1AC

1AC
Adv 1 is Public Health

Insurance coverage gaps threaten public health response – makes

bioterror and disease outbreaks likely
Laura Kahn 17, M.D. from Mt. Sinai School of Medicine, M.A. in Public Policy from Princeton
University, research fellow of the American College of Physicians, 6-5-17, “Why access to health
care is a national security issue,” http://thebulletin.org/why-access-health-care-national-
security-issue10819
Cutting the Prevention and Public Health Fund, which deals directly with planning for bioterror attacks and pandemics, was only the
most obvious way in which the House bill attempted to undermine American security. Over the long term, there is also a movement
afoot to put basic health care out of reach of many Americans. Simply making
healthcare unaffordable may seem
less dramatic than slashing an emergency-preparedness budget, but doing so also undermines national
security .
As the Congressional Budget Office report suggests, the American Health Care Act would make healthcare essentially unaffordable
for people with pre-existing conditions, because it would allow insurance companies to dramatically increase their premiums. Ten
years ago, I wrote about the security impact of the uninsured during the George W. Bush presidency. In 2005, almost 47 million
people (about 16 percent of the total US population) were uninsured. Thanks to the Affordable Care Act passed under the Obama
The
administration, that number dropped to a low of 11 percent, according to a Gallup poll taken during the first quarter of 2016.
A ffordable C are A ct was a big step in the right direction, but it didn’t close the gap , and the
national security and public health challenges of having a large fraction of the population
uninsured remain as relevant today as they were a decade ago.

Uninsured people delay seeking health care. Once they seek it, often in a busy emergency room, they are
typically given less attention than people with insurance. This failure to get care becomes a
danger not only for the individual but for the public at large when the problem is a deadly infectious
disease . We saw this scenario play out in Dallas during the Ebola crisis of 2014 and 2015. A poor
Liberian man, infected with the virus, presented himself to Texas Health Presbyterian Hospital with severe abdominal
pain and a high fever. He was examined and sent home with a bottle of antibiotics. Amazingly, he did
not set off an Ebola outbreak in his community, though the risk that he could have was significant
and the wider public shouldn’t count on being so lucky next time . Before dying, he infected two nurses who
had received inadequate training and equipment to protect themselves.

During the anthrax crisis of 2001, in which spores of the deadly disease were sent through the US
mail, many people infected were federal employees with health insurance. If these postal
workers hadn’t had easy access to health care, the death toll might have been higher than only
five; 17 more were infected but survived thanks to timely medical attention. Anthrax spores do not spread from person to person,
but it’s no stretch to imagine a different scenario: Suppose a future attack involves smallpox , a highly
communicable virus, and that the initial victims are uninsured childcare workers or food
handlers. The initial signs of smallpox include fever, chills, and headache. Uninsured victims would likely delay
trying to get care, hoping for the symptoms to pass. By waiting they would certainly expose
others to the virus, potentially setting of a pandemic .

Countries like Canada, which has universal health coverage and a well-funded public health
infrastructure, are much better prepared to handle deadly epidemics. In 2003, Canada confronted Severe
Acute Respiratory Syndrome (SARS), which originated in China. A physician from Guangdong province inadvertently infected a
number of tourists with the SARS virus, setting off a global pandemic after everyone returned to their home countries. Among the
infected travelers was an elderly Canadian woman who returned to Toronto after a 10-day vacation in Hong Kong.

Over the course of about four months, the Canadian health system worked hard to contain the virus, treating 400 people who
became ill and quarantining 25,000 Toronto residents who may have been exposed. Ultimately, 44 people died from the disease in
Canada, but the result would have been much worse without a quick and well-organized response.

The Canadian government’s response had its glitches—primarily in the form of poor political leadership. Mel Lastman, the mayor of
Toronto and a former furniture salesman, became angry when the World Health Organization (WHO) issued a travel advisory
against his city. He railed against the WHO’s decision on television, revealing his complete lack of knowledge about either the
organization or public health in general. As a result of Lastman’s poor leadership, he was ultimately relegated to a secondary role as
the deputy mayor took his place. Lastman’s credibility and legitimacy never recovered from the SARS outbreak. Likewise, US
leaders will be judged by how they handle a bioterrorist attack or pandemic .

Unlike Canada, America’s piecemeal healthcare and public health systems are inherently less able to
handle such crises. The Affordable Care Act helped fill in the gaps, but really, the only way to prepare for the eventuality of
pandemics or bioterrorist attacks is with a single-payer government-run system that covers everyone. The United States might
consider modeling its health care system after the one in Israel, a country that, given longstanding threats, takes every terrorist risk
very seriously. In 1994, it established universal health coverage for all citizens. The country’s Ministry of Health monitors and
promotes public health, oversees the operations of the nation’s hospitals, and sets healthcare priorities. As a result, Israel’s public
health, emergency response, and hospital systems are state-of-the-art, highly efficient, and coordinated—a necessity when
responding to terrorist attacks.

The preamble to the US Constitution states the goals to “provide for the common defense” and
“promote the general Welfare.” The US government won’t fulfill either of these duties if it fails to
protect its citizens against pandemics and bioterrorism. The mandate requires a robust
public health infrastructure and a universal healthcare system that covers all
Americans . The Trump Administration and Congressional Republicans threaten to undermine
this essential function of government, unnecessarily jeopardizing American lives.

Attacks are coming – motivation and capability exists

Yonah Alexander 16, Director of the Inter-University Center for Terrorism Studies and
Senior Fellow at Potomac Institute for Policy Studies, 12-12-16, “Can we prevent ISIS’s
Doomsday Revenge?” http://www.timesofisrael.com/can-we-prevent-isiss-doomsday-revenge/
Make no mistake, the worst terrorist attack on civilized order is yet to come. Tragically, it is not if but when,
where, and at what cost. We have already seen, in recent times, mass casualties from nuclear and chemical weapons.

The 14th century Black Plague, which wiped out 30-60 percent of Europe’s population from a natural biological pathogen, serves as
a stark reminder of the capacity of microbes to inflict deadly harm, as does the 1918 influenza pandemic that killed an estimated 50-
100 million people worldwide. Consider
the catastrophic losses that could arise today from biological
pathogens designed especially to target crops, livestock, or humans, and engineered to do the
most damage.
Just imagine what might happen in the aftermath of the anticipated collapse of Daesh (also
known as ISIS, ISIL, Islamic State) in Iraq and subsequently in Syria. Daesh leadership has promised
to regain “lost areas,” and its fighters and supporters are orchestrating their deadly attacks in dozens
of countries in the Middle East and beyond, including the United States . Since the self-declared
“Islamic Caliphate” represents a territorial vision without borders, Daesh is likely to resort, without compunction, to a
broad range of biological weapons in battles for regional and global dominance.
In 2016 alone, Daesh operatives planned to contaminate Turkish water sources with bacteria
causing tularemia, a potentially fatal human illness; another Daesh-linked plot that involved an anthrax
attack in Kenya was foiled by the police; and in Nigeria, the army intercepted poisoned fish allegedly
brought into the country by Boko Haram terrorists.
Facing potential biological threats, several European countries have recently focused attention
on the looming challenge. The United Kingdom expressed concern that Daesh might weaponize Ebola, Germany hosted an
international symposium on protection against biological warfare agents, Italy engaged its scientific community to deal with
biological defense, and France performed a nationwide drill to prepare for biological attacks.

The U.S. Government is also concerned with the biothreat, spending billions annually to address
it. But federal efforts are incomprehensive and fragmented . A bipartisan Blue Ribbon Study Panel
on Biodefense, co-chaired by Senator Joseph Lieberman and Governor Tom Ridge, released a report that identified deficiencies and
mapped out actions that the President and Congress should undertake to improve the nation’s capabilities to prevent, deter, and
mitigate biological incidents.

Preparatory meetings for the recent 2016 Biological Weapons Convention Review Conference recognized the need
for adapting to the increasing risk of bioterrorism from scientific advances such as CRISPR
gene-editing technology and emerging infectious diseases such as the Zika virus.
To be sure, the vast background of, knowledge for verification and intelligence gathering within the U.S. government in response to
chemical and nuclear terrorism can inform our preparedness for biothreats. Although there are major differences, some of the
infrastructure and processes are the same. Also on the international level, the Organization for the Prohibition of Chemical Weapons
(OPCW) and the International Atomic Energy Agency (IAEA) have extensive experience in safeguard verification for materials and
technology.

For all WMD types – nuclear, chemical, and biological – there are problems that arise in verifying
that the technologies involved are being used solely for peaceful purposes. However, the problem is
most severe for biological weapons, first, because of the lack of oversight by a verification
organization under the 1972 Biological Weapons Convention, and second, because of the depth of peaceful
biomedical research and extent of the pharmaceutical industry in many member states , such as
India and Iran.

A special feature of biological weapons is the reliance on living organisms, with unique security
and strategic challenges that complicate arms control, verification, and intelligence collection.
The very large array of pathogens and toxins which exist or could be created increases the
difficulty of more organized control.

Health insurance is key to pandemic response---increases early

detection
Kimberly Ann Peterson 14, M.A. Candidate in Security Studies, Naval Post-Graduate
School, September 2014, “THE AFFORDABLE CARE ACT: A PRESCRIPTION FOR
HOMELAND SECURITY PREPAREDNESS?” p. 53-56
A. HOW IS ACA MOST LIKELY TO POSITIVELY IMPACT HOMELAND SECURITY EFFORTS
TO ACHIEVE ALL-HAZARDS PREPAREDNESS?

The fact that millions of U.S. residents do not possess health insurance negatively affects our
collective safety and homeland security preparedness level. The consequences of uninsurance and its
relation to homeland security are discussed here. Implementation of the A ffordable C are A ct will expand
health insurance to millions of U.S. residents not currently covered . This expansion has
significant potential to positively impact homeland security preparedness in a variety of ways .
These potential impacts are explored in this chapter, both from the health perspective and the economic perspective.
According to a report by the Institute of Medicine, 43
percent of working-age adults who did not have health
insurance reported that they chose not to see a doctor for a medical problem in a one-year time
period; in contrast, only 10 percent of working-age adults who did have coverage for the entire
year reported not seeing a physician for a medical issue.157 Jack Hadley’s comprehensive analysis of 51 studies
in Sicker and Poorer—The Consequences of Being Uninsured: A Review of the Research on the Relationship between Health
Insurance, Medical Care Use, Health, Work, and Income finds “ the
uninsured receive fewer preventive
and diagnostic services , tend to be more severely ill when diagnosed, and received less
therapeutic care.” 158 Numerous studies over the long-term have shown that uninsured
Americans are less likely to obtain preventive health care, care for chronic conditions and more
likely to suffer from undiagnosed medical conditions. As a result, uninsurance is associated with a
higher rate of mortality 159 and decreased access to health care.160
In the National Strategic Narrative, authors Captain Wayne Porter and Colonel Mark Mykleby promote the idea thatsecurity
means more than physical safety, “for Americans, security is very closely related to freedom,
because security represents freedom from anxiety and external threat, freedom from disease and
poverty… [emphasis added].” 161 They urge us to focus on, among other things, “quality health care and education” 162 and the
prioritization of “a sustainable infrastructure of education, health and social services to provide for the continuing development and
growth of America’s youth.” 163 While Porter and Mykleby do not advocate for any particular type of health care system or structure,
they point out that health
care is an integral part of a secure and prosperous society. Griffen Trotter echoes
the idea that basic
health care provides a foundation for a physical infrastructure that promotes “a
social and physical that enhances the quality and security of ordinary lives …” 164 Health, in and of
itself, contributes to one’s sense of security, and health care is a component of maintaining one’s
health.
The Congressional Budget Office estimates that the ACA will bring down the proportion of uninsured, nonelderly adults in the U.S.
from 20 percent to 11 percent.165 Some early proof that implementation of the ACA will equate to health insurance coverage gains
can already be found. As noted earlier in this paper, the ACA goes into effect in stages. One of the earliest prongs of the law went into
effect on September 23, 2010. This aspect of the ACA allowed young adults to remain on their parents’ insurance plans up to age
26.166 This is a gain of seven years beyond when children “aged-out” of coverage prior to the ACA.

A study published in Health Affairs journal in January of 2013 studied the early effects of the ACA on health insurance coverage and
access to care for young adults. The study by Benjamin Sommers et al. notes that between September of 2010 and December of 2011,
approximately three million uninsured adults between the ages of 19–25 gained health insurance coverage as a result of the ACA.167

This particular study demonstrated that not only did more young adults enjoy coverage gains, but also enjoyed increased access to
care, which is ultimately one of the primary goals of the law.168 As Shane Green noted in 2004, “ A
nation’s greatest
defense against bioterrorism, both in preparations for and in response to an attack, is a
population in which an introduced biological agent cannot get a foothold, i.e., healthy people
with easy access to care.” 169
By expanding health insurance to 33 million more people through the implementation of the
ACA, the results of these studies support the likelihood that this newly insured population will
overall seek medical care earlier on, be in a better state of health when seen, and have
better health outcomes . This will have positive ripple effects for homeland security in
dealing with emerging disease, bioterror, flu pandemic, mental illnesses, and potentially
economic security .
B. HEALTH SURVEILLANCE SYSTEM

An effective health surveillance system requires that those stricken by illness or disease—
whether accidentally contracted or intentionally afflicted —seek treatment from a health care
professional. The health care professional works to diagnose the problem, prescribe care,
mitigate further spread, and report the illness as necessary to the health care community and
possibly the government. This process is critical to our nation’s security in the event of a
bioterror attack , such as with an Ebola virus or anthrax attack. The same holds true in managing
contagious diseases such as influenza or newly emerging diseases . The sooner an illness or
disease is correctly diagnosed, the more options remain available to help mitigate the spread or
effect. Delays in diagnoses and therefore the development of appropriate treatments can have a
limiting effect on both the health care community’s and the homeland security community’s
choices and options in managing the spread and effect of the affliction .
Jack Hadley’s analysis
showed statistically significant and positive support for the hypothesis that
having health insurance or greater medical care use improves health : seven of the 10 natural experiments
analyzed, six of the seven longitudinal studies, 29 of 35 of the observational studies showed “statistically significant results
consistent with a positive relationship between health insurance or medical care use and health.” 170

According to author G. Kenny, the

uninsured received only 55 percent of the medical services received by
the insured.171 Increased health insurance coverage correlates with an increased use of health
care services,172 which is likely to increase the chance of earlier identification and mitigation
of disease. This is good news for homeland security. The uninsured are more than four times
more likely than the insured to delay needed medical care or forego it altogether due to cost
concerns.173 By increasing the number of insured Americans, we also increase the likelihood that
those with contagious diseases will seek treatment earlier on, allowing health professionals to
identify, treat and mitigate disease spread more successfully. This would include diseases of
concern to the homeland security community such as influenza virus, or any disease that has the
ability to spread from person-to-person.
A 2012 report from the Office of the Director of National Intelligence focused on “megatrends” and future
possibilities for the global world in the year 2030.174 One area of focus was the increasing
likelihood that viruses previously unknown in humans would continue to cross over from the
animal reservoir to humans due to increased livestock production and human encroachment
into the jungles. Examples of prior occurrences include a prion disease in cattle that jumped to humans in 1980 to cause
variant Creutzeldt-Jacob disease in humans and the bat corona virus transferring to humans in 2002, known now as SARS.175
These diseases can be devastating to the human population, due to the lack of prior
exposure , as well as the lag-time required to diagnose the disease and develop treatments .

The same is true for any emerging disease, regardless of source. Early detection,
identification, and mitigation are particularly critical with emerging diseases . New
viruses appear on a daily basis. Viruses utilize RNA rather than DNA in the reproductive
process. The RNA process is not as exact as the DNA process, and the reproductions vary in
their genetics compared to the parent. This phenomenon is termed “antigenic drift,” and it makes viruses a moving
target in terms of vaccination and treatment. As an example, there are multiple strains of the rhinovirus (the common cold)
circulating at any one time. By the time a rhinovirus has passed through a given population, it will be genetically different than the
strain that touched off the contagion.

Early medical care, diagnosis, and treatment are particularly critical when dealing with newly
emerging diseases that are more dangerous than the rhinovirus, such as hemorrhagic viruses like the Ebola virus.
These viruses have an extremely high mortality rate, as high as 90 percent in some cases ,176 and
for many there are no known cures . When there are no cures for such deadly diseases early
identification and quarantine become the primary management tools. Increased health
insurance coverage makes the U.S. better positioned to find and manage emerging diseases
earlier on in an outbreak.
The same holds true for the health surveillance system as it relates to food safety: an increase in
the number of Americans with health insurance is likely to increase the health surveillance
system’s ability to help us in spotting food-safety issues. More insured people will seek medical
care earlier on, which allows the surveillance system to pick up on patterns sooner .

Attacks cause international lashout and domestic crackdown---decks

alliances and encourages radicalization
Daniel L Byman 17, senior fellow in the Center for Middle East Policy at Brookings, PhD
from MIT, 5/3/2017, https://www.brookings.edu/blog/markaz/2017/05/03/trump-and-the-
next-terrorist-attack/
The best response in the hours after an attack involves a mix of rhetoric, leadership, and caution. The president should publicly
honor the dead and reassure Americans that the government is working to hunt down the guilty and care for those injured. At the
same time, he should point out that American Muslims have proven vital allies against terrorism. As FBI Director James Comey put
it, “They do not want people committing violence, either in their community or in the name of their faith, and so some of our most
productive relationships are with people who see things and tell us things who happen to be Muslim.” Almost half of all tips on
extremism come from the community.¶ An
immediate retaliatory strike —one that on its surface would signal
toughness and thus be attractive to a president who talks about toughness a lot —might be a mistake.
Initial information on responsibility or the extent of overseas links is often flawed or incomplete,
and it is useful for the administration to assess a full range of options before plunging in. Since
the Trump administration is already hitting the I slamic S tate hard, it’s difficult to imagine an
easy way to ratchet up the pressure that does not involve significant costs or downsides. Instead, various agencies
should be scrutinizing intelligence and security procedures to determine culpability and identify real and potential holes while the
military and intelligence agencies assess options overseas. ¶ Based on his initial record in office and rhetoric on the campaign trail,
however,Trump might opt for a disastrous approach . The president acts out of impulse,
whether this involves sarcastic tweets to Arnold Schwartzenegger or the sudden decision to bomb Syria
after the regime’s use of chemical weapons. It’s safe to say that restraint and deliberation are not
characteristics of this administration—or the man himself. Perhaps even worse, this administration has a track record
of mismanaging policy processes. This includes signature items like the “Muslim Ban” executive order or less prominent but
important announcements, like the supposed deployment of an aircraft carrier to Korea .
This bungling and the
president’s many about-faces on issues have damaged his credibility as a messenger and are
likely to make people more skeptical of the content of his statements and actions in the
aftermath of a terrorist attack.¶ The president is likely to want to overreact abroad. He seems to
want to appear tough more than he wants to be effective. So he boasted, for example, about
dropping a massive bomb on Islamic State targets in Afghanistan without waiting to learn
whether it achieved its objectives. On the campaign trail, the president wanted to “bomb the shit
out of them” even though it was not clear an increase in the scale of bombing would achieve
much. Trump might also expand the war, bringing it to new zones that have only a tenuous Islamic State or al-Qaida
presence. He has already authorized the intensification of US operations targeting Shabaab and
increased the pace of strikes targeting terrorist groups more generally. ¶ Even more worrisome is
what the President might do at home. On the campaign trail, the President repeatedly conflated
Muslims and terrorists , and with tensions and emotions running high after an attack this
demonization might be especially likely. In the name of border security, he might further limit
immigration and travel from Muslim-majority countries or try to single out Muslims over other
faith communities. He might embrace the decision to declare the Muslim Brotherhood a
terrorist group even though this would be counterproductive and cause difficulties with
several allies. Surveillance of Muslim communities around the country might be stepped up,
further alienating Muslims from law enforcement and make them less likely to turn in suspected
terrorists. After 9/11, the U nited S tates detained over one thousand Muslims, gaining almost
no useful intelligence but harming relations with the community. As Daniel Benjamin, a former senior
counterterrorism official, warns, “Repairing the damage from that crackdown took years.” ¶ Such unthinking measures
might benefit Trump politically while inadvertently helping the terrorists operationally . Trump
would look tough, and his argument that the terrorism danger is high and Muslims are the enemy would be vindicated, at least to his
supporters and to some who are undecided on this question. The
I slamic S tate would gain more evidence to
back up the narrative that the U nited S tates is hostile to Muslims, while the vast majority of
Muslims who loath the group would be less eager to work against it because it means working
with what they see as a hostile government. It’s just the American people who would suffer.

Lashout causes global war within a week

Daniel Hayes 15, M.F.A Sarah Lawrence College, 12/28/15, “What It Would Look Like If We
Just Decided To ‘Screw It’ And Nuke ISIS,” http://thoughtcatalog.com/daniel-
hayes/2015/12/what-it-would-look-like-if-we-just-decided-screw-it-and-nuked-isis/

So, President Nukem has spread hot, impatient freedom all over the Middle East and killed, lets’
be frank, likely several million people over the coming weeks and months. He’s wiped out some ISIS fighters (there’s only
30,000) but mostly he’s killed regular people. But still, that was cathartic and that’s go to be worth something, right? Surely the rest
of the world will understand why the U.S. did this?

Surprisingly, they wouldn’t. The

results of nuking any place at all in the Middle East would likely be
broad Muslim outrage and horror that would make ISIS the most popular Muslim
organization in the world. Every U.S. embassy in the Middle East would likely be destroyed and all our
diplomats killed. American citizens would be murdered in the streets and all across Europe you’d have formerly peaceful
Muslims becoming radicalized.

we wouldn’t have any allies anymore . It’s a funny thing, murdering

But what about our allies? Oh,
millions of people because you’re impatient with the degradation of a terrorist organization isn’t
generally viewed as a valid reason to deploy nuclear weapons on civilians. You can pretty much bet the farm
that every nation in the world would deploy sanctions agains the U.S. and we would be 100%
diplomatically and economically isolated by the end of the week . We’d be booted from the
U.N., from NATO, and we’d have every other nation’s nukes suddenly pointing us right in
the face ready to kill us .

The stock market would crash and by crash I mean fall through the ground into the center of the Earth.
Inflation would skyrocket and your money would soon have almost no value at all. What’s more, you’d have fighting in the streets as
outraged U.S. citizens (including this writer) declared war against their own insane and genocidal government.

7. The Lesson

Only the supremely ignorant talk about using nuclear weapons against small groups of terrorists or non-aggressive nations who
haven’t started a war for well over 100 years (Iran).

This isn’t serious talk but it is dangerous talk. Nuke talk makes angry people feel powerful and it gets people pumped up about just
how awesome they think they are but an
actual nuclear engagement like this would completely destroy
the country in every way and would risk setting off an exchange with the U.S. as a
target.
US response is key – failure to counteract the attack threatens U.S.
legitimacy and norms against use -- causes a wave of bioterror
NDU 09, National Defense University, June 2009, Are We Prepared?, Center for the Study of
Weapons of Mass Destruction,
http://wmdcenter.ndu.edu/Portals/97/documents/publications/articles/2009_4_wmd_crises.
pdf
Senior decisionmakers are consumed with the enormous ¶ tasks of saving lives and preventing follow-on attacks. ¶ Modeling suggests
that 90 percent of those actually infected¶ can be saved if they are located and treated within 48 ¶ hours. Activation of the Strategic
National Stockpile is under¶ way, and health departments in the National Capital Region ¶ have begun to identify and mass treat the
potentially¶ exposed population. That said, it
is not clear how many of the infected can be located and
treated within this critical¶ window or how the area will cope with the tens of thousands¶
likely to require intensive medical intervention. At the same¶ time, law enforcement and
intelligence agencies are trying¶ to attribute the attacks and prevent follow-on attacks,
but¶ they have little to report. Word of the attack reached the¶ press within minutes of the start of responses, and senior ¶
officials worry that panic will spread across the country .¶ Policy Implications¶ Biological attacks

on U.S. urban areas would have unprecedented and potentially catastrophic

consequences for the Nation. Today, the U nited S tates probably could not stop a
biological attack even after receiving strategic warning. At best, officials might be able to detect an attack within a
day, but only if, as in the above scenario, an attack occurs in a place and manner that can trigger BioWatch sensors to provide an
alert. Moreover, U.S.
leaders would be forced to rely on response capabilities that are largely
untested for crises of this magnitude. Complicating matters, many of those affected would be
government officials responsible for response operations. Local and state governments,
aided by the Federal Government, would need to distribute antibiotics to millions within
days to minimize loss of life. Even with a highly effective response, senior officials know
that tens of thousands of people would probably die. With a failed response, fatalities could easily
exceed 100,000. Mounting an effective response to such a crisis would pose challenges that could make the difficulties of
Hurricane Katrina seem small. It would not be a time for hesitation. ¶ The impact of such an attack would
extend far beyond those actually infected. Because of the recognition that “reload” is
highly feasible with biological agents, the population will probably expect follow-on
attacks. That will generate widespread fear, as was evident from the public reaction to the 2001 anthrax
letters, and fear could degenerate into panic if government responses do not enhance confidence. People across the
country would likely alter normal patterns of commerce and transportation. Some may
flee urban areas in the hope of being less vulnerable. Others may refuse to go to work or
send their children to school, especially if the government’s handling of the attack raises
doubts about its ability to protect its citizens. If fear of repeated attacks takes hold in the
population, it could disrupt the country’s financial and economic systems and thus the fabric
of our society .¶ Such circumstances will require decisionmakers to undertake operations of a scope and complexity with
which they will have had no previous experience. They will be obliged to act with incomplete or inaccurate information. At the
same time, the world will be looking to the U nited S tates to take the lead in organizing
the global effort to prevent additional attacks. Drastic measures will be needed to regain
public confidence since any subsequent attacks could destroy the legitimacy of our
national institutions .¶ Other implications of such an event include the following:¶ ✦ Responding to a
bioterrorism attack will require an unprecedented national effort calling for integrated
responses by both government (Federal, state, local, and tribal) and private institutions. Given our Federal form of
government, this will pose an extraordinary challenge. ¶ ✦ Enormous
pressures to locate the perpetrators and
prevent additional attacks may result in unprecedented intrusions of law enforcement in daily
life and curbs on civil liberties.¶ ✦ Other nations will try to ensure that they are not attacked
and may drastically restrict the movement of people and goods.¶ ✦ The economic cost to the United
States could easily exceed $1 trillion, and cumulative international costs would be far higher. Such an attack could devastate¶
economies already faltering in the global recession. ¶ ✦ A large swath of the Nation’s capital could be rendered
unusable/uninhabitable until people feel confident they are not at risk for infection from the reaerosolization of spores blanketing
the area.¶ ✦ Thecatastrophic use of a biological weapon could result in broader adoption of
biological agents as terrorist weapons and erode global norms against their use.¶
Response Requirements¶ The unique characteristics of biological weapons will profoundly impact responses. First, biological
agents used intentionally to cause disease are the only weapons other than nuclear
devices capable of causing catastrophic casualties . Second, once a group develops the
capability to produce and disseminate biological agents, it will be relatively easy to generate
multiple attacks, what Richard Danzig has called “reload.” Third, it is extremely difficult to detect a biological attack. In the
absence of effective environmental sensors, the first instance of a bioterrorism attack is likely to be the onset of illness. A small-scale
effective
attack might never be detected, and even a larger attack could be misidentified as a natural outbreak. Finally,

medical countermeasures can prevent serious illness, and, in some instances (that is,
smallpox and antibiotic susceptible bacterial agents), it may be possible to prevent the onset of disease
altogether. But all this often means identifying and treating exposed individuals within days of
exposure, placing a premium on both rapid detection of the attack and mass prophylaxis of those who are
potentially exposed.

Bioterror causes extinction

Nathan Mhyrvold 13, Began college at age 14, BS and Masters from UCLA, Masters and PhD,
Princeton “Strategic Terrorism: A Call to Action,” Working Draft, The Lawfare Research Paper
Series
Research paper NO . 2 – 2013
most of the classic
As horrible as this would be, such a pandemic is by no means the worst attack one can imagine, for several reasons. First,
bioweapons are based on 1960s and 1970s technology because the 1972 treaty halted
bioweapons development efforts in the United States and most other Western countries. Second,
the Russians, although solidly committed to biological weapons long after the treaty deadline, were never on the cutting edge
of biological research. Third and most important, the science and technology of molecular biology have
made enormous advances, utterly transforming the field in the last few decades. High school
biology students routinely perform molecular-biology manipulations that would have been impossible even
for the best superpower-funded program back in the heyday of biological-weapons research. The
biowarfare methods of the 1960s and 1970s are now as antiquated as the lumbering mainframe computers of that era. Tomorrow’s
terrorists will have vastly more deadly bugs to choose from. Consider this sobering development: in
2001, Australian researchers working on mousepox, a nonlethal virus that infects mice (as chickenpox does in humans), accidentally discovered that a
simple genetic modification transformed the virus.10, 11 Instead of producing mild symptoms, the new virus killed 60% of even those mice already
immune to the naturally occurring strains of mousepox. The new virus, moreover, was unaffected by any existing vaccine or antiviral drug. A team of
researchers at Saint Louis University led by Mark Buller picked up on that work and, by late 2003, found a way to improve on it: Buller’s variation on
mousepox was 100% lethal, although his team of investigators also devised combination vaccine and antiviral therapies that were partially effective in
protecting animals from the engineered strain.12, 13 Another saving grace is that the genetically altered virus is no longer contagious. Of course, it is
quite possible that future tinkering with the virus will change that property, too. Strong reasons exist to believe that the genetic modifications Buller
made to mousepox would work for other poxviruses and possibly for other classes of viruses as well. Might the same techniques allow chickenpox or
another poxvirus that infects humans to be turned into a 100% lethal bioweapon, perhaps one that is resistant to any known antiviral therapy? I’ve
asked this question of experts many times, and no one has yet replied that such a manipulation couldn’t be done. This case is just one example. Many
more are pouring out of scientific journals and conferences every year. Just
last year, the journal Nature published a
controversial study done at the University of Wisconsin–Madison in which virologists enumerated the changes
one would need to make to a highly lethal strain of bird flu to make it easily transmitted from
one mammal to another.14 Biotechnology is advancing so rapidly that it is hard to keep track
of all the new potential threats. Nor is it clear that anyone is even trying. In addition to lethality and drug
resistance, many other parameters can be played with , given that the infectious power of an epidemic depends on many
properties, including the length of the latency period during which a person is contagious but asymptomatic. Delaying the onset of serious symptoms
allows each new case to spread to more people and thus makes the virus harder to stop. This dynamic is perhaps best illustrated by HIV , which is very
difficult to transmit compared with smallpox and many other viruses. Intimate contact is needed, and even then, the infection rate is low. The balancing
factor is that HIV can take years to progress to AIDS , which can then take many more years to kill the victim. What makes HIV so dangerous is that
infected people have lots of opportunities to infect others. This property has allowed HIV to claim more than 30 million lives so far, and approximately
34 million people are now living with this virus and facing a highly uncertain future.15 A
virus genetically engineered to infect
its host quickly, to generate symptoms slowly—say, only after weeks or months—and to spread easily through
the air or by casual contact would be vastly more devastating than HIV . It could silently penetrate
the population to unleash its deadly effects suddenly. This type of epidemic would be almost impossible to combat because most of the infections would
occur before the epidemic became obvious. A
technologically sophisticated terrorist group could develop such a
virus and kill a large part of humanity with it. Indeed, terrorists may not have to develop it
themselves: some scientist may do so first and publish the details. Given the rate at
which biologists are making discoveries about viruses and the immune system, at some point in the
near future, someone may create artificial pathogens that could drive the human
race to extinction. Indeed, a detailed species-elimination plan of this nature was openly proposed in a scientific journal. The ostensible
purpose of that particular research was to suggest a way to extirpate the malaria mosquito, but similar techniques could be directed toward humans.16
When I’ve talked to molecular biologists about this method, they are quick to point out that it is slow and easily detectable and could be fought with
Modern
biotech remedies. If you challenge them to come up with improvements to the suggested attack plan, however, they have plenty of ideas.
biotechnology will soon be capable, if it is not already, of bringing about the
demise of the human race— or at least of killing a sufficient number of people to end high-
tech civilization and set humanity back 1,000 years or more. That terrorist groups could achieve this level of
technological sophistication may seem far-fetched, but keep in mind that it takes only a handful of individuals to
accomplish these tasks. Never has lethal power of this potency been accessible to so few, so easily. Even more dramatically than nuclear
proliferation, modern biological science has frighteningly undermined the correlation between the
lethality of a weapon and its cost, a fundamentally stabilizing mechanism throughout history. Access to extremely
lethal agents—lethal enough to exterminate Homo sapiens—will be available to anybody with a solid
background in biology, terrorists included.

Disease causes extinction and no burnout---global transportation

networks
Yaneer Bar-Yam 16, Founding President of the New England Complex Systems Institute,
“Transition to extinction: Pandemics in a connected world,” NECSI (July 3, 2016),
http://necsi.edu/research/social/pandemics/transition
Watch as one of the more aggressive—brighter red — strains rapidly expands. After a time it goes extinct leaving a black region. Why
does it go extinct? The answer is that it spreads so rapidly that it kills the hosts around it. Without new hosts to infect it then dies out
itself. Thatthe rapidly spreading pathogens die out has important implications for evolutionary
research which we have talked about elsewhere [1–7].¶ In the research I want to discuss here, what we were interested
in is the effect of adding long range transportation [8]. This includes natural means of dispersal
as well as unintentional dispersal by humans, like adding airplane routes, which is being done
by real world airlines (Figure 2).¶ When we introduce long range transportation into the model, the
success of more aggressive strains changes. They can use the long range transportation to find
new hosts and escape local extinction . Figure 3 shows that the more transportation routes introduced into the
model, the more higher aggressive pathogens are able to survive and spread. ¶ As we add more long range transportation, there is
a critical point at which pathogens become so aggressive that the entire host population dies. The
pathogens die at the same time, but that is not exactly a consolation to the hosts . We call this the phase transition to
extinction (Figure 4). With increasing levels of global transportation, human civilization may
be approaching such a critical threshold .¶ In the paper we wrote in 2006 about the dangers of global
transportation for pathogen evolution and pandemics [8], we mentioned the risk from Ebola. Ebola is a horrendous disease that was
present only in isolated villages in Africa. It was far away from the rest of the world only because of that isolation. Since Africa was
developing, it was only a matter of time before it reached population centers and airports. While the model is about evolution, it is
really about which pathogens will be found in a system that is highly connected, and Ebola can spread in a highly connected world. ¶
The traditional approach to public health uses historical evidence analyzed statistically to assess the potential impacts of a disease.
As a result, many were surprised by the spread of Ebola through West Africa in 2014. As the connectivity of the world increases, past
experience is not a good guide to future events. ¶ A
key point about the phase transition to extinction is its
suddenness. Even a system that seems stable, can be destabilized by a few more long-range
connections, and connectivity is continuing to increase.¶ So how close are we to the tipping
point? We don’t know but it would be good to find out before it happens. ¶ While Ebola ravaged three
countries in West Africa, it only resulted in a handful of cases outside that region. One possible reason is that many of the airlines
that fly to west Africa stopped or reduced flights during the epidemic [9]. In the absence of a clear connection, public health
authorities who downplayed the dangers of the epidemic spreading to the West might seem to be vindicated. ¶ As with the choice of
airlines to stop flying to west Africa, our analysis didn’t take into consideration how people respond to epidemics. It does tell us what
the outcome will be unless
we respond fast enough and well enough to stop the spread of future
diseases, which may not be the same as the ones we saw in the past. As the world becomes more connected, the
dangers increase.¶ Are people in western countries safe because of higher quality health systems? Countries like the U.S. have
highly skewed networks of social interactions with some very highly connected individuals that can be “superspreaders.” The
chances of such an individual becoming infected may be low but events like a mass outbreak pose a much greater risk if they do
happen. If
a sick food service worker in an airport infects 100 passengers, or a contagion event
happens in mass transportation, an outbreak could very well prove unstoppable .
 1AC
Advantage (_) 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 c ompared 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)
most of the
reviewing the literature on government health spending and economic growth concluded that “[g]iven that
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
Korea, a nuclear Iran, modern terrorism, or climate change. Although all of these constitute potential or actual threats, the biggest
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 w eapons of m ass d estruction, 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 f reedom- o f- n avigation op eration 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 U nion o f
C oncerned S cientists, 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.
 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 fewerthan one
third of the uninsured seeking individual coverage and making between 200 percent and 300
percent of the f ederal p overty l evel 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 A ffordable C are A ct 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. “ The penalty 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 c ost -s haring r eductions 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 accident al 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 A l
Q aeda has sought to obtain or construct nuclear weapons and to use them against the U nited
S tates. 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
***2AC Source Doc***
 Case
Pharma companies don’t invest in the “innovative drugs” necessary to
combat new diseases---the hard work is done by academic institutions
or start-ups that the plan doesn’t effect
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
N ational I nstitutes of H ealth. 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 v enture c apital. 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 U nited S tates 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
v enture c apital 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 v enture c apitalists 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 r esearch and d evelopment. 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 r esearch and d evelopment.
Topicality
 2AC – T Public
We meet---ACA reform is both government financed and
administered

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. N ational h ealth i nsurance 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

Medicare is a social insurance

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

program, 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 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 ¶

Many 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

government-financed national health insurance proposal. The plan came to be known as the
Program offered a new

“ single-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,
 Under the most ambitious versions of the individual mandate, employer-sponsored insurance and
1991).

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

Medicaid
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. ¶

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.
In a June 2015 6–3 decision, the Court affirmed that both the federal and state-based exchanges could offer
subsidies, thereby preventing a huge number of people from losing their subsidized health insurance .¶
Through all this, the ACA persevered. Though the precise numbers are debated, it appears that 15 million people have been newly insured under the

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 n ational h ealth i nsurance 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. ¶

Reform of Health Care Delivery¶ Throughout the history of US n ational h ealth i nsurance proposals, reformers
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
 PIC
Doesn’t solve coverage or it links to the DA

Perm do both

Subsidies alone fail—mandate is key to induce low-risk individuals –

studies
Juergen Jung 11, Assistant Professor of Economics, Towson University, PhD in Economics
from Indiana University, Chung Tran, 1/29/2011, Market Inefficiency, Insurance Mandate and
Welfare: U.S. Health Care Reform 2010∗, https://editorialexpress.com/cgi-
bin/conference/download.cgi?db_name=mmm2011&paper_id=52
In this section we study the role of the penalties for not having insurance and the subsidies as
enforcement mechanisms of the insurance mandate. We first consider a situation without any
penalties for uninsured individuals and second, we analyze the effects of the policy without subsidies to low income
individuals.¶ Insurance mandate enforced only by subsidies to low income families (no penalty). We set the
penalty rate for uninsured individuals to zero and re-run the experiment under the three
financing regimes: (i) payroll tax, (ii) government consumption, and (iii) consumption tax . We
report the results in table 7. We find that subsidies alone increase the private insurance coverage rates only to
72 percent leaving a large portion of the population uninsured. This indicates that the subsidies alone
have a small effect on insurance take-up rates and if health insurance is not enforced by a
tax penalty on people without health insurance, the low risk type agents will opt out of insurance. This
result is in line with empirical evidence reported in Gruber and Washington (2005) who find
that subsidies have a very small effect on insurance take up, but tend to make people buy more
expensive health insurances. From column 2 in table 7 we also see that in the absence of the penalty,
the payroll tax to finance the reform is actually slightly higher than in the benchmark regime
and the negative efficiency effects (measured as drop in output) are slightly larger. This result
carries an important policy implication. If the reform is enacted using a flawed process (i.e.
absence of real enforcement of the mandate) the outcomes of the reform do not meet the
target to significantly increase the population with health insurance, while also worsening
the growth prospects of the economy.

Can’t solve balanced risk pool – high income individuals have low
demand elasticity to subsidies which makes penalties key
Jesse M Hinde 16, PhD Candidate in Public Policy, University of North Carolina at Chapel
Hill, Incentive(less)? October 2016, The Effectiveness of Tax Credits and Cost-Sharing Subsidies
in the Affordable Care Act,
http://jessehinde.web.unc.edu/files/2014/08/hinde_2016_aca_tax_credits_october2016.pdf
While similar tax credits have been used in past programs related to self-employment and for
recently unemployed individuals, the results here suggest that these ACA tax credits may have
broader appeal for lower-income individuals. The estimated elasticities are also on the high end
of existing estimates, suggesting low-income individuals may be more price responsive than
previous studies have found. There is no evidence for changes in IPI coverage at 250% FPL and weak evidence
for changes at 400% FPL, consistent with existing low elasticity estimates for higher income
individuals. ¶ One policy implication is that the APTC and CSR levels would need to be raised at
higher incomes to induce more participation. Furthermore, these results suggest the long-term
impact beyond the lowest-income group could be minimal. However, given that the individual
mandate penalty and the exchange premium increases in 2015 could further incentivize participation,
consumer awareness of and responsiveness to these changes are a key determinant of how much the
APTC and CSR levels would need to be raised in the future.

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
Kritik
 2AC – Security
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

Floating pics are a voting issue – they shift the scope of aff offense and
undermine the 1AC as the locus of the debate

Prefer our framework – prior questions will never be fully settled and
can’t guide health policy
Jennifer Prah Ruger 06, Assistant Professor, Yale School of Medicine, Adjunct Professor at
Yale School of Law, Toward a Theory of a Right to Health: Capability and Incompletely
Theorized Agreements, 2006, Yale Journal of Law & Humanities,
http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1313&context=yjlh
High level principles can have an important role in democratic political life generally and in major social
movements specifically. Decisionmaking in public policy settings, however, requires reasoned agreement
on particular outcomes, regardless of whether there is agreement on political
abstractions . Legal decision-making has to produce agreement on particular outcomes; and because there rarely is
agreement on high-level principles, those particular outcomes must be justified by low level principles. People can disagree
on general principles but agree on concrete cases. Lawyers and judges are more likely to converge on lower levels
of abstraction than higher ones-- dealing with necessary decisions of "what to do rather than
what to think ."' 3 7 This approach is therefore more appropriate for well-functioning legal systems in democratic societies. ¶
Sunstein's incomplete theorization typology is usefully applied to decision-making about health and health policy. I created
diagrams to capture the three types of incompletely theorized agreements: incompletely specified agreements (Figure 4),
incompletely specified and generalized agreements (Figure 5), and incompletely theorized agreements on particular outcomes
(Figure 6) to help illustrate this point.¶ B. Incompletely Specified Agreements¶ The first type of incompletely theorized agreement
occurs when there is agreement on a general principle, accompanied by sharp disagreement about particular cases. Here, Sunstein
argues, people
who accept a general principle-murder is wrong, for instance-need not agree on
what this principle entails in particular cases--e.g. abortion. 3 8 Similarly, I argue, people who
accept the general principle of good health may disagree on what good health requires in
provision of health care and other concrete social services.¶ C. Incompletely Specified and Generalized
Agreements¶ The second type of incomplete theorization occurs when people agree on a mid-level principle, but disagree both about
the more general theory that accounts for it and about outcomes in particular controversies. Here, Sunstein states that the
connections are unclear both between the general theory and mid-level principles and between specific cases and mid-level
principles.'3 9 As a health example, I argue, people
might agree on universal health insurance coverage
without settling on a large-scale theory of equality or on a specific health plan. In this model, there is a great
deal of uncertainty and ambiguity leading to more divergence than convergence . 4 0¶ D. Incompletely
Theorized Agreements on Particular Outcomes¶ Incompletely theorized agreements on particular outcomes involves, in
a public policy and human rights context, how people make decisions and come to agreement on particular policy options. In this
model, parties reach agreement on low-level principles that do not necessarily derive from one particular high-level theory. In other
words, low-level principles may be compatible with more than one high-level principle. People may agree on individual judgments
while disagreeing on the level of general principle. ¶ E. Incompletely Theorized Agreements and Public Policy ¶ While the ITA
framework has been applied generally in law, I have argued that it also has promise as a descriptive and normative analytical
framework for public policy,' 4 ' and now for human rights. In applying the ITA framework in a human rights or public policy setting,
at least two points are important: (1) the approach is well suited to human goods that are plural and ambiguous; and (2) it allows for
different but converging paths to the same agreement. In matters of public philosophy concerning inherently plural and indistinct
concepts, and in dealing with collective choice involving numerous views and disagreements, ITA can help bring participants in a
public policy and human rights discussion to agreement on certain specific outcomes. ¶ In social decision-making about health
capabilities, health policy, and a right to health, the ITA framework is particularly useful and complementary to the capability
approach in at least three important respects. First, health, and thus health
capabilities are multi-dimensional
concepts about which different people have different and sometimes conflicting views .
Complete theorization is thus difficult to achieve . No unique view of health or health capabilities exists.
No view is ideal or unanimously agreed upon for all evaluative purposes. Second, the
incomplete, partial ordering of the capability approach combined with incompletely theorized agreement on
that ordering allows for reasoned public policy decision-making in particular
situations . Third, given the demands of certain evaluative exercises , in particular human rights
and public policy contexts, the flexibility of these approaches allows reasoned agreement on
central aspects of health and capabilities, without requiring agreement on non-central aspects. It also allows for
different paths to the same conclusion . ¶ F. Pluralism, Ambiguity, and Incompletely Theorized Agreements¶
Often in decision-making settings people "can know that something is true without entirely knowing why this something is true."14
Consider these instances: people might agree that murder is wrong, that the government should prevent famines, that society should
not let people starve and die in the streets, that we should try to prevent the spread of communicable diseases, and that people
in
should not be subject to forced genital mutilation. People can hold these views without knowing exactly why. For example,
Oregon's Medicaid experiment, 143 there was substantial agreement that cystic fibrosis and viral
pneumonia claimed allocational priority in providing medical care over tooth-capping, acute
headaches, and thumb-sucking. But people did not generally agree on or know exactly why this
should be the case. In hospital emergency rooms, physicians will agree on triage decisions
prioritizing life-saving interventions over quality of life enhancements, without fully theorizing
why. And in certain applications of the capability approach, there is considerable agreement on
urgent basic needs without a full understanding of the reason.¶ The need for reasoned
public policy in the face of these ambiguities makes the ITA approach appealing
especially in the context of human rights. Like many concepts in human rights, "health" and "human
flourishing" are multidimensional and ambiguous. Still, people can understand the
concepts of "health" or "human flourishing" or "capability" without fully articulating their details. Through
these partially theorized concepts, humans can judge and evaluate policy as desirable or
undesirable.¶ The ITA theory allows people to agree on an outcome despite these ambiguities. Decision-makers
need not fully share a common set of foundations for their beliefs and are allowed
to leave unarticulated the "right" reasons for their respective convictions.

When their convergence over a human right is incompletely theorized, it enables them to obtain some clarity and decisiveness in the
result without precisely specifying their reasons for it. ¶ G. Incompletely Theorized Agreements and Capability¶ I return here to
obtaining collective agreement on the selection and weighting of health capabilities for evaluating the right to health. The ITA
framework complements the capability approach in this phase because it allows for collective agreement on a dominance partial
ordering of capabilities without requiring that political participants agree on other capabilities. It can thus obtain agreement on the
dominance partial ordering of basic or central capabilities without requiring agreement on non-basic or non-central capabilities as
noted in Part II above. ¶ The ITA framework also assumes pluralism in many forms. Plural value structure and plural agents do not
upset the framework so long as there are at least some areas of consensus. In this sense it allows the capability approach to apply
more widely. As Sunstein notes, "People value things not just in terms of weight, but also in qualitatively different ways. Human
goods are plural and diverse, and they cannot be ranked along any unitary scale without doing violence to our understanding of the
qualitative differences among those very goods." 1"¶ Applyingthe ITA framework to questions of health, health
capability, and health policy, one sees that people can agree on particular outcomes. Individuals can agree, for
instance, on. those health capabilities that are essential to a right to health and the low-level principles that justify
them without agreeing on complete answers to metaphysical questions, such as "what is
human flourishing" or "what is health?"
The thesis of (coloniality/bio-political governmentality) is wrong---it’s
based on a faulty understanding of liberal peace-building
Jan Selby 13, Senior Lecturer of IR at the University of Sussex, "The myth of liberal peace-
building", March 13, www.tandfonline.com/doi/pdf/10.1080/14678802.2013.770259
Most of the above features are shared right across the liberal peace-building debate and have been advanced from any number of theoretical
perspectives. Thus it
has been claimed from a constructivist perspective that contemporary peace-building is rooted
in liberal ‘international norms’.36 Invoking Foucault, it has been argued that the liberal peace-building
project is an exercise in global bio-politics or governmentality, which aims to govern and
construct liberal populations and subjectivities.37 From a post-colonial perspective, liberal peace-
building has been described as a colonial project , ‘cast in the mould of colonialism’, and aiming to
restructure Southern societies in accordance with Northern metropolitan ideology.38And in neo-Gramscian
terms, peace-building has been critiqued as part of a transnational neo-liberal project, ‘reflecting
the hegemony of liberal values that reigns in global politics’.39 Right across this variegated theoretical terrain, peace-
building is represented as a liberal project, founded on liberal ideas, pushed forward by a decentralised plurality of institutions irrespective of the
particularity of war-endings and peace agreements, in which global consensus is counterposed by local dissensus or disorder. ¶ Yet
for all this
trans-theoretical consensus, these shared emphases within liberal peace- building discourse constitute a

questionable foundation for the analysis of contemporary peacemaking. Again, this is not to suggest that the liberal peace-
building literature is without merit: the critical literature, in particular, provides much compelling evidence of the hubris of liberal internationalism, of
the destruction wrought by World Bank-IMF policies and of the frequent complicity of peace-building projects in coercive processes of state-building,
the above parameters
dispossession and subjugation. My contention is not that liberal peace- building research is without value, but that

are unnecessarily limiting , and can generate significant interpretive errors . To advance this
case, my focus in the remainder of this paper is on the relations between post-conflict peace-building on the one hand, and peace agreements and their
negotiation on the other. What this will reveal is that peace-building is neither a discrete sphere of action, nor
the dominant element within contemporary peace processes; that states, strategy and
geopolitics continue, as ever, to be crucial determinants of these processes; and that the influence of
liberalism, and the degree of global consensus over the liberal peace, are significantly overstated within liberal peace-
building discourse. We start by considering one case in some depth, before generalising from this case with the aid of insights from a broader
range of examples.

Security doesn’t require violent constructions of the human & is

actually the opposite of reducing life to mere survival---you’re not
voting to impose a universal definition of security or emancipation,
you’re voting on the concrete choice presented by the 1ac
João Nunes 12 , Lecturer in International Relations at University of York, Reclaiming the political : emancipation and
critique in security studies. Security Dialogue, Vol.43 (No.4). pp. 345-361.

Security as emancipation has been met with some suspicion. It has been criticized for being idealistic (Eriksson, 1999); for
wishing to impose Western values (Ayoob, 1997; Barkawi and Laffey, 2006); because of its connection to
‘liberalism’ (Shepherd, 2008: 70); and for assuming an essentialized individuality (Sjoberg, 2011). It has been accused of relying on an abstract moral framework that
ignores contemporary security (McCormack, 2010); and it has even been connected with Western military interventionism (Chandler, 2006 ). These criticisms

seem to rely on the assumption that security as emancipation is but an expression of the
modern, universalist Enlightenment narrative of emancipation (analysed, among others, by Pieterse, 1992; Laclau, 1996).
This has resulted in the lack of a sustained engagement with what the proponents of
security as emancipation have actually written (but see Aradau, 2008).
However, the work of Booth and Wyn Jones shows that security as emancipation does not assume an abstract
individual or an essentialized human . In addition to highlighting the corporeal, concrete nature of the referent of security, Booth has
defined ‘human sociality’ (2007: 210) as one of the mainstays of his approach: according to this idea, being human is an open condition based

on the capacity to invent oneself as such. Responding to the ethnocentrism charge, Pinar Bilgin (2012)
argued that the idea that some values ‘originate’ in a particular culture is itself based on
essentialized views.
far from presupposing a blueprint to be imposed or a unidirectional path towards an
Moreover,

emancipated end-state, this literature has painstakingly argued that emancipation only makes
sense when seen as a localized and unfinished process . The meaning of emancipation can
only be determined by local stakeholders, when faced with concrete choices between more or less
emancipatory options for a given situation .10 A passage in Booth’s work shows the extent to which this approach has successfully
dealt with the most common criticisms:

[f]alse emancipation… is any conception that understands emancipation as timeless or static

(whether in relation to ideas, institutions, or situations); undertakes emancipatory politics at the expense of others (making the emancipatory goals of
others impossible); or uses emancipation as a cloak for the power of ‘the West’ or any other entity claiming to have the
monopoly of wisdom (Booth, 2007: 113).
It can be said that the persistence of a climate of suspicion towards the idea of emancipation – conjoined with the growing tendency to see security as something to be avoided – has led to CSS being, in the current situation, particularly inhospitable to notions of
security as emancipation.11 This has impaired the theoretical development of emancipatory approaches, which have devoted a substantial amount of their energies to the defensive reiteration of their own assumptions. Moreover, this development has been
detrimentally affected by the fact that security as emancipation is still commonly identified with the Aberystwyth School – which, in turn, has shown some reluctance to engage with contributions from other critical approaches to security.12 The prominent position
of the Aberystwyth School in the emancipation literature has also meant that discussions are overwhelmingly centered on – and limited by – a view of emancipation as the removal or alleviation of constraints upon the lives of individuals and groups. There is,
however, scope for nudging the debate in a more productive direction – one that allows for a deeper engagement with the actual shortcomings of security as emancipation and that, as a result, enables its potential to be fully realized. In fact, whilst Booth and others
have done much work on fine-tuning the account of what emancipation is, not enough attention has been given to the complexities of what one is to be emancipated from. Here, the literature has remained at a rather unspecified level: in order to justify the need for
emancipation, Booth has either referred to the experiences of the ‘victims’ of insecurity (2007: 160) or described a global historical crisis characterized by the combustible interplay of interstate conflict, globalization, population growth, extremist ideologies,
apparently unstoppable technological momentum, terrorism, consumerism, tyranny, massive disparities of wealth, rage, imperialism, nuclearbiological-chemical weapons, and brute capitalism – as well as more traditional cultural threats to peoples’ security as a
result of patriarchy and religious bigotry (Booth, 2005b: 1-2). A thorough understanding of the condition of insecurity requires that we go beyond simple enumeration – as extensive as it might be. How exactly are these situations a threat? How do they constitute
impediments upon life? How do they translate into claims for security and emancipation? Looking at the claims themselves does not solve the problem, particularly when one is faced with conflicting claims, or when one begins to question the ways in which the
‘victims of insecurity’ are defined. In order to provide a convincing account of the need for emancipation and devise practical steps to achieve it, emancipatory approaches need to include a sophisticated account of what the problem is. The condition of insecurity
upon which visions of emancipation are to be predicated must not be taken for granted Two themes, largely overlooked by Booth and Wyn Jones, can help to specify the condition of insecurity. By improving its capacity to understand the political intricacies of the
‘reality’ of security and the different dimensions of its power, security as emancipation would be in a better position to contribute to the critical security field. To begin with, security as emancipation has much to gain from fully taking on board the ways in which the
reality of security is traversed by politics – even in its most ‘material’ core. More precisely, this approach needs to shift from an unquestioned reliance upon material individuals (or bodies) suffering insecurity towards an analysis of the politics of materialization. The
work of Michael C. Williams shows that an engagement with materialization is essential for understanding the modern politics of security. He argues that the security understandings that constitute the modern sovereign state were underpinned by a transformation
of the way in which the individual was conceived. This transformation implied the materialization of the individual, that is, the ‘reduction of the “referent objects” of security to abstract, individual persons, rendered as atomistic, material bodies united through a
political authority’ (Williams, 1998b: 438; see also Williams, 1998a). Thus, instead of a truthful depiction of reality, the focus on material individuals is the result of political practices. Judith Butler has explored materialization by arguing that bodies need to be
understood politically as well. She maintains that gender is not an essential biological characteristic of the body but rather an organizing principle. In her words, gender ‘does not describe a prior materiality, but produces and regulates the intelligibility of the
materiality of bodies’ (Butler, 1992: 17; see also Butler, 1993). She gives the example of the practice of coercive surgery on infants and children with sexually indeterminate or hermaphroditic anatomy, which aims at normalizing their bodies in accordance with
idealized morphologies. For her, the body is always embedded within culturally and historically specific processes of materialization. Williams and Butler highlight the importance of questioning what is taken for granted as ‘real’ – even when this reality appears to us
as embodied and material. Their contribution is important for emancipatory approaches because unpacking the politics of reality is an essential step towards a detailed and nuanced view of the insecurities that justify emancipation. It provides the opportunity to
conceptualize insecurities beyond the enumeration of threats, namely by identifying the social relations and structures that constitute the condition of insecurity

Emancipatory accounts in the feminist security literature (Tickner, 1995; Hoogensen and Rottem, 2004; Lee-Koo, 2007; Basu, 2011) provide indications of how insecurity can be specified along these lines. Starting from the analysis of the gendered practices that
place certain individuals and groups in situations of vulnerability, feminist approaches have helped to unpack situations of insecurity by highlighting some of the social relations, political structures and institutional settings that produce and perpetuate it. The
gender-security nexus scrutinized by feminist authors – with the aid of a series of innovative research methodologies (see for example Ackerly, Stern, and True, 2006) – shows that it is possible to go beyond the enumeration of threats and conduct an analytically
rigorous critique of important aspects of insecurity. Security as emancipation can be strengthened by expanding on these insights and exploring in greater depth gender-based relations and structures of insecurity – in addition to other aspects that have been largely
overlooked, such as class and economic relations (Herring, 2010).

The security as emancipation literature can also benefit greatly from a more developed understanding of power. Despite mentioning the term frequently, Booth has remained at a very abstract level in what comes to pinning down what power is and does. No
indication is given as to how power operates; no systematic analysis is provided of its effects. Even though a Gramscian understanding of hegemony is present in Wyn Jones’s writings, his critical approach to security has not included a detailed engagement with the
power of predominant security understandings and practices. How can these be seen as instances of power? How do they reflect and reproduce existing relations and structures? An engagement with these questions is essential if security as emancipation is to
provide a sophisticated analysis of existing insecurities. At the same time, an emancipatory approach must be based upon a solid diagnosis of the power relations and structures in which claims for emancipation and possibilities for transformation are embedded.

The understanding of power in security as emancipation can be enhanced, first, by the incorporation of Michel Foucault’s notion of power as government. So far, security as emancipation has overwhelmingly relied on the assumption that security understandings
and practices work through the determination of action – that is, by encroaching upon and restricting what would otherwise be free decision and action. This latter view is present in the work of Steven Lukes, for whom power consists in ‘the ability to constrain the
choices of others, coercing them or securing their compliance, by impeding them from living as their own nature and judgment dictate’ (2005: 85). Action can be constrained by coercion, threat, by the delimitation of acceptable and desirable behaviour or by
foreclosing dissent and alternatives.

The idea of power as government (Dean, 1999) introduces important revisions to this model. It sees power as not merely constraining but also productive. For Foucault, government signals a shift, from the exclusive concern with the protection of the sovereign
towards the optimization of the natural capacities of individuals and populations – in the name of an efficient economic and political organization. This means that power does not just repress and stifle subjects, but plays a fundamental role in constituting them
(Foucault, 2000 [1982]). Seeing power as productive of subjects enables a recognition of its multiple instances and sites: power becomes a network of relations between various nodes – such as schools, hospitals, prisons and armies – that interact in the management
of actions and dispositions.

Incorporating this view of power into the security as emancipation framework has decisive implications for the latter’s ability to recognize the effects of predominant security arrangements and to act upon them. It allows this approach to analyse in detail how
security is involved in the constitution of subjects. In addition to these analytical benefits, power as government can also reinforce the political agenda of security as emancipation: after all, in order to be truly effective, the identification of opportunities for resisting
and transforming security arrangements requires a recognition of their power, its multiple sites and modalities, and the way it runs through the fabric of society in the form of social relations.

Whilst adding the notion of governmentality would help security as emancipation catch up with recent developments in the critical security field, a further revision of its understanding of power would allow this approach to ‘give something back.’ It is surprising that
an approach that has drawn from the Marxist tradition to highlight the global production of inequality is yet to include an in-depth account of the domination side of power – and, concomitantly, of understandings and practices of security as instances of domination.
Domination can be conceived as ‘a condition experienced by persons or groups to the extent that they are dependent on a social relationship in which some other person or group wields arbitrary power over them’ (Lovett, 2010: 2). Iris Marion Young’s work
supplements this definition: for her, the groups themselves must be seen as collective experiences and ‘forms of social relations’ (2011 [1990]: 44), and not entities reified around shared attributes. Thus, rather than a binary confrontation between a dominating and a
dominated group, domination is at once a structural phenomenon and the result of fluid and complex relations. Young

writes:

[d]omination consists in institutional conditions which inhibit or prevent people from participating in determining their actions or the conditions of their actions. Persons live within structures of domination if other persons or groups can determine without
reciprocation the conditions of their action, either directly or by virtue of the structural consequences of their actions (Young, 2011 [1990]: 38).

Even though a dominated group need not have a correlate, consciously dominating one, Young recognizes that a situation of domination implies the existence of a group that is systematically privileged in relation to another. Put differently, to be dominated means to
be involved in an unequal relationship, the terms of which are not fully controlled by all groups involved. The terms of the relationship force some groups to be subordinate or deferential ‘in order to secure reasonably good outcomes or results’ (Lovett, 2010: 47).
Determination of action is thus embedded in a broader relational and structural context.

In addition to there being imbalance or inequality, domination also means that a certain degree of arbitrariness is present. Arbitrary power implies that decisions are made or effects are produced to the benefit of certain groups, without the constraint of effective
rules and procedures and not reflecting the interests of all parties affected. Dominated groups are thus vulnerable to decisions and outcomes with a high impact upon their life, and which they cannot control or predict.

This notion of power as domination advances the emancipatory agenda by taking further the idea of power as determination of action and by allowing for a specification of the ‘oppressions’ that Booth mentions in his definition of emancipation. Domination allows
for an enquiry into the context-specific, structurally-constrained relations through which life chances are curtailed for some and through which vulnerability is intertwined with the systematic production of disadvantage. Simultaneously, domination is also useful in
that it supplements governmentality: firstly, it allows for an analysis of the connections between structures, disadvantaged subjectpositions and their accompanying subjectivities; secondly, it adds a normative edge that, as has been noted (O'Malley, Weir, and
Shearing, 1997), is often lacking in governmentality studies. More precisely, it provides a clearer direction for the transformation of existing power relations in the transformation of unequal subject positions. By incorporating, into its account of power, the notions of
governmentality and domination – with the former’s focus on the fluid production of subjects and the latter’s emphasis on systematic disadvantage in subject-positions – security as emancipation has

the potential to make an important contribution to critical security debates.

In sum, the reconsideration of security as emancipation advanced here is based upon a view of the reality of security as a politically-shaped ensemble of relations and structures. It sees the power of security ideas and practices as entailing the constitution of subjects
and political possibilities via governmental strategies and, often, via practices of domination. This revised version of security as emancipation yields a more detailed view of the condition of insecurity, a more substantiated assessment of the need for emancipation
and a more grounded judgment on the potential and strategies for alternative security arrangements.

, security as a form of emancipation can be understood as the transformation of

With these revisions in place

structures, relations and processes of subject-constitution that entail systematic disadvantage

and vulnerability; this transformation is enabled by the creation of spaces in people’s lives in
which they can make decisions and act beyond the basic necessities of survival .13

The alternative fails -- collective struggle requires building on existing

governmental rationality -- contingent uses of risk like the aff can be
reformist and inclusionary
Pat O’Malley 8, Professorial Research Fellow in law at the University of Sydney,
“Experiments in risk and criminal justice” Theoretical Criminology 2008; 12;
451, http://www.uk.sagepub.com/cross/files/Chapter10-Article4.pdf
In analyzing this domain, I want to argue that while
risk—like all government—is dangerous, critical theory
and especially criminology has attended too much to risk’s negative side. I want to argue that a critical social theory
has a responsibility to consider the promise, as well as the problems, of risk. Such an exercise, however, cannot merely be a review of
‘what works’—of the effectiveness (or otherwise) of risk techniques for protecting victims, reducing crime, etc. The result of such an
exercise is unlikely to do more than rehearse already familiar arguments pro and con, and in any case begs the question of what we
seek to achieve. As well, such
ways of examining risk tend to make assumptions that are problematic.
They assume risk’s unity, as if risk-centered government can be imagined as one
thing, rather than a heterogeneous array of practices with diverse effects and
implications (O’Malley, 2004). They assume that risk can only be imagined and operationalized as
azero-sum—a game between potential victims and potential offenders—in which the risks to one
party’s security are created by the other. They assume that risk is an arcane science practiced by
a cadre of experts inevitably co-opted by the state or simply effecting technocratic domination.
Finally, together with many arguments also put forward by critics of risk, they assume that the difference between risk and other
technologies of government is more significant than the differences between diverse risk technologies. ¶ We might begin analysis
with very different assumptions. In particular, that risk as an abstract technology is
always shapedand given effect by
specific social and political rationales and environments (Ewald, 1991). Consequently, risk may take a
wide diversity of forms that reflect the purposes to which it is put and the assumptions on which it based. This implies
that risk is never technically neutral . It is always a moralized way of governing, and the specific moral
foundations should be made explicit. Elsewhere (O’Malley, 1999, 2004) I have argued at length that Actuarial Justice and Megan’s
Laws reflect a specific politics closely associated with conservative brands of neo-liberalism, rather than being ‘pure risk’ regimes.
This is seen, for example, in their rejection of social reform agendas that are visible in other judicial risk regimes (such as risk–needs
there is no obvious reason why risk cannot be inclusive and
analyses). Accordingly,
reformist rather than exclusionary and merely incapacitating . By extension I will later argue
there is no reason why risk has to pit ‘offenders’ against ‘victims’, or why it cannot be collectivist
rather than individualist, unifying rather then polarizing. And thus there is no reason why
risk cannot be consistent with programs of social justice rather than individual or
market justice. Social insurance , for example, achieves a number of these possible
conditions. If so, then in relation to the governance of crime why cannot risk form part of a politics of (post-) social justice
and help realize the visions of security that go along with this? ¶How could we proceed with such a politics? I want to suggest here
that an analysis that draws on the governmentality literature (a ‘governmental analytic’) offers considerable promise in this respect.
Such a statement may come as a surprise for several reasons—not least being that a common criticism of governmentality is its
refusal to engage in a normative politics, something that is linked to the further observation that it focuses primarily on the
diagnosis of governmental programs and pays little heed to the possibilities of resistance (O’Malley et al., 1997). This has sometimes
been interpreted as a form of complicity, as critique rarely if ever emerges out of restatements of governing regimes. However, I
want to argue that nothing in governmentality deflects it from either political engagement or the
development of alternative futures. Rather, the difficulties are only with certain forms of truth claim and the political programs of
domination they engender. ¶ Governmentality, strategic knowledge and risk¶ Broadly speaking, governmentality may be defined in
terms of several loose organizing principles. First, its focus is primarily on the ‘ideal’ knowledges of plans to govern—rather than the
details of how they are implemented and what effects they may have empirically. This includes, although is not exhausted by, a
concern with the ways in which the world is understood for the purposes of government. Such ‘governmental rationalities’ are not
usually complex and detailed descriptions so much as schematic ways of rendering phenomena problematic or governable. The issue
of ‘unemployment’, for example, may be imagined diversely as a problem of idle individuals, of failures in the demand side of the
economy to create employment, the development of a culture of dependency among working people, and so on. Here, it should be
stressed, the approach resiles from pronouncing on the reality or otherwise of these ‘imaginaries’: seeking rather to understand
government in terms of its own constitution of reality. Such problematics are linked to ‘governmental technologies’, or ways of
governing these ‘imagined’ problems. Thus if the problem of unemployment is imagined as one of a failure of the ‘the demand
economy’, then the techniques for intervention clearly will differ from those relevant to an understanding in terms of idle
individuals. Second, and this is vital for considering the first point, it assumes that government is a generalized and dispersed
practice rather than being only what states ‘do’. Many agencies govern, whether in the state sector or the private sector, and of
course individuals have always been expected to ‘govern’ themselves and their dependants This is significant because, as I will raise
at a later point, in relation to any specific problem, it is nearly always possible to identify a diversity of governmentalities existing at
any given point in time, dispersed throughout the polity. Thus, for example, current ‘neo-liberal’ visions of the culture of
dependency, and techniques to govern this through the creation of ‘active individuals’, coexist in rivalry with social security
imaginaries and techniques established during the era of the welfare state. ¶ In keeping with Foucaultian analysis more generally,
governmentality analyses do not seek to reduce these governmental rationalities and technologies to the effects of some explanatory
variable—such as ‘post-modernization’ or the development of the ‘mode of production’. Thegovernmentality
analytic is
thus specifically opposed to grand explanatory theorizations that purport to reduce broad
swathes of phenomena to being the effects of some underlying determinants (‘explanation’). A key
part of this opposition is that such ‘regimes of truth’ provide a license to domination , in the name of
the theoretically revealed truth. Such theorizations admit of little contestation, for those refusing to accept the account are
neutralized through one of a number of truth strategies: ‘false consciousness’, ‘brainwashed’, ‘irrational’, ‘unscientific thinking’, and
so on. Further, such explanatory accounts provide maps of history, past and future, in which ‘meaningful’ change can only be
achieved by addressing the factors identified by the theory as relevant and important. ¶ By contrast, governmentality is
associated with a genealogical approach in which history appears as invented and
contingent

rather than as determined by some grand theory or logic. One consequence is that whatever
currently prevailsas true can be regarded as not inevitable : things could have been otherwise. Likewise, it
implies that whatever is currently in place remains open to further innovation. The future can be
invented. Of course, this does not mean that absolutely anything is possible. The genealogical analysis in
governmentality puts emphasis on what is feasible with given conditions of existence .
This would include drawing upon elements in existing intellectual and material resources—such as
existing governmental rationalities—that can be selectively valorized and assembled together for
some new purpose. Thus we might point to the neo-liberal ideas of‘stakeholder politics’ and
‘markets’ as having the potential to democratize the definition of what are risks and the practices
of how to deal with them.¶Understanding existing regimes of power and the opportunities and dangers that they present us,
was referred to by Foucault as ‘strategic knowledge’: the role of theory today seems to me to be just this: not to formulate the global
systematic theory which holds everything in its place, but to analyse the specificity of mechanisms of power, to locate the
connections and extensions, to build little by little a strategic knowledge. (Foucault, 1980)¶ Strategic
knowledgein this
sense I interpret to be the building up of a knowledge—a diagnosis—of the ways in which
existing government formulates its truths, and links these truths to specific programs of
government whereby problems are to be named and resolved. It also involves an understanding
of the governmental techniques whereby these effects are to be achieved, of the kinds of subjects that are
to be formed, of what will be a ‘successful outcome’ of the program, and so on. To those familiar with
governmentality, this is reasonably well understood. But to date I think it has been true to say that most
governmental analysis has stopped here without addressing the purpose of such strategic knowledge.
Or perhaps it is fairer to say, that its purpose has been understood only as a tool in diagnosing the
existing situation: to ‘disturb its truths’; to identify the costs to existence of being governed in certain ways; to allow
one to determine an ethical course of action in this light (cf. Rose, 1999). ¶ Thisapproach has been open to the criticism that it is
a form of solution that continues a liberal ethic of the self : causing as little harm to others as possible, but
ultimately not seeking to develop alternative forms of governance of others for fear of imposing domination. This is a possible
reading of Foucault’s comments that: I do not think that a society can exist without power relations, if by that one means the
strategies by which individuals try to direct and control the conduct of others. The problem, then, is not to try to dissolve them in the
utopia of completely transparent communication, but to acquire the rules of law, the management techniques, and so the morality,
the ethos, the practice of the self, that will allow us to play these games of power with as little domination as possible. (Foucault,
1997: 298)¶ Such interpretations place most emphasis on one aspect only—on the practices of the self. An alternative vision is that
government —‘the rules of law, the management techniques’ that are directed toward the
this is a general ideal toward which
conduct of others— should be developed . This seems reasonable if we follow Foucault’s implication that there is always
government in some form. If there is no practical alternative but to govern, would it not follow that a
focus on an ethic of the self abandons others to whatever fate or other political regimes have
dealt them? I would take Foucault’s preference for the minimization of domination in this context to be that if government is
neither necessarily ‘bad’ nor avoidable then it should proceed in terms of the maximization of opportunities for contestation. As I
will suggest later, this emerges more generally in the imagery of an agonistic
politics—a politics that is never
closed, but always open to revision and provocation.¶ In this light, governmentality may
become a tool for political development, not merely an analytic. That is, if governmentality
provides a technique for the diagnosis of existing government, then it can become an analytical resource for the development of
alternative forms of governance that minimize domination. In this role, it seems to me to provide a useful tool for several purposes: ¶
What I have in mind does not involve the construction of a new political program. Rather, and in keeping with what has been
suggested thus far, it is consistent with a more piecemeal and experimental advance, that ‘builds little by little’ a constructive
strategic knowledge in terms of which we may develop feasible alternatives. In this, as Foucault would say, we are embarking on an
exercise in government which is inherently ‘dangerous’ in the sense that all government is dangerous. We should always keep this in
the foreground as a principle of auto-critique, as a caution with respect to tendencies to silence inconvenient voices and alternatives.
In this sense, ‘dangerous’ is not the same as ‘bad’. Governmentality, within this caveat, is my preferred tool for assessing such
dangerousness within an experimental framework. This framework, for the moment, I will refer to as ‘experiments in government’—
meaning by that term only attempts to govern with the minimization of domination, the maximal provision of contestation
consistent with getting things done.

Risk regimes are good and stop real catastrophic impacts – flaws are
not features of the system but reasons to make insurance more
inclusionary
Darryl S.L Jarvis 07, Associate Professor, Lee Kuan Yew School of Public Policy, National
University of Singapore, Risk, Globalisation and the State: A Critical Appraisal of Ulrich Beck
and the World Risk Society Thesis, Global Society Vol 21(1), January 2007,
http://www.sfu.ca/~poitras/gs_jarvis.pdf
Beck gives too little attention to the autonomous ideational changes that have championed the neo-liberal agenda—incorrectly
ascribing these to structural forces endemic to radical modernisation. Of course, it is entirely conceivable that, depending on the
prevailing political climate and the constellation of political forces, this agenda might be reversed, partially abandoned or modified.
Thus therise of the risk society, at least as it relates to the individualisation of risk through
declining welfare provision or progressive taxation systems and globalisation, might not be as
predetermined as Beck suggests.¶ Equally, some of Beck’s other “interrelated processes” also appear problematic. For example,
his assertion that rising and endemic underemployment will usurp the distributive function necessary to the reproduction of
industrial modernity and transpose greater risks and vulnerabilities onto a growing segment of society does not appear empirically
sustainable. To be sure, there has been a pronounced increase in the rate of casual and flexible employment practices, but the
wholesale offshore movement of jobs has not taken place. Job redundancy and the replacement of “old economy” industries, for
example, while a feature of the latter part of the 20th century and early part of the new millennium, have also been accompanied by
job creation in the so-called “new economy” sectors (such as biotechnology, information technology, financial services, education,
and the hospitality and tourism industries). Consequently, the fact that global unemployment stood at only 6.2% of the global
workforce in 2003 (according to the International Labour Organisation—ILO) fails to indicate the emergence of a structural
employment crisis.48 Indeed, this rate came off the back of a severe global economic slowdown (2000–2003), the war on terror and
disruptions to the global hospitality, tourism and aviation industries, and global panic associated with the outbreak of SARS in Asia.
This rate, in other words, is cyclical not systemic and, according to the ILO, likely to trend downwards as global economic activity
picks up over the next couple of years.49¶ What, then, might account for these premature assertions by Beck? The answer perhaps
lies in appreciating the historical backdrop to his central thesis. Beck formulated many of his observations amid a period of
tumultuous change in Germany. First, the rise of the Greens led to rapidly changing political affiliations in the 1980s, while the
events surrounding the fall of the Berlin Wall and the problems of economic restructuring as a result of German reunification and
post-reunification economic adaptation were tumultuous. The latter, in particular, have posed continuing challenges for Germany,
especially in terms of labour market integration, economic equalisation and the modernisation of East German industry and
infrastructure. Beck has undoubtedly been influenced by these events and the processes of accommodation and dislocation that
naturally accompany them. At worst, Beck might thus be accused of a kind of “presentism”—a preoccupation with proximate current
events and an assumption of both their ubiquity and universal validity as indices of a new risk civilisation.50 Robert Dingwall, for
example, goes so far as to describe Risk Society as “a profoundly German book”. As he notes, “most of the citations are to other
German authors, the acknowledgements are to German colleagues and the book’s drafting ‘in the open hill above Starnberger See’
(p. 15) is lovingly recorded”.51 This is not, Dingwall insists, a xenophobic criticism but an observation of the milieu in which Beck’s
thoughts were influenced and the context in which his thesis has evolved— perhaps making Beck’s concerns more local and
parochial than he would care to admit. The point is a broader one, however. Anthony Elliott, for example, asks whether Beck’s
observations overstate the phenomena and relevance of risk. 52 How, for example, should
we compare risks in different historical periods? Are we really living in a unique historical epoch
in which the calculus of risk is so extreme that it distinguishes itself from all previous epochs? As
Brian Turner notes: [A] serious criticism of Beck’s arguments would be to suggest that risk has not changed so
profoundly and significantly over the last three centuries. For example, were the epidemics of
syphilis and bubonic plague in earlier periods any different from the modern environment
illnesses to which Beck draws our attention? That is, do Beck’s criteria of risk, such as their impersonal and
unobservable nature, really stand up to historical scrutiny? The devastating plagues of earlier
centuries were certainly global, democratic and general. Peasants and aristocrats died equolly horrible deaths.
In additiuo, with the spread of capitalist colonialism, it is clearly the case that in previous centuries many aboriginal peoples such as
those of North America and Australia were engulfed by environmental, medical and political catastrophes which wiped out entire
populations. If
we take a broader view of the notion of risk as entailing at least a strong cultural
element whereby risk is seen to be a necessary part of the human condition, then we could argue
that the profound uncertainties about life, which occasionally overwhelmed earlier civilizations,
were not unlike the anxieties of our own fin-de-sie`cle civilizations. 53 This goes to the core of Beck’s
thesis and questions its basic assumptions about the depth and extent of risk under reflexive
modernity. Yet Turner fails to take his critique one step further and question whether, regardless of how extensive risk is, the
regime of control and the social compact that distributes risk under industrial modernity is, in fact, breaking down as Beck asserts.
Again, it
seems highly problematic to suggest that the orderly distribution of risk or the ability to
compensate or insure against risk are automatically mitigated on the basis of exceptionalism—the
advent of nuclear weaponry, the prospects of nuclear mishap or the looming prospect of ecological disaster possibilities, and until
Many states
they manifest themselves their possibility should not detract from the strength of existing regimes of control.
continue to display a high level of adeptness in indemnifying their constituents against natural
disasters (floods, hurricanes, earthquakes, famine, humanitarian disaster). Indeed, the control regimes surrounding
emergency management and response have probably never been so well formulated a

s they are today. The tsunami tragedy of 26 December 2004 in the Indian Ocean, for example, while representing one of the
most devastating natural disasters of the last few centuries, inflicting cataclysmic destruction on multiple populations in several
countries, was also one of the most well managed in terms of emergency response, humanitarian assistance and reconstructive aid
efforts. Within hours of the disaster, emergency response teams were activated in Thailand, Sri Lanka and Indonesia, and within
days international emergency and humanitarian assistance was deployed on a global scale, with these efforts redoubled as the
calamity of the devastation became apparent. Perhaps only in terms of the immediate humanitarian emergency response in Western
Europe at the end of the Second World War has the world witnessed such a massive mobilisation of resources, inter-agency effort
and coordination, and global political coordination and response. Rather
than a crisis of risk control and
management, current crisis and emergency response systems represent an historical highpoint,
having achieved greater levels of response effectiveness, early warning preparedness and crisis
management than at any time before in history.54¶ But for Beck, of course, this is not important, since all this
would be swept away by the magnitude of looming, exceptional risks. But how accurate is this assumption? The Cold War has ended,
the risk of nuclear confrontation has diminished (although proliferation may raise it), and so has the prospect of nuclear weapons
accidents. Nuclear arsenals continue to be reduced and technical safety systems increased. Whilst there remains the prospect of
weapons of mass destruction “falling into the wrong hands” and the development and deployment of so-called “dirty-bombs” based
on the use of low-grade uranium, such a prospect scarcely matches the level of terror threatened during the Cold War. The
consequences of risk exposure in these instances have traditionally been socialised, so why does Beck assume that such would not be
the case again? The social compact would be stressed and challenged but not necessarily irreversibly broken. Likewise, even with
recent events such as the BSE crisis in the United Kingdom, Europe and Canada, the outbreak of AIDS and SARS, the terrorist
attacks in the United States, the ecological catastrophe of the cod crisis in Eastern Canada, the fish stock crisis in Europe, or any
number of other events, the social compact has remained intact and subject to collective accommodation and response efforts.
Imperfect though these may be, they have not yet led to systemic failure in the sense of realising the penultimate consequences of
reflexive modernity. Nearly all have been addressed, most rectified or at the very least processes put in place to ameliorate their
worst consequences and systemic causes. ¶ Beck prefers to discount the success of these risk management efforts and tends to adopt,
instead, a fatalistic view of the human condition, pointing to our inability to correct errors, an
ineptitude when it comes to moderating risk-producing behaviour, and a collective inertia in the
face of looming risk(s). Yet these assumptions seem to be less founded on empirical realities and
more on a philosophy of fatalism, leading Beck to proffer a relatively simplistic prognosis that “institutions founder on
their own success”.55 But do they? Again, the empirical evidence for this is problematic . Beck, for
example, invokes the case of the German crystal lead factory in Upper Palatinate in the Federal
Republic of Germany: Flecks of lead and arsenic the size of a penny had fallen on the town, and
fluoride vapours had turned leaves brown, etched windows and caused bricks to crumble away.
Residents were suffering from skins rashes, nausea and headaches. There was no question where all of that originated. The white
dust was pouring visibly from the smokestacks of the factory.56 In terms of responsibility for the environmental risks produced by
the factory, Beck is quite adamant that this was “a clear case”. But, as he explains in disgust, on the tenth day of the trial the
presiding judge offered to drop charges in return for a fine DM10,000, a result which is typical of environmental crimes in the
Federal Republic (1985: 12,000 investigations, twentyseven convictions with prison terms, twenty-four of those suspended, the rest
dropped).57 Science and the “organized irresponsibility” of the “security bureaucracies”, Beck insists, increasingly dominate under
reflexive modernity and, in the process, the apportionment of blame becomes obfuscated by an inept technocracy. In the case of the
German crystal lead factory, Beck notes, “the commission of the crime could not and was not denied by anyone. A mitigating factor
came into play for the culprits: there were three other glass factories in the vicinity which emitted the same pollutants”. As a result,
“the greater the number of smokestacks and discharge pipes through which pollutants and toxins are omitted, the lower the ‘residual
probability’ that a culprit can be made responsible”.58 The limits
of science and of the bureaucracy are revealed
by their inability directly to connect the polluter with specific pollutants. The more pollution generated
and the more polluters, for Beck, essentially dilutes the social compact and the ability to apportion blame, responsibility and thus
secure compensation. ¶ The example provided by Beck is meant to demonstrate the increasing failure of
the social compact, of science and the technocracy to apportion blame and compensate for risk
production. Eloquent though this example is, again its reification onto a universal plane seems
premature. To what extent, for example, is the paucity of environmental law in the Federal
Republic true, say, of the United States, Australia, Canada, or New Zealand? And in what sense
should the example of the crystal lead factory be taken as a systemic condition of reflexive
modernity? Surely it reflects little more than the paucity of outdated law in the German Federal
Republic—a process that can be easily rectified by drafting better laws and by engaging
political processes —much as Green movements throughout the world have done with
increasing success.59 Beck, it seems, denies politics and the ability of political actors to change laws
and respond to environmental damage. More generally, Beck fails to recognise that risk
distribution and compensation have always been contentious affairs fraught with different legal
opinions and with those responsible for the generation of risk keen to avoid the costs associated
with it. Why, then, is this epoch distinctive from previous epochs where the same motifs have applied?
Medical Tourism
 2AC
No link---their evidence is about decreasing the cost of healthcare
services, plan doesn’t do that, it just subsidizes insurance

Medical tourism is for specialty services that aren’t covered by basic

coverage offered on exchanges

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 thekinds 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
Deterrence solves Indo-Pak war
David White 16, writer for Inter Press Service, citing Pakistan’s former president and army
chief Pervez Musharraf, “Pakistan and India Unlikely to Move to All-out War: Musharraf,”
12/3/16, http://www.ipsnews.net/2016/12/pakistan-and-india-unlikely-to-move-to-all-out-
war-musharraf/

High levels of both conventional and nuclear deterrence are likely to prevent the recent
surge in clashes between India and Pakistan from escalating into all-out war, according to Pakistan’s
former president and army chief Pervez Musharraf.

In an exclusive interview with IPS in London, Musharraf predicted that

low-intensity conflict would
continue in disputed border areas. But he did not share the belief of many Pakistanis that
hostilities could slide into full-scale war between the two nuclear-armed countries.

“Any military commander knows the force levels being maintained by either side,” he said. “ I don’t
think war is a possibility because the lethality and accuracy of weapons has increased so
much.”
Although Pakistan has reserved the right to make a nuclear first strike, he said it had
sufficient controls to ensure
that its nuclear weapons, including new short-range tactical missiles, were not used accidentally or stolen by
terrorist groups. “They are in good hands, in secure hands.” he said.
“Thank God, the
level of conventional deterrence that we have in terms of weapons and manpower
is enough to deter conventional war . So therefore I’m reasonably sure that in case of a war it is the
conventional side which will be played and we will not go on to the unconventional.”

Deterrence solves Sino-India escalation

Commodore Katherine Richards 15, Marine Engineer Officer who has served in the Royal
Australian Navy for 26 years, “China-India: An analysis of the Himalayan territorial dispute,”
Feb 2015, available at http://webcache.googleusercontent.com/search?q=cache
%3Awww.defence.gov.au%2FADC%2FPublications%2FIndoPac%2FRichards%2520final
%2520IPSD%2520paper.pdf&rlz=1C1CHFX_enUS602US602&oq=cache
%3Awww.defence.gov.au%2FADC%2FPublications%2FIndoPac%2FRichards%2520final
%2520IPSD%2520paper.pdf&aqs=chrome..69i57j69i58.1061j0j4&sourceid=chrome&ie=UTF-8

Moreover, Jonathan Holslag surmises that the overall strategy of both nations is to maintain the balance of
power in the border area and that this balance is ‘nourished’ by small‐scale incursions and the build‐up of military
infrastructure.200 He further argues that both sides are not looking for military supremacy along the

border , although ‘they are seeking … to develop the capability to react flexibly on a wide range of
challenges’.201 For China, such challenges include combating Tibetan separatism, while for India, Pakistan continues to be a constant source of
‘an all‐out conflict , although possible, appears improbable because it could spiral
irritation. ¶ On balance,

into nuclear war and would upset the prevailing harmonious development model adopted by both sides’.202 Hence a

combination of conventional and nuclear deterrence serves to keep hostilities in

check. Furthermore, as China and India are both ‘vulnerable to potential acts of hostility’, a ‘multi‐
level soft deterrence’ is now a feature of the relationship.203 In the border dispute, China’s key
vulnerability is Tibet and India’s is Pakistan, which makes the potential cost of conflict
extremely high for both nations . ¶ Thus India’s and China’s military modernisations have
created a ‘stronger security interdependence’, suggesting the current security dilemma ‘will
 lead to a precarious form of stability as the costs of war rise significantly on
not bring peace, but it will

both sides of the Himalayas’. 204 In effect, the military power of both nations will assist in perpetuating the stalemate, wherein
the dispute will continue to fester, albeit within bounds.
 Politics
DA not intrinsic---logical policy maker could do the plan and focus of
FAA

Link ev says the horse trade is internal so it wouldn’t spill over

Tax reform is chief concern for GOP and Trump is investing

energy to get support
Ashley Killough and Lauren Fox 17, Political Producer and Congressional
Reporter for CNN, “Tax reform near the top of Congress' lengthy to-do list,”
9/3/17, CNN, http://www.cnn.com/2017/09/03/politics/tax-reform-congress-
return/index.html
Washington (CNN)When lawmakers return this week from the August recess, they'll face a bevy of must-do tasks, but chief
among them is a long-held Republican agenda item: comprehensive tax reform.¶ Enthusiasm
levels are high for the mountainous challenge, as tax reform is a widely popular idea, and Republicans
are desperate for a major legislative accomplishment they can tout in next year's midterm elections.
And it would be major: The last time Congress successfully passed a comprehensive tax overhaul
was in 1986.¶ While lawmakers in the tax-writing committees have been working on it for years, the current legislative effort is still in its infancy.
Broad principles have been established, and President Donald Trump has begun to use his bully
pulpit to make the case to the American people for the overhaul. But few details have been released to the public -- in
large part because they are still getting hammered out among Republicans.

Haven’t read impact UQ for aerospace

Obviously will pass, defense hawks and Trump love the military---
horsetrade would be for something else if it happens

Childrens health thumper---their ev

Alan Fram 9/4 “Obstacles await as Congress resumes health care fight” Reporter for the AP
http://abcnews.go.com/Health/wireStory/obstacles-await-congress-resumes-health-care-fight-
49610268

CHILDREN'S HEALTH
Funding for the popular Children's Health Insurance Program expires Sept. 30. It provided
health care to more than 8 million low-income children in 2015.
Democrats and most Republicans want to extend the program and success seems likely. First
they must compromise on details like how many years to finance it and at what
levels.

Washington pays for most of the federal-state program, and in recent years the federal share
was bumped up by 23 percent for each state. Many Republicans want to phase out that
boost, but Democrats are resisting .

Some Republicans say Congress needn't act by Sept. 30 because states have enough money to
continue coverage. Democrats and program advocates say without fresh funds by September's
end, some states would be forced to make cuts to wind down services.

UQ ev says it is garuinntreed pass

Status quo failure on health care destroys Trump’s international

credibility---causes a laundry list of hotspot impacts---the plan is key
to reverse it
Dov Zakheim 17, former Under Secretary for Defense, 3/27/17, “The Dangerous National
Security Implications of Trump’s Obamacare Fiasco,”
http://foreignpolicy.com/2017/03/27/the-national-security-implications-of-trumps-
obamacare-fiasco-china-iran/
Whatever his staff might say, however much the White House finger may be pointed at Speaker Paul Ryan, it is President Donald
Trump who is the biggest loser in the Republican failure to bring Obamacare repeal to a vote in the House of Representatives.
Trump promised America’s voters that he would rid them of Obamacare. He asserted that only he , as an outsider, had
the ability to negotiate a replacement for the health care program. He has failed , at least for now,
and his credibility has taken a major jolt .
Beyond the Obamacare defeat, for that is what it is, the president has yet to make good on his new immigration proposals. A single
judge in Washington state stopped his first executive order, and two judges, in Hawaii and Maryland stopped his second. The
decision not to have a vote on a replacement for Obamacare renders problematic Trump’s ability to bring about tax reform or
modernize America’s aging infrastructure, two more of his critical priorities.

The collapse of the Republican effort to reform Obamacare has international

ramifications , as well. Though he kept his promise to withdraw from the Trans Pacific Partnership (TPP), Trump has yet to
offer a substitute of any kind. He has thereby opened the door for China to create an alternative trading bloc that excludes the
United States. He has yet to declare China a currency manipulator. He has yet to renegotiate NAFTA, or the Transatlantic Trade and
Investment Partnership. He is unlikely to be moving the American embassy from Tel Aviv to Jerusalem. And he has yet to explain
how he will fund a wall with Mexico, for which that country certainly will not contribute as much as a peso.

Clearly, Trump has a credibility problem that goes far beyond his tweets, which foreign leaders have
begun to recognize that they can simply ignore. Whereas until now it appeared that America’s
NATO partners were being frightened into spending 2 percent of GDP on defense needs,
they may no longer have to do so. The Chinese may feel more confident about maintaining, or
even building upon, their aggressive posture in the S outh C hina S ea. The Israelis may now look for
clever ways to circumvent the president’s admonition not to build more settlements , knowing that their
support in Congress — where Trump’s influence clearly has taken a blow — will remain as solid as ever. The Russians may
surmise that they have little incentive to reach an understanding over Ukraine, Syria, or
anywhere else . The Iranians may act on their threat to abandon the so-called Joint Comprehensive Plan
of Action ( JCPOA ) if, as expected Congress passes new sanctions against the Tehran regime. And, most dangerously, the mad
Kim Jong Un may conclude that Secretary of State Rex Tillerson’s threats of military action are
baseless , and that he has nothing to fear from an administration that cannot even mobilize
its own party in Congress to pass the president’s high-priority legislation .
The House non-vote also has serious ramifications for the administration’s national security budget proposals. The administration’s
budget reflected the president’s priorities: it called for a $25 billion increase in the Fiscal Year 2017 budget and a $54 billion increase
in the Fiscal Year 2018 national security budget, of which $52 billion was allocated to the Department of Defense, while reducing the
budgets of dozens of domestic programs. Congressional opposition to the president’s proposals, emanating from some Republicans
as well as Democrats, was mounting even before the Obamacare debacle. In its aftermath, there will be more resistance to the
domestic program cuts, which in turn will mean either that the defense budget be reduced, or that the sequester be lifted. The latter
prospect has just become more difficult, meaning that the president’s promises to bolster America’s forces also may ring hollow.
Should that be the case, it will fuel international cynicism about the president’s ability to deliver on his promises.

Congressional inaction on Obamacare was clearly a defeat for the president , but having only
been in office less than 100 days, he certainly has time to recover .

There question is whether he, or his advisors, will recognize that blaming the speaker of the House is not the
solution, and that the true “art of the deal,” is to tone down the rhetoric and begin to find real ways

to find common ground with the Congress, including moderate Democrats ,

at least insofar as international security is concerned. This will not be an easy transformation for President Trump. Nevertheless,
unless he stops reveling in his outsider image, his fate will be that of that other outsider president — Jimmy Carter, whose record in
the White House was nothing short of dismal. It is a prospect that the president and his aides surely will wish to avoid at all costs.

All those crises risk global nuclear escalation

Michael T. Klare 17, professor of peace and world security studies at Hampshire College,
1/17/17, “Escalation Watch,” http://www.tomdispatch.com/blog/176231/

Within months of taking office, President Donald Trump

is likely to face one or more major international
crises , possibly entailing a risk of nuclear escalation . Not since the end of the Cold War
has a new chief executive been confronted with as many potential flashpoints involving such
a risk of explosive conflict . This proliferation of crises has been brewing for some time, but the situation appears
especially ominous now given Trump’s pledge to bring American military force swiftly to bear on any threats of foreign
transgression. With so much at risk, it’s
none too soon to go on a permanent escalation watch ,
monitoring the major global hotspots for any sign of imminent flare-ups, hoping that early
warnings (and the outcry that goes with them) might help avert catastrophe.

four areas appear to pose an especially high risk of sudden crisis and
Looking at the world today,
conflict: North Korea, the S outh C hina S ea, the Baltic Sea region, and the Middle East. Each of them
has been the past site of recurring clashes, and all are primed to explode early in the Trump presidency.

Why are we seeing so many potential crises now? Is this period really different from earlier presidential transitions?

It’s true that the changeover

from one presidential administration to another can be a time of global
uncertainty, given America’s pivotal importance in world affairs and the natural inclination of
rival powers to test the mettle of the country’s new leader. There are, however, other factors that make this
moment particularly worrisome, including the changing nature of the world order, the personalities of its key leaders, and an
ominous shift in military doctrine.

Just as the United States is going through a major political transition, so is the planet at large. The
sole-superpower
system of the post-Cold War era is finally giving way to a multipolar, if not increasingly fragmented, world in
which the United States must share the limelight with other major actors, including China, Russia,
India, and Iran. Political scientists remind us that transitional periods can often prove disruptive, as “status
quo” powers (in this case, the United States) resist challenges to their dominance from “revisionist” states seeking to alter the global
power equation. Typically, this
can entail proxy wars and other kinds of sparring over contested areas ,
as has recently been the case in Syria, the Baltic, and the S outh C hina S ea.
This is where the personalities of key leaders enter the equation. Though President Obama oversaw constant warfare, he was
temperamentally disinclined to respond with force to every overseas crisis and provocation, fearing involvement in yet more foreign
wars like Iraq and Afghanistan. His critics, including Donald Trump, complained bitterly that this stance only encouraged foreign
adversaries to up their game, convinced that the U.S. had lost its will to resist provocation. In a Trump administration, as The
Donald indicated on the campaign trail last year, America’s adversaries should expect far tougher responses. Asked in September,
for instance, about an incident in the Persian Gulf in which Iranian gunboats approached American warships in a threatening
manner, he typically told reporters, “When they circle our beautiful destroyers with their little boats and make gestures that... they
shouldn’t be allowed to make, they will be shot out of the water.”

Putin’s
Although with Russia, unlike Iran, Trump has promised to improve relations, there’s no escaping the fact that Vladimir
urge to restore some of his country’s long-lost superpower glory could lead to confrontations
with NATO powers that would put the new American president in a distinctly awkward position. Regarding Asia, Trump has
often spoken of his intent to punish China for what he considers its predatory trade practices, a stance guaranteed to clash with
President Xi Jinping’s
goal of restoring his country’s greatness. This should, in turn, generate additional
possibilities for confrontation , especially in the contested South China Sea. Both Putin and Xi, moreover, are
facing economic difficulties at home and view foreign adventurism as a way of distracting public attention from disappointing
domestic performances.

These factors alone would ensure that this was a moment of potential international crisis, but something else gives it a truly
dangerous edge: a growing strategic reliance in Russia and elsewhere on the early use of nuclear weapons to overcome deficiencies
in “conventional” firepower.

For the United States, with its overwhelming superiority in such firepower, nuclear weapons have lost all conceivable use except as a
“deterrent” against a highly unlikely first-strike attack by an enemy power. For Russia, however, lacking the means to compete on
equal terms with the West in conventional weaponry, this no longer seems reasonable. So Russian strategists, feeling
threatened by the way NATO has moved ever closer to its borders, are now calling for the early use of “tactical”
nuclear munitions to overpower stronger enemy forces. Under Russia’s latest military doctrine, major combat units are now
to be trained and equipped to employ such weapons at the first sign of impending defeat, either to blackmail enemy countries into
submission or annihilate them.

Following this doctrine, Russia has developed the nuclear-capable Iskander ballistic missile (a successor to the infamous “Scud”
missile used by Saddam Hussein in attacks on Iran, Israel, and Saudi Arabia) and forward deployed it to Kaliningrad, a small sliver
of Russian territory sandwiched between Poland and Lithuania. In response, NATO strategists are discussing ways to more
forcefully demonstrate the West’s own capacity to use tactical nuclear arms in Europe, for example by including more nuclear-
capable bombers in future NATO exercises. As a result, the “firebreak” between conventional and nuclear warfare -- that theoretical
barrier to escalation -- seems to be narrowing, and you have a situation in which every crisis involving a nuclear
state may potentially prove to be a nuclear crisis .
With that in mind, consider the four most dangerous potential flashpoints for the new Trump administration.

North Korea

North Korea’s stepped-up development of nuclear weapons and long-range ballistic missiles may present the Trump administration with its first great international challenge.
In recent years, the North Koreans appear to have made substantial progress in producing such missiles and designing small nuclear warheads to fit on them. In 2016, the
country conducted two underground nuclear tests (its fourth and fifth since 2006), along with numerous tests of various missile systems. On September 20th, it also tested a
powerful rocket engine that some observers believe could be used as the first stage of an intercontinental ballistic missile (ICBM) that might someday be capable of delivering a
nuclear warhead to the western United States.

North Korea’s erratic leader, Kim Jong-un, has repeatedly spoken of his determination to acquire nuclear weapons and the ability to use them in attacks on his adversaries,
including the U.S. Following a series of missile tests last spring, he insisted that his country should continue to bolster its nuclear force “both in quality and quantity,” stressing
“the need to get the nuclear warheads deployed for national defense always on standby so as to be fired at any moment.” This could mean, he added, using these weapons “in a
preemptive attack.” On January 1st, Kim reiterated his commitment to future preemptive nuclear action, adding that his country would soon test-fire an ICBM.
President Obama responded by imposing increasingly tough economic sanctions and attempting -- with only limited success -- to persuade China, Pyongyang’s crucial ally, to
use its political and economic clout to usher Kim into nuclear disarmament talks. None of this seemed to make the slightest difference, which means President Trump will be
faced with an increasingly well-armed North Korea that may be capable of fielding usable ICBMs within the coming years.

How will Trump respond to this peril? Three options seem available to him: somehow persuade China to compel Pyongyang to abandon its nuclear quest; negotiate a
disarmament deal directly with Kim, possibly even on a face-to-face basis; or engage in (presumably nonnuclear) preemptive strikes aimed at destroying the North’s nuclear and
missile-production capabilities.

Imposing yet more sanctions and talking with China would look suspiciously like the Obama approach, while obtaining China’s cooperation would undoubtedly mean
compromising on trade or the South China Sea (either of which would undoubtedly involve humiliating concessions for a man like Trump). Even were he to recruit Chinese
President Xi as a helpmate, it’s unclear that Pyongyang would be deterred. As for direct talks with Kim, Trump, unlike every previous president, has already indicated that he’s
willing. “I would have no problem speaking to him,” he told Reuters last May. But what exactly would he offer the North in return for its nuclear arsenal? The withdrawal of U.S.
forces from South Korea? Any such solution would leave the president looking like a patsy (inconceivable for someone whose key slogan has been “Make America Great Again”).

That leaves a preemptive strike. Trump appears to have implicitly countenanced that option, too, in a recent tweet. (“North Korea
just stated that it is in the final stages of developing a nuclear weapon capable of reaching parts of the U.S. It won’t happen!”) In
other words, he is open to the military option, rejected in the past because of the high risk of triggering an unpredictable response
from the North, including a cataclysmic invasion of South Korea (and potential attacks on U.S. troops stationed there). Under the
circumstances, the
unpredictability not just of Kim Jong-un but also of Donald Trump leaves North
Korea in the highest alert category of global crises as the new era begins.
The South China Sea

The next most dangerous flashpoint? The ongoing dispute over control of the S outh C hina S ea, an area
bounded by China, Vietnam, the Philippines, and the island of Borneo. Citing ancient ties to islands in those waters, China now
claims the entire region as part of its national maritime territory. Some of the same islands are, however, also claimed by Brunei,
Malaysia, Vietnam, and the Philippines. Although not claiming any territory in the region itself, the U.S. has a defense treaty with
the Philippines, relies on free passage through the area to move its warships from bases in the Pacific to war zones in the Middle
East, and of course considers itself the preeminent Pacific power and plans to keep it that way.
In the past, China has clashed with local powers over possession of individual islands, but more recently has sought control over all of them. As part of that process, it has begun
to convert low-lying islets and atolls under its control into military bases, equipping them with airstrips and missile defense systems. This has sparked protests from Vietnam
and the Philippines, which claim some of those islets, and from the United States, which insists that such Chinese moves infringe on its Navy’s “freedom of navigation” through
international waters.

President Obama responded to provocative Chinese moves in the South China Sea by ordering U.S. warships to patrol in close proximity to the islands being militarized. For
Trump, this has been far too minimal a response. “China’s toying with us,” he told David Sanger of the New York Times last March. “They are when they’re building in the South
China Sea. They should not be doing that but they have no respect for our country and they have no respect for our president.” Asked if he was prepared to use military force in
response to the Chinese buildup, he responded, “Maybe.”

The South China Sea may prove to be an early test of Trump’s promise to fight what he views as China’s predatory trade behavior and Beijing’s determination to resist bullying
by Washington. Last month, Chinese sailors seized an American underwater surveillance drone near one of their atolls. Many observers interpreted the move as a response to
Trump’s decision to take a phone call of congratulations from the president of Taiwan, Tsai Ing-wen, shortly after his election victory. That gesture, unique in recent American
presidencies, was viewed in Beijing, which considers Taiwan a renegade province, as an insult to China. Any further moves by Trump to aggravate or punish China on the
economic front could result in further provocations in the South China Sea, opening the possibility of a clash with U.S. air and naval forces in the region.

All this is worrisome enough, but the prospects for a clash in the South China Sea increased significantly on January 11th, thanks to comments made by Rex Tillerson, the former
CEO of ExxonMobil and presumptive secretary of state, during his confirmation hearing in Washington. Testifying before the Senate Foreign Relations Committee, he said,
“We’re going to have to send China a clear signal that, first, the island-building stops and, second, your access to those islands also is not going to be allowed.” Since the Chinese
are unlikely to abandon those islands -- which they consider part of their sovereign territory -- just because Trump and Tillerson order them to do so, the only kind of "signal"
that might carry any weight would be military action.

What form would such a confrontation take and where might it lead? At this point, no one can be sure, but once
such a
conflict began, room for maneuver could prove limited indeed. A U.S. effort to deny China
access to the islands could involve anything from a naval blockade to air and missile attacks on the
military installations built there to the sinking of Chinese warships. It’s hard to imagine that
Beijing would refrain from taking retaliatory steps in response, and as one move tumbled onto the next, the
two nuclear-armed countries might suddenly find themselves at the brink of full-scale war. So
consider this our second global high alert.

The Baltic Sea Area

If Hillary Clinton had been elected, I would have placed the region adjoining the Baltic Sea at the top of my list of potential
flashpoints, as it’s where Vladimir Putin would have been most likely to channel his hostility to her in particular and the West more
generally. That’s because NATO forces have moved most deeply into the territory of the former Soviet Union in the Baltic states of
Latvia, Estonia, and Lithuania. Those countries are also believed to be especially vulnerable to the kind of “hybrid” warfare --
involving covert operations, disinformation campaigns, cyberattacks, and the like -- that Russia perfected in Crimea and Ukraine.
With Donald Trump promising to improve relations with Moscow, it’s now far less likely that Putin would launch such attacks,
though the
Russians continue to strengthen their military assets (including their nuclear war-
fighting capabilities ) in the region, and so the risk of a future clash cannot be ruled out.
The danger there arises from geography, history, and policy. The three Baltic republics only became independent after the breakup of the USSR in 1991; today, they are members
of both the European Union and NATO. Two of them, Estonia and Latvia, share borders with Russia proper, while Lithuania and nearby Poland surround the Russian enclave of
Kaliningrad. Through their NATO membership, they provide a theoretical bridgehead for a hypothetical Western invasion of Russia. By the same token, the meager forces of the
three republics could easily be overwhelmed by superior Russian ones, leaving the rest of NATO to decide whether and in what fashion to confront a Russian assault on member
nations.

Following Russia’s intervention in eastern Ukraine, which demonstrated both Moscow’s willingness and ability to engage in hybrid warfare against a neighboring European
state, the NATO powers decided to bolster the alliance’s forward presence in the Baltic region. At a summit meeting in Warsaw in June 2016, the alliance agreed to deploy four
reinforced multinational battalions in Poland and the three Baltic republics. Russia views this with alarm as a dangerous violation of promises made to Moscow in the wake of
the Cold War that no NATO forces would be permanently garrisoned on the territory of the former Soviet Union. NATO has tried to deflect Russian complaints by insisting that,
since the four battalions will be rotated in and out of the region, they are somehow not “permanent.” Nevertheless, from Moscow’s perspective, the NATO move represents a
serious threat to Russian security and so justifies a comparable buildup of Russian forces in adjacent areas.

Adding to the obvious dangers of such a mutual build-up, NATO and Russian forces have been conducting military “exercises,” often in close proximity to each other. Last
summer, for example, NATO oversaw Anaconda 2016 in Poland and Lithuania, the largest such maneuvers in the region since the end of the Cold War. As part of the exercise,
NATO forces crossed from Poland to Lithuania, making clear their ability to encircle Kaliningrad, which was bound to cause deep unease in Moscow. Not that the Russians have
been passive. During related NATO naval exercises in the Baltic Sea, Russian planes flew within a few feet of an American warship, the USS Donald Cook, nearly provoking a
shooting incident that could have triggered a far more dangerous confrontation.

Will Putin ease up on the pressure he’s been exerting on the Baltic states once Trump is in power? Will Trump agree to cancel or
downsize the U.S. and NATO deployments there in return for Russian acquiescence on other issues? Such questions will be on the
minds of many in Eastern Europe in the coming months. It’s reasonable to predict a period of relative calm as Putin tests Trump’s
willingness to forge a new relationship with Moscow, but the
underlying stresses will remain as long as the
Baltic states stay in NATO and Russia views that as a threat to its security . So chalk the region up as high
alert three on a global scale.

The Middle East

The Middle East has long been a major flashpoint. President Obama, for instance, came to office hoping to end
U.S. involvement in wars in Iraq and Afghanistan, yet U.S. troops are still fighting in both countries today. The question is: How
might this picture change in the months ahead?
Given the convoluted history of the region and its demonstrated capacity for surprise, any predictions should be offered with caution. Trump has promised to intensify the war
against ISIS, which will undoubtedly require the deployment of additional American air, sea, and ground forces in the region. As he put it during the election campaign, speaking
of the Islamic State, “I would bomb the shit out of them.” So expect accelerated air strikes on ISIS-held locations, leading to more civilian casualties, desperate migrants, and
heightened clashes between Shiites and Sunnis. As ISIS loses control of physical territory and returns to guerilla-style warfare, it will surely respond by increasing terrorist
attacks on “soft” civilian targets in neighboring Iraq, Jordan, and Turkey, as well as in more distant locations. No one knows how all this will play out, but don’t be surprised if
terrorist violence only increases and Washington once again finds itself drawn more deeply into an endless quagmire in the Greater Middle East and northern Africa.

The overriding question, of course, is how Donald Trump will behave toward Iran. He has repeatedly
affirmed his opposition to the nuclear deal signed by the United States, the European Union, Russia, and China and insisted that he
would either scrap it or renegotiate it, but it’s hard to imagine how that might come to pass. All of the other signatories are satisfied
with the deal and seek to do business with Iran, so any new negotiations would have to proceed without those parties. As many U.S.
strategists also see merit in the agreement, since it deprives Iran of a nuclear option for at least a decade or more, a decisive shift on
the nuclear deal appears unlikely.

On the other hand, Trump could be pressured by his close associates -- especially his pick for national security advisor, retired
Lieutenant General Michael Flynn, a notoriously outspoken Iranophobe -- to counter the Iranians on other fronts. This could
take a variety of forms, including stepped-up sanctions, increased aid to Saudi Arabia in its war against the Iranian-backed Houthis
in Yemen, or attacks on Iranian proxies in the Middle East. Any of these would no doubt prompt
countermoves by
Tehran, and from there a cycle of escalation could lead in numerous directions, all dangerous,
including military action by the U.S., Israel, or Saudi Arabia. So mark this one as flash point four and take a deep
breath.

Going on Watch

Starting on January 20th, as Donald Trump takes office, the clock will already be ticking in each of these flashpoint regions. No one
knows which will be the first to erupt, or what will happen when it does, but don’t
count on our escaping at least
one, and possibly more, major international crises in the not-too-distant future.
1AR
PIC
 Death Spiral
Mandate is key to solve the death spiral
Kristopher Grant 8/1, Policy Analyst at the Colorado Center on Law and Policy, 8/1/2017
Enough is Enough: Lets Turn the Page and Fix the ACA, Colorado Center on Law and policy,
http://cclponline.org/enough-is-enough-lets-turn-the-page-and-fix-the-aca/
Strengthen the individual mandate. The individual mandate is the ACA provision that requires people to carry health insurance for
at least nine months out of the year, or pay a fine when they file their taxes. An
effective individual mandate is
needed to ensure that there are enough young, healthy people participating in insurance pools
whose low costs counterbalance the higher costs associated with sicker enrollees. Without an
effective individual mandate, risk pools may end up with a high a proportion of costly enrollees,
leading insurance companies to raise premiums. Meanwhile, those high costs push healthy
enrollees out of the market. This cycle is commonly referred to as the “insurance death
spiral.” The Trump administration has already contributed to instability in the insurance
market by suggesting that it won’t enforce the individual mandate. By ensuring that the
administration enforces the mandate Congress can boost participation in the insurance market,
stabilize risk pools and lower premium costs

Death spiral now---mandate is key

Bill Hammond 16, Director of Health Policy at the Empire Center, 10/8/2016, Bill
Hammond: The modest surgery Obamacare needs, Daily News,
http://www.nydailynews.com/opinion/bill-hammond-modest-surgery-obamacare-article-
1.2821923

There’s no denying that President Obama’s A ffordable C are A ct shows signs of trouble that, if left
untreated, could turn into a dreaded insurance “death spiral.”¶ The danger derives from a vicious
cycle: Not enough young, healthy people are buying insurance on the Obamacare exchanges,
which causes premiums to soar, which drives away even more young, healthy customers. ¶ But the
presidential candidates’ plans smack more of partisan button-pushing than practical problem-solving.¶
Hillary Clinton, playing to her Democratic base, wants to graft an ill-defined “public option” onto Obamacare’s struggling
insurance marketplaces. Private plans, which are already losing money on the ACA exchanges, would
suddenly face competition from some kind of government-backed plan, likely with the unfair
advantage of being able to dictate provider fees, tap public funds, or both .¶ The trickle of
major insurers walking away from Obamacare would almost certainly grow to a
gusher .¶ Donald Trump has adopted the Republican position that Obamacare should be repealed and replaced
with, in his words, “something terrific.” He vaguely proposes expanding health savings accounts, which, as
usually understood, allow consumers to take a tax deduction for out-of-pocket spending on doctors,
drugs, X-rays, etc.¶ HSAs, coupled with bare-bones insurance plans, can be a viable, attractive option for the middle and
upper classes. But income-tax deductions are little help for the working poor — who make up most of
the uninsured population.¶ The Commonwealth Fund projects that Trump’s proposals would result in 16 million to 25
million fewer Americans with coverage compared to the status quo. ¶ So Clinton is talking about ill-advised major surgery for the law;
Trump is calling for a death panel.¶ Before resorting to any such drastic measures, the next President
should at least try
the less-invasive options that might well put Obamacare on a healthier track. ¶ Written into the famously
complex law are dozens upon dozens of highly specific judgment calls — from the cutoff for Medicaid eligibility (138% of the federal
poverty level) to the maximum premium surcharge on smokers (50%). ¶ Each of these numbers was an educated guess about how to
influence the unpredictable behavior of millions of Americans. Each needs periodic fine-tuning to reflect court decisions, lessons
learned and even routine inflation. With majorities in Congress committed to killing the ACA, that routine maintenance has not
happened.¶ Especially
in need of adjustment is the tax penalty for those who fail to obtain coverage,
which is proving ineffective as an enforcement tool. As of this year, it stands at $695 per adult,
or 2.5% of income above the threshold for filing taxes, whichever is greater. A typical ACA health
plan can cost several times that much, even with federal tax credits factored in.¶ And so, many
potential Obamacare customers are opting to take the penalty and live without insurance —
gambling that the nation’s health care safety net, however tattered, will catch them in an
emergency. This is the recipe for a death spiral .¶ Other countries with personal mandates,
such as Germany and Switzerland, enforce them “brutally,” as Princeton economist Uwe Reinhardt told Vox.¶
“You make young people sign up and pay,” Reinhardt said. “But we are too chicken to do that, so we allow people to stay out by
doing two things: We give them a mandate penalty that is lower than the premium. And we tell them, ‘If you’re really sick, we’ll take
care of you anyhow.’ ”¶The fix is straightforward : Strengthen the personal mandate. Increase the
penalty on free riders, and get serious about enforcement. Balance that stick with the carrot of more generous
tax breaks for those who comply.¶ The exchanges would stabilize, insurers would stop leaving,
competition would improve and premiums would moderate.
 AT Reinsurance
Reinsurance cant solve – doesn’t offset other insurer concerns
Maura Monaghan 17, et. al, Attorney at Debevoise and Plimpton, 7/24/2017, How Section
1332 Waivers Could Impact Health Care Reform,
https://www.law360.com/articles/946530/how-section-1332-waivers-could-impact-health-
care-reform
Section 1332 waivers present both opportunities and risks for the health care industry. ¶ The
current instability in many
state ACA exchanges has significant downsides for health insurers. Some insurers are having
difficulty selling profitable exchange plans due to the combination of high enrollment in
exchange plans among sick people and low enrollment among healthy people. This instability
also has a negative impact on health care providers, pharmaceutical companies and device
manufacturers. To the extent health insurance is unavailable or unaffordable, fewer people are
likely to be insured — with the result being that fewer people can purchase health care goods and services. The opposite is
true as well: States that enact successful waiver programs will provide opportunities for nearly everyone in the health care industry. ¶
To the extent that Section 1332 waivers allow states to establish reinsurance programs that reverse
the current instability in the exchanges, everyone will benefit. However, it is yet far from
certain that simply instituting reinsurance programs will be sufficient to stabilize
states’ individual markets. HHS touted the reinsurance waiver model based on one year of
experience in Alaska. Alaska is unique because of its small population. It remains to be
seen how such reinsurance programs will work in other states. In particular, reinsurance
programs may not have sufficient funding to offset other market forces that cause
premiums to rise. Such factors may include healthy people declining to purchase
insurance on the exchanges and uncertainty as to whether the federal government will
continue funding cost sharing reductions.¶ While some states may simply use Section 1332 waivers to establish
reinsurance programs, others may use the waivers to seek more comprehensive reform. To the extent states are open to significant
reforms, Section 1332 waivers create opportunities for strategic decision-making. Health care companies that are located in states
that are receptive to Section 1332 waivers have a unique opportunity to shape the development of waiver applications. As many
states may lack the sophistication to develop wholesale changes to their health care programs, health care companies may be able to
offer their expertise in accomplishing those objectives. Additionally, companies that are willing to develop innovative models for
providing insurance, offering care or selling products may find unique opportunities to develop or invest in states that use Section
1332 waivers to develop new mechanisms for financing and delivering health care. ¶ That being said, Section 1332 waivers also create
potential downsides. The
possibility exists for significant changes to health insurance
regulations that are harmful to the interests of particular industry subsectors. For example, a
state might consider a waiver that would allow insurers to offer low-cost plans that would be attractive only to young, healthy
individuals. Such plans could segment the market between healthy people enrolled in low-cost plans and sick people enrolled in
“traditional” ACA plans. Health insurers have recently warned that such market segmentation would be damaging to their business
operations. A similar risk would arise if a state is considering a waiver that would allow insurers to omit a particular essential health
benefit. Providers that offer the now-omitted benefit could experience significant business losses as a result. At the very least, the
possibility that states may adopt waivers that would harm particular business interests may complicate decisions about investing in
potentially impacted businesses in those states.
DA
 Turn
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.

crowd outs locals, increases drug prices ---- crashes india econ
Leigh Turner 7, Associate Professor and William Dawson Scholar in the Biomedical Ethics
Unit and Department of Social Studies of Medicine at McGill University, ‘First World Health
Care at Third World Prices’: Globalization, Bioethics and Medical Tourism, BioSocieties, Issue 2,
http://web.mnstate.edu/robertsb/390/First%20World%20Health%20Care%20at%20Third
%20World%20Prices.pdf
When journalists express concerns about possible dangers associated with international medical travel, they commonly focus upon
risks to individuals leaving Canada, the United States and the United Kingdom and travelling to comparatively inexpensive health
care facilities. Though risks to health travellers require much more detailed exploration and far better data collection, few
commentators address possible harms to inhabitants of destination countries (Mudur, 2003, 2004b; Sengupta and Nundy, 2005).
While business executives and government ministers in these countries commonly emphasize the benefits of expanding local
 undesired outcomes could emerge from increasing
markets for international medical travel, some serious,
the flow of Europeans and North Americans into health care facilities located in such countries as
India, Malaysia, Singapore and Thailand.¶ Perhaps 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. Many countries are making significant investments to become
regional ‘biomedical hubs’. However, there will presumably be winners and losers in the struggle
for market share of international patients. Public resources might better be put into publicly
funded health care rather than into promoting for-profit initiatives intended to generate trickle-
down effects through the larger economy. In some countries, cost–benefit estimates leading to
the conclusion that there will be a significant return on investment of public and
private funds are likely to be wrong . India, Thailand and Singapore are already well positioned to attract
patients from other countries. It is unclear that Indonesia, Hong Kong, Malaysia, the Philippines, South Korea and Taiwan will all
benefit from similar national economic strategies. Investing public funds into preventive medicine, public
health care and basic social infrastructure might generate more predictable population-level
benefits. Directing public funds toward specialized medical centres and advanced
biotechnologies is a particularly questionable decision when most citizens of a country lack
access to basic health care and social services.¶ The phenomenon of ‘crowding out’ is another problem associated
with drawing international patients to health care facilities in India, Thailand and Singapore. If large numbers of
international patients flow into a country, the cost of health care will likely climb for local
patients. Salaries of physicians, nurses and other health care providers will escalate . Health care
could become less accessible to local patients. This problem could disappear if economic benefits ripple through society and entire
populations benefit from national economic development. However, if benefits are captured by
socioeconomic elites and never reach the poorest members of society, some local
citizens could have even worse access to health care than they had prior to the
arrival of large numbers of international medical travellers . ¶ The challenge
international medical travel poses to health equity is perhaps the greatest problem facing
countries promoting medical tourism. Singapore promotes international medical travel while also dedicating
substantial public resources to preventive medicine and publicly funded health care. Even with this investment, visitors to
Singapore commonly have access to therapies most local citizens cannot afford to purchase .¶ Government
documents in Singapore express concern that local citizens might demand higher-quality, more expensive medical care if they see
what international patients receive. Policy documents note the possibility that the ‘demonstration effect’ of providing expensive,
specialized, advanced care to international patients could lead to demands for costlier health care. One proposed solution to this
problem involved segregating Singaporean patients and international patients, and ensuring they receive treatment in different
facilities. This arrangement was dismissed by government planners as impractical. The more serious problem that the Singapore
that promotion of
government needs to face, as with other governments promoting the regional medical hub strategy, is
international medical travel will generate a scenario where patients from other countries can
purchase considerably better health care than what most local patients can afford. Focusing upon the
‘demonstration effect’ obscures fundamental questions about social justice and how to improve access to health care for the poorest
members of society.¶ The
health equity problem facing Singapore is even more significant in such
countries as India, Indonesia, Malaysia and Thailand. With appropriate financing, auditing and regulatory
mechanisms, perhaps revenues generated from international patients could be used to improve access to care for local citizens.
However, if profits from providing care to international patients are not used to cross-subsidize and improve care of local patients,
the already massive health equity gap in India and Thailand will widen. What could emerge in many countries is what has already
taken shape in India. Elite, high-quality medical facilities could offer health care that is unaffordable to all but a tiny segment of local
individuals. Access to the best medical facilities would be limited to the wealthiest local citizens and paying patients from other
countries. Instead
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 society (Gawande, 2003; Sengupta and Nundy, 2005; Wibulpolprasert et al., 2004). ¶
Conclusion¶ The US $190,000 gap between what Howard Staab was told he would have to pay for health care in Durham and what
he was charged in Delhi helps explain why some uninsured and underinsured Americans are travelling to
India, Thailand and other countries in search of affordable health care. They simply cannot afford health
care in the United States. If the cost of health insurance was lower, their earnings were higher or the
United States offered universal health insurance, most of these individuals would presumably
prefer the convenience and comfort of receiving care in their local communities . In Canada and the
United Kingdom, universal health insurance means that local health care is publicly funded. However, long treatment delays and
rationing decisions that block access to particular drugs, medical devices and medical procedures prompt patients to travel for
health care.¶ Medical brokerage closes the gap between prospective patients in one country and medical facilities elsewhere around
the world. Inexpensive air travel, low-cost telecommunications and the internet help patients arrange travel to affordable health care
destinations. As small businesses, larger corporations and government agencies get involved, international medical travel is shifting
toward a more institutionalized and bureaucratized process. If businesses and governments begin offering economic incentives to
encourage travel to low-cost health care facilities, we might see a rapid increase in the number of patients travelling in search of
health care to countries such as India and Thailand. How common international health travel will become is impossible to predict.
Textile plants were once a major source of jobs for American workers. The textile industry has now largely relocated to other
countries. Automobile manufacturing once provided a huge number of jobs for American factory workers. Automotive plants remain
in American but large numbers of factories have relocated to Mexico, China, Thailand and other countries. The health care industry
will never entirely relocate from the United States, Canada, the United Kingdom or any other country. Some aspects of health care
must be locally offered and received. Emergency medical care needs to be locally available. With inexpensive forms of health care
there is no reason to travel elsewhere in search of treatment. However, it is possible that multiple factors could push an increasing
amount of health care from such countries as the United States and Canada and toward such countries as India, Thailand and
Singapore. Various bodies— governments in these nations, tourism agencies, medical brokerages, private hospital associations and
investors—are working to achieve this outcome. Their actions are generating results.
 Impact d

No impact uq---Modi is already a hindu nationalist, but he won’t nuke

anyone because that would wreck international perception of India
Nikhil Kumar 16, India correspondent for Time, citing Happymon Jacob, an expert on
Indian-Pakistani relations at Delhi’s Jawaharlal Nehru University, “Narendra Modi Pulls India
Back From the Brink on Pakistan,” 9/27/16, http://time.com/4509347/india-pakistan-kashmir-
clash-narendra-modi/
Which is why all eyes have been on Indian Prime Minister Narendra Modi ever since four gunmen attacked an Indian
military base near the LoC on Sept. 18. Eighteen Indian soldiers died in the raid on the base in the Kashmir town of Uri, making it
the worst such attack in more than two decades. India says the gunmen came from across the LoC, a charge Pakistan rejects.

As tensions rise, prominent voices from within Modi’s right-wing Bharatiya Janata Party (BJP) have
turned up the heat with war-like rhetoric. Ram Madhav, a BJP leader and close ally of Modi’s, signaled that the days
of Indian restraint were over, saying: “For one tooth, the complete jaw. If terrorism is the instrument of the weak and coward (sic),
restraint in the face of repeated terror attacks betrays inefficiency and incompetence. India should prove otherwise.” A growing
clamor for a strong response from sections of the Indian media, along with Modi’s own past statements criticizing previous Indian
governments for being soft on Pakistan, fanned uncertainty about what might follow the Uri attack.

But in a speech this past weekend, Modi

signaled that his government would stick to a longstanding
Indian policy of treading carefully when it comes to provocations by Pakistan, stepping up
efforts to pressure its troublesome neighbor diplomatically, rather than militarily . “I want to tell
the people of Pakistan, India is ready to fight you,” he said at a BJP meeting in southern India. “If you have the strength, come
forward to fight against poverty. Let’s see who wins. Let’s see who is able to defeat poverty and illiteracy first, Pakistan or India.”

Analysts say Modi's stance is the result of India’s recognition of the risks of a military clash .
War with Pakistan would cast a shadow over India’s growing economy—its the fastest-growing big
economy in the world—as well as raising international alarm . “They [the Modi government] have realized
that military escalation is next to impossible given the circumstances,” says Happymon Jacob, an expert on
Indian-Pakistani relations at Delhi’s Jawaharlal Nehru University. “Having gone through some discussion, the government of
India has come to the conclusion that you can only escalate this diplomatically and
politically , which is exactly what they are doing.”
There's also the question of whether India even has the capacity to wage war. A recent report from the Carnegie Endowment for
International Peace in Washington noted that many of the Indian Air Force’s frontline aircraft were obsolete, while a 2015
assessment by Indian government auditors highlighted worryingly inadequate army ammunition stockpiles.

Ultimately, Modi
must balance the demands of the different constituencies at home and abroad,
explains Ashok Malik, a senior fellow at the Observer Research Foundation think tank. Domestically, the
Prime Minister
faces pressure “to be seen to be doing something in response to this attack,” he says. But internationally,
India also recognizes the need to build “an even stronger case against Pakistan and emphasize that
[terrorism linked to] Pakistan is a challenge not just for India but also the rest of the world.” India’s Foreign Minister Sushma Swaraj
pursued this strategy in her speech at the U.N. General Assembly in New York on Sept. 26, when she placed the Uri attack in the
context of other recent terror attacks around the world. A day later, India sought to add to the diplomatic pressure on Pakistan by
withdrawing from an upcoming meeting of the South Asian Association for Regional Cooperation, a regional grouping, in Islamabad.
Modi had planned on traveling to Pakistan for the summit.
No risk of an arms race---Indian nuclear restraint is locked in
regardless of Pakistan
Alexander Mosesov 15, Political-Military Reporter w/Sputnik News Agency, citing Toby
Dalton, Co-Director of the Nuclear Policy Program at the Carnegie Endowment for International
Peace, and Michael Krepon, co-founder of the Stimson Center, “India Unlikely to Enter Nuclear
Arms Race With Pakistan,” Sep 1 2015,
http://sputniknews.com/analysis/20150901/1026418194.html

a nuclear arms race between India and Pakistan is highly unlikely even if Pakistan
The possibility of

decides to enlarge its own nuclear arsenal significantly in the coming decades, experts and authors of the recent report on Pakistan’s
nuclear program told Sputnik on Monday.¶ MOSCOW (Sputnik), Alexander Mosesov – Last week, the Carnegie Endowment for International Peace and the Stimson Center, two US-based think tanks, published a
report entitled "A Normal Nuclear Pakistan." It predicts that if Pakistan continues to grow its nuclear arsenal at the current pace, it will take just ten years for the country to become the world's third-largest
nuclear power, after the United States and Russia. ¶ While Pakistan currently has the sixth-largest nuclear arsenal in the world, behind the United States, Russia, France, China and the United Kingdom, media
quoted a senior Pakistani government official as saying that the report’s projections were "highly exaggerated" and that Pakistan was "a responsible nuclear state, not a reckless one." ¶ According to the data by the
Federation of American Scientists (FAS), Pakistan has about 120 warheads at its disposal, while India has about 110. But massive buildup of Pakistan’s nuclear might become a headache for its neighbor India. ¶

Toby Dalton, Co-Director of the Nuclear Policy Program at the Carnegie Endowment for International Peace and co-
author of the Pakistan’s nuclear program report, told Sputnik that there was "a strong inclination toward minimum

deterrence" in India .¶ According to Dalton, this inclination, coming from the country’s political elite ,
"may dampen technological and military pressures for a larger arsenal." ¶ His colleague and co-author,
Michael Krepon, who is also a co-founder of the Stimson Center, noted that whether India would reply with scaling up its own arsenal was an open question. ¶ "Given the history of the US-Soviet

competition, we would assume so. But New Delhi doesn't think about nuclear weapons the way we did, and still do," Krepon said.¶

Speaking about India’s own nuclear strategy, Toby Dalton underlined that it was "not Pakistan-specific , but caters to both Pakistan and

China."¶ "Most of the activity in its nuclear program at this point (testing of long-range ballistic missiles, consideration of MIRVs, develop of SSBNs) is more oriented

toward China than Pakistan," Dalton explained.¶ At the same time, his colleague Michael Krepon noted that the rate of Chinese nuclear arsenal’s
growth appeared to be less than Pakistan's . FAS data shows China currently has 250 nuclear
warheads at its disposal.