring opposition to Obamacare. The plaintiffs challenged that only state-based exchanges could offer subsidies; yet millions of people had obtained insurance through the federal exchange.

the Court affirmed that both the federal and state-based exchanges could offer
In a June 2015 6–3 decision,

subsidies, thereby preventing a huge number of people from losing their subsidized health insurance.¶
 15 million people have been newly insured under the
Through all this, the ACA persevered. Though the precise numbers are debated, it appears that

ACA, about half through Medicaid expansion and half through the health insurance exchanges. The national
uninsured rate has dropped. 87% of those receiving insurance through the individual mandate received a federal subsidy in 2014. 8.2 million seniors have saved an average of $1,407 in prescription costs due to the

Yet stormy weather

ACA’s gradual closing of the Medicare Part D donut hole (see Chapter 2). The ACA is costing the federal government about 20% less than what was projected in 2010.¶

still threatens, mainly centered on the problem of patient cost sharing . Many people insured through the
exchanges face deductibles of $5,000 per year plus 20% or more coinsurance when receiving services. The
out-of-pocket limit of $6,600 per individual and $13,200 per family is unaffordable for many people. If the ACA is unable
to generate significant health care cost containment, the costs borne by individuals and
families could seriously threaten the individual mandate portion of the ACA.¶ SECONDARY FEATURES OF NATIONAL
HEALTH INSURANCE PLANS¶ The primary distinction among national health insurance approaches is

the mode of financing: government versus employment-based versus individual-based health insurance, or
a mixture of all three. But while the overall financing approach is the headline news of reform proposals, details in the fine print are important in
determining whether a universal coverage plan will be able to deliver true health security to the public (Table 15-4).
What are some of these secondary features?¶ Benefit Package¶ An important feature of any health plan is its benefit package .

Most national health insurance proposals cover hospital care, physician visits, laboratory, x-
rays, physical and occupational therapy, inpatient pharmacy, and other services usually emphasizing
acute care. One important benefit not included in the original Medicare program was coverage of outpatient medications. This coverage was later added in 2003 under Medicare Part D. Mental health
services were often not fully covered, a situation in part addressed by the Mental Health Parity Act of 1996 and Mental Health Parity and Addiction Equity Act of 2008 which apply to group private health
insurance plans. Neither the ACA nor most previous reform proposals include comprehensive benefits for dental care, long-term care, or complementary medicine services such as acupuncture.¶ Patient Cost

Patient cost sharing involves payments made by patients at the time of receiving medical
Sharing¶

care. It is sometimes broadened to include the amount of health insurance premium paid directly by an individual. The breadth of the benefit package
influences the amount of patient cost sharing: the more the services are not covered, the more
the patients must pay out of pocket. Many plans impose patient cost sharing requirements on
covered services, usually in the form of deductibles (a lump sum each year), coinsurance payments (a percentage of the cost of the service), or copayments (a fixed fee, e.g., $10 per visit or per
prescription). In general, single payer proposals restrict cost sharing to minimal levels, financing most benefits from taxes. In comparison, the individual mandate provisions of the ACA include high levels of cost
sharing. The ACA would require an individual such as Mandy Must to pay 9.5% of her income toward a health insurance premium, in addition potentially paying thousands of dollars per year in deductibles and
copayments at the time of service. Critics have argued that this degree of out-of-pocket payment raises questions about whether the ACA is a misnomer and that people of modest incomes will be seriously
underinsured, subject to large out-of-pocket expenses. These criticisms are borne out to a degree by studies of the outcomes of the Massachusetts Health Plan. In 2014, 8 years after the law was passed, over one-
quarter of insured people in Massachusetts reported difficulty paying for health care (Skopec and Long, 2015). The arguments for and against cost sharing as a cost-containment tool are discussed in Chapter 9.¶

Any national health insurance program must interact with existing

Effects on Medicare, Medicaid, and Private Insurance¶

health care programs, whether Medicare, Medicaid, or private insurance plans. Single-payer proposals make far-reaching
changes: Medicaid and private insurance are eliminated in their current form and melded into a single
insurance program that resembles a Medicare-type program for all Americans. The most sweeping versions of individual
mandate plans, proposed by the Heritage Foundation, would dismantle both employment-based private insurance
and government-administered insurance programs. Employer mandates, which extend rather than supplant employment-
based coverage, have the least effect on existing dollar flows in the health care system, as do pluralistic

models such as the ACA that preserve and extend existing financing models through the employer mandates and broadened Medicaid eligibility.¶ Cost Containment¶ By increasing
access to medical care, national health insurance has the capacity to cause a rapid rise in national health expenditures, as did Medicare and Medicaid (see Chapter 2). By the 1990s, policymakers recognized that

National health insurance proposals have vastly disparate methods

access gains must be balanced with cost control measures.¶

of containing costs. As noted above, individual- and employment-based proposals tend to use patient cost
sharing as their chief cost-control mechanism. In contrast, government-financed plans look to global
budgeting and regulation of fees to keep expenditures down. Single-payer plans, which concentrate health care funds
in a single public insurer, can more easily establish a global budgeting approach than can approaches with

multiple private insurers.¶ Proposals that build on the existing pluralistic financing model of US health care, such as the ACA, face challenges in taming the unrelenting increases in
health expenditures endemic to a fragmented financing system. An item contributing to the demise of President Bill Clinton’s health reform proposal, before it could even be formally introduced in Congress, was a
measure to cap annual increases in private health insurance premiums. President Obama eschewed such a regulatory approach in developing the ACA, resulting in weak language about private insurance plans
needing to “justify” premium increases to participate in health insurance exchanges. In an effort to control costs, the ACA limits the percentage of health insurance premiums that can be retained by an insurance
company in the form of overhead and profits (a concept known as the “medical loss ratio,” whereby a greater loss ratio means more premium dollars being “lost” by the company in payments for actual health care
services). The ACA also caps the amount that an employer can contribute toward a health insurance premium as a nontaxable benefit to the employee ($10,200 for an individual policy and $27,500 for a family
policy), in an attempt to discourage enrollment in the most expensive plans. Many savings in the ACA are expected to come from slowing the rate of growth in expenditures for Medicare through measures such as
reducing payments to Medicare Advantage HMO plans. The ACA has benefited by the 2009–2013 slowing of health expenditure growth caused by the severe economic recession of those years, but the ACA cannot
take credit for this slowdown (Hartman et al., 2015). The architects of the ACA put most of their cost-containment hopes in proposals to redesign health care delivery to achieve better value, discussed next.¶

Throughout the history of US national health insurance proposals, reformers

Reform of Health Care Delivery¶

viewed their primary goal as modifying the methods of financing health care to achieve
universal coverage . Addressing how providers were paid often emerged as a closely related consideration because of its importance for making universal coverage affordable.
However, intervening in health care delivery did not feature prominently in reform proposals. Reformers were loath to antagonize the AMA and hospital associations by challenging professional sovereignty over
health care organization and delivery. Even advocates of single payer reform in the United States looked to the lessons of government insurance in Canadian provinces, where until recently government took great

The ACA goes farther than previous reform efforts

pains to focus on insurance financing and payment rate regulation and not on care delivery reform.¶

in proposing measures to shape health care delivery. The ACA created and funded an Innovation Center in the Centers for Medicare and Medicaid
Services to spearhead care redesign, including the promotion of Accountable Care Organizations. As discussed in Chapter 6, Accountable Care Organizations are intended to be provider-organized systems for
delivering care that seek the ideal of higher quality at lower cost by emphasizing more integrated and coordinated models of care for defined populations of patients, along with financial incentives rewarding
higher value care. A group of pilot ACOs for Medicare beneficiaries authorized by the ACA achieved a small cost reduction compared with traditional care and sustained reasonable quality performance (Casalino,
2015). The Innovation Center also encourages development of primary care Patient-Centered Medical Homes, discussed in Chapter 5. Other ACA measures call for pilot programs to expand the roles of nurses,
pharmacists, and other health care professionals in redesigned care models.¶ WHICH FINANCING MODEL FOR NATIONAL HEALTH INSURANCE PLAN IS BEST?¶ Historically, in the United States the
government-financed single payer road to national health insurance is the oldest and most traveled of the three approaches. Advocates of government financing cite its universality: Everyone is insured in the same
plan simply by virtue of being a US resident. Its simplicity creates a potential cost saving: The 31% of health expenditures spent on administration could be reduced, thus making available funds to extend health
insurance to the uninsured (Woolhandler et al., 2003). Employers would be relieved of the burden of providing health insurance to their employees. Employees would regain free choice of physician, choice that is
being lost as employers are choosing which health plans (and therefore which physicians) are available to their workforce. Health insurance would be delinked from jobs, so that people changing jobs or losing a
job would not be forced to change or lose their health coverage. Single-payer advocates, citing the experience of other nations, argue that cost control works only when all health care moneys are channeled through
a single mechanism with the capacity to set budgets (Himmelstein & Woolhandler, 1989). While opponents accuse the government-financed approach as an invitation to bureaucracy, single-payer advocates point
out that private insurers have average administrative costs of 14%, far higher than government programs such as Medicare with its 2% administrative overhead. A cost-control advantage intrinsic to tax-financed
systems in which a public agency serves as the single payer for health care is the administrative efficiency of collecting and dispensing revenues under this arrangement.¶ Single-payer detractors charge that one
single government payer would have too much power over people’s health choices, dictating to physicians and patients which treatments they can receive and which they cannot, resulting in waiting lines and the
rationing of care. Opponents also state that the shift in health care financing from private payments (out of pocket, individual insurance, and employment-based insurance) to taxes would be unacceptable in an
antitax society. Moreover, the United States has a long history of politicians and government agencies being overly influenced by wealthy private interests, and this has contributed to making the public mistrustful
of the government.¶ The employer mandate approach—requiring all employers to pay for the health insurance of their employees—is seen by its supporters as the most logical way to raise enough funds to insure
the uninsured without massive tax increases (though employer mandates have been called hidden taxes). Because most people younger than 65 years now receive their health insurance through the workplace, it
may be less disruptive to extend this process rather than change it.¶ The conservative advocates of individual-based insurance and the liberal supporters of single-payer plans both criticize employer mandate
plans, saying that forcing small businesses—many of whom do not insure their employees—to shoulder the fiscal burden of insuring the uninsured is inequitable and economically disastrous; rather than
purchasing health insurance for their employees, many small businesses may simply lay off workers, thereby pitting health insurance against jobs. Moreover, because millions of people change their jobs in a given
year, job-linked health insurance is administratively cumbersome and insecure for employees, whose health security is tied to their job. Finally, critics point out that under the employer mandate approach, “Your
boss, not your family, chooses your physician”; changes in the health plans offered by employers often force employees and their families to change physicians, who may not belong to the health plans being
offered.¶ Advocates of the individual mandate assert that their approach, if adopted as the primary means of financing coverage, would free employers of the obligation to provide health insurance, and would
grant individuals a stable source of health insurance whether they are employed, change jobs, or become disabled. There would be no need either to burden small businesses with new expenses and thereby disrupt
job growth or to raise taxes substantially. While opponents argue that low-income families would be unable to afford the mandatory purchase of health insurance, supporters claim that income-related tax credits
(as in the ACA) are a fair and effective method to assist such families.¶ The individual mandate approach is criticized as inefficient, with each family having to purchase its own health insurance. To enforce a
requirement that every person buy coverage could be even more difficult for health insurance than for automobile insurance. Moreover, to reduce the price of their premiums, many families would purchase high-

The concept of n ational h ealth i nsurance

deductible plans with high cost-sharing, leaving lower- and middle-income families with unaffordable out-of-pocket costs.¶ CONCLUSION¶

rests on the belief that everyone should contribute to finance health care and everyone
should benefit . People who pay more than they benefit are likely to benefit more than they pay years down the road when they face an expensive health problem. In the years during and
after the passage of the ACA, n ational h ealth i nsurance took center stage in the United States with fierce debate
over “Obamacare.” This debate revealed a wide gulf between those who believe that all people should have financial access
to health care and those who do not. The fate of the ACA, still in question in 2015, will determine
which of those two beliefs holds sway in the United States.
Prefer our interp:
Overlimiting – debate gets value from refining new arguments – that
process is tapped out by Wake if the aff only has single payer or public
option – but our topic still has limits based on guaranteed
universality and basic care

Ground – the most balanced topic is centered on whether greater

government intervention in insurance is good or bad, which still
builds in neg ground while they limit core topic discussions like the
ACA

Reasonability -- centering debates on the best interpretation of the

topic creates a moral hazard to go for topicality
States
 Fed Key – Uncertainty
States fail---can’t predict Trump actions, cover less people, can’t solve
CSRs and public perception
Nathaniel Weixel 17, Health Reporter at The Hill, 8-13-2017, "States enter the breach to
protect ObamaCare," The Hill, http://thehill.com/policy/healthcare/346256-states-enter-the-
breach-to-protect-obamacare

State officials are using every tool at their disposal to try to keep their insurance
marketplaces stable in the face of uncertainty from the Trump administration over the future of
ObamaCare.¶ Insurance commissioners are working with providers, advocates and insurance companies to help keep the system
running, but it’s an uphill climb. ¶ Insurers are skittish and pleading for certainty from
Washington. They want assurances that they will continue to receive cost-sharing reduction
(CSR) payments from the federal government, which total about $7 billion this year. Those payments reimburse
insurers for providing discounted insurance to low-income ObamaCare enrollees.¶ They also want assurances that the
administration will enforce the mandate requiring people to have insurance or pay a penalty.¶ States
don’t have a lot of options , but some officials are actively trying to make sure the public is shielded as much as
possible from the consequences if Trump follows through on his promise to let ObamaCare “implode.”¶ “In general there’s not
a whole lot they can do, because states don’t have any more information about what the
Trump administration is doing than insurance companies,” said Cynthia Cox of the Kaiser Family
Foundation.¶ Some states are letting plans file multiple sets of rates to account for the uncertainty. The strategy can work, Cox said,
if all insurers are on the same page. ¶ “The concern is that one company assumes the worst case scenario and adds 40 percentage
points on for uncertainty, and another assumes the best case and prices significantly lower,” Cox said. ¶ The
administration
has been sending mixed signals about whether it will take the dramatic step of ending payments
to insurers. The CSRs have been paid on a monthly basis, but the administration has not promised that will continue.¶ If the
administration does cut off the CSRs, some states will add a surcharge onto certain plans to cover the cost of losing those payments.
¶ California, North Carolina and Pennsylvania, for example, say they will increase the cost of all the mid-level “silver” health plans
that consumers can buy on the exchange. ¶ The idea is that by making the silver plans more expensive, the other plans will be
cushioned from the price increase. If the price of a silver plan increases, tax credits that help customers purchase insurance will also
increase.¶ But states will have to educate consumers about why the change is taking place.¶ “Customers are going to be confused and
[insurance] carriers will have to explain” why one plan is so much more expensive than the others, Katherine Hempstead, senior
adviser to the executive vice president at Robert Wood Johnson Foundation, said. ¶ So-called “silver loading” isn’t a new idea,
Hempstead said, but if states decide they can’t wait for the administration to make a decision, it becomes “more and more likely this
is the situation states are going to be in.” ¶ Pennsylvania is telling insurers to price as if there was no uncertainty, but
Pennsylvania Insurance Commissioner Teresa Miller told The Hill that may have to change.¶ “We were
hoping we could keep rates in single digits but if we don’t get certainty [from the administration]
we will have to let [insurers] build it in,” she said¶ If the CSRs were funded, rates would only
increase an average of 8.8 percent in the state’s plans. Without CSRs, Miller said rates would rise
over 20 percent on average. ¶ States are also preparing for the possibility that the administration stops spending
money to promote enrollment in the exchanges.¶ The Obama administration ran advertisements to encourage enrollment, but
Trump officials have signaled that promotion effort might come to an end. If that happens, states could spend their own money on
outreach and promotion.¶ Some states are better prepared for such a campaign than others; blue states with an insurance
department that supports the law are likely to have more resources available. ¶ Miller said her state is planning a massive outreach
effort. ¶ The goal is “to encourage Pennsylvanians to enroll in coverage and highlight the benefits if they do,” Miller said. "We’re
working with various stakeholders to develop and coordinate messaging.”¶ Miller said she wasn’t sure the state
could reach as many people as the federal government. ¶ “If all of us have the same messaging, the
same materials ... the hope is that we can reach a lot of people. I don’t know if we can fill this gap completely, but
we’re going to do everything we can,” she said. ¶ Michelle Osborne, chief deputy insurance commissioner of North Carolina, said the
state’s General Assembly would have to appropriate money for the department to engage in outreach, but wouldn’t speculate if that
might happen.¶ One
thing states can’t do anything about is the possibility that the Trump
administration will stop enforcing the individual mandate.¶ Without a mandate,
insurers fear that only sick people would remain in the market, causing premium increases.¶
According to a recent Kaiser Family Foundation analysis, insurers factoring in the possibility that the
administration will not enforce the individual mandate increased their rates an additional 1.2 to
20 percent. ¶ Cox said part of the problem is public perception.¶ “It’s not just that insurers assume
[the mandate] won’t be enforced, it’s a public perception that it won’t be. That’s a harder
issue for states to address ,” she said.

Permutation do both
 50 State Fiat -- 2AC
Fifty state fiat is a voting issue---our interpretation is the neg gets to
fiat a unitary actor or body currently existing
---Fairness – makes research and ground impossible because the lit
doesn’t contemplate uniform nationwide action so they can always
fiat through the best solvency deficits
---Education – they drive the topic into the worst version that’s only
tailored to beat states rather than one that’s focused on core health
care controversies
No solvency advocate is an independent voter – no comparative lit
which makes effective clash impossible
Reject the team because it’s a no cost option

Links to DA’s---
 2AC – States CP
Double penalties are a nightmare – cause policy confusion – turn
solvency
Linda J Blumberg 12, Phd in Economics from the University of Michigan, former Health
Policy Advisor to the Clinton Admnistration, Senior Fellow in Health Policy at the Urban
Institute, Lisa Clemans-Cope, December 2012, RECONCILING THE MASSACHUSETTS AND
FEDERAL INDIVIDUAL MANDATES FOR HEALTH INSURANCE: A COMPARISON OF
POLICY OPTIONS, http://www.urban.org/sites/default/files/publication/26301/412718-
Reconciling-the-Massachusetts-and-Federal-Individual-Mandates-for-Health-Insurance-A-
Comparison-of-Policy-Options.PDF
Keeping the state’s individual mandate in place alongside the federal mandate beginning in 2014 would avoid all of the concerns
detailed above that are associated with the elimination of the MCC standard. However, the potential for double penalties
could be widely perceived as being unfair or overly punitive. The different penalties and their
application under different circumstances—for example, an individual could satisfy the federal
requirements but still face a state penalty—could create significant confusion , particularly if the
federal government pursues strong public outreach and education related to the federal law as 2014 approaches. Relying on
federally provided information, some households might believe they are
complying with all relevant laws when in fact they are not meeting state
requirements . Explaining the intersection of the two sets of rules and their components to a
broad audience is likely to be challenging.¶ Specifically, relating to the five policy objectives:¶ Simplicity for the
public: This approach ranks low, as it imposes two separate sets of rules on households, leading to potential confusion and
complexity in compliance.¶ 2. Political acceptability: The approach ranks low on this measure as well, as it will lead to double¶
penalties for some families, reducing perceived fairness relative to today. This approach does¶ not differ from the current approach
in terms of equity across and within levels of income.¶ 3. Ease of state administration: Administration would be similar to that under
current Massachusetts law, except that some additional interactions related to public confusion are likely to occur. ¶ 4. Impact on
state revenues: State revenues are unlikely to change appreciably.¶ 5. Minimizing disruption of the current system: This approach
ranks high in maintaining the strong state incentives to enroll in coverage and comply with the MCC standards, as it leaves current
Massachusetts requirements in place in their entirety.¶ MAINTAIN THE MASSACHUSETTS MANDATE STRUCTURE BUT
REDUCE STATE PENALTIES BY ANY AMOUNT PAID FOR FEDERAL PENALTIES¶ This policy option differs from the previous
one in that it reduces any state individual mandate penalties an individual or family owes by the amount that the tax unit owes to the
federal government for the ACA’s individual mandate penalties. Residents for which the federal penalty exceeds the state penalty
would only face the federal penalty. Those whose state penalty exceeds the federal penalty would pay the
federal penalty and pay the state the amount by which the state penalty exceeds the federal
penalty. In the latter case, federal plus state payments equal the original computed state penalty.¶ Under this approach, if the
resident enrolls in coverage that satisfies the federal requirements but does not meet Massachusetts requirements (e.g., the policy
purchased does not satisfy the MCC standard), the resident owes the full state penalty. In this way, the state’s standards would not
be undermined, and no one would pay more in aggregate than the greater of the federal or state computed amount.¶ While this
strategy addresses the issues of fairness and maintenance of state standards, confusionover having two sets of
individual mandate rules would likely occur. Taxpayers would still need to compute
penalty amounts for both the state and federal penalties on their tax forms, and they
would have to compute the federal amount before the state amount to accurately determine the
amount owed. In addition, this approach is likely to significantly reduce the revenue currently collected by the state through
the penalty.
Independently, multi actor fiat – doesn’t test Aff internal link and lets
them fiat out of every solvency deficit---interp is fifty state fiat without
fg
 2AC -- Subsidies
The CP spikes state budgets and they’re already tight
Jordan Weissmann 17, Slate’s senior business and economics correspondent, 5-9-2017, "If
Trumpcare Becomes Law, Living in a Blue State Won’t Save You," Slate Magazine,
http://www.slate.com/blogs/moneybox/2017/05/09/living_in_a_blue_state_won_t_save_yo
u_from_the_republican_health_care_bill.html
The problem is that Obamacare's
market rules likely won't work well without its coverage subsidies,
which Republicans would slash for many families. Requiring
insurers to cover a wide array of basic services
makes insurance more expensive, and forcing them to charge sick customers the same rates as
everybody else drives up the cost for healthier men and women. The ACA makes up for all of this (or tries
to, anyway) by offering tax credits that are more generous for people with lower incomes or who
live in places where coverage tends to be more expensive. But the GOP's bill offers much skimpier financial support to the young and
relatively poor, likely pricing them out of Obamacare-style plans.

Making matters worse, the

House plan would kill off the individual mandate's requirement that all
Americans buy health insurance, which could lead more young and healthy men and women to
go without. That would likely drive up prices for remaining customers, also making it hard for states to
justify keeping Obamacare's regulations in place.

Some large states like New York or California could theoretically offer their own subsidies or pass a
state-level individual mandate, just as Massachusetts did under Romneycare. But state budgets are
already tight, and legislators will already have to grapple with the cuts to Medicaid that the
GOP is planning. Will pols in Albany or Sacramento be willing to raise taxes to preserve the Obamacare status quo? I wouldn't
necessarily count on it. And if not, their only other choice may be to apply for a waiver.
Death
 2AC – Death
Framework—the debate should be about the results of the plan—key
to fairness because the plan is the locus of affirmative offense and
there are infinite arbitrary negative frameworks

Perm do both

Conditionality’s bad --- encourages run-and-gun negative strategies

which destroy depth, logical advocacy, and 2AC strategy --- reject the
team because the damage is already done

Catastrophes empirically cause a focus on practical solutions---denial

is false
Robert Wuthnow 10, Gerhard Andlinger Prof of Sociology at Princeton, PhD in Sociology
from Cal Berkeley, “Be Very Afraid: The Cultural Response to Terror, Pandemics,
Environmental Devastation, Nuclear Annihilation, and Other Threats,” p. 21, google books
The notable feature of the perilous times that humanity has faced over the past half century is that
the response has made them seem manageable enough that we roll up our collective sleeves and
work on practical solutions . There have been relatively few panics involving spontaneous
outbreaks of irrational behavior . Work, family life, and other routine activities have continued. Individuals have sometimes shouldered the small tasks of
learning about impending crises and pitching in to support research or protect their families. These responsibilities, though, have seldom required great sacrifices on the part of
large populations, at least not in the Western world. Social movements have emerged and policies have been affected, but regimes have rarely been toppled as a result.

None of this can be understood simply as denial. Were denial the correct interpretation,
billions would not have been spent on weapons, deterrence programs, research, and communication.
Millions of readers and television viewers would not have paid attention to warnings and
documentaries. People responded, but in ways that incorporated the problem solving into ordinary

roles and competencies. Nor can the normality of the response be explained by arguing that the dangers envisioned generated little upheaval because they
never happened. A nuclear holocaust did not occur, but enough destruction did take place that people could imagine the

results. There were also chemical spills, accidents at nuclear plants, terrorist attacks, and natural disasters. Enough went wrong, even with well-intentioned planning, that
danger could not be ignored. Indeed, it is truly surprising that more chaos, more panic, more soul searching, and more enervating fear

did not ensue .

Don’t love death

Tax Reform
 UQ---Will Pass
Dems receptive to Trump deals
Laura Davison 9/13, Capitol Hill tax reporter at Bloomberg, “Trump Talks Tax With
Democrats as Budget Deal Remains Elusive,” https://www.bna.com/trump-talks-tax-
n57982087783/

Congressional Republicans expect they can pass a tax bill without needing Democratic
votes.

But if they can’t, President Donald Trump has begun courting Democrats in states he won who
he thinks could be persuaded to sign onto a tax plan. He invited Sens. Heidi Heitkamp (N.D.), Joe Manchin III
(W.Va.), and Joe Donnelly (Ind.) to dinner Sept. 12 to talk tax reform. The three lawmakers are up for re-election in
2018 and could face political pressure from voters in their states to back tax legislation.
The purpose of the dinner is “to find out where some of the moderate-leaning Democrats in the
Senate might be and if there is a way we might be able to get a bipartisan tax bill,” Sen. John Thune (R-
S.D.), who was also invited, told reporters Sept. 12. Finance Committee Chairman Orrin G. Hatch (R-Utah) and Sen. Patrick J.
Toomey (R-Pa.) were also included in the meeting.

Heitkamp, Manchin, and Donnelly could provide a buffer to the Republicans’ two-seat majority
in the Senate. If some Republicans were to object to the tax bill, as was the case with the health
care measure, having a back bench of Democratic supporters could be enough to win
a vote .
Every other Senate Democrat, except for those three, signed an August letter that said they wouldn’t support a tax bill that increased
the burden on the middle class, went through reconciliation, or added to the deficit.

Manchin said he, too, would oppose a bill that added to the deficit and he doesn’t like the idea of using reconciliation, because it
breaks with the traditions of the Senate.

“This is a bipartisan gesture, and I think the President is approaching us because he needs 60 votes,” Manchin told reporters.

Reconciliation Road

“It most likely will get done through reconciliation,” Thune said. “It would be great if it gets done with Democrat votes, but I don’t
know how you get eight Democrats to vote for something.”

Trump has been reaching out to Democrats more in recent weeks. Earlier this month, he sided
with Senate Minority Leader Charles E. Schumer (D-N.Y.) and House Minority Leader Nancy
Pelosi (D-Calif.) on a debt limit and government funding deal. Heitkamp traveled with Trump when he spoke in
North Dakota about taxes.

UQ card is an op should package tax reform not that they will

Passing the plan makes budget reform impossible---GOP needs repeal

to free money for tax cuts
Wagner 17 (John, national political reporter covering the White House, and *Abby Phillip is
a national political reporter covering the White House for The Washington Post, “ The cost of
failure on health care? It may be the rest of Trump’s agenda,”
3/15, https://www.washingtonpost.com/politics/the-cost-of-failure-on-health-care-it-may-be-
the-rest-of-trumps-agenda/2017/03/14/f502a846-08be-11e7-93dc-
00f9bdd74ed1_story.html?utm_term=.e8b14a249607)

But falling short on a marquee campaign promise — when both chambers are controlled by the
president’s party — would almost certainly sap momentum for Trump’s agenda. Moreover,
Republicans are counting on cuts from former president Barack Obama’s health-care law to
make the budget math work on other Trump priorities, particularly major tax reductions.
 No Trump PC – Lame Duck
No PC – Trump is functionally a lame duck president – party defiance,
controvery, exodus of staffers, approval
David A. Graham 17, Staff Writer at the Atlantic, “Donald Trump Is a Lame-Duck
President”, The Atlantic, https://www.theatlantic.com/politics/archive/2017/08/is-trump-
already-a-lame-duck/537198/

Whatever the turning point, thinking

about Trump as a lame-duck president seems a better rubric
for making sense of his administration than most. Consider the things that happen in a lame-duck period.¶ A
lame-duck president’s legislative agenda starts to stall out. Members of Congress are just no longer interested in following the
president’s lead, especially where it might create a political liability for them. Big bills start to waste away on Capitol Hill, and where
a new president would bring both political capital and novelty to bear, a lame duck just doesn’t have the juice. So it is with Trump.
His various attempts to repeal and replace Obamacare have all failed, and while he was able to force both houses of Congress to take
them back up before, largely through sheer force of will, his more recent pleas have fallen on deaf ears. Senate Majority Leader Mitch
McConnell has indicated he has no interest in heading into the breach once again, and GOP members have largely agreed with him.¶
A lame-duck president gets caught in a vicious cycle. Once legislators start refusing to follow his
lead, he begins to look like a paper tiger, so they follow his lead even less. Now that Republican senators
have defied Trump once, why should they get in line on other controversial bills, like tax
reform?¶ By the time a president reaches his lame-duck period, scandals have begun to pile up. Sometimes they are minor and
varied; sometimes they’re blockbusters, from Iran-Contra to Monica Lewinsky. Either way, the taint of controversy tarnishes
the president, diminishes his political capital, and starts to absorb time and energy that once
would have been spent on constructive rather than defensive actions. Trump is already facing an
open-ended investigation, unmatched in breadth by anything except the Clinton-era Whitewater
scandal—taking in allegations of money-laundering, of espionage, and of violations of campaign-
finance laws, and potentially reaching into Trump’s own personal financial dealings prior to
becoming president. It’s already proving a large distraction, as demonstrated by Trump taking time while
returning from a trip to Europe to dictate a statement on behalf of his son, Donald Trump Jr. The statement he dictated turned out
to be an obfuscatory disaster that only made the matter worse. Meanwhile, Trump’s personal lawyer is busy sending defenses of
Trump’s Charlottesville comments to conservative journalists.¶ As
controversy and inaction set in during a president’s
lame-duck period, he starts to lose staffers who see no reason to stick around for a final stretch of
inaction. Others stick around but grumble to the press about lack of discipline and lack of progress—and as they look ahead to
their next job, they often put preserving their own reputations ahead of advancing their boss’s
agenda. T

rump’s West Wing has a busy revolving door—he’s already lost two communications directors,
one press secretary, one chief of staff, and a national-security adviser, among others—and the tenor
of leaks about the White House, once largely a chronicle of internecine warfare, is increasingly full of statements of disappointment
and frustration about the president himself.¶ Another problem for a lame-duck president is that exhaustion sets in. It’s the seven-, or
in some cases, three-, year itch, as someone who was a fresh and exciting face at the start of his term has become tired, boring, or
irksome. Trump benefited from his outsize media personality during the campaign, but now he’s paying for it. Barely a day goes by
without a new Trump-involved controversy. The public, and even the journalists paid to care, have become numb. Some of Trump’s
aides and allies want him to take a less public approach, but that’s beyond him. He has one mode: on, and public-facing. Just take
his alleged vacation over the last week or two, which has produced a surfeit of presidential news even by Trump standards.¶ As a
result, most—though not all—presidents
see a slow slide in their approval rating toward the end of their
terms. Trump’s presidency has been one long slide, with his numbers now resting in the mid-
30s.
 2AC – Link Turn – Delay

Debates over the plan will push tax reform off the docket
Politico 8/13, Think Obamacare repeal was hard? Wait for tax reform,
http://www.politico.com/story/2017/08/13/trump-congress-tax-reform-241506

Returning to health care would take precious time away from tax reform efforts.
But on the flip side, the GOP's failure to enact a health care bill is complicating their tax reform efforts. Obamacare includes
hundreds of billions of dollars in taxes, which the GOP spent months vowing to repeal.

Now, opponents of policies like the medical device tax will be seeking relief in tax reform. And because Republicans couldn't roll
back an Obamacare tax on higher earners' investment income, they likely won't be able to reduce capital gains rates as much as they
would like.

Crammed congressional calendar

Even if health care is sidelined, tax reform will have competition this fall for Republicans' attention.
The White House has said a tax package will get marked up in September, pass the House in October and clear the Senate by
Thanksgiving. But most Hill GOP insiders know that's unlikely — if not impossible — because of the busy fall schedule.

Upon returning from August recess, lawmakers will have to raise the debt ceiling and avert a government shutdown by the end of
September. Both votes are tough and will require bipartisan negotiations, sucking up GOP leadership's energy to
the point that tax reform will have to take a backseat.
Hill insiders and the White House have also begun talks about a major bipartisan budget deal to raise strict spending caps on the
Pentagon and domestic programs — yet another distraction from a tax bill. Both chambers will also need to pass a unified budget, a
difficult feat given the divisions in the party.

the clock is ticking on tax reform . GOP insiders say they have approximately four
Meanwhile,
months to pass a bill before the 2018 election season kicks into high gear in January or February.
Passage after that becomes even more precarious, as vulnerable Republicans turn skittish about taking tough votes.

"Time's the most precious commodity they have," said Liam Donovan, a former top aide at the National
Republican Senatorial Committee who is now legislative director for Associated Builders and Contractors.
 2AC – Link Turn
ACA decks tax reform because of revenue neutrality
Brittany De Lea 17, Fox Business, “Health Care Domino: Why Trump's Tax Cuts Depend on
the ObamaCare Repeal,” 3/22, http://www.foxbusiness.com/politics/2017/03/22/health-care-
domino-why-trumps-tax-cuts-depend-on-obamacare-repeal.html
Why Did Republicans Choose to do Health Care First?

Reconciliation requires a bill to reduce the deficit over the long-term. The Congressional
Budget Office estimated the American Health Care Act would reduce federal deficits by $337
billion over the next ten years.
Tax reform, on the other hand, won’t be as straightforward.
“[Repealing the ACA first] would give them extra money to play around with for tax reform. Tax
reform wouldn’t have to be revenue neutral. It would end up being revenue neutral on a
dynamic level but the CBO doesn’t always measure all the dynamic effects,” Diana Furchtgott-
Roth, former Trump transition team member and former chief economist for the U.S.
Department of Labor, told FOX Business.
Speaker Ryan’s health care bill is designed to reduce taxes and spending, which will help
improve deficit projections. The idea is health care will improve the baseline and pave the way
for the tax overhaul, Paul Howard, senior fellow director in health policy at the Manhattan
Institute, told FOX Business.
 2AC – Israel Econ Resilient
Israel econ resilient – empirics, energy reserves, and service sector
all overwhelm startups
Aberdeen 16, Aberdeen is an investment fund providing access to emerging markets,
“Israel: A Country of Opportunity,” Feb 10, http://marketrealist.com/2016/02/israel-country-
opportunities/
3. Energy Independence
The future health of the Israeli economy received a substantial boost in 2009 with the discovery
of substantial natural gases reserves offshore. The largest of these discoveries, the Leviathan
field in the Levant basin, contains an estimated 16 trillion cubic feet of gas.

Israel is expected to become an energy exporter by the end of this decade and the
government is planning to establish a sovereign wealth fund to ensure that the windfall proceeds
from this unanticipated source of public revenue are wisely invested.
4. A Resilient, Growing Economy

The country’s economy displayed great resilience during the worldwide economic crisis,
growing by 1.3% in 2009 while other economies were contracting sharply. This reflected
structural differences in the Israeli economy that set it apart from many others. The country’s
banks were relatively well capitalized and steep deposit requirements for would-be homeowners
prevented the development of a debt financed housing bubble of the kind that occurred in the
United States.
Also worth noting is that Israel’s government debt as a proportion of gross national product has
declined steadily this century, to 67.6% in 2014 from 96.7% in 1998, according to the Bank of
Israel.

Market Realist – Israel’s economy remains resilient.

Israel (ISL)(EIS) boasts a resilient economy. As you can see from the graph above, the economy
didn’t slump into a recession in 2009, unlike most other developed markets (VEA)(EFA). Since
2010, Israel’s average year-over-year GDP growth rate has been 3.7%, which is pretty solid. The
service sector accounts for as much as 80% of the country’s GDP. Plus, Israel is a relatively
young country with a median age of ~30, and this boosts its economy.
Midterms
 2AC – GOP Win
GOP will win but gaining a filibuster proof majority is unlikely
Harry Enten 17, Senior Political Analyst at FiveThirtyEight, 5/22/2017, “Why The 2018
Senate Elections Are Looking Bad For Both Parties”, FiveThirtyEight,
https://fivethirtyeight.com/features/why-the-2018-senate-elections-are-looking-bad-for-both-
parties/
The 2018 midterms are a story of two chambers. Democrats are in the best position they’ve been in since 2010 to win a majority of
seats in the House of Representatives. The Senate map, on the other hand, is so tilted toward the GOP that most political analysts
have all but dismissed Democrats’ chances of winning the chamber before 2020. It has even been suggested that
Republicans could gain enough Senate seats (eight) in 2018 to amass a filibuster-proof majority
(60 seats).¶ This is normally the part of the article where I push back on the conventional wisdom and argue something like,
actually, the 2018 Senate map isn’t that bad for Democrats. But no, it’s pretty bad: Democrats are a long shot to
take back the Senate.¶ What I will argue, however, is that it’ll also be difficult for the GOP to pick up a
bunch of seats. Republicans would need to oust incumbent Democrats, and it’s extremely
difficult to beat an incumbent senator in a midterm when his or her party doesn’t control the
White House.¶ It may seem a little nuts to suggest that Senate Minority Leader Chuck Schumer can keep losses to a minimum
in 2018. Democrats hold 23 of the 33 seats up for a vote. There are 10 Democratic senators running in states that
President Trump won, five of whom (Sens. Joe Donnelly of Indiana, Heidi Heitkamp of North Dakota, Joe Manchin of West
Virginia, Claire McCaskill of Missouri and Jon Tester of Montana) are from states that Trump won by about 20 percentage points or
more. Meanwhile, there are only two Republican senators (Arizona’s Jeff Flake and Nevada’s Dean Heller) up for re-election in
states Hillary Clinton came within 5 points of winning in 2016.¶ But while
a lot of Democrats are up for re-election
in red states, there’s also a Republican in the White House, and incumbent senators1 in the
opposition party — for simplicity, let’s call them “opposition senators” — tend to survive in those
situations.¶ There have been 114 opposition senators who have run in a midterm general
election2 since 1982. Only four of the 114 (4 percent) lost. Most won by wide margins, with the
average opposition senator beating the candidate of the president’s party3 by 28 percentage
points. Even in the worst year for opposition senators (1998), 86 percent were re-elected. If 86
percent of incumbent Democrats win in 2018, the party would lose three seats.4 That would
leave Republicans with 55 seats, a more comfortable majority but far short of filibuster-
proof.

Impact inevitable – if they don’t get a filibuster proof majority, GOP

will repeal the filibuster
Charles Lane 17, Columnist for the Washington Post, 8/13/2017, “Why the GOP may kill the
filibuster in the end”, http://bangordailynews.com/2017/08/13/opinion/contributors/why-the-
gop-may-kill-the-%EF%AC%81libuster-in-the-end/
And, of course, McConnell shows no signs of agreeing to the rule change Trump impatiently favors.¶ Still,
there is a
reasonable case to be made that it would be in the GOP’s interest to do what Trump says — if not
immediately, then certainly if the Republicans manage to overcome Trump’s declining approval
numbers and do well in the 2018 midterm elections.¶ GOP senators have made two main
arguments against such a power grab: It would be bad for the Senate and, hence, the country to convert the
“world’s greatest deliberative body” into the plaything of shifting majorities. And it would be unwise for the
Republicans to risk a rule change that the Democrats could turn to their advantage by regaining
control of the chamber, possibly in as little as two years.¶ But the second of those two arguments
may be getting less compelling for the GOP: It’s eminently foreseeable that not only the
gerrymandered House but also the Senate will remain in GOP hands for at least the next half-
decade and maybe longer.¶ This is due not only to the fact that the 2018 Senate electoral map favors Republicans, in that
they only have to defend eight of the 33 seats at stake, while 25 Democrats are up for re-election, 10 in states Trump carried in 2016.¶
Even more striking is the developing and seemingly durable GOP edge in rural states, which
have two Senate seats each just like the heavily populated coastal states that Democrats
dominate.¶ Republican Trump carried 26 states (that’s 52 senators’ worth) with a share of the vote at least 5 percentage points
larger than his national vote percentage, according to an analysis by Dave Wasserman of the Cook Political Report.¶ By contrast to
these deep-red strongholds, there are only 14 states (with 28 senators) in which Democrat Hillary Clinton beat her national share by
at least five points. Wasserman counts 10 remaining “swing” states (20 senators).¶ Overall, the
statistical “pro-GOP bias”
of Senate races is at its highest level since the direct election of senators became the law of the
land in 1913, Wasserman notes. And the 2020 map looks only slightly less favorable to the GOP than the 2018 one.¶ The
temptation to do away with the legislative filibuster could therefore prove irresistible if 2018
produces another GOP majority of fewer than 60 votes, especially if Republicans also retain the
House.¶ Certainly, Trump might see a once-in-a-generation opportunity to transform a whole host
of policies — taxes, spending, regulation, immigration — in ways Democrats could not reverse until that far-
off day when they manage to capture both houses of Congress and the executive branch.¶ To be
sure, this scenario depends on a long series of assumptions, the most important of which is that public dissatisfaction with Trump,
or some Trump-triggered crisis, doesn’t drag the whole GOP down to defeat in the midterms.
 Link Turn – GOP Base Turnout
Turn – dem turnout is inevitable but strengthening the ACA causes
GOP base backlash – swings the midterms
Jonathan Martin 17, Political Correspondent for the NY Times, co-author of the New York
Times best seller “The End of the Line: Romney vs. Obama: The 34 Days That Decided the
Election”, 2018 Dilemma for Republicans: Which Way Now on Obamacare?, The New York
Times, https://www.nytimes.com/2017/03/28/us/politics/2018-dilemma-for-republicans-
which-way-now-on-obamacare.html
WASHINGTON — As they come to terms with their humiliating failure to undo the Affordable Care
Act, Republicans eyeing next year’s congressional campaign are grappling with a new dilemma:
Do they risk depressing their conservative base by abandoning the repeal effort or anger a
broader set of voters by reviving a deeply unpopular bill even closer to the midterm elections?¶ The question is
particularly acute in the House, where the Republican majority could be at risk in 2018 if the
party’s voters are demoralized, and Democratic activists, energized by the chance to send a
message to President Trump, stream to the polls.¶ Sifting through the wreckage of a disastrous week, Republican
strategists and elected officials were divided over the best way forward. Some House Republicans pressed to move on to other issues
and notch some victories that could delight their own loyalists while not turning off swing voters.¶ “We’ve got a lot of time to do real
things on infrastructure, to do real things on tax reform, on red tape reform, and really get the American economy moving,” said
Representative Steve Stivers of Ohio, chairman of the National Republican Congressional Committee, the House campaign arm. “We
do those things and we still have a lot of time to recover.”¶ “If you’re going to fumble the ball,” he added, “better to do so in the first
quarter of a football game.Ӧ Devising
health care legislation that could appeal to both wings of the
House Republican Conference — the hard-line conservatives and more moderate members —
would require a nearly superhuman feat, added Representative Billy Long, Republican of Missouri.¶ “Not unless
Harry Houdini wins a special election to help us,” Mr. Long said about the prospects of cobbling together a coalition that could agree
on how to repeal and replace the health care law.¶ But other longtime Republicans warned that if
the party did not address
what they have derided as Obamacare, an issue that has been central to their campaigns for the
last seven years, they would incur a heavy political price in the midterm elections.¶ Midterm
campaigns have increasingly become akin to parliamentary elections — referendums on the
party in power rather than on individual candidates, where turnout by dependable partisan
voters is the deciding factor.¶ “If they fall on their sword on this, they’re going to get slaughtered,”
said former Representative Thomas M. Davis III, a Virginia Republican who himself was once at the helm of the House campaign
committee.¶ “Where
parties get hurt in midterms is when their base collapses,” Mr. Davis said.
“Democrats are going to show up regardless of what you do. If our voters don’t see
us fulfilling what we said we were going to do, they’ll get dispirited.” ¶ What troubles
many Republican strategists is the specter of the party’s most reliable voters being bombarded
by reminders of their leaders’ failure to address the health law. Th ey fear a recurring story
line sure to pop up every time insurance premiums increase, providers leave local networks, or , most
worrisome, Republicans fund President Barack Obama’s signature achievement.

EU resilient---specifically to banking crises

EU Business 17 – independent European business information service, 8/14/17, “EU
recovery resilient as economy turns the corner,” http://www.eubusiness.com/news-eu/eu-
economy.98es
With Europe's economy expanding for the fifth year in a row, the EU Wednesday looked back at 10
years since the start of the financial crisis confident it has turned a corner and delivering on jobs and
growth.
The global financial crisis which began 10 years ago led to the European Union's worst recession in its six-decade history. While the
crisis did not start in Europe, shortcomings in the initial set-up of the EU's Economic and Monetary Union were laid bare.

Today, the EU boasts unemployment at its lowest since 2008, stronger banks, rising investment, and public finances in better shape.

The E uropean C ommission welcomed the signs of resilience in the European economy but says
much remains to be done to overcome the legacy of the crisis years.

Economic Affairs Commissioner Pierre Moscovici said the

European economy's recovery had firmed and
broadened: "We must use this positive momentum to complete the reform of our Economic and Monetary Union." But he drew
attention to the social and economic divergences which had developed in and among Member States. "It is
essential that our work going forward contributes to the real and sustained convergence of our economies," he said.

It was ten years ago today, on 9 August 2007, that BNP Paribas became the first major bank to acknowledge the impact of its
exposure to sub-prime mortgage markets in the United States, having to freeze exposed funds.

In the years that followed, what was initially a financial crisis turned into a banking crisis and a crisis of
sovereign debt, soon affecting the real economy. TheE uropean U nion fell into the worst recession in its
history , which left deep marks on the public, on companies and on Member States' economies.

The Commission says EU institutions and Member States responded to the crisis with strong political decisions
to contain the crisis , preserve the integrity of the euro and to avoid worse possible outcomes.

The EU brought more regulation to the financial sector and improved economic governance; bolstered new
and common institutional and legal frameworks; established a financial firewall

for the euro area ; supported countries in financial distress; improved Member States' public finances; pursued
structural reforms and encourage investment; improved
banking sector supervision; increased the ability of
financial institutions to cope with future challenges ; and established ways to manage and
better prevent possible crises .

As a result of these actions, Europe's

Economic and Monetary Union has been significantly
overhauled and the European economy – and notably the eurozone economy – is looking back in
shape.economy.

The European recovery is sustained and unemployment is steadily going down. The number of Member States
belonging to the euro has increased from 12 to 19 and the euro is now the second-most important currency in the world. Out of the
eight EU Member States that received financial assistance, only Greece is still under a programme and is due to exit it in mid-2018.

No impact---countries will prevent rollback of existing regs from

spreading, Trump inevitably tanks the new Basel rules which are
more important, and Trump will use Treasury to alter Dodd-Frank
Silvia Amaro 17, Digital Reporter, CNBC, 3/17/17, “Europe is worried about Trump’s plans to
de-regulate banks,” https://www.cnbc.com/2017/03/17/europe-is-worried-about-trumps-
plans-to-de-regulate-banks.html
President Donald Trump's plans to to ease banking regulation is raising eyebrows in Europe.

Trump has asked the U.S. Treasury Department to submit a report on possible changes to
Dodd-Frank – the set of rules established in the wake of the 2008 financial crisis to clamp down on banks risk-taking. Other
banking rules, including the Basel III international framework seem to be on hold since
the new administration came in.
Mark Carney, governor of the Bank of England, said Friday that G-20 countries should not fall into "reform fatigue".

Carney, who is also Chair of the global financial industry watchdog the Financial Stability Board, wrote in a letter sent by the FSB to
the G-20 finance ministers that "a decade after the start of the crisis, an element of reform fatigue is understandable.

"But giving into it would mean that essential standards are neither completed nor fully implemented."

A European official working in banking regulation, who asked to remain anonymous because of the sensitive state of legislation, told
CNBC that the world was close to finishing the Basel III regulation last January, until the new administration arrived in the U.S. and
delayed the expected conclusion of the process.

The U.S. needs to appoint a new Federal Reserve official for banking supervision, which is expected to happen only next month.
Until then, the Basel III committee is not aware of the official position from the U.S.

President Trump has said that banking regulation does not allow lending to the economy to take place.

Without the U.S.'s approval for Basel III, it is unlikely that Europe will accept the rules. The
aim of the regulation is to ensure a level playing field for banks

independently of their geographic operations.

Shortly after the election of Donald Trump, Daniele Nouy, the European Central Bank's chief for supervision, stressed that "Basel III
should be finalized."

"How can banks plan for the future when they do not know what rules they will have to comply with? Regulators must therefore
provide regulatory certainty," she said in mid-November.

An international economic official, who also asked to remain anonymous, told CNBC that the rollback in financial regulation was a
"concern" and that it is a "real danger."

"People have short memories and seem to have forgotten how bad things got (during the crisis,)" the European banking official said.

Meanwhile The German finance minister, Wolfgang Schaeuble, said Friday that the
world's top economies are not
concerned that regulations would be rolled back. These are needed to ensure stability and
cancelling them could lead to a new financial crisis, Reuters reported.
 Innovation
Pharma invests in commercial drugs, not vaccines
James Thomas 16, correspondent at Science Based Medicine, 10-15-16, “R&D and the High
Cost of Drugs,” https://sciencebasedmedicine.org/rd-and-the-high-cost-of-drugs/

First, importantinnovation that leads to new drug products is often performed in

academic institutions and supported by investment from public sources such as the
National Institutes of Health. A recent analysis of the most transformative drugs of the last 25
years found that more than half of the 26 products or product classes identified had their origins in
publicly funded research in such nonprofit centers. Other analyses have highlighted the
importance of small companies, many funded by venture capital. These biotech startups frequently
take early-stage drug development research that may have its origins in academic laboratories
and continue it until the product and the company can be acquired by a large manufacturer, as
occurred with sofosbuvir.

Arguments in defense of maintaining high drug prices to protect the strength of the drug
industry misstate its vulnerability. The biotechnology and pharmaceutical sectors have for years
been among the very best-performing sectors in the US economy . The proportion of revenue of
large pharmaceutical companies that is invested in research and development is just 10% to 20% (Table 4); if only innovative
product development is considered, that proportion is considerably lower. The contention that high prescription
drug spending in the United States is required to spur domestic innovation has not been borne
out in several analyses. A more relevant policy opportunity would be to address the stringency of congressional funding for
the National Institutes of Health, such that its budget has barely kept up with inflation for most of the last decade. Given the
evidence of the central role played by publicly funded research in generating discoveries that
lead to new therapeutic approaches, this is one obvious area of potential intervention to address
concerns about threats to innovation in drug discovery.
Americans invest over $32 billion annually in medical research through the National Institutes
of Health (NIH) alone. To put that in perspective Pfizer’s entire 2014 R&D budget was about
$7.2 billion. But even this doesn’t tell the whole story because R&D means research and
development. While NIH funding is almost entirely for basic research, the sort of
fundamental research that fuels new understandings, opens new avenues and leads to new
drugs and therapies, Big Pharma spends most of its R&D money on the development end –
clinical trials.
So of Pfizer’s $7.2 billion R&D budget, perhaps 1.5 billion goes to basic research. Even
there much of pharmaceutical
companies’ R&D feeds on publicly-funded research. In a study published in Health Affairs, Kesselheim et al.
note:

Perhaps the most common pattern of interaction involved academic scientists’ conceptualizing a
therapeutic approach based on basic research about disease mechanisms and then
demonstrating the proof of concept for a given molecule. Industry collaborators then developed
the product for more extensive clinical testing.

pharmaceutical companies are increasingly in the business of

The point here is that
running clinical trials and marketing drugs rather than plowing the hard ground
for new discoveries . In this sense the basic research costs are socialized while the profits,
increasingly breathtaking profits, are privatized.
This is not to ignore the very high costs associated with clinical trials. As the Statistica chart above shows, half of pharmaceutical
company R&D spending goes to clinical trials. The curious can find a brief explanation of clinical trial phases on the NIH website.
The Biotechnology Innovation Organization, a trade association, states that less than 10% of new drugs make it
through clinical trials and are ultimately approved.

This high attrition rate magnifies the cost per drug approved . So why is the attrition rate so
high? Part of the problem is the misuse and misinterpretation of p-values. Friend of SBM David Colquhoun explored this problem at
some depth concluding that, “if you use p=0.05 as a criterion for claiming that you have discovered an effect you will make a fool of
yourself at least 30% of the time.” When
the consequences are measured in tens or hundreds of millions
of dollars, foolishness is to be discouraged. David Granger used Professor Colquhoun’s approach to examine the
impact of p=0.05 idolatry and misinterpretation specifically as it applies to drug trials and concluded that fewer than “2 out of every
three positive trial results were real.”

This would seem to demand rigorous replication of foundational laboratory and pre-clinical
results. As Errington, Nosek, et al. note, “Despite being a defining feature of science, reproducibility is more an assumption than a
practice in the present scientific ecosystem.” Without careful vetting at the earliest stages of investigation,
hundreds of millions of dollars can be wasted chasing a false premise through the gauntlet of
clinical trial. Garbage in will never produce gospel out regardless of the amount of cash
squandered in the effort. The important point here is that this is not a failure of science and not a
failure of regulatory overreach, it is a failure of basic due diligence. Some of this procedural elision may owe
to competitive pressures. Patent law is a winner-take-all system that places absolute value on being first.

This and other market forces have driven changes in the industry. For a while the industry went
through a period of “swinging for the fences” where every company chased blockbuster drugs.
That model is changing with drug companies now trying to produce more drugs for smaller
markets and then trying to expand the indications for which the drug is used. This is sometimes
successful as it was with Novartis’ Afinitor (everolimus). First approved for patients with advanced renal cancers, everolimus was
later approved for subependymal giant cell astrocytoma (SEGA), then for pancreatic neuroendocrine tumors, then for non-cancerous
kidney tumors in patients with tuberous sclerosis complex, then for women with ER-postive, HER2-negative breast cancer, then for
certain lung and gastrointestinal tumors. In
essence this model tries to squeeze ever more toothpaste out of
the same tube. Sometimes this is tried without the niceties of clinical trials and formal approvals by promoting off-label uses.
Many of Big Pharma’s biggest players have been hit with fines running into the hundreds of millions and even the billions of dollars
for promoting drugs for unapproved indications. The
judgment can be (but isn’t always) made that gambling on
clinical trials for expanded use is less expensive than attracting the ire of regulatory
authorities.
Finally, anincreasing amount of pharmaceutical innovation is done in the offices of investment
bankers where merger and acquisition (M&A) deals are cobbled together. Small startups raise
venture capital to develop an idea that often grew from the academic research of one or more of
the founders. As the concept matures one of the multinational Pharma giants steps in, offers a
deal that allows the venture capitalists and founders to cash out, and carries the product
through the final stages of approval and marketing. Or a company like Turing or Mylan acquires a legacy product
from another manufacturer and jacks up the price without, in fact, doing much of anything else. This model is very much
closer to merchandising than to traditional pharmaceutical research and development. It is a
particularly egregious form of what economists call ‘ rent-seeking’ , where resources are employed to obtain
economic gain without the concomitant reciprocal benefit to society of wealth creation. The significant regulatory
burden associated with pharmaceutical products make this sort of rent-seeking particularly easy.
And the case can be made that industry-wide rent-seeking explains the legal prohibition of federal negotiation of drug prices. The US
alone allows drug companies to charge whatever the market will bear.

The very bottom line

The bottom line is that industry
claims that highly inflated drug prices are necessary to fuel new drug
research doesn’t bear close scrutiny. Much of the fundamental research is done in
academic settings using public money . The regulatory expense of bringing entirely new drugs to market is
high but much of that cost owes to a high attrition rate during clinical trialing which itself owes to fundamental errors in choosing
promising candidates. And a
growing trend is for pharmaceutical companies to specialize in sales and
marketing rather than research and development.

Big Pharma amended bylaws to require significant R&D spending---

concerned about public perception of price hikes
Jared S. Hopkins 17, reporter for Bloomberg News covering the U.S. pharmaceutical
industry, 5-9-17, “Pharma Lobby Ousts 22 Drugmakers Amid U.S. Pricing Debate,”
https://www.bloomberg.com/news/articles/2017-05-09/pharma-lobby-ousts-22-drugmakers-
amid-u-s-pricing-debate
The pharmaceutical industry’s powerful Washington trade association fell in size by almost two
dozen companies after revising membership rules amid the debate over U.S. drug prices.

Pharmaceutical Research and Manufacturers of America, or PhRMA, will require that members
spend at least $200 million a year on research and development and that their R&D
spending is at least 10 percent of global sales . The changes, reported by Bloomberg Sunday, follow a three-
month review that has already seen several member companies leave the lobbying group.

“Being a member of PhRMA means being committed to doing the time-intensive, scientifically sound research it takes to bring bold
new advances in treatments and cures to patients,” said Joaquin Duato, chairman of PhRMA and Johnson & Johnson’s worldwide
chairman for pharmaceuticals, in a statement announcing the changes.

Drugmakers of all sizes use price increases to raise revenue. The changes will result in a trade
group made up of mostly large, established drugmakers, such as Pfizer Inc., GlaxoSmithKline
Plc and AstraZeneca Plc. Some smaller companies that have attracted the ire of insurers,
patients and politicians for buying older drugs and raising their prices will be shut out. Companies
that don’t yet have drugs on the market will also be less likely to remain with the group.

Eli Lilly & Co. supports the membership criteria, which will “allow the association to focus even more effectively on the issues that
are important to research-based biopharmaceutical companies,” Mark Taylor, a spokesman, said in an email.

The drug industry is one of Washington’s most powerful. In 2016, PhRMA spent nearly $20
million on lobbying, according to the Center for Responsive Politics. PhRMA is in the midst of a media advertising campaign
and public events effort to highlight the value of members’ treatments.

Pricing Outcry

Companies are embroiled in a national debate over U.S. drug pricing . Industry critics
range from patients to President Donald Trump, who’s accused drugmakers of “getting away
with murder.” His administration has said he wants to use the government’s negotiating power
to lower drug prices, but he hasn’t provided details.
PhRMA’s website now lists about three dozen member companies. All those affected by the changes are
eligible to reapply for membership, according to the trade group. Some companies that fall short of eligibility now
had recently resigned from the group.
No food wars---no causal evidence, only maybe true for the poorest
countries, and government responses solve the impact
Mark W. Rosegrant 13, Director of the Environment and Production Technology Division at
the International Food Policy Research Institute, et al., 2013, “The Future of the Global Food
Economy: Scenarios for Supply, Demand, and Prices,” in Food Security and Sociopolitical
Stability, p. 39-40
The food price spikes in the late 2000s caught the world’s attention, particularly when sharp increases in food and fuel
prices in 2008 coincided with street demonstrations and riots in many countries. For 2008 and the two
preceding years, researchers identified a significant number of countries (totaling 54) with protests during what was called the
global food crisis (Benson et al. 2008). Violent protests occurred in 21 countries, and nonviolent protests occurred in
44 countries. Both types of protest took place in 11 countries. In a separate analysis, developing countries with low government
effectiveness experienced more food price protests between 2007 and 2008 than countries with high government effectiveness
(World Bank 201la). Although the incidence of violent protests was much higher in countries with less capable governance, many
factors could be causing or contributing to these protests, such as government response
tactics, rather than the initial food price spike .
Data on food riots and food prices have tracked together in recent years. Agricultural commodity prices started strengthening in
international markets in 2006. In the latter half of 2007, as prices continued to rise, two or fewer food price riots per month were
recorded (based on World Food Programme data, as reported in Brinkman and Hendrix 2011). As prices peaked and remained high
during mid-2008, the number of riots increased dramatically, with a cumulative total of 84 by August 2008. Subsequently, both
prices and the monthly number of protests declined.

Several researchers have studied the connection between food price shocks and conflict, finding at least some relationship between
food prices and conflict. According to Dell et al. (2008), higher
food prices lead to income declines and an
increase in political instability, but only for poor countries . Researchers also found a positive and
significant relationship between weather shocks (affecting food availability, prices, and real income) and the probability of suffering
government repression or a civil war (Besley and Persson 2009). Arezki and Bruckner (2011) evaluated a constructed food price
index and political variables, including data on riots and anti-government demonstrations and measures of civil unrest. Using data
from 61 countries over the period 1970 to 2007, they found a direct connection between food price shocks
and an increased likelihood of civil conflict, including riots and demonstrations.

Other researchers have broadened the analysis by considering government responses or

underlying policies that affect local prices, and consequently influence outcomes and the linkage between food
price shocks and conflict. Carter and Bates (2012) evaluated data from 30 developing countries for
the time period 1961 to 2001, concluding that when governments mitigate the impact of food price shocks
on urban consumers, the apparent relationship between food price shocks and civil
war disappears . Moreover, when the urban consumers can expect a favorable response, the protests
only serve as a motivation for a policy response rather than as a prelude to something
more serious, such as violent demonstrations or even civil war .
Many in the international development community see war and conflict as a development issue, with a war or conflict severely
damaging the local economy, which in turn leads to forced migration and dislocation, and ultimately acute food insecurity.
Brinkman and Hendrix (2011) ask if it could be the other way around, with food insecurity causing
conflict. Their answer, based on a review of the literature, is "a highly qualified yes ," especially for
intrastate conflict. The primary reason is that insecurity itself heightens the risk of democratic breakdown and civil conflict.
The linkage connecting food insecurity to conflict is contingent on levels of economic
development (a stronger linkage for poorer countries), existing political institutions, and other factors.
The researchers say establishing causation directly is elusive, considering a lack of evidence
for explaining individual behavior. The debate over cause and effect is ongoing.
Policies can nevertheless be implemented to reduce price variability. Less costly forms of stabilization, at
least in terms of government outlays, include reducing import tariffs (and quotas) to lower prices and
restricting exports to increase food availability. However, these types of policy responses, while perhaps helping an
individual country's consumers in the short run, can lead to increased international price volatility, with potential for
disproportionate adverse impacts on other countries that also may be experiencing food insecurity.
1AR
T
 XT Not government
Their definitions are based on over-simplifications of health policy---
leads to less nuanced, educational debates about different
mechanisms
Federico Toth 16, Associate Professor. Department of Political and Social Sciences, University
of Bologna, May 2016, “Classification of healthcare systems: Can we go further?,” Health Policy,
Vol. 120, No. 5, p. 535-543

This article deals with a

classic topic, already widely explored and debated in the literature: the
classification of healthcare systems. The topic is worth revisiting because of its undeniable
centrality . Indeed, every scientific community aims at defining firm and widely shared
classification criteria, an indispensable condition for the advancement of
comparative research. This applies to all subject areas, and the study of healthcare systems
is no exception.
Over the years, many proposals have been put forward to classify healthcare systems. Many works propose to classify systems “on
base 3” [1–5]. The
most widely used classification indeed subdivides healthcare systems into three
large models [2]: (1) voluntary insurance; (2) social health insurance (SHI); (3) national health service
(NHS). The breakdown of healthcare systems based on these three ideal types can be considered the standard tripartite
classification[5], which many authors have shared and used in their research [4,6,7].

Other scholars have proposed classifications of healthcare systems “on base 4” [8–11]: each of these proposals, however, uses
different classification criteria, and different labels to identify the four types.

Wendt et al. [12] went as far as theorising the existence of 27 different possible healthcare system “combinations”. However, 24 of
these combinations can be considered hybrid forms, leaving only three pure models (and thus returning, even in this case, to a
trichotomous classification). Böhm et al. [13] analysed the 27 combinations mentioned above and pointed out that many of them are
“scarcely plausible” from a logical viewpoint, and that, in practice, some types are not applicable in the real world: healthcare
systems in OECD countries can therefore be grouped under five main models.

Regardless of whether the classification is on base 3, 4 or 5, all

the foregoing proposals seem to have – some more, some
less – the same limits: (1) they end up including in the same category healthcare systems that differ
from one another (some typologies also result in the opposite problem, in that similar systems fall into different categories); (2) for
each country, only the prevailing model is taken into account, which risks being an oversimplification. Let us
discuss a few examples.

Some classifications place the healthcare systems of Australia and Canada in the same category as those of countries like the UK,
Italy or New Zealand [3,11,13–15]. But the Canadian and Australian systems are not organised like the British or the Italian NHS
[16,17].

In many research works, Switzerland is listed with social health insurance countries like France or Germany [3,13,18,19]. But the
Swiss model is substantially different from the classic Bismarckian prototype and adheres to different logics [13,20].

The United States is another example. Labelling the American system as a simple case of “voluntary private insurance” is an obvious
over-simplification. The American system is a very complex patchwork [21], where government intervention is anything but minor,
as demonstrated by the fact that, in the USA, public health expenditure is around 7.9% of GDP [22]; it is therefore higher than that
of “universalist” countries such as the UK, Spain, Italy or Canada. Given its complex architecture, the US system cannot be classified
as a mere private insurance system.

These few problematic cases – but there are many others – lead us to consider the classifications of
healthcare systems proposed to date in the literature as not fully satisfactory. In this work, we ask
ourselves whether we can go further.

We ought to clarify right from the start that the author does not consider the classic tripartite classification and the other types
proposed so far wrong, or useless: they are certainly helpful. However, it all depends on the type of analysis that one wants to make.
If a certain degree of simplification is acceptable, then the classifications proposed so far, starting from the standard tripartition, are
adequate. Conversely, a deeper
analysis that places greater emphasis on the differences between
systems, and aims at fully understanding the architecture of each healthcare system,
requires the adoption of a more sophisticated conceptual scheme .
In the following sections we shall outline 10 models of healthcare organisation: these types in part take up and in part develop the
classification proposals already presented in the literature. However, this work is not limited to proposing a new typology, but rather
aims to suggest a classification logic that differs from traditional pigeonholing. The classic classification logic starts off
by defining some ideal models, and then tries to make the different objects of analysis – in our case, the
national healthcare systems – fit into one, and only one, of the identified models, so as to obtain
classes as homogeneous as possible [23]. It is, however, generally agreed that national healthcare systems are, in
actual fact, hybrid and composite systems that mix and combine elements inspired by different
models [1,8,12,13,24,25]. Grouping countries on the sole basis of the prevalent model thus risks
producing simplistic descriptions of the national systems that are quite far from the actual
state of affairs.
To avoid this limitation, we propose to make a different use of the typology. The ideal types will serve primarily to identify and label
the different elements composing each national healthcare system. The typology will therefore be the common analytical framework
through which we can put the system's components into focus, understand how each component works and grasp the relationships
between the various subsystems. This will make it possible to compose a concise overview, revealing the logic underlying the overall
design of each healthcare system. We shall refer to this way of proceeding as the “identikit logic”: indeed, it aims at providing more
accurate and realistic descriptions of each single national healthcare system, reconstructing the various combinations based on
which it was designed.

Some authors [4,26] suggest to consider

the healthcare system as a triangle, due to the relationships
existing between the three different categories of subjects: users, providers and insurers. When
focussing on the relationship between users and insurers, we are talking about the financing of the system; financing methods
usually also affect the manner in which providers are paid. When considering the relationship between providers and users, we are
instead dealing with healthcare service provision; service provision methods are in turn affected by the relationship that users and
providers have with insurers.

Some healthcare system classifications made in the past almost exclusively consider the financing dimension [1,25,27]. Many
authors, however, believe that focussing only on financing is reductive, and that a proper classification should also include the
service provision dimension [2,4,12,26,28]. Sure enough, financing mechanisms on the one side and provision methods on the other
are considered the two “core dimensions” [13] required to classify healthcare systems [2,11,14,26,29]. Fully agreeing with this
approach, in this work we shall take these two dimensions into account, first discussing them separately and then intercrossing
them.

In Section 2, we shall start from healthcare service financing mechanisms, comparing five different financing systems. In Section 3,
we shall discuss the provision of healthcare services and, in particular, the relationship between providers and insurers. We shall
therefore make a distinction between integrated and separated systems. By intersecting the financing and service provision
dimensions, we obtain 10 different types of healthcare organisation.

As already mentioned, at this point, however, the logic will not be to pigeonhole the various national systems into these 10 types. The
operation suggested in this work will rather be to draw up an identikit picture of each single healthcare system. The concepts of
“population segmentation” and “healthcare segmentation”, as defined in Section 4, will be key to reasoning according to the identikit
logic. Section 5 will attempt to elucidate the usefulness of the framework proposed here, providing some concrete examples of
“identikit” pictures. The last section will wrap up the discussion, underscoring the elements of greater originality of this work.

2. Financing models

Multiple criteria can be used to classify the financing mechanisms of healthcare systems.

A first, widely used criterion concerns the public or private nature of the insurance scheme [25,30]:
insurers may indeed be public, private for-profit or private non-profit entities [6,12,26].

A second criterion refers to the level of compulsoriness of the insurance scheme [14,25], hence the
freedom of choice granted to the insured [31]: there are indeed voluntary insurance programs, compulsory schemes
where it is possible to choose the insurer, and systems that leave no choice to the citizen, who is required by law to take out an
insurance and is assigned by law to a given insurer.
We can thus make a distinction between single- or multi-payer systems [27]. In the case of multi-payer
systems, it is important to determine whether the relationship between insurers is competitive or not [25,26].

Many classifications attach great importance to the contribution method[4,8,25,30]; the

insurance scheme may indeed be
financed by taxes, social security contributions proportional to the salary, or insurance
premiums; in the latter case, the formula by which premiums are calculated is of relevance [25,26].
Another criterion used to categorise the different health insurance schemes is the basis for eligibility[1,24,26]: belonging to a
particular insurance scheme may, indeed, depend on being residents in a particular country, having paid regular contributions,
belonging to certain “weak” or “privileged” categories [24]. The eligibility criterion usually influences the rate of insurance coverage
of the population [2,4], and this represents a further classification criterion.

Financing schemes can finally be compared according to the level and modes of regulation of financing bodies and the insurance
market [25]; public regulation can be more or less stringent [6].

Trying to
condense the foregoing criteria, three ideal types of financing systems were
developed : (1) voluntary insurance (called both “private health insurance” and “voluntary health insurance”); (2)
social health insurance; (3) universal coverage.

The proposal put forward in this article is to keep the three models mentioned above and add two more :
the category of “ residual” programs, and national health insurance . For the sake of completeness, we
should not forgo mentioning that some authors have identified an additional financing model: the Medical Savings Accounts (MSAs)
[7,26,27,32]. This latter model is still scarcely widespread. It has been adopted in Singapore and – to a lesser extent – in the United
States, South Africa and China. However, the MSA system is not autonomous in any of these countries: it is always combined with
some other form of insurance coverage. For this reason, MSAs will not be discussed in this work.

We shall therefore focus on five financing models. Let us consider them individually.

2.1. Voluntary insurance

The voluntary insurance model does not envisage the obligation to obtain insurance coverage against
health risks. Tax or cash incentives may be provided to those who opt for insurance [26], whereas penalties may be imposed on those
who, despite having the economic means, decide against insurance. In any event, citizens are basically free to choose whether or not
to sign up for insurance [25]. Thosewho cannot or do not want to get insurance coverage will pay for the
required healthcare services out-of-pocket.
Conversely, those wishing to take out a health insurance policy can choose from a number of private insurers. The latter are in
competition with one another, and can offer policies tailored to individual subscribers. Insurers may be for-profit insurance
companies or non-profit institutions and funds [33]. In the former case, the premium will probably be risk rated, i.e., calculated on
the basis of the individual risk of each single subscriber [4]. Nothing prevents non-profit insurance entities from calculating
premiums based on individual risk, but they often prefer community rated or group rated insurance premiums [26], meaning that
they discriminate on the basis of the characteristics of larger groups (all belonging to a given group thus contribute in the same way),
rather than of individual subscribers.

2.2. Social health insurance

The basic principle behind the

social health insurance (SHI) model is that the state requires certain
categories of workers to pay contributions from their salary into a sickness fund. Sickness funds are
quasi-public, non-profit organisations subject to strict governmental regulation, appointed to collect their subscribers’ contributions
[18]; in
exchange, sickness fund subscribers receive total or partial reimbursement of the medical
expenses incurred.
The SHI model therefore divides the population into two groups, who have different levels of freedom. On the
one hand, there are those who, as members of certain professions, must pay mandatory
contributions. They cannot choose whether or not to sign up for the health insurance scheme as they are forced to do so. On the
other hand, there are those who are not subject to any obligations; they may, if they wish, take out a
voluntary insurance policy, or bear out-of-pocket spending for their healthcare.
The classic SHI model – for the sake of clarity, the one introduced by the late 19th-century Bismarckian legislation – provides for
different sickness funds, not in competition with one another, to be operative within the same country: workers are assigned to a
given fund by law, depending on their profession. Only in recent times, some countries have introduced a variant of the original
model: the worker is entitled to choose his/her own sickness fund [34]. In these countries, including Germany, it is mandatory to
pay contributions, but one can choose which sickness fund to sign up for.

We ought to recall that an

essential feature of SHI is that it is a typical occupational system: the
obligation to pay health contributions is not prompted by nationality or residency, but rather by
one's occupation. We should also point out that the contributions to be paid into a sickness fund – which may be co-paid by
employee and employer – are not calculated as a percentage of the overall income, but only of the earned income [26,34].

2.3. Residual programs

In countries where either voluntary or social health insurance prevails, there often are programs
that can be defined as “residual”. The term “residual” is taken from the literature on the Welfare State [35,36]. The programs
that we define as residual for the purposes of this article are those that are financed by general taxation and
intended for particular target populations . The beneficiaries of these programs are generally
the most vulnerable categories, those that are most exposed to health risks: low-income individuals, the elderly and
minors, persons suffering from serious illnesses, prisoners, and refugees. Various countries have residual programs not only for the
“weaker groups”, but also for certain professional categories considered particularly worthy of protection by the state, such as the
military or civil servants.
A key difference between residual programs and other financing models is that in the latter those who pay earn the right to benefit
from the program being financed. In the case of residual programs, this is not necessarily true: beneficiaries coincide only in part (or
not at all) with those who finance such programs. A healthcare program for the unemployed, for example, is financed by tax payers
who do have a job; healthcare for prisoners is paid by those who are not in prison; a program designed for minors is financed by
adults who pay taxes, and so on. Residual programs are, in short, programs financed by the community, but only available to
particular categories.

2.4. Compulsory national health insurance

The label “ national health insurance” has been used in the literature with multiple
meanings [11,13,14,24,37]. It is therefore necessary to immediately clear up possible
misunderstandings . In this work, national health insurance (NHI) is understood as the principle according
to which the state requires all residents to take out a private health insurance policy
covering essential healthcare services, using individual resources. There not being one single
public scheme into which contributions can be paid, the policy has to be taken out with
different, for-profit or non-profit insurers in competition with one another . The NHI is therefore a
multi-payer system , in which citizens can choose their insurers.
The state may provide subsidies for low-income citizens (who might otherwise find it difficult to pay
the insurance premium regularly), and may impose a regulation, even a very strict one, of the insurance market.
The insurance packages usually differ from one another, and may provide coverage additional to the minimum required by law; we
must therefore bear in mind that there may be differences between the services provided to individual healthcare users.

2.5. Universalist system

A universalist system is defined as a single-payer insurance scheme (therefore, one for the entire
population) covering all residents and financed through taxation. The universalist system, as we shall see later, is
not synonymous with the National Health Service.

Compared with other insurance schemes, the universalist system is marked out by the fact that the right to
healthcare is not linked with payment of a premium or a contribution, but to residing in a given
country. Healthcare is therefore a right of the citizens of that country.
From the point of view of those who have to contribute financially, the universalist system does not grant freedom of choice. Aside
from the few countries where some form of opting out is possible, residents cannot choose whether or not to finance the universalist
scheme: they are required to pay taxes, and therefore also to finance the program. And, given that (direct) taxes are usually paid
more than proportionally with respect to income, the universalist scheme turns out to be a typically progressive financing system
[26,27].

It is important to underscore that, unlike the SHI model, the universalist system envisages taxation not only on earned income, but
on all forms of income. Financing of the universalist scheme therefore has a clear redistributive intent: the richest end up paying, at
least in part, the healthcare services provided to the poorer citizens.

Mandates are NHI

OECD 4 – Organisation for Economic Cooperation and Development, Study on Private
Health Insurance, June 2004, “PROPOSAL FOR A TAXONOMY OF HEALTH INSURANCE,”
https://www.oecd.org/els/health-systems/31916207.pdf
A simplified classification of health insurance schemes into mandatory and voluntary is
proposed:

Mandatory health insurance includes schemes where individual participation is compulsory

by government through legal stipulation4 , whether there is a unique system or a choice among
scheme/insurer. The mandate can apply to the entire population or to groups within it (e.g.,
individuals with income lower than a threshold). When mandated health insurance
covers the population at large such as all residents of a country, the scheme can be
referred to as National Health Insurance ( NHI ).

Voluntary health insurance includes insurance where insurees participate on a voluntary basis, or
where employers can choose themselves whether to offer health insurance cover to their employees either
voluntarily or per effect of collective agreements.

Mandate not enforced now – silent returns are being accepted

Colleen Murphy 17, Professor in the College of Law and the Departments of Philosophy and
Political Science at the University of Illinois , 8/21/2017, “Obamacare: What’s Next for the
IRS?”, https://www.bna.com/obamacare-whats-next-n73014463382/
Officials in the White House and presidential appointees at the Treasury Department could also steer the IRS. Trump on Jan. 20
signed an executive order directing agencies to reduce the law’s burdens. Dana Trier, the newly appointed deputy assistant secretary
for tax policy, is also expected to play a large role in coordinating guidance and implementing administrative priorities.¶ “Although
matters of tax administration should be left to IRS and matters of tax policy to Treasury, such direction could include enforcement of
the individual mandate and the employer mandate,” said Elliott, who was previously the lead IRS employee overseeing ACA
implementation.¶ Underthe ACA, individuals are required to maintain coverage, and employers with
50 or more full-time equivalent employees are required to provide it. The Trump administration
will likely try to push back against those mandates, attorneys said, though the IRS has repeatedly said
the requirements must be met as long as the law is in place.¶ The employer mandate and individual mandate
penalties were zeroed out in the House-passed bill and Senate version. Earlier this month, House Democrats asked the Government
Accountability Office to investigate how the Trump administration has undermined the ACA by signaling it won’t enforce the
individual mandate.¶ The
IRS in February indicated it would accept tax returns that don’t indicate
whether an individual had health insurance, walking back a previous decision to begin requiring
an indication of coverage on returns. The agency likely won’t stop accepting those so-called silent
returns, attorneys said.¶ Trump’s Threats¶ The IRS may still be reticent to invest too much time on
health care regulations given Trump’s previous executive orders and the precarious political
situation in Congress, Kalick said.¶ The Trump administration agreed to make cost-sharing
reduction payments in August, which reimburse insurers for using the subsidies to reduce
health costs for low-income individuals. But Trump has previously threatened to stop the
payments—which would be a devastating blow to the ACA .
 AT: ACA = Universal Now
The combination of stronger penalties and adequate subsidies is key
to universal coverage – health insurance models prove its key to risk-
pooling
Barak Richman 17, JD from Harvard Law School, PhD in Economics from Berkeley,
Regina Herzlinger, Richard J Boxer, 2/27/2017, Achieving Universal Coverage Without Turning
to a Single Payer Lessons From 3 Other Countries,
http://www.boxerhealthstrategies.com/blog/2017/2/27/achieving-universal-coverage-without-
turning-to-a-single-payer-lessons-from-3-other-countries
This leaves a third strategy: the
individual mandate—or as the Supreme Court characterized it, an annual tax
assessed against individuals who have not purchased qualified health insurance within the
calendar year. Although vilified by some, the mandate is attractive for several reasons. It is relatively easy to
implement, is effective in pooling risk, and reflects the values of individual responsibility.
Coverage is primarily funded by the enrollees rather than by general taxation. For these reasons,
some nations that are committed to a private health insurance sector have achieved universal
coverage and effective risk pooling by mandating the purchase of insurance.¶ Examples of the Individual
Mandate and Penalties¶ Switzerland, Singapore, and Germany have achieved universal coverage and
made insurance affordable even for their citizens with highest health care costs by instituting an
individual mandate. One major difference, however, is that unlike the ACA, the mandates instituted
by these countries are reinforced with effective penalties for nonparticipation, thus ensuring
that lower-cost enrollees—generally healthier individuals—balance out the costs of the others
who require more medical resources.¶ In Switzerland, citizens must purchase health insurance. If they do not,
government authorities automatically enroll them, selecting the insurance provider on the individuals’ behalf. Moreover, insurers
can implement debt enforcement proceedings against anyone failing to pay their premiums and collect a penalty in addition to back
premiums. TheSwiss government subsidizes premium payments for more than a quarter of the
population, including retirees who purchase the same insurance as workers.¶ Singapore
institutes compulsory contributions from employers on behalf of their employees to create medical savings accounts.
Employees maintain these accounts for health care expenses such as health and disability insurance premiums, hospitalization,
surgery, rehabilitation, end-of-life care, and outpatient services. Those
failing to pay their premiums are subject to
garnished wages and other legal actions that can force payment of back premiums, penalties,
and interest. Unemployed or low-income individuals are eligible for government subsidies that
enable them to pay for the premiums.¶ In Germany, insurance is funded by compulsory
contributions to private insurers levied as 7.3% of income. Unemployed individuals have their contribution
taken out of their unemployment benefits coupled with means-based sliding-scale subsidies, and uninsured self-employed persons
who later attempt to purchase insurance face payment of back premiums for the period in which they were uninsured.¶ To be sure,
these health care systems differ from that in the United States in other important ways. For instance, all allow individual tax
deductions for health insurance expenditures and thus have evolved from an employer-based to a consumer-based system, whereas
the United States limits the individual market with constraints on such deductions. In addition, these countries have many more
insurers than the United States, and consumers benefit from vigorous competition among them.7 Germany in 2015, for example,
had 124 sickness funds and 42 private health insurance companies, and the average resident of Switzerland in 2011 could choose
from 59 health insurers offering coverage, with the 5 largest insurers covering 43% of the population. By comparison, in California, a
state with approximately half Germany’s population, only 7 firms covered more than 95% of privately insured individuals in 2011,
with the 3 largest firms covering 75%. In Massachusetts, with a population slightly smaller than Switzerland’s, 3 insurance
companies enrolled 79% of individuals with private insurance.¶ As
with the ACA, these nations provide financial
support for insurance mandate purchases. Singaporean employers contribute to their
employees’ medical savings accounts, and German employers match their employees’ payroll
contributions to insurance premiums.¶ In sum, health insurance models in Switzerland,
Singapore, and Germany suggest that an individual mandate, with adequate
subsidies, can achieve affordable universal coverage. But the recipe for their success
also includes firm penalties. They also suggest that the ACA’s individual mandate failed to pool risk
adequately, in large part because its penalties were too weak. In 2014, approximately 7.5 million
individuals paid the penalty rather than purchasing insurance, and of the approximately 15
million uninsured people who were ineligible for Medicaid, an estimated 7.1 million would pay a
penalty lower than the cost of the least expensive plan.8 The Internal Revenue Service’s recent
announcement that, to comply with President Trump’s January 20, 2017, executive order rolling
back the ACA, it might not pursue individuals who fail to provide evidence of health insurance
will further dilute the current individual mandate.9 Achieving universal coverage , like these 3
nations, requires a more forceful approach .¶ Conclusions¶ Although insurance mandates and
penalties may seem unattractive, policies that induce citizens to purchase insurance are as old as
the republic and as common as the most popular programs. In 1790, President George Washington required
that ship owners purchase medical insurance for their seamen, and Medicare has long assessed penalties on healthy people who do
not enroll by age 65 years. If
the goal is universal health coverage that provides care even for patients
with the highest health care costs without relying on public insurance programs, the financial
burden must be spread across the whole population. This requires either massive government
spending, whether through high-risk pools or Medicare, or requiring individuals to purchase insurance.¶ It is
time to stabilize the premiums of the universal insurance market by neutralizing the political
disagreements surrounding the ACA’s mandate and penalties. As these 3 countries demonstrate, maintaining
the popular aspects of the ACA requires keeping its less popular part, and achieving the stated goal of
universal coverage requires a serious commitment to individual responsibility .
 Tax v. Penalty
The low cost of the individual mandate made it an acceptable use of
the taxation power---raising it turns it into a penalty that can only be
justified under the commerce clause---fiat means the aff gets upheld
Trevor Burrus 16, research fellow in the Cato Institute’s Center for Constitutional Studies
and managing editor of the Cato Supreme Court Review, 10/28/16, “Could It Be
Unconstitutional to Raise the Obamacare “Tax” for Not Purchasing Health Insurance?,”
https://www.cato.org/blog/could-it-be-unconstitutional-raise-obamacare-tax-not-purchasing-
health-insurance
As many predicted, especially us at Cato, the Affordable Care Act is beginning to make health
insurance less affordable for many Americans. Part of the problem, in a nutshell, is precisely what my colleague
Michael Cannon described in 2009, the young and the healthy avoiding signing up for health insurance
and choosing to pay the fine, or, as Chief Justice John Roberts would call it, a tax.
MIT economist Jonathan Gruber, often described as an architect Obamacare, recently said that some of these problems can be
alleviated by increasing the “tax” on those without insurance. “I think probably the most important thing experts would
agree is we need a larger mandate penalty,” said Gruber.

Depending on how high the penalty goes, there

could be a constitutional problem with that . In the
opinion that converted the “penalty” into a constitutional “tax,” Chief Justice Roberts described
the characteristics of the “shared responsibility payment” that made it, constitutionally speaking, a tax
rather than a penalty. One of those characteristics is that the penalty was not too high: “for
most Americans the amount due will be far less than the price of insurance, and, by statute, it
can never be more. It may often be a reasonable financial decision to make the payment rather than purchase insurance, unlike the
‘prohibitory’ financial punishment in Drexel Furniture.” In
Drexel Furniture, also known as the Child Labor Tax
Case, the Court struck down a 10 percent tax on the profits of employers who used child labor in
certain businesses. One reason the Court struck it down was because its “prohibitory and
regulatory effect and purpose are palpable.”
Roberts actually went out of his way to describe paying the “tax” as a voluntary and permissible act. Even though they won, this
should have irked the government a bit because the Chief was essentially giving millions of people permission to not buy insurance,
which the government knew would severely undermine the law. In Roberts’s words:

Neither the Act nor any other law attaches negative legal consequences to not buying health insurance, beyond requiring a payment
to the IRS. The Government agrees with that reading, confirming that if someone chooses to pay rather than obtain health
insurance, they have fully complied with the law.

Indeed, it is estimated that four million people each year will choose to pay the IRS rather than buy insurance. We would expect
Congress to be troubled by that prospect if such conduct were unlawful. That Congress apparently regards such extensive failure to
comply with the mandate as tolerable suggests that Congress did not think it was creating four million outlaws. It suggests instead
that the shared responsibility payment merely imposes a tax citizens may lawfully choose to pay in lieu of buying health insurance.

So could raising the “tax” turn it into a “penalty” and thus make it unconstitutional?
Possibly. At some point, the tax would take on a punitive character, and, if people like Gruber get their
way, the tax might have to be pretty stiff. With health insurance prices going up, it can still be cheaper to pay the “tax”
rather than purchase insurance. And that tax might have to go up a lot to make some people change their minds. If the government
ever tries to attach criminal penalties to noncompliance, then the argument is even stronger that it would become an
unconstitutional regulation of commerce, given that the Court held that the individual mandate isn’t a valid use of the commerce
power.
States CP
 Links to MT -- Devolution
The CP is perceived as kicking health care to the states – that
links – it is unpopular
Scott Clement 17, Polling Manager for the Washington Post, Amy Goldstein, 4/26/2017,
Public pans Republicans’ latest approach to replacing Affordable Care Act, Washington Post,
https://www.washingtonpost.com/national/health-science/public-pans-republicans-latest-
approach-to-replacing-affordable-care-act/2017/04/25/25355eb0-26aa-11e7-bb9d-
8cd6118e1409_story.html?utm_term=.da9fa0cdd357
Public sentiment is particularly lopsided in favor of an aspect of the current health-care law that blocks insurers
from charging more or denying coverage to customers with medical conditions. About 8 in 10 Democrats, 7 in
10 independents and even a slight majority of Republicans say that should continue to be a
national mandate, rather than an option for states to retain or drop.¶ ¶ [Read: Full Post-ABC poll results]¶ ¶ “ All states should be required to
do the same thing ,” said Bayonni Handy-Barker of Killeen, Tex., who supports nationwide requirements on both preexisting conditions and minimum benefits for insurance plans. As
the 25-year-old Army veteran and political independent reasoned, “when you have people picking and choosing what to cover, you have this system of holes and disruption and disorder.”¶ ¶ ¶ Those views
heighten the challenge for Trump and congressional Republicans as they try to thread their way through disagreements over health-care policy within the House GOP conference. The Freedom Caucus, the
chamber’s most conservative faction, announced its support on Wednesday for an amendment that would permit individual states to decide whether insurers must treat all customers the same. A state could ask
for federal permission to let insurers again charge higher prices to people with preexisting conditions, as long as it offered high-risk insurance pools for such customers.¶ ¶ The amendment also would let states
seek federal approval to drop the “essential health benefits” the ACA requires in all health plans sold to individuals and small businesses.¶ ¶ These latest ideas are an effort to recover after a remarkable failure last
month in attempting to pass a health-care bill. House Speaker Paul D. Ryan (R-Wis.), who has championed the ACA’s repeal for years, canceled a vote on the American Health Care Act shortly before the roll call
was to begin because the chamber’s ­Republican majority was so splintered. Since then, the White House has been prodding GOP lawmakers to regroup, unite and vote quickly on a new version of the legislation.¶

beyond the criticism of GOP

¶ [Affordable Care Act remains ‘law of the land,’ but Trump vows to explode it]¶ ¶ The Post-ABC poll shows that,

proposals for devolving health policy to the states , many Americans appear leery in general
about a major overhaul to the health-care law often called Obamacare, with 61 percent
preferring to “keep and try to improve” it, compared with 37 percent who say they want to “repeal and replace” it. About three-quarters of Republicans
prefer repealing and replacing the ACA, but more than 6 in 10 independents and nearly 9 in 10 Democrats favor working

within its framework.

Causes insurers to bail from the market

Nicholas Bagley 16, Professor of Law at the University of Michigan, 12/16/16, “Patching
Obamacare at the state level,” http://theincidentaleconomist.com/wordpress/patching-
obamacare-at-the-state-level/
If Congress zeroes out the individual mandate—and my hunch is that it will—it’s game over for the exchanges, even if subsidies
continue to flow for years. In
many states, the exchanges are already precarious. Without the spur
to get healthy people into the market, adverse selection will do its inexorable work.
Congress may try to devise an alternative—a continuous-coverage requirement, perhaps, or maybe auto-enrollment.
But those alternatives probably can’t be passed in a reconciliation bill because they don’t involve revenues or outlays. Even if one or
the other is adopted, it’s unlikely to be effective enough to forestall huge premium spikes for
2018 coverage.

So unless
Republicans opt to retain the mandate for several years, the states should brace
themselves for the collapse of their individual insurance markets. It’s that simple.

But here’s a wild idea. Nothingprevents state legislatures from adopting their own individual
mandates. What if California, say, passed a law with the same structure as the federal mandate, to go into effect
when and if the federal mandate lapsed?
The gambit might not work. Insurers might still head for the hills because they doubt
that the Republicans will pass a viable replacement. But the California exchange is healthy and, if a mandate
replacement is in place by mid-2017, the economic picture for insurers in 2018 and 2019 won’t look all that different than it does
today. There’s a chance that California could save 1.6 million people from losing coverage.
Midterms
 AT: Dodd-Frank
GOP won’t repeal Dodd-Frank
David Dayen 17, Writer at Salon, 6/7/2017, “Republicans Can’t Really Repeal Dodd-Frank”,
https://www.thenation.com/article/republicans-cant-really-repeal-dodd-frank/
Republicans have no interest in bending on principle. The House has spent half a year making
the same kinds of messaging votes they did when they knew Barack Obama would veto the
finished product. There’s probably a bill out there that would reduce Dodd-Frank rules for
community banks (although there’s plenty of tailoring in bank supervision already) that could pass Congress; in fact,
here is that bill. But Republicans don’t want to make the choice of getting that done without freeing
the big banks as well. So they pass the CHOICE Act, and it falls into the ether, and they can say
to their lobbyist pals that they tried.
This is ultimately why congressional Republicans have full legislative control in Washington but
no legislative accomplishments. It’s highly unusual for a dominant political party to do nothing
with that power. But Republicans in Congress are more interested in making speeches than in
making laws. And that cedes the playing field for governing almost entirely to Donald Trump.
In the case of financial regulation, the administration’s goals align with the intentions of the
Choice Act. Trump has continually selected a rogue’s gallery of bank executives and corporate
lawyers to oversee the industries where they used to work. Just this week, he picked Joseph Otting, the former
CEO of OneWest Bank, to run the Office of the Comptroller of the Currency. So both OneWest CEOs in the bank’s ignominious
history, Otting and Steve Mnuchin, command top regulatory positions. SEC chair Jay Clayton, former law partner at Sullivan and
Cromwell, just hired Steven Peikin, former law partner at Sullivan and Cromwell, to run the agency’s enforcement division.

These personnel moves are playing out exactly as you’d expect. Enforcement is expected to be
light to nonexistent. Rules are expected to exist in name only. Banks are expected to run wild.
But this repeal by neglect is temporary by design. A new administration would carry new priorities. Only statutory law can maintain
policy continuity. But Republicans
don’t want to do the work. Instead they write the Choice Act and
other sparkle-pony wishes for industry that have no chance of success, abdicating their
lawmaking role. They might as well not exist. And when the current White House occupant has a scattershot
relationship to reality, that’s downright dangerous.
 Too Early/Multiple Issues Pound
It’s too early to tell – a number of other issues besides health care
could swing the election
Lauren Gibbons 17, Reporter, 6/11/2017, “What factors might shape 2018 election results?
Michigan lawmakers weigh in”,
http://www.mlive.com/news/index.ssf/2017/06/could_the_health_care_debate_i.html
Following major Democratic defeats in the 2016 presidential election and Congressional races throughout the country, some
progressives have looked to 2018 as a possibility to recoup losses and make a statement against policies
pushed by President Donald Trump and the Republican-majority Congress.¶ But Republicans are busy laying
groundwork to hold onto and advance gains made in 2016 in next year's state and federal races.
And several members of Michigan's Congressional delegation think it could be too early to tell how 2018 will play out. ¶ U.S. Rep.
Debbie Dingell, D-Dearborn, was open about her concerns for the Democratic Party in Michigan during both the 2016 primary and
general elections. In a column for the Washington Post following the election - which saw Trump taking the state for Republicans in
a presidential election for the first time since 1988 - Dingell criticized her party, particularly former candidate Hillary Clinton's
campaign, for missing the signs and not taking states like Michigan seriously. ¶ "I point blank said I thought Donald Trump could be
president and that Michigan was not the blue state that everybody thinks that it is," she said. "I turned out to be right, not happily."¶
Dingell warned those thinking 2018 could be a slam dunk for Democrats that many Trump voters
believe he's doing exactly what he said he would do during the campaign. ¶ "I think it's too early
to know what is going to happen , and I'm not making predictions, but this is not a slam dunk for either party,"
Dingell said. "We can't afford to take it for granted, shouldn't take it for granted." ¶ The 2018 election has the possibility
of being "transformative" for Democrats, said U.S. Rep. Dan Kildee, D-Flint Twp. But whether that happens
or not depends on a number of factors , including whether the current enthusiasm is
sustained and whether the Democratic Party can move beyond criticism of the current
administration. ¶ "Democrats have to offer something more than criticism," Kildee said. "We probably don't need to offer
criticism - Trump is offering a lot of that himself. We need to offer a plan...the wind blowing in our direction
isn't enough." ¶ U.S. Rep. Tim Walberg, R-Tipton, said the 2018 election cycle will go well for Republicans "if we do what we
said we would do" and make a good faith effort to get meaningful legislation passed through Congress. ¶ "We're well on our way, but
we need to be better at messaging at times," he said.¶ How
Republicans respond to opposition coming from
progressive groups like Indivisible at public town halls and meetings could also impact how
2018 elections play out, Walberg said. He said the town hall meetings he's hosted in 2017 have had record crowds - often
filled with people who oppose his views - but he said they have been constructive. ¶ "Those are my constituents too," he said. "I hear
from them, I don't agree with all that they're saying, but forces me to go back and do more research...I hear them, and I hope they
hear me." ¶ U.S. Sen. Debbie Stabenow, D-Lansing, said the women's marches that took place throughout the country following
Donald Trump's inauguration, health care demonstrations and other showings of activism are signs of people getting engaged in a
way she hasn't seen in a long time. ¶ "Folks were sitting back and letting politics happen without them - now they're realizing they
have to be involved," she said. "I think we will see a very different group of people showing up in 2018 - people who are much more
activated." ¶ U.S. Rep. Brenda Lawrence, D-Southfield, said she's viewed the activism since the 2016 election as a "political
awakening in our country," and hopes that translates into people staying engaged in the political process. ¶ Several
key policy
issues, including Trump's pulling out of the Paris climate accord, Congressional votes on repealing and
replacing Obamacare, the nomination of Betsy DeVos to head the Department of Education and
proposed budget cuts could be motivators going into the 2018 election cycle, Lawrence said. ¶ "Elections
have consequences," she said. "A lot of people had checked out of politics for whatever reason, but now you see individuals who
weren't normally activists or engaged standing up, asking questions and demanding results."
 GOP Demoralization---1AR
The link turn outweighs – angering the base by flipping on repeal is
worse than alienating other voters
Jonathan Martin 17, Political Correspondent for the NY Times, co-author of the New York
Times best seller “The End of the Line: Romney vs. Obama: The 34 Days That Decided the
Election”, 2018 Dilemma for Republicans: Which Way Now on Obamacare?, The New York
Times, https://www.nytimes.com/2017/03/28/us/politics/2018-dilemma-for-republicans-
which-way-now-on-obamacare.html
WASHINGTON — As they come to terms with their humiliating failure to undo the Affordable Care
Act, Republicans eyeing next year’s congressional campaign are grappling with a new dilemma:
Do they risk depressing their conservative base by abandoning the repeal effort or anger a
broader set of voters by reviving a deeply unpopular bill even closer to the midterm elections?¶ The question is
particularly acute in the House, where the Republican majority could be at risk in 2018 if the
party’s voters are demoralized, and Democratic activists, energized by the chance to send a
message to President Trump, stream to the polls.¶ Sifting through the wreckage of a disastrous week, Republican
strategists and elected officials were divided over the best way forward. Some House Republicans pressed to move on to other issues
and notch some victories that could delight their own loyalists while not turning off swing voters.¶ “We’ve got a lot of time to do real
things on infrastructure, to do real things on tax reform, on red tape reform, and really get the American economy moving,” said
Representative Steve Stivers of Ohio, chairman of the National Republican Congressional Committee, the House campaign arm. “We
do those things and we still have a lot of time to recover.”¶ “If you’re going to fumble the ball,” he added, “better to do so in the first
quarter of a football game.Ӧ Devising
health care legislation that could appeal to both wings of the
House Republican Conference — the hard-line conservatives and more moderate members —
would require a nearly superhuman feat, added Representative Billy Long, Republican of Missouri.¶ “Not unless
Harry Houdini wins a special election to help us,” Mr. Long said about the prospects of cobbling together a coalition that could agree
on how to repeal and replace the health care law.¶ But other longtime Republicans warned that if
the party did not address
what they have derided as Obamacare, an issue that has been central to their campaigns for the
last seven years, they would incur a heavy political price in the midterm elections.¶ Midterm
campaigns have increasingly become akin to parliamentary elections — referendums on the
party in power rather than on individual candidates, where turnout by dependable partisan
voters is the deciding factor.¶ “If they fall on their sword on this, they’re going to get slaughtered,”
said former Representative Thomas M. Davis III, a Virginia Republican who himself was once at the helm of the House campaign
committee.¶ “ Where
parties get hurt in midterms is when their base collapses ,” Mr. Davis
said. “Democrats are going to show up regardless of what you do. If our voters don’t
see us fulfilling what we said we were going to do, they’ll get dispirited.” ¶ What
troubles many Republican strategists is the specter of the party’s most reliable voters being
bombarded by reminders of their leaders’ failure to address the health law. Th ey fear a
recurring story line sure to pop up every time insurance premiums increase, providers leave local networks, or,
most worrisome, Republicans fund President Barack Obama’s signature
achievement.
 No Link
Dem outrage is inevitable and they fail at creating momentum on
healthcare
Jeet Heer 17, Senior Editor at the New Republic, PhD Candidate at York University, writing a
dissertation on cultural politic, 6/14/2014, The Russia Scandal Is Distracting Democrats From
Trumpcare, New Republic, https://newrepublic.com/article/143321/russia-scandal-distracting-
democrats-trumpcare
Gillibrand and Murphy are speaking to a simple point: Attention and outrage are limited resources for an
opposition party trying to mobilize the masses, and right now, the Russia story is dominating
headlines. But not long ago, the Republicans’ Obamacare repeal efforts did command the media’s attention and public’s
outrage—specifically when the House first attempted to pass the AHCA, and when it succeeded in its second attempt. Republican
congressmen were literally running scared from angry constituents, and the press couldn’t get enough of the raucous town hall
meetings.¶ This, undoubtedly, is why Republican senators have decided to keep their own bill secret—to deprive the media of details,
and thus deprive the public of fuel for outrage. By all appearances, their strategy is working.¶ Gillibrand and Murphy’s rhetoric
notwithstanding, Democrats in the Senate seem to be treating healthcare as a secondary concern .
A top Senate aide told Stein that “not going nuclear on AHCA also allows them to hammer out bipartisan Russian sanctions deal.”
From a parliamentary point of view, this is a defensible position. The Democrats have few cards to play; they can’t filibuster the
legislation, but they can hold a vote-a-rama. They might want to wait for a later emergency to grind the Senate to a halt. Also, “going
nuclear” might make more sense once the details of the bill are public, giving the Democrats a more specific enemy to rally against. ¶
Still, whatever the logic behind the Democrats’ strategy, some activists are starting to panic,
believing that the fight is being lost due to complacency and disengagement. “There’s no
shortage of passionate opposition to Trumpcare, but there’s a profound shortage of
awareness that the beast is back,” Ben Wikler, Move On’s Washington director, told the New Republic’s Graham Vyse. “Big
chunks of the American public have been lulled into a dangerous belief that Trumpcare is not going anywhere. The fact is, we’re in a
code-red emergency.” Stopping the Senate’s health care bill will require massive mobilization, he said. “ A biblical flood of
phone calls is necessary but not sufficient to stop Trumpcare. At this point, for Republican senators to vote
against the bill they would have to feel like supporting it is an existential threat to their political careers, and that means surround-
sound, defending resistance. It means phones ringing off the hook. Emails being jammed. Protesters shouting at them when they go
to the grocery store.Ӧ The
ubiquitous Russia story is a barrier to this type of political mobilization. For
all the attention the scandal deserves, it is also, from the point of view of resisting the Trump
agenda, counterproductive and politically demobilizing. The Russia story is high political
theater, with senators grilling top government officials and damaging information leaking
almost daily from the White House and law enforcement agencies. There’s very little room in
this drama for activists. At best, if the Senate or some other branch of the government is seen as failing to do its duties,
protestors might play a role in raising a stink. But on the whole, the Russia investigation is one where the system proceeds according
to its own rules, while the public looks on.¶ The
battle over health care, by contrast, requires enflaming mass
passions. Democrats and activists were able to do so earlier this year, mobilizing voters to attend
town halls and call their congressional representatives. But as the Republicans started working
in secret and the Russia story started dominating the news, it’s been hard to sustain the
needed level of outrage. While there have been massive rallies over the last few months
focused on women, climate change, immigrants, and impeachment, attempts to organize large
marches around healthcare have fizzled . ¶ Which brings us back to the question: What is the goal of the
Resistance? If the goal is to defeat Trump, then it makes sense to a focus on finding an impeachable offense. If the goal is to defeat
Trumpism, the battle should focus on dislodging Trump’s ideological allies, like Steve Bannon and Stephen Miller, from power. And
if the goal is to fight the Republican Party, then the highest priority has to be issues like health care, where the divide between the
Democrats and the GOP is stark. If the Republican health care bill becomes law, Democrats must take some of the blame. They
are too narrowly focused on opposing Trump—on trying to take him down over Russia—rather
than opposing the policies he’s pursuing, which couldn’t get anywhere without the Republican
Party.