1NC

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Topical affs must establish national health insurance

Establish means to originate- not increase something that already exists

Words and Phrases, ‘50 [1950, VOL. 15, P. 261]

To “establish” means to originate, to found, to institute, to create; not to acquire something

which has already been brought into existence. As used in Village Laws, §223, relating to
propositions to establish a system of waterworks, it contemplates, in part at least, a construction as
distinguished from a purchase. Village of Hempstead v. Seymour, 69 N.Y.S. 462, 463, 34 Misc. 92.

NHI means universal and government financed

Medical Dictionary, 9
[9th edition, 2009, Farlex and Partners, in The Free Dictionary, http://medical-
dictionary.thefreedictionary.com/national+health+insurance, accessed 8-7-17]

national health insurance

A form of health insurance coverage whereby all of a country's citizens receive care financed by
their government. Countries with national health insurance include Canada and the United Kingdom.

The public option is neither

Holahan, 9 – Urban Institute Health Policy Center director
[John Holahan, PhD, Robert, MD, Urban Institute Fellow, and Stephen Zuckerman, PhD, Urban Institute
Health Policy Center senior fellow, "Getting to a Public Option that Contains Costs: Negotiations, Opt-
Outs and Triggers," Health Policy Center, November 2009,
www.urban.org/sites/default/files/publication/30756/411984-Getting-to-a-Public-Option-that-Contains-
Costs-Negotiations-Opt-Outs-and-Triggers.PDF, accessed 7-25-17]

What Is a Public Option? Before considering how a public option would be designed, it is
critical to understand some basic parameters of the policy. First, the public option would be one
of several plans available to individuals through the health insurance exchange. No one
would be required to choose the public option . Government subsidies would be available to modest-
income individuals and families purchasing health insurance through the exchange, and could be applied
to the purchase of a private plan or the public option. The subsidies are structured as limits on the share
of income that households would have to pay for their coverage. The percentage of income required of
individuals and families to contribute toward their premium increases as family income increases. Subsidy
amounts are calculated based upon a benchmark, or reference, premium computed as an average of the
three lowest-cost plans offered within the exchange.4 The same subsidy amount, computed in this way,
would be available to income-eligible people regardless of whether they enroll in a private or a public plan
through the exchange. A low-cost public option would produce savings primarily to the government, with
smaller savings for individuals and families. For plans that were more costly than the benchmark,
individuals would have to pay the full marginal cost. Second, a public option would not be funded with
federal tax dollars. It would participate as a national plan in the exchange but would be legally
and administratively separate from the exchange itself. Rather than the public option receiving
direct financial support, the plan would be sustained by contributions from enrolling individuals,
families, and employers along with subsidies provided to low-income people—exactly the same
terms as an exchange-participating private plan. In other words, it is the subsidies that drive
government costs, not the public option. The public option would have startup costs, but these would
have to be built into its rates, with the startup cost fully paid back over time. The plan should not be
able to return to Congress to obtain additional government support if costs exceed premiums; rather,
premiums would increase and the market share of the public plan would fall. Third, the public option
would have to follow the same insurance rules established for all plans participating inside and outside
exchanges. The benefit packages and cost sharing offered by the public option would have to meet the
standards established for all plans. All exchangeparticipating plans, public and private, would participate
in a risk adjustment system. To the extent that any plan, public or private, enrolled a disproportionate
share of highcost persons, the exchange would redistribute a portion of total collected premiums to offset
differences in risk and ensure that no plan serving a higher-need population was placed at a competitive
disadvantage.

Vote neg:
our interp requires big changes that cover everyone—that’s key to ensure the neg
always has stable ground—like cost shifting bad and their interp allows countless
small fixes to the ACA which destroys limits
 2
Dems will win the House – generic ballot lead is predictive and stable – but not
insurmountable for the GOP
Cohn 12/20 (Nate Cohn is a domestic correspondent for The Upshot. He covers elections, polling and
demographics. Before joining The Times in 2013, he worked as a staff writer for The New Republic.
“Democrats Are Dominating the Generic Ballot. What Does That Mean?”
https://www.nytimes.com/2017/12/20/upshot/democrats-2018-congressional-elections-polling.html)

Despite all the unusual political events of the last few years, one thing in electoral
politics is proceeding by the book: the growing Democratic advantage on the generic
congressional ballot. The generic ballot is a poll question that asks voters whether they’ll vote for
Democrats or Republicans for Congress, and historically it’s been a decent predictor of the
House popular vote. Democrats now lead by over 13 points, according to the FiveThirtyEight
generic ballot tracker, after a CNN/SSRS poll on Wednesday gave Democrats a staggering 18-point
edge, 56 percent to 38 percent. A 13-point edge would be similar to or larger than their
advantage in 2006, when Democrats won control of both the House and the Senate. Although the size
of the advantage seems startling, a Democratic edge on the generic ballot is not that much of a surprise.
All of the conditions for a big Democratic victory seem to be in place. The president’s
approval rating is in the mid-30s. Republicans have full control of government heading
into a midterm election. And an unpopular tax bill may be at least partly responsible for
the increased Democratic edge over the last month or so. It’s a bad sign for the
Republicans next November. It’s probably enough to make the Democrats fairly clear if
modest favorites to retake the House, despite their structural disadvantages in the
chamber. Here’s what you need to know about the generic ballot. First, You Can Care About It Now
Yes, the midterm elections are still 11 months away. But among the various measures of
American public opinion, the generic ballot is about as stable as it gets. As FiveThirtyEight’s
Harry Enten wrote months ago, even the very earliest generic ballot polls tend to correlate
with the final generic ballot polls. There’s a tendency for the polls to drift toward the
party out of power — and that’s exactly what has happened over the last few months. At this later
stage, the generic ballot is even more stable than it was when he wrote about it in April. Since 1970, there
has been surprisingly little movement between generic ballot polls taken between 221 and 421 days
ahead of the midterms — we’re at 321 today — and those taken over the final 30 days. The average shift
is just 2.4 points. I can’t think of any other measure of political sentiment that tends to be so stable. This is
probably because the generic congressional ballot isn’t about a specific race. It’s a lot easier for news or
events to move views of a specific race than to move the overall national political environment. The tax
debate may be the sort of thing that could yield a temporary shift in the generic ballot, especially since
polls show that the Republican tax plan is deeply unpopular. It is possible that Republicans could gain
some ground back if the tax debate is responsible for the recent decline in their support. Sometimes there
are larger shifts. In 2010, for instance, the generic ballot moved decisively toward the Republicans
between December 2009 and Election Day. This is in keeping with the tendency for the generic ballot to
shift toward the party out of power; it is also a result of the switch from registered to likely voters in polling,
which generally helps Republicans. But this is a reminder that there’s time for the generic ballot to move a
lot between now and Election Day — even if it usually does not. It’s a Pretty Good Predictor of the House
Popular Vote The final generic ballot polls — and, for that matter, generic ballot polls taken
221 to 421 days ahead of the election — tend to do a solid job of predicting the final
national popular vote. It’s not a perfect relationship, of course, and the record of generic ballot polling
gets fairly sparse before 1990 or so. But even including the years of sparse data, the average of generic
ballot polls over the final 30 days of the race misses the popular vote by only an average of 4.1 points.
That’s not perfect, but it makes a 13-point lead look pretty strong. It Is Not Realistic for the G.O.P.
to Survive a 13-Point Loss in the Popular Vote Gerrymandering, incumbency and the tendency
for Democrats to win urban areas by lopsided margins combine to give Republicans a
considerable advantage in the fight for control of the House. It gives the party a chance
to survive a so-called wave election, like the one that brought Democrats to power in
2006 or the one that swept Republicans to House control in 2010. But it is very doubtful that
Republicans would survive a 13-point loss in the popular vote. We’ll go into this in more detail
next year, but for now my view is that Republicans have a realistic chance to survive up to
around an eight-point deficit in the popular vote. There isn’t a serious argument that they have a
real chance to survive with a deficit of 13 points. One (Possible) Bit of Good News for the G.O.P. Isn’t
Good Enough There’s one potential bit of good news for Republicans: Historically, parties have
struggled to match landslide margins on the generic ballot with landslide margins in the
popular vote. For instance, Democrats in 2006 had an 11.5-point lead in the final RealClearPolitics
average on the generic ballot but won the popular vote by eight points. Similarly, Republicans in 2010 had
a nine-point lead and won the popular vote by seven points. Typically, there would be no reason to pay
attention to this kind of difference between the polls and the outcome of so few elections. But the generic
ballot is unusual: It’s generic. It doesn’t directly measure attitudes about the actual ballot that voters will
cast. And some generic polls ask which party voters would prefer to see in control of Congress, not
whether they’ll vote for Democrats or Republicans. You can think of it as somewhere between a
presidential horse race poll and presidential approval ratings. Both are highly correlated with presidential
election results, but the latter is just a correlate of presidential vote choice, while the former is a direct
measurement. It is well acknowledged that a 25 percent approval rating may signal only, say, a 12-point
loss rather than a 50-point loss. The empirical evidence does hint at bias in the relationship between the
generic ballot and the popular vote, but it’s not conclusive. On the other hand, there’s a decent theoretical
case that it’s close enough to a direct measurement of congressional vote choice that it can be treated as
such. Whether there’s such a bias makes a difference. If you assume that, over the long run, the generic
ballot yields an unbiased estimate of the popular vote, the Democrats might be poised to do
better than they did in 2006, for example, since Democrats won the popular vote by only eight points.
If it is biased, an 11.5-point Democratic generic ballot lead might yield only an eight-point popular vote
edge, like in 2006, and the House might still be something closer to a tossup. But today’s generic
ballot polls give Democrats an even larger lead than the one they had in 2006 or that the
Republicans had in 2010. The president’s approval rating is lower as well. That doesn’t
guarantee that the Democrats will do better than they did in 2006 — or than the Republicans did in 2010.
But it does mean that it’s the best estimate based on the available indicators of the national
political environment. If it holds up, Democrats are favored to retake the House.

The GOP’s digging their own grave but fully enacting the public option saves
them
Chris Weigant 17, HuffPo political commentator, 6/28/17, “Democrats Should Bring Back The Public
Option,” http://www.huffingtonpost.com/entry/democrats-should-bring-back-the-public-
option_us_595449bee4b0f078efd98746 *edited for language

Up until now, congressional Democrats have been smart to merely stand on the sidelines
and watch Republicans flail on their “repeal and replace Obamacare” efforts. This follows
the sound political theory of: “When your opponent is digging his [their] own grave, don’t
interrupt him.” But at some point in the near future, Democrats are going to have to offer up their own
better ideas for what to do next on health care. There are already many pushing for single-payer or (as
Bernie Sanders likes to call it) “Medicare for all.” This, however, is quite likely a bridge too far ― even
within the Democratic Party. Instead of such a radical change, Democrats would do much better to rally
around a more transitional idea that was jettisoned during the drafting of the Obamacare law: the public
option.

The biggest political selling point about this is that a public option would be just that ―
optional. Call it “Medicare for all, if that’s what you want,” perhaps. Or rebrand it entirely as something
like “Medichoice,” to take its place alongside Medicare and Medicaid. By doing so, Democrats could avoid
a tsunami of Republican negative ads which screamed: “Washington bureaucrats are going to force you
into their plan!” But unlike universal single-payer, Medichoice might actually have a prayer of
garnering Republican votes and passing this Congress .

If the Senate Republican bill fails (which is by no means assured, even at this point), then Mitch
McConnell has already expressed an interest in working with Democrats to fix some of the
worst problems with Obamacare, because McConnell knows that if the system collapses at this
point, Republicans will be held accountable for letting it happen. Fixing Obamacare mostly means
addressing the problems with the individual market exchanges (a relatively small part of Obamacare, but
also the most publicly visible). This could probably be quickly accomplished with a good-faith effort by
both parties, and it may indeed be all that happens to Obamacare for the next two years. But
Democrats should at least make the attempt at something more ambitious in these
negotiations. Even if they fail , they will at least have created a campaign platform for the 2018
midterm elections ― a positive message of change instead of just “we’re not as bad as those
evil Republicans.”
Many Democrats ― including, now, Elizabeth Warren ― are convinced that this next step should be a
push for single-payer. But while they’re right that this should be the ultimate goal, to push too hard for it
now only sets Democrats up for another round of massive disappointment. In the first place, to get
anything passed now would require not just a unified Democratic Party, but also peeling off a significant
amount of Republican votes in both the House and Senate. Does anyone expect any single-payer plan to
clear this very high bar in the next year and a half? I don’t.

Regular readers of mine know that I am not generally a big fan of incrementalism. I regularly take
Democrats to task for being too timid and for not thinking big enough (including, most prominently, Hillary
Clinton). But with the congressional math Democrats currently face, at this point it seems like the best that
could even be reasonably hoped for. So while I would support an eventual move to single-payer, I just
don’t now see it as a realistic possibility, unless Democrats have a spectacular midterm election and
regain control of both houses of Congress. Until that comes to pass, though, I think the public option is
what Democrats should focus on.

The recent history of single-payer efforts at the state level bears this out. At least two states have
attempted to move to this liberal Utopia of health care for all. They both failed, when confronted with the
cost. Politically, single-payer couldn’t even get enough support in deep-blue Vermont and California, so
it’s hard to see the entire country getting behind the idea at this point.

The political problem isn’t so much the cost as it is the disruption to the system. This disruption wouldn’t
just impact the insurance companies and health care providers, it would also radically change everyone’s
paychecks. Even if your take-home pay turned out to be exactly the same as before, how it got to that
figure would be very different. Change scares people, to state the obvious, and it’s clear that not
everyone’s take-home pay would be exactly the same. There would be winners and losers, most likely. It
would be incredibly disruptive to everyone’s paycheck, even if you turned out to be one of the winners.
Another political problem is the sheer size of the numbers involved. Take the case of California. This
year, the state senate passed a single-payer bill. The only problem? It didn’t address the funding for the
program at all. They were trying to punt that thorny problem to the state assembly (which, in response,
just refused to deal with the bill). Single-payer care in California would cover everyone, at a projected total
cost of $400 billion per year. Of that, something like $200 billion would be from federal funds, and the rest
would have to be made up with a new income tax. This tax would replace all the money now paid by both
employers and employees for health insurance. An academic study found that doing so ― even while
insuring all the currently-uninsured people in the state ― would successfully save California something
like $37 billion each year. Even so, that $400 billion number is huge. By comparison, California’s entire
state budget (including federal aid) is currently only $250 billion a year.

What true single-payer systems lack is choice. Absent that choice, everyone is forced into the new
system. But American voters aren’t crazy about being forced into much of anything. The liberal dreamers
insist that since the new system will be so much better, everyone just needs to bite the bullet, adapt to the
change, and happiness will then ensue for all. But such technocratic “we know what’s best for you, trust
us” thinking is not exactly a proven winner at the ballot box. This reason alone is why the better route for
Democrats to take would be a public option, or Medichoice ― in other words, “we think it’s better, but the
choice is totally up to you.” This is a much easier political message to sell, for obvious reasons.

Which is why more attention should have been paid to what recently happened in Nevada, rather than to
California and the other states attempting true single-payer. Because Nevada attempted to create a
“Medicaid-for-all” system, which is just another way of saying “a public option.” It passed the statehouse,
but the governor vetoed it, mostly due to lack of specifics (the entire bill was reportedly only four pages
long). But what was proposed is exactly what Democrats should consider proposing nationwide.

The Republicans have been complaining about Obamacare since before it was even
written. Most of their criticisms were wildly inaccurate, designed merely as scary stories to frighten the
public (see: death panels, Sarah Palin). But since Obamacare has become law, they have had to
refocus their complaints on the reality of Obamacare. In the health care debate this year, their
complaints have focused on three flaws with the exchanges: rising premiums, lack of choice
in certain counties and states, and large deductibles.
Introducing a public option would seem to address all of these problems . It would provide a choice
for everyone in every county. It would stabilize the premiums and deductibles by giving the private
insurance companies a baseline to shoot for. It would guarantee that Republicans couldn’t complain that
there were “zero” choices on the exchanges in certain parts of the country.

Of course, the insurance companies would howl, but they had their chance ― and in the places that
currently only have one or zero choices, the private marketplace has obviously failed to deliver. Perhaps
the system could be phased in, initially only covering markets with fewer than three insurers on the
exchanges. But eventually, everyone in the country should get the same choice ― buy private health
insurance in some fashion (through employer-provided insurance or through the exchanges), or sign up
for the public option instead.

The Nevada legislators obviously weren’t completely serious about their new idea. Four pages? That’s
not much detail. Studies would have to be done to figure out how many people would choose a public
option if offered, what such a public option would actually cover, and what all the expected costs would be
(premiums, deductibles, and other out-of-pocket costs for consumers; as well as the government’s costs
to run the system). But at least Nevada moved the debate forward in a significant way. They have shown
there may be a possible compromise to be struck between those demanding single-payer health systems
and those who just want to fix the worst problems of the Obamacare system already in place.

Over time, if enough people migrated to the public option, either through choice on the exchanges or
through employers deciding to sign their workers up for the idea, then the American insurance market
would have to change to adapt. It would move towards a system already in use in several European
countries (France or Ireland, for instance), where basic health insurance is provided on a single-payer
basis, but private insurance also exists for a whole range of extras ― lower out-of-pocket costs, better
hospital rooms (private instead of shared), and other enticements. American insurance companies would
turn to concentrating on selling such extras, and the public option could begin to morph into a basic
guarantee of health insurance for all (a real universal single-payer system instead of an optional one).

Because health insurance is such a contentious issue, this would seem to be the better path forward.
Defining it as Medichoice rather than single-payer would be a lot more appealing to a lot more people,
perhaps on both sides of the political divide. It would only be an incremental step forward, not the giant
leap towards single-payer some now wish to see, but it would be a lot more possible politically. A few
Blue Dog Democrats killed the possibility of the public option in Obamacare (Max Baucus and Joe
Lieberman, to name the two most prominent), but it now seems like an idea whose time has come. The
national Democratic Party should closely examine what Nevada just tried to do, and then dive
deep into the details to see how plausible such a system could be, nationwide. Then when
the time is ripe (when either the Republican plan dies in the Senate or passes and begins throwing
people off their insurance by the tens of millions), Democrats would have a solid plan ready on a
better way to move forward. For now, it’s fine that they’re content to sit back and watch
Republicans shoot themselves in the foot, but at some point in the very near future, Democrats are
going to need to be ready and willing to offer a way forward that actually solves problems with the health
care system by making it better for more people, rather than (as with the GOP plan) making all the
problems much worse.

House loss means Trump will be impeached, guts his presidency

Tim Marcin, journalist, “Donald Trump Will Be Impeached if Democrats Win the House in 2018,
Conservative Pundit Predicts,” NEWSWEEK, 8—3—17, www.newsweek.com/donald-trump-will-be-
impeached-if-democrats-win-house-2018-conservative-645974, accessed 8-4-17.

President Donald Trump

should keep his eyes on the 2018 midterm election s , according to one conservative writer,
because he'll be impeached if Republicans don't hold on to majority control of the House of
Representatives. That's not to say he'd necessarily be removed from office, but John Podhoretz of Commentary magazine and the New York Post
predicted that Trump would likely face at least impeachment proceedings should Democrats take the House. Podhoretz made this comment during a
segment on MSNBC's Morning Joe, during which a panel was discussing the president's historically low approval ratings. Trump hit a new low
Wednesday in both the right-leaning Rasmussen Reports daily survey and a Quinnipiac University poll. In the latter, just 33 percent of voters said they
approved of the job he's doing. Morning Joe co-host Joe Scarborough brought up the possibility that Republican voters would abandon Trump in the
2020 presidential campaign should a conservative try to challenge him, but Podhoretz responded by pointing to 2018. "You're jumping pretty far ahead
in time, and we're going to have an election next year. And the simple fact of the matter is if [Trump's] got 80 percent [approval] in Alabama, it's not like
a Democrat is going to win the Senate in Alabama," Podhoretz said. "There is actually a senatorial race in Alabama, and no Democrat is going to win
that now or in 2018. That's not the issue." The conservative columnist and pundit—who is not a fan of the former reality-TV star—then shifted to what
he felt was the most important thing to note about 2018: the potential for Trump to be impeached. He even brought up the last commander in chief to
be impeached, Bill Clinton. "The plain political issue is Democrat s need 24 House seats to take the
House back in 2018," Podhoretz said. "The table is being set pretty nicely for them to get that number.
And if they get that number or 10 more than that number, he's going to get impeached. I'm not saying he's going to be convicted
and thrown out of office—I'm saying that the House will impeach him if Democrats have a 10-seat majority. And if he doesn't right the
ship, he's writing his own—he's Clinton in 1998 and 19 99 , with no recovery possible, Clinton was doing that at a time
of explosive economic growth." Suggestions of impeachment have been frequent during Trump's brief but tumultuous tenure in the White House.
House Democrats even filed articles of impeachment last month, but they stand little chance of going anywhere, since Republicans have a majority.
The president's involvement in the ongoing investigation into his administration's connections to Russia has reportedly worried some advisers. Notably,
there was the recent revelation that he fed his son Donald Jr. a misleading statement about a meeting he took with a Kremlin-connected lawyer to hear
about supposedly damaging information on Democratic presidential nominee Hillary Clinton. Obstruction of justice has long been considered an
impeachable offense, and The Washington Post reports that aides close to Trump worry he has opened himself up to allegations of a cover-up. As long
as Republicans control Congress, impeachment remains very unlikely. But for what it's worth, some oddsmakers are putting the chances Trump is
impeached or resigns before 2020 as high as 48 percent.

Extinction—multiple scenarios
Seth Baum, Executive Director, Global Catastrophic Risk Institute & PhD, Penn State University, “What
Trump Means for Global Catastrophic Risk,” BULLETIN OF THE ATOMIC SCIENTISTS, 12—9—16,
http://thebulletin.org/what-trump-means-global-catastrophic-risk10266, accessed 3-7-17.

In 1987, Donald Trump said he had an aggressive plan for the United States to partner with the Soviet Union on nuclear non-proliferation. He was
motivated by, among other things, an encounter with Libyan dictator Muammar Qaddafi’s former pilot, who convinced him that at least some world
leaders are too unstable to ever be trusted with nuclear weapons. Now, 30 years later, Trump—following a presidential campaign marked by impulsive,
combative behavior—seems poised to become one of those unstable world leaders. Global catastrophic risks are those that
threaten the survival of human civilization. Of all the implications a Trump presidency has for global catastrophic risk—and
there are many—the prospect of him ordering the launch of the massive US nuclear arsenal is by far the
most worrisome. In the United States, the president has sole authority to launch atomic weapons. As Bruce Blair recently argued in Politico,
Trump’s tendency toward erratic behavior, combined with a mix of difficult geopolitical challenges ahead, mean the probability of a nuclear launch order
will be unusually high. If Trump orders an unwarranted launch, then the only thing that could stop it would be disobedience by launch personnel—
though even this might not suffice, since the president could simply replace them. Such disobedience has precedent, most notably in Vasili Arkhipov,
the Soviet submarine officer who refused to authorize a nuclear launch during the Cuban Missile Crisis; Stanislav Petrov, the Soviet officer who refused
to relay a warning (which turned out to be a false alarm) of incoming US missiles; and James Schlesinger, the US defense secretary under President
Richard Nixon, who reportedly told Pentagon aides to check with him first if Nixon began talking about launching nuclear weapons. Both Arkhipov and
Petrov are now celebrated as heroes for saving the world. Perhaps Schlesinger should be too, though his story has been questioned. US personnel
involved in nuclear weapons operations should take note of these tales and reflect on how they might act in a nuclear crisis. Risks and opportunities
abroad. Aside from planning to either persuade or disobey the president, the
only way to avoid nuclear war is to try to
avoid the sorts of crises that can prompt nuclear launch. China and Russia, which both have large arsenals of
long-range nuclear weapons and tense relationships with the United States, are the primary candidates for a nuclear conflagration with Washington.
Already, Trump has increased tensions with China by taking a phone call from Taiwanese President Tsai Ing-wen. China-Taiwan relations are very
fragile, and this sort of disruption could lead to a war that would drag in the United States. Meanwhile, Trump’s presidency could create some
interesting opportunities to improve US relations with Russia. The United States has long been too dismissive of Moscow’s very legitimate security
concerns regarding NATO expansion, missile defense, and other encroachments. In stark defiance of US political convention, Trump speaks fondly of
Russian President Vladimir Putin, an authoritarian leader, and expresses little interest in supporting NATO allies. The authoritarianism is a problem, but
Trump’s unconventional friendliness nonetheless offers a valuable opportunity to rethink US-Russia relations for the better. On the other hand,
conciliatory overtures toward Russia could backfire. Without US pressure, Russia could become aggressive, perhaps invading the Baltic states. Russia
might gamble that NATO wouldn’t fight back, but if it was wrong, such an invasion could lead to nuclear war. Additionally, Trump’s pro-Russia stance
could mean that Putin would no longer be able to use anti-Americanism to shore up domestic support, which could lead to a dangerous political crisis.
If Putin fears a loss of power, he could turn to more aggressive military action in hopes of bolstering his support. And if he were to lose power,
particularly in a coup, there is no telling what would happen to one of the world’s two largest nuclear arsenals. The best approach for the United States
at home.
is to rethink Russia-US relations while avoiding the sorts of military and political crises that could escalate to nuclear war. The war
Trump has been accused many times of authoritarian tendencies, not least due to his praise for Putin. He also frequently defies
democratic norms and institutions, for instance by encouraging violence against opposition protesters during his presidential
campaign, and now via his business holdings, which create a real prospect he may violate the Constitution’s rule against accepting foreign bribes.
Already, there are signs that Trump is profiting from his newfound political position, for example with an end to project delays on a Trump Tower in
Buenos Aires. The US Constitution explicitly forbids the president from receiving foreign gifts, known as “emoluments.” What if, under President Trump,
the US government itself becomes authoritarian? Such an outcome might seem unfathomable, and to be sure, achieving authoritarian control would
not be as easy for Trump as starting a nuclear war. It would require compliance from a much larger portion of government personnel and the public—
compliance that cannot be taken for granted. Already, government officials are discussing how best to resist illegal and unethical moves from the
inside, and citizens are circulating expert advice on how to thwart creeping authoritarianism. But the president-elect will take office at a time in which
support for democracy may be declining in the United States and other Western countries, as measured by survey data. And polling shows that his
supporters were more likely to have authoritarian inclinations than supporters of other Republican or Democratic primary candidates. Moreover, his
supporters cheered some of his clearly authoritarian suggestions, like creating a registry for Muslims and implying that through force of his own
personality, he would achieve results where normal elected officials fail. An authoritarian US government would be a
devastating force. In theory, dictatorships can be benevolent, but throughout history, they have been responsible for some of the largest
human tragedies, with tens of millions dying due to their own governments in the Stalinist Soviet Union, Nazi Germany, and Maoist China. Thanks to
the miracles of modern technology, an
authoritarian U nited S tates could wield overwhelming military and
intelligence capabilities to even more disastrous effect. Return to an old world order. Trump has suggested he
might pull the United States back from the post-World War II international order it helped build and appears to favor a pre-World War II isolationist
mercantilism that would have the United States look out for its unenlightened self-interest and nothing more. This would mean retreating
from alliances and attempts to promote democracy abroad, and an embrace of economic protectionism at
home. Such a retreat from globalization would have important implications for catastrophic risk. The post-World War II
international system has proved remarkably stable and peaceful. Returning to the pre-World War II system risks putting the
world on course for another major war, this time with deadlier weapons. International cooperation is also essential
for addressing global issues like climate change, infectious disease outbreaks, arms control, and the safe management of
emerging technologies. On the other hand, the globalized economy can be fragile. Shocks in one place can cascade around the world, and a
bad enough shock could collapse the whole system, leaving behind few communities that are able to support themselves. Globalization can also bring
dangerous concentrations of wealth and power. Nevertheless, complete rejection of globalization would be a dangerous mistake. Playing with climate
dangers. Climate
change will not wipe out human populations as quickly as a nuclear bomb would, but it is
wreaking slow-motion havoc that could ultimately be just as devastating. Trump has been all over the map on the subject, variously
supporting action to reduce emissions and calling global warming a hoax. On December 5th he met with environmental activist and former vice
president Al Gore, giving some cause for hope, but later the same week said he would appoint Oklahoma Attorney General Scott Pruitt, who denies the
science of climate change, to lead the Environmental Protection Agency. Trump’s energy plan calls for energy independence with development of both
fossil fuels and renewables, as well as less environmental regulation. If
his energy policy puts more greenhouse gas
into the atmosphere—as it may by increasing fossil fuel consumption—it will increase global catastrophic risk.
For all global catastrophic risks, it is important to remember that the US president is hardly the only important actor. Trump’s election shifts the
landscape of risks and opportunities, but does not change the fact that each of us can help keep humanity safe. His election also offers an important
reminder that outlier events sometimes happen. Just because election-winning politicians have been of a particular mold in the past, doesn’t mean the
same kind of leaders will continue to win. Likewise, just because we have avoided global catastrophe so far doesn’t mean we will continue to do so.
 3
Innovation strong
BDO, 7-12-17-- BDO provides transaction, risk, and executive analysis, 7-12-2017, "Boosts in R&D
Spending Drive Biotech Innovation, BDO USA Analysis Finds," No Publication,
https://www.bdo.com/news/2017-july/%E2%80%8Bboosts-in-r-d-spending-drive-biotech-innovation,

Fueled by a desire for innovation and new medical breakthroughs, the biotech industry continues to
enjoy substantial growth due to increased investment in research and development (R&D), according to the sixth
annual study from BDO USA, LLP. The 2017 BDO Biotech Briefing, which examines the most recent 10-K SEC filings of publicly traded companies included in the NASDAQ

R&D spending across all mid-market biotech companies increased about 18 percent from
Biotechnology Index, found that average

The uptick in R&D spending is one factor that can explain

2015 to 2016, from an average of $65.9 million to an average of $80.6 million.

the recent surge of innovation across all areas of the biotech industry, including significant advances in biological
sciences and pharmaceuticals, and the expansion of more effective drugs a nd curative and preventive treatments aimed at enhancing the quality of
human life. In particular, a rising incidence of chronic illnesses due to an increasingly aging population continues to drive more advancements in drug products targeted at oncology and gene therapy to prevent and treat chronic illnesses. Recent legislative
developments—such as the 21st Century Cures Act, aimed at streamlining Food and Drug Administration (FDA) approval processes—will help speed up product development, and will potentially support novel innovation that can deliver efficacious drug therapies in
the sector. Already in 2017, the FDA has approved 23 novel drugs, compared to 22 in all of 2016. Broken down by size, small biotechs (those with less than $50 million in revenue) surged: R&D spending increased by 24 percent, from $65.4 million in 2015 to $81.2
million in 2016. Large biotechs (those with more than $50 million in revenue) followed suit, boosting R&D spending by 20 perc ent in 2016, from $66.4 million in 2015 to $80 million in 2016. The benefits of this increase are clear: Large biotechs have seen their

average revenue increase 24 percent, from $113.7 million in 2015 to $141.1 million in 2016. “A fresh perspective at the FDA driven by its new Commissioner Scott Gottlieb is expected to bring changes at the
agency which are sure to have a ripple effect across the industry,” said Ryan Starkes, Assurance partner and leader of BDO’s Life Sciences practice. “ Plans to continue
streamline approval processes, increase competition and transparency around drug pricing, and facilitate advancements in medicine and digital health technology
to

are likely to expand innovations with the potential to improve treatment for millions.”

Public option slashes pharma prices and kills innovation

Pitts, 9-- Peter Pitts, former FDA associate commissioner, president of the Center for Medicine in the
Public Interest, 7-16-2009, "Government negotiations in drug prices are dangerous," Reuters,
http://blogs.reuters.com/great-debate/2009/07/16/drug-price-negotiations-in-the-public-option-dangerous/

An important power of this “public option” has yet to receive much scrutiny, though. The secretary of H ealth and
H uman S ervices will be given the authority to “negotiate” prescription drug prices for the public option. This
is a big deal . Government “negotiations” with private vendors almost always mean public officials
simply dictating below-market prices . If that holds true in the public option, drug companies that want to participate in
will be forced to deeply discount their meds . These negotiations might translate into cost-savings for patients up
the program

front. But the

long term effect would be a stifling of pharmaceutical innovation , leading to fewer
new breakthrough medicines and compromised patient care. How so? Developing a new pharmaceutical drug is
incredibly expensive. The whole process –including the initial research stages, the countless in-lab experiments required to turn a
promising chemical into a usable drug, and the slow, grinding navigation through the FDA’s notoriously difficult safety approval pathway — costs over a
billion dollars and takes over a decade for the average drug. Forcing
pharmaceutical makers to sell at artificially
low prices for a substantial slice of their customer base would drastically reduce their
revenues , and leave an increasingly small amount for financing the discovery of new drugs.

Pharmaceutical profits are key to innovation against emerging disease threats –

that solves extinction
Engelhardt 8 – PhD, MD, Professor of Philosophy @ Rice
(Hugo, “Innovation and the Pharmaceutical Industry: Critical Reflections on the Virtues of Profit,” EBrary)
Many are suspicious of, or indeed jealous of, the good fortune of oth-ers. Even when profit is gained in
the market without fraud and with the consent of all buying and selling goods and services, there is a
sense on the part of some that something is wrong if considerable profit is secured. There is even a
sense that good fortune in the market, especially if it is very good fortune, is unfair. One might think of
such rhetorically disparaging terms as "wind-fall profits". There is also a suspicion of the pursuit of profit
because it is often embraced not just because of the material benefits it sought, but because of the
hierarchical satisfaction of being more affluent than others. The pursuit of profit in the pharmaceu-tical
and medical-device industries is tor many in particular morally dubious because it is acquired from those
who have the bad fortune to be diseased or disabled. Although the suspicion of profit is not well-founded,
this suspicion is a major moral and public-policy challenge. Profit in the market for the
pharmaceutical and medical-device industries is to be celebrated. This is the case, in that if one is
of the view (1) that the presence of additional resources for r esearch and d evelopment
spurs innovation in the development of pharmaceuticals and med-ical devices (i.e., if one is of
the view that the allure of profit is one of the most effective ways not only to acquire
resources but productively to direct human energies in their use), (2) that given the limits of
altruism and of the willingness of persons to be taxed, the possibility of profits is necessary to secure
such resources, (3) that the allure of profits also tends to enhance the creative use of available
resources in the pursuit of phar-maceutical and medical-device innovation, and (4) if one
judges it to be the case that such innovation is both necessary to maintain the human species in an
ever-changing and always dangerous environment in which new microbial and other
threats may at any time emerge to threaten human well-being, if not survival (i.e., that such
innovation is necessary to prevent increases in morbidity and mortality risks), as well as
(5) in order generally to decrease morbidity and mortality risks in the future, it then follows (6) that
one should be concerned regarding any policies that decrease the amount of resources
and energies available to encourage such innovation. One should indeed be of the view that the
possibilities for profit, all things being equal, should be highest in the pharmaceutical and medical-device
industries. Yet, there is a suspicion regarding the pursuit of profit in medicine and especially in the
pharmaceutical and medical-device industries.
 4

Public option would cause a death spiral for private insurance – it would
functionally result in single-payer.
Hoff ‘9 [John S. Hoff, Bradley Fellow in Education Policy at the Heritage Foundation, The Public Health
Insurance Option: Unfair Competition on a Tilting Field, August 26, 2009, http://www.heritage.org/health-
care-reform/report/the-public-health-insurance-option-unfair-competition-tilting-field]

Advocates of the government insurance plan assure us that it would compete with
private insurers on a level playing field. In reality, the "competition" would be rigged, with the
government plan enjoying a number of advantages . As a result, the government plan would likely
capture a large percentage of the insurance market, marginalizing and undermining
private insurance. For example, the Lewin Group estimates that the America's Affordable Health Choices Act,[2] the health reform bill
currently under consideration in the House of Representatives, would reduce the number of Americans with private insurance by 83.4 million and that
the new public plan would cover 103.4 million people.[3] Coupled
with the federal regulatory system that the
legislation would impose on the remaining private plans, this would clearly by itself constitute
a government takeover of health care. Even worse, the federal takeover would accelerate . The
private plans' relatively small market share would likely render them increasingly uneconomical
and lead to a death spiral in which private insurance would serve an ever-decreasing share of the
market . In short, the federal insurance plan is a giant step toward the single-payer system that
the President has admitted that he prefers. The single payer would be the federal government. This would create a nationalized health care system
much like those in Europe and Canada. Tilting the Playing Field The President and his allies in Congress have attempted to allay fears about how the
government plan would affect Americans' private insurance system by saying that it would merely provide them an additional choice and would
compete on the same terms as the private plans offered through the new Health Insurance Exchange. To that end, the House bill even contains a
section entitled "Ensuring a Level Playing Field."[4] However, the actual terms of Section 221 do not live up to the title. Private insurers and the
government plan would not compete on a level playing field. The provision that is touted as "ensuring" a level playing field fails to do so in three
respects. Tilt #1: Provisions for leveling the playing field are limited to the requirements of the bill. Most important, the scope of Section 221 is limited. It
requires the "public health insurance option [to] comply with requirements that are applicable under" Title II of the bill to other insurance plans offered
through the Health Insurance Exchange, including those that are related to consumer protections, benefits, cost-sharing, notices, and provider
networks.[5] Disregarding the grammatical conundrum of how an "option" can do anything, Section 221 makes the government plan subject only to the
requirements that are imposed by Title II. It
does not impose on the government plan the broad variety of
other federal and state requirements with which private insurers must comply, such as
taxes, antitrust laws, and licensing requirements. Undoubtedly, other requirements would quickly become apparent if
the legislation were implemented. Depending on their tax status, private insurers must pay federal and state taxes,
including premium taxes, property taxes, and income taxes. The government insurance
plan, which would be run by the U.S. Department of Health and Human Services (HHS), would not pay these taxes, and Section
221 does not change this. Nor would the government plan be subject to the federal and state
antitrust laws that regulate the operations of private insurers. Moreover, the bill is unclear on whether the
government plan would be required to meet state licensing standards and obtain state licenses. Section 204 contains a general requirement that a plan
offering insurance through the exchange must be licensed under state law for each state in which it offers coverage,[6] yet state laws do not apply to
the federal government unless federal law provides that they do. The general language in Section 204 and Section 221 may not be sufficiently explicit
to require the government plan to obtain state insurance licenses. If not, the government plan would avoid state solvency and other requirements that
private plans must meet. Similarly, the language is unclear on whether the government plan must provide specific benefits and include providers as
required by state laws. Section 203 specifies that such state mandates "shall continue to apply" to plans offered through the exchange,[7] but it is
unclear whether this is a "requirement" within the meaning of Section 221 that would apply to the government plan. If not, the government plan would
avoid the expenses that private insurers incur in complying with the extra benefit requirements imposed by the states. Whether these general
provisions would require the government plan to comply with state law is complicated by Section 225, which explicitly makes state law applicable to the
government plan's selection of providers. It specifies that the government plan can include only providers that are licensed or certified by the state. The
absence of similarly explicit provisions in other sections would suggest--according to the rules of statutory construction--that the government plan
The government plan would be shielded from the
would not be subject to state laws in other aspects of its operation.
high costs of tort litigation that private plans face. Unless exempted by the Employee Retirement Income Security
Act as an employee benefits plan, a private insurer can be sued for a variety of torts, including actions for consequential and non-economic damages
for death and injury resulting from a wrongful denial of coverage. Yet the government plan, as an arm of the federal government, would probably be
immune from tort liability. The federal government can be sued under the Federal Tort Claims Act (FTCA), but not for discretionary actions of its
 Even if suit could be brought against
agents, and a coverage decision would probably qualify as such a discretionary act.
the government plan under the FTCA, it could not be heard in a state court or before a
jury, and the government plan would not be liable for punitive damages. Furthermore, the FTCA
imposes strict caps on attorneys' fees, which significantly reduces economic incentives to stir up suits against the government, which is certainly not
the case in litigation against private parties.[8] Tilt #2: Even with the requirements imposed by the bill, the field is not level. Because the bill does not
spell out the scope of Section 221(b)(2), it is unclear precisely which "requirements...are applicable under" Title II. Title II requires plans to submit bids
to the newly created Health Choices Commissioner, who would review the adequacy of their provider networks and presumably would make demands
on price and service before accepting a bid and entering into a contract.[9] Provider networks are briefly mentioned in Section 221 as one of the
applicable requirements,[10] but the commissioner's obligation to enter into contracts with plans and the process for doing so are not mentioned. The
bill is unclear on whether these requirements are applicable under Title II and therefore whether Section 221 gives the commissioner the authority to
require bids from the government plan and to negotiate contracts with it. Even if the bill does give the commissioner this authority, the structure of Title
II makes it unclear what requirements the commissioner could impose on the government plan. The commissioner is required to develop standards on
various aspects of plan operations in order to carry out the requirements of Title I. Even if the government plan is expected to negotiate with the
commissioner as other plans do, it is unclear whether a requirement under Title I that is embodied in the commissioner's standards is a requirement
applicable under Title II with which the government plan must comply.[11] The bill does not explicitly require the commissioner to treat the government
plan the same as it treats the other plans. In the absence of such clear direction, it is unlikely that the government plan would face the same bidding
and contractual process (which, in essence, will be the foundation of a costly regulatory regime) that the private plans face. In fact, despite the
language of Section 221(b)(2), other language in the bill leaves open to interpretation whether the government plan must meet any of the requirements
of Title II or Title I. Section 100 states that the HHS Secretary, in connection with the government plan, "shall be treated as" offering an exchange-
participating health benefits plan and that "the term 'qualified health benefits plan' means a health benefits plan that meets the requirements for such a
plan under title I and includes the public health insurance option."[12] This language could be read as requiring private plans to meet certain
requirements under Title I but not requiring the government to do so. Because "treated as" and "includes" are used to describe the government plan's
status, it might be argued that the government plan is not required to meet those requirements through the operation of Title II or even those
requirements included in Title II, notwithstanding Section 221(b)(2). This language could be read as giving the government plan a free pass to
qualification. In addition to creating the illusion of a level playing field, Section 221 is drafted craftily in other ways. It introduces the ambiguous
requirement, discussed above, that the government plan comply with the provisions imposed by Title II with the qualifying phrase "consistent with this
subtitle [Subtitle B]." Importantly, Section 221 also states that HHS's "primary responsibility" in creating the government plan is to create "a low-cost
insurance plan."[13] The qualification that the level playing field must be consistent with the subtitle could embolden the Secretary to claim exemptions
from costly requirements of the bill on the grounds that the exemptions are needed to carry out the mandate for a low-cost plan. These ambiguities
could also support claims that the government plan is not required to submit bids, have its premiums approved by the commissioner, enter into a
contract with the commissioner, submit to state mandate laws, or obtain state licenses. The bill also seems to give the government plan the ability to
obtain proprietary information about competing private plans. It confers on the Health Choices Commissioner unspecified and virtually unchecked
authority to collect data from plans, including the government plan. The commissioner is required to collect the data needed for carrying out his or her
duties,[14] and plans are required to report "such information as the Commissioner may specify."[15] The information collected could include the health
status of each person covered by insurance plans and which services were obtained from which providers. It could also include information on the
terms of providers' participation in plans, how much each provider is paid by the plan, the profits earned by a plan, and other information relevant to
plan operations. Disturbingly, the commissioner is authorized to "share" this information with the HHS Secretary, the operator of the government plan,
without any restriction on the Secretary's use of the information.[16] Thus, the government plan may obtain extensive data about the operations of
competing private plans, but private plans will not have access to this information about either the government plan or each other.[17] Tilt #3: A
government-operated plan has other inherent advantages. The government plan would have a number of other
advantages. It would be marketed with the imprimatur of the federal government, and that
status itself would be persuasive to many potential enrollees. In addition, the government
could use its ongoing contacts with the citizenry to market its insurance plan. Nothing in
the bill would explicitly prohibit the government from including promotional materials in
mailings or as an electronic message accompanying automatic deposit of government
benefits, such as Social Security checks and tax refunds. The bill requires the Health Choices Commissioner to
set "uniform marketing standards" for all insurance plans selling through the exchange.[18] Whether these standards would apply to the government
plan is unclear. Nor is it clear whether the government plan would be subject to the same information-disclosure requirements as private plans.[19]
These provisions are contained in Title I of the bill, and, as discussed, Section 221 explicitly imposes only the Title II requirements on the government
plan. The government plan would also have the advantage of having law-making authority
behind it. The bill would make reimbursement rates for doctors and hospitals under
Medicare applicable to the government plan.[20] These are unilaterally imposed by the government--a power that no
private plan would have--and are lower than what private plans have been able to negotiate in the market. Even if this is changed to
require the government plan to "negotiate" reimbursement rates, its larger size and clout
would give it bargaining advantages that no private plan could match. In any event, neither of these
reimbursement methodologies would likely be the last word. The bill gives the government plan blanket authority to establish reimbursement rates for
providers unilaterally as long as they are "innovative."[21] Finally, in
competing with private plans, the government
plan will enjoy one overriding advantage: Because the government can force the
taxpayer to make up any shortfalls, the government plan can charge premiums that do
not cover its costs. The bill requires the government plan to charge premiums as
necessary to meet its costs, plus a margin for contingencies.[22] However, political
realities and the pressure to provide "affordable" insurance could result in this being
disregarded or fudged.

Private insurance collapse kills the economy—investments and jobs

Hellner, 17-- Jack Hellner, writer, The American Thinker, April 20, 2017, The single-payer health care
insurance trap,
http://www.americanthinker.com/blog/2017/04/the_single_payer_health_care_insurance_trap.html

Individuals , corporations , mutual funds , and private and public pension funds would lose when
the private health companies become worthless. I am curious how they would handle the loss
of hundreds of billions (if not more) in value of the stocks, bonds and property that private
health companies own. What would happen to the millions of employees supported by
the private health care system? Over 500,000 people work in the offices of health insurance
companies. Think of the number of family members these people support and how many additional
jobs these people generate by buying cars, houses, and all other products. How would
communities and states replace the property taxes, income taxes, sales taxes, and all other taxes these
people generate with their income? Think of the cost to the government if a significant proportion become
dependent on the government.

Asset price collapses create spiraling recessions.

Miao et al. 12 (Jianjun Miao† , Pengfei Wang‡ , and Lifang Xu§. †Department of Economics, Boston University ‡Department of Economics,
Hong Kong University of Science and Technology, §Department of Economics, Hong Kong University of Science and Technology, “Stock Market
Bubbles and Unemployment”, https://pdfs.semanticscholar.org/51ee/14529d89b630638b0ca428e929f56d7f3b48.pdf)

This paper provides a theoretical study that links unemployment to the stock market bubbles and crashes. Our theory is based on three observations
from the U.S. labor, credit, and stock markets. First, the U.S. stock market has experienced booms and busts and these large swings may not be
explained entirely by fundamentals. Shiller (2005) documents extensive evidence on the U.S. stock market behavior and argues that many episodes of
stock market booms are attributed to speculative bubbles. Second, the stock market booms and busts are often accompanied by the credit market
A boom is often driven by a rapid expansion of credit to the private sector
booms and busts.
accompanied by rising asset prices. Following the boom phase, asset prices collapse and
a credit crunch arises . This leads to a large fall in investment and consumption and an
economic recession may follow.1 Third, the stock market and unemployment are highly
correlated.2 Figure 1. plots the post-war U.S. monthly data of the price-earnings ratio (the real
Standard and Poor’s Composite Stock Price Index divided by the ten-year moving average real earnings on the index) constructed by Robert Shiller
and the unemployment rate downloaded from the Bureau of Labor Statistics (BLS).3 This figure
shows that, during recessions, the stock price fell and the unemployment rate rose. In particular,
during the recent Great Recession, the unemployment rate rose from 5.0 percent at the onset of the recession to a peak of 10.1 percent in October
2009, while the stock market fell by more than 50 percent from October 2007 to March 2009.

[Insert Figure 1 Here.]

Motivated by the preceding observations, we build a search model with credit constraints, based on Blanchard and
Gali (2010). The Blanchard and Gali model is isomorphic to the Diamond-Mortensen-Pissarides (DMP) search and matching model of unemployment
(Diamond (1982), Mortensen (1982), and Pissarides (1985)). Our key contribution is to introduce credit constraints in a way similar to Miao and Wang
(2011a,b,c, 2012a,b).4 The
presence of this type of credit constraints can generate a stock market
bubble through a positive feedback loop mechanism . The intuition is the following: When investors have
optimistic beliefs about the stock market value of a firm’s assets, the firm wants to borrow
more using its assets as collateral . Lenders are willing to lend more in the hope that they can
recover more if the firm defaults. Then the firm can finance more investment and hiring
spending . This generates higher firm value and justifies investors’ initial optimistic
beliefs. Thus, a high stock market value of the firm can be sustained in equilibrium.
There is another equilibrium in which no one believes that firm assets have a high value.
In this case, the firm cannot borrow more to finance investment and hiring spending . This
makes firm value indeed low, justifying initial pessimistic beliefs. We refer to the first type of equilibrium
as the bubbly equilibrium and to the second type as the bubbleless equilibrium. Both types can coexist due to self-fulfilling beliefs. In the bubbly
equilibrium, firms can hire more workers and hence the market tightness is higher, compared to the bubbleless equilibrium. In addition, in the bubbly
equilibrium, an unemployed worker can find a job more easily (i.e., the job-finding rate is higher) and hence the unemployment rate is lower.

[Insert Figure 2 Here.]

After analyzing these two types of equilibria, we follow Weil (1987), Kocherlakota (2009) and Miao and Wang
(2011a,b,c, 2012a,b) and introduce a third type of equilibrium with stochastic bubbles . Agents

believe that there is a small probability that the stock market bubble may burst . After the
burst of the bubble, it cannot re-emerge by rational expectations . We show that this shift of beliefs
can also be self-fulfilling . After the burst of the bubble, the economy enters a recession
with a persistent high unemployment rate . The intuition is the following. After the burst of the bubble, the
credit constraints tighten, causing firms to reduce investment and hiring. An unemployed
worker is then harder to find a job, generating high unemployment. Our model can help
explain the high unemployment during the Great Recession. Figures 2 and 3 plot the hires rate and the job-
finding rate from the first month of 2001 to the last month of 2011 using the Job Openings and Labor Turnover Survey (JOLTS) data set.5 These
figures reveal that both the job-finding rate and the hires rate fell sharply following the stock market crash during the Great Recession. In particular, the
hires rate and the job-finding rate fell from 4.4 percent and 0.7, respectively, at the onset of the recession to about 3.1 percent and 0.25, respectively,
in the end of the recession.

Economic decline leads to nuclear war

Stein Tønnesson 15, Research Professor, Peace Research Institute Oslo; Leader of East Asia Peace
program, Uppsala University, 2015, “Deterrence, interdependence and Sino–US peace,” International
Area Studies Review, Vol. 18, No. 3, p. 297-311

Several recent works on China and Sino–US relations have made substantial contributions to the current
understanding of how and under what circumstances a combination of nuclear deterrence and
economic interdependence may reduce the risk of war between major powers. At least four
conclusions can be drawn from the review above: first, those who say that interdependence may both inhibit and drive conflict are

right. Interdependence raises the cost of conflict for all sides but asymmetrical or unbalanced

dependencies and negative trade expectations may generate tensions leading to trade wars
among inter-dependent states that in turn increase the risk of military conflict (Copeland, 2015: 1, 14, 437;
Roach, 2014). The risk may increase if one of the interdependent countries is governed by an inward-looking socio-economic coalition (Solingen, 2015); second, the risk of war
between China and the US should not just be analysed bilaterally but include their allies and partners. Third party countries could drag China or the US into confrontation; third,
in this context it is of some comfort that the three main economic powers in Northeast Asia (China, Japan and South Korea) are all deeply integrated economically through

decisions for war and peace are

production networks within a global system of trade and finance (Ravenhill, 2014; Yoshimatsu, 2014: 576); and fourth,

taken by very few people, who act on the basis of their future expectations. International relations
theory must be supplemented by foreign policy analysis in order to assess the value attributed by national decision-makers to economic development and their assessments of

If leaders on either side of the Atlantic begin to seriously fear or anticipate their own nation’s
risks and opportunities.

decline then they may blame this on external dependence, appeal to anti-foreign sentiments,
contemplate the use of force to gain respect or credibility, adopt protectionist policies, and
ultimately refuse to be deterred by either nuclear arms or prospects of socioeconomic calamities.

Such a dangerous shift could happen abruptly , i.e. under the instigation of actions by a third party – or against a third party.
 in East Asia are unlikely to escalate to war. As Chan (2013) says, all states in the
Yet as long as there is both nuclear deterrence and interdependence, the tensions

The greatest risk is not that a

region are aware that they cannot count on support from either China or the US if they make provocative moves.

territorial dispute leads to war under present circumstances but that changes in the world economy alter those
circumstances in ways that render inter-state peace more precarious. If China and the US fail to rebalance
their financial and trading relations (Roach, 2014) then a trade war could result, interrupting transnational production networks, provoking social distress, and exacerbating

This could have unforeseen consequences in the field of security, with

nationalist emotions.

nuclear deterrence remaining the only factor to protect the world from Armageddon , and
unreliably so . Deterrence could lose its credibility : one of the two great powers might gamble that
the other yield in a cyber-war or conventional limited war, or third party countries might engage in conflict with each other, with a
view to obliging Washington or Beijing to intervene.
Case – Women’s HC
 Advantage

Public option will deck hospitals and reduce access to services

Nickels, 16 -- AHA executive vice president
[Thomas, American Hospital Association, and Charles Kahn III, Federation of American Hospitals
president, "Comments on the Public Option," letter to Elijah Cummings, 7-8-16, www.aha.org/advocacy-
issues/letter/2016/160708-let-publicoption.pdf, accessed 7-25-17]

We strongly support universal health coverage as a right of all Americans and endorsed the 2010
Affordable Care Act as a major step toward achieving that goal. We hope the Democratic platform draft
will continue to move the nation in the direction of more equitable, affordable health coverage and
access to care, resulting in improved population health. However, our members have serious concerns
that creating a public option with Medicare-like payments would subvert those goals by
depressing insurer payments to health care providers and disrupting the fragile finance system
that sustains hospitals today. Data from our member hospitals confirms that nearly two-thirds received
less than the cost for treating Medicare beneficiaries in 2014. Further, Congress’ own advisory
commission, the Medicare Payment Advisory Commission, reported that hospitals had a negative 5.8
percent Medicare margin in 2014, on average, and projects that hospital Medicare margins will decline to
negative 9 percent in 2016, the lowest such margin ever recorded. Adding millions more enrollees
whose health care would be reimbursed at Medicare rates would likely threaten access to needed
health care services, particularly for those in vulnerable communities. We continue to believe the
framework of health care exchanges providing subsidized coverage, combined with expansion of the
Medicaid program, was the best means of achieving universal coverage. The addition of a public option at
this time would only introduce greater uncertainty to a health care system that is experiencing rapid
transformation.

Public option can’t solve access barriers – maintains profit motive, wasteful
spending, and doesn’t help coverage or utilization
Gaffney 17, Adam – a physician whose work has appeared in Salon, Dissent, and In These Times,
2017 (“The Case Against the Public Option,” Jacobin, July 19, 2017, accessible online at
https://www.jacobinmag.com/2017/07/trumpcare-obamacare-repeal-public-option-single-payer)

The truth is, both approaches have a common underlying flaw: the notion that “managed
competition” between a mixture of public and private insurance plans could save the
American health care system. But we don’t need competing public and private insurance plans any
more than we need competing public and private air traffic controllers. It adds nothing but waste and
a not insignificant degree of hazard.

The Public Option’s Cardinal Flaws

Obamacare, most agree, has been going through a rough patch. As of July 12, some 24,525 enrollees in
thirty-eight counties were at risk of not having a single insurance option on the ACA marketplaces in
2018, according to the Kaiser Family Foundation.
To some extent, this dysfunction stems from Republican sabotage, especially President Trump’s
sometimes-childish yet very consequential threats to cut off payment of Obamacare subsidies to health
insurers.

But that’s not the whole story — the malaise in the marketplaces predated Trump. Last
summer, for instance, Aetna announced that it was withdrawing from most Obamacare
marketplaces, a decision that followed exits by other insurers. Writing in Vox at the time,
Hacker, like others, touted the public option as a solution to such troubles. “It’s enough to make
a frazzled health care consumer in one of those feeble markets wish there were another option —
perhaps even (dare one say it?) a public option,” he wrote.

But here again lies one of the public’s option’s cardinal flaws: whatever it does for those
buying insurance on the Obamacare marketplaces (which I’ll return to in a minute), it does
basically nothing for the large majority of the nation not insured through them. The so-
called “Obamacare” plans cover some 12.2 million enrollees — a substantial number of people to be
sure, but still a very small fraction of the population.

What would a public option do, for example, for the 28.6 million US residents who are
uninsured? According to the Congressional Budget Office’s (CBO) 2013 scoring of a public
option added to the ACA marketplaces, the answer is nothing: the public option, the CBO
estimated, “would have minimal effects . . . on the number of people who would be
uninsured.”
The goal of single-payer is to reduce that 28.6 million figure to zero; under the public option — at
least according to this admittedly old CBO score of one particular variation of the public option — the
number wouldn’t so much as budge. Perhaps a more ambitious public option could do a bit better.
Nonetheless, it’s not clear that even a more robust plan would be a step toward universal coverage.

And how about for the underinsured? The roughly half of the nation currently covered through their
employer saw a 2016 deductible that was 300 percent higher than a decade ago. Such cost-shifting
of health care costs to workers is a major cause of financial suffering, as well as deferred
medical care. Yet the public option would do nothing for the great majority of these families.
A longstanding aim of universal health care advocates — stretching back to the German Social
Democrats’ 1891 Erfurt Program, which called for “[f]ree medical care, including midwifery and medicines”
— has been to eliminate out-of-pocket payments (for example, copayments and deductibles) at
the time of health care use. In Canada and the United Kingdom, this goal has largely been achieved:
most health care remains free when patients use it. The public option, however, would do little to
nothing to bring us closer to this goal.
Nor would the public option ameliorate existing deficiencies in the two big public insurance
programs, Medicare and Medicaid. Medicare, like private insurance, often imposes high out-of-
pocket payments on enrollees, and it excludes coverage for important health services like
dentistry and long-term care. The partial privatization of the program (via Medicare Advantage
plans, which are managed by private insurance companies) has yielded little but colossal waste over
the years.” And while Medicaid has broader benefits and usually minimal out-of-pocket payments, as a
result of its lower reimbursements, it sometimes provides inferior access to providers (a vestige of
its heritage as a “poor person’s program).

The public option wouldn’t address the inadequacies of either public program.
Finally, in terms of global costs, the public option’s effect would again be quite minor, as
single-payer advocates have long noted. Eliminating both uninsurance and underinsurance
would cost money, and reduced administrative spending ($503 billion dollars a year, according
to one estimate) and reduced drug costs ($113.2 billion a year) are typically cited as key
sources of savings. But although a Medicare-like public option may have lower administrative costs,
only a small fraction of the efficiency savings of single-payer would be achieved if the
multi-payer framework persisted (and drug prices wouldn’t be controlled on a system-wide level).
Or as Physician for a National Health Program’s Don McCanne puts it, the “public option would be
only one more player in our wasteful, administratively-complex, fragmented system of
financing care.” The upshot? It wouldn’t generate anywhere near the savings needed to
fund a truly universal expansion of health care.

Use would not increase—capacity constraints

King, 16-- Susanne L. King, M.D., February 5, 2016, “Facts vs. falsehoods on single-payer,” The
Berkshire Eagle, Lexis.

False assumption : There would be significant increases in the utilization of health care if
everyone were covered by single-payer. This would dramatically increase health care costs
because previously untreated people would flock to receive care.

Fact : When Canada implemented single-payer health insurance there was no significant
change in the number of doctor visits and hospitalizations. "Capacity constraints ," a
limited supply of hospital beds and doctors, would limit a surge in utilization in the U.S.
as well.

Deductibles and co-pays mean they don’t solve

Watson, 17-- Matthew Watson, Senior Analyst at the Johns Hopkins Center for Health Security and
Research Associate at the Johns Hopkins Bloomberg School of Public Health, 2-1-2017, "Strengthening
US Public Health Preparedness and Response Operations," Health Security,
http://online.liebertpub.com/doi/full/10.1089/hs.2016.0115

As discussions about the future of the Affordable Care Act progress, the Administration should work with
Congress to ensure that future healthcare legislation enables patients with infectious diseases that pose a
significant threat to the public's health to have access to care. It is critical that cost concerns not
stand as a barrier to care for patients with communicable diseases. Cost barriers such as high
deductibles and copayments can preclude even those covered by health insurance from
seeking care, prolonging the course of their disease and increasing the likelihood of
community transmission.
Free and charitable clinics solve the advantage now
Birs, 16-- Antoinette Birs, MD, University of Central Florida College of Medicine, "Medical Care in a
Free Clinic: A Comprehensive Evaluation of Patient Experience, Incentives, and Barriers to Optimal
Medical Care with Consideration of a Facility Fee," Cureus. 2016 Feb; 8(2): e500, PubMed Central
(PMC), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4803534/

Free and charitable clinics across the U.S. help bridge this gap in health care coverage and
provide services to fit the medical needs of these uninsured Americans. According to the National
Association of Free and Charitable Clinics (NAFCC), there are approximately 1,200 free and charitable
clinics nationwide, all of which are 501(c)(3) tax-exempt organizations that do not receive funding from
the federal government [3]. With an average of over 4,000 patient visits and almost 800 new patients per
year, a recent study surveying over 360 clinics nationwide found that there is an increasing demand and
need for free and charitable clinics [2, 4]. Without clinics, the uninsured population will not
have access to the same standard of medical care and preventive services provided to the
insured population and may likely experience a delay in disease diagnosis as is described in a study
by Ayanian and colleagues who surveyed over 200,000 Americans [5]. A delay in diagnosis and
preventative care can ultimately lead to negative health outcomes and higher healthcare costs for this
population [6-7]. It is estimated that patients who have been without insurance for over one year will pay
approximately one-fifth of their care out of pocket and typically pay higher fees than the insured [8-9].
Moreover, financial stressors have been shown to lead to increased levels of depression and anxiety [10]
and can negatively impact or worsen other mental and physical ailments [11]. These clinics have
become a vital contributor to the medical and preventative care of the uninsured [12]. Today, most
uninsured patients report that they would either not seek medical care or would use the
emergency department if free clinics were not available [4]. Free clinics lessen the burden placed on
emergency departments while providing care that is comparable to the national standard of
care [13-14]. Clinics are reported to have increased staff friendliness and a generalized positive
perception of the depth of medical explanation received and the amount of time spent with
the medical provider [15-19].

Increasing insurance access collapses safety-net providers—turns the advantage

because of legal and fiscal barriers
Keirns, 16 –University of Kansas Medical Center history and philosophy of medicine professor
[Carla, “Health-Care Justice, Health Inequalities, and U.S. Health System Reform,” Understanding Health
Inequalities and Justice, ed. by Mara Buchbinder, 2016, p285-303, accessed 8-18-17]

The overarching value system embedded in these new models for payment reform is a rough
utilitarianism with conceptual origins in economic analysis. These models largely imagine using
financial incentives to change the behavior of physicians, hospitals, and patients. While these utilitarian-
based innovations in insurance and payment policy have often proven to improve access and
quality of care in the aggregate, they have frequently been shown to have less benefit or even
cause harm to vulnerable populations. This chapter demonstrates how improvements in quality of
care frequently have the unintended consequence of widening disparities, either because the
populations who had the worst outcomes to start with are more difficult to reach with improved-
care models, or because the mechanisms designed to increase access and quality actually
destabilize institutions that have long served the poor. Such challenges remain outside the scope of
the economic-based conceptualizations that shape mainstream health-care reform models . As health reforms are implemented, attention to

their impact on poor patients and the institutions that serve them will be essential. The U.S. health-care system is undergoing a major transition in financing, intended to both improve health-care access for millions of Americans and create structural changes to reduce cost and improve qu ality, We have been here before, The last time the United States
saw major new programs that offered health-care coverage to large groups who lacked it was 1965, when Medicare and Medicaid were passed (Marmor 1970; Oberlander 2003; R. B. Stevens and Stevens 1974). 'Ihese programs odered broad new entitlements to care for the elderly who qualified for Social Security based on their work history, and to
certain classes of poor people. They stabilized the iinances of hospitals that had previously cared for those populations without compensation. They also catalyzed numerous changes to the health-care'delivery system and the politics of health care. The programs were telling in who they included, predominantly single, divorced, or wid- owed mothers
with small children and the elderly consistent with a vari- ety of more piecemeal programs that had preceded them (Skocpol 1991). Even more telling was who they left out-predominantly able-bodied sin- gle adults and families headed by Working adults. This pattern ofwho is considered worthy ofpublic charity and who is not is so long-standing in
American welfare policy as to be almost unexamined B, Katz 1986). It also set up the crisis of the "uninsured"• that this cycle of health reform is designed to improve (if not solve), since low-income working adults and their children remained the bulk of those without access to insurance on the eve of implementation ofthe Aifordahle Care Act in zoio
(Smith and Medalia 2014), Medicare and Medicaid did something else that is underappreciated: they changed the incentives within the health-care delivery system and within the larger political environment. Municipal, university and charity hospitals had long sought tax dollars and contributions in part to pay for their provision of care to the poor (Rosner
1982; Rosenberg 1987; R. Stevens 1999), Now that "everyone was a paying customer"•-even the poor mothers and grandmothers who had long evoked sympathy and inspired support- those hospitals reorganized their clinical services, closed their large open wards, and began billing everyone who sought care (Risse 1999; see also R. B. Stevens and
Stevens 1974; Engel z.oo6). University hospitals began to see clinical care as a revenue stream rather than just a public obligation and opportunity to train their students (Rothstein 1987, Ludmerer 1999). Hospitals founded and supported by African American communities closed as Medicare and Medicaid provided a powerful mechanism to enforce
racial integration in all clinical services (Gamble 1995; Quadagno zooo), Commu- nity health centers, a separate Great Society federal program, ofered access to doctors with sliding-scale fees, drawing some of the tax subsidies that had previously gone to hospitals (Sardell 1988; Lefkowitz zoo7). I.u many cities, municipal hospitals, always financially
fragile and beholden to local politicians, started to go bankrupt or be closed. The closure of Philadelphia General in 1979 left one of the country's largest cities without a municipal hospital, and Washington, DC, Los Angeles, and many other cities were soon in the same boat (Olfner zooi; Whiteis and Salmon 1991; Rice 1987; McLaiferty 19 81. ;
Friedman 19 87; Landry and Landry 1009), Taken together, Medicare and Medicaid oifered health-care coverage to millions of Americans who had not been able to buy insurance before, either due to absolute poverty or because an "actuarially fair"• insurance pre- mium (one calculated to cover the anticipated cost of care) for someone over sixty-fnve
is unaffordable for almost everyone. In covering individuals who many agreed had a claim on social resources-the elderly poor children under Hve, and their mothers-this expansion of coverage carried an implicit message that those left out had a lesser claim (Lynch zoo6). Furthermore, Lhe changes in the health-care safety net that Medicare and
Medicaid brought about dismantled much ofthe charity care that had existed (inadequate as it always was) and set the scene for the problems of uninsurance and medical bankruptcy that have grown considerably over the past thirty years. HEALTH INEQUALITIES UNDER REFORM This chapter explores the consequences of a set of recent health
reforms, quality improvement elforts, and delivery innovation projects in the U.S. health-care system, tracking how they alter benefits and burdens, with special attention to their impacts on vulnerable populations. The vulner- ability model considers the overlapping health impacts of race/ethnicityg socioeconomic position, medical need, discrimination,
and social depri- vation (Shi and Stevens 2005; Hofrichter 2003; Wilson 2009). Health-care reform in Massachusetts, Hrst ixnplementedin 2006, which was the model for the federal Affordable Care Act (ACA) of zo1o, showed that a system of near universal health care can expand access but still undercut the care ofthe most vulnerable (Hanchate et al.
2012; Andrulis and Siddiqui 2011; Ku et al, 2011). This happened through two mechanisms: decreasing access to insurance or increasing copayments for individuals (Dennis et al, 2012), and decreasing funding for the health-care institutions that serve the poor, even though they continue to provide a disproportionate share of care to the uninsured and
underinsured (M. H. Katz 2011). The stated goals, predicted results, and actual outcomes of these health reform projects will be explored using public policy and legislative debates; reviews of the medical, health policy and economics literature; and the lan- guage and political promises used to advocate for particular changes. The values embedded in
these proposed, piloted, and enacted reforms will he explored, along with their public justifications and their impacts on patients, providers, and populations. 'This approach is part policy analysis, part content analysis of statements, and embedded in a larger historical understanding of how change has happened in US. health care in the past century.
HEALTH-CARE REFORM: BOTH NEW AND DIEJA vu The existing policy literature on the development, design, and passage of U.S. health reform in zoxo reveals both the animating ideas and ideals and the political compromises made to pass the law (McDonough 2011; Starr 1011; Altman and Shactman zou; Kirsch 1011). The ongoingpolitical
debate about health-care reform reflects differing visions of the good society but also of what constitutes fairness, Debates between perspectives favoring individualism and social solidarity have traditionally been decided in the United States in favor of individualism, and as multiple scholars have shown, the United States has a weak tradition of
solidarity particularly across class and ethnic lines (Hochscl-nild 1981; M. B. Katz 1996; Conley zoio; Gilens 1999). The continuing power ofhealtl-1-care reform as a political issue reflects these dilferences in political constituencies, but also reflects (1) worldviews about the proper relationships of government, families, and individuals, and (2) the
powerful linkage of health insurance to employment in the United States, which is largely by historical accident (Hoffman 2011; Quadagno 2.0053 Pauly 1997), but set up a "path-dependent"• approach to health care that is politically dilhcult to change. The ongoing debate about health system reform in the United States also reflects a larger discussion
about health care: V\fhat kind of good does it rep- resent in a democratic republic with an economy based on capital markets with some govemment regulations, subsidies, and incentives? If health care is a Commodity like any othelg with no special moral significance, then its alloca- tion either on a first-come-first-served basis or through a market-
determined price system presents no particular questions of justice. IL on the other hand, health care is special-for example, under John Rawls's notion of special goods, discussed below-then its distribution largely by market mechanisms, which fail to provide health care to those who cannot pay would be deeply problematic. There are anumber ofways
of thinking about health-care justice that would be relevant to health reform. Egalitarian views focus on the equal distribution of health outcomes, health-care access, or opportunities or freedoms related to health. The simplest, a "strict egalitarian"• approach, offers the same resources to everyone The first objection to this in an American health context
is presented by the political Right. This objection turns on Whether provision for health care is a legitimate role for government, versus a personal responsibility of the peo- ple who need medical care and their families. The second objection, from the political Left, asks whether an equal distributi on of health care is appropriate, since some people need
more than others to reach the same level of health or functioning. This is most trivially true when comparing the acutely sickto every- one else but also, more importantly applies to those with disabilities, chronic conditions, or socioeconomic disadvantages, w ho may need more resources to reach, or even have the opportunity to reach, a similar level of
health to most who get the equal share In part as a response to these worries about resource egalitarianisrn, a capabilities approach focuses instead on promoting people's equal capacities to do and be what they value (see chapter 2, this volume, by jennifer Ruger). Both resource egalitarianisru and the capabilities approach aim to correct inequalides
in people`s life circumstances, while a relational egalitar- ian approach elaborates instead on the core idea of what is required for people to relate to one another as moral equals (including political and social equality). For more on these considerations, and what they might mean for health justice, see chapter 3 in this volume by_]. Paul Kelleher.
Another common approach, embodied in most economic modeling, is a utilitarian perspective which seeks the "greatest good for the greatest number,"• without much attention to the distribution of goods in societyg or meeting some kind of absolute minimum need for everyone. This utilitarian approach may offer a good first approximation when
Hguring out how to collect taxes, set subsidies, and create a system of health insurance, as the Affordable Care Act does. The challenge to a utilitarian approach to distribution of health care comes in evaluating fairness and consequences. Health insurance has long faced value trade-oifs such as Whether it should only cover catastrophic and
unpredictable expenses, as the original Lloyds of London and other compa- nies did when they created the first modern insurance policies to cover ships and their cargos at sea in the eighteenth century The alternate view says that health insurance should be as comprehensive as possible, both to protect in- dividuals from catastrophic costs and to
allow them to have predictable med- ical expenses to ensure Hnancial access to all benencial treatment. The com - prehensive perspective is often taken by those concerned that individuals of modest means may not be able to pay even routine medical expenses, and that cost may discourage them from services such as checkups, cholesterol tests,
gynecological exams, and other preventive services that may prevent greater health problems and costs in the future. The Aifordable Care Act has split the differeneebetween comprehensive and catastrophic medical insurance, encouraging plans with relatively deductibles that encourage their use la rgely for large and unanticipated expenses, while
also requiring that preven- tive services be covered without copays and not subject to deductibles, The American philosopher john Rawls was concerned about faimess, particularly in the distribution of what he called "primary goods," which he described as "things that any rational person would want regardless of their particular c onception of the
good"• (Rawls 1971, 79-81). Rawls goes on to divide primary goods into "natural"• goods with which an individual may be endowed, including intelligence, imagination, health, and other traits; and social primary goods, including civil and political rights, liberties, income, and wealth, the social bases of self-respect, and others. In contrast to a "strict
egalitarian"• perspective, under which everyone would be entitled to an equal share of all of these goods, Rawls allows for diferences in the distribution, but describes a fail process for allocation, much like the strategy used by a par- ent: letting one child divide a cake or cookie and the other child pick the first piece. Rawls argues that an unequal
distribution of primary goods is only fair to the extent that it improves the condition of the worst-oil This approach, of maximizing the welfare of those with the least, is called "maxi-min"• in his framework. Norman Daniels, extending Rawlss framework to health care, ar- gues that health care is a special good because it is fundamental to "fair equal- ity of
opportunity"• in education, work, and other realms of life (Daniels 1985; see also Richards 1971). An alternate approach to health-care justice is capabilities theory inwhich economic arrangements are seen to be just to the extent that they support the freedom of individuals to be and do what need to achieve goals such as health, happiness, and
economic self-sufficiency This approach, developed by the de- velopment economist Amartya Sen and the philosopher Martha Nussbaum, and extended by many others, underlies the UN "human development index,"• which ranks countries by how well they perform in life expectancy educa- tion, and income for their populations (UNDP 2014). A
capabilities approach would also support viewing health care as a special good to which individ- uals have claims on society more fully explored by Jennifer Ruger (Ruger zoog; Ruger, chapter 2, this volume). Both of these approaches would also support social responsibility for goods such as pri.mary and secondary educa- tion, which are fundamental
to both "equality of opportunity" in the Rawlsian framework and development of human capabilities in Sen and Nussbau.m's formulation of justice (Baker and LeTendre zoo5). Furthec as epidemiolo- gists have developed a richer understanding of the importance for health of other goods such as healthy food, well-designed housing, meaningful work,
education, and safe neighborhoods that facilitate exercise, along with protec- tion from violence, pollution, and other detrimental features, scholars such as Daniels have tumed their concems toward just distribution of these goods as well, both in their own right and because of their contribution to health and opportunity (Marmot and V\Hlkinson 2006;
Krieger 2005; Daniels zooS). Finally health care in the United States presents numerous examples in which similarly situated individuals are treated diiferentlv This violates the principle of formal justice that like cases should be treated alike, common to all ofthe more elaborated theories of justice above. HEALTH-CARE REFORM AND THE
AFFORDABLE CARE ACT According to the Congressional Budget Oiiice, implementation ofthe ACA was expected to provide health ins urance to 12 million ofthe 54 million currently uninsured Americans in 1014, and hy 1017 provide insurance to 16 million Americans who would otherwise lack it (CBO 1014). These esti- mates changed from the
passage of the ACA through implementation, most notably after the Supreme Court, in 2011, made expansion of state Medicaid programs to everyone under 138 percent of the poverty line optional in National Federation cflnclependent Business 11. Selfelius, While most discus- sions of health-care reform have focused on broadening access to health
insurance and changing payment structures for hospitals and physicians, other recent changes have the potential to be almost as wide-ranging in their impacts, Report cards for hospitals and physicians, ranking them on their quality ofcare, and pay-for-performance and accountable care programs tie payment to health outcomes rather than simply
reimbursing for the unit of care provided. These strategies attempt to use the payment system to reim - burse better health instead of simply more service. The overarching value system embedded in these new models for pay- ment reform is a rough utilitarianism drawn from their origins in economic analysis and plans to use financial incentives to
change tl1e behavior of physi- cians, hospitals, and patients. Utilitarianism, which originated in the work of the British philosophers jeremy Bentham (1748-1832) and john Stuart M.ill (i8o6~73), is Sometimes understood as calling for the greatest good for the greatest number. In a utilitarian scheme, units of "utility"• or happiness are measured in the
aggregate; each additional unit of happiness improves society as a whole,`regardless of who enjoys it. In the context of heal th care, an action that improved the health of anyone would be good, as long as it did not re- duce anyone elses health by a greater magnitude. Thi.s suggests that improving the care of heart attacks, asthma, or trauma in richer
communities and among better-oifindividuals-as has been done over t.he last generation-would be laudable. From the perspective of health disparities, however; improvement for one group without increasing access to the worse-oif-such as providing advanced cardiac care to urban residents on the coasts but not to residents of the Appalachian coal
belt, or oifering preventive asthma-aiiack medications to middle-class children but not to poor residents of inner cities-is a chief mechanism by which disparities grow. New models of health-care delivery and payment-such as paying pro- viders fnr outcomes instead of services, or behavioral economicsfinspired wellness programs paying patients for
completing Wellness assessments and penalizing patients who smoke or have a high body-mass index-are intended to alter incentives for patients and providers throughout the system While many of these incentives are designed to make care efficient and cost-effective, others are designed to reward quality of care and align incentives with cl.in- ically
desirable outcomes. For instance, continuing the current practice of paying hospitals and providers more for surgeries with complications than for those without (Eappen et al. 2013), or paying obstetricians more for cesarean sections than for vaginal deliveries, appears to reduce incentives to improve clinical care, since providers are paid more for the
"bad"• outcome than the "good"• one Erom the patient's perspective (Rehavi andjohnson 1013). Unless these payment practices change, they will blunt financial incentives to change practice. Many of these policy approaches are also based in other normative approaches tn medic al care. For example, the Affordable Care Act draws on welfare
theories of economics and arguments about health as a driver of equal- ity of opportunity most associated with john Rawls and Norman Daniels. Quality improvement programs, including pay for perfonnance and nonpay- ment for complications, are based on beneflcenoe toward patients and a con- sequentialist or compensatory justice approach to
health-care providers. DOES INSURANCE MEAN ACCESS TO CARE? PREMIUMS, COPAYMENTS, AND THE CADILLAC TAX While insurance sold after implementation of the ACA promises to be more comprehensive than many policies sold to individuals and small businesses before reform, plans available in the health-care exchanges (state-
based on- line marketplaces) often have substantially greater cost-sharing than most large group employer-based health insurance plans. 'Actuarial value" for a health plan is defined by the fraction of anticipated health-care costs the plan would cover; the remainder is the responsibility of the individual. A "Bronze" plan under the health exchanges has
to cover 60 percent of expected health- care costs. A "Silver" plan must cover 7o percent, "Gold" plans 80 percent, and "Platinum" plans 90 percent. Income tax subsi dies were calculated to make a Silver plan affordable (set for each market based on the second- lowest-price Silver plan available in the marketplace, the "benchmark" plan). Health plans
may use a combination of premiums, deductibles (an amount of health-care costs the individual has to pay before insurance covers any- thing), copayments (fixed dollar amounts for doctor's visits, prescriptions, and other services), and coinsurance (a percentage of costs that the patient may be responsible for, commonly io to zo percent) to reach that
average value. This combination of patient costs makes it extremely difficult for individuals to shop for insurance based on price, because the premium figure quoted up front is only one factor in how much the patient is likely to pay for health care over the course of the year (Frakt 2ox4). The finding that providing insurance does not guarantee access to

Finally health reform carries the

services has been demonstrated repeatedly at least since the beginning of Medicaid: not all providers accept all insurance programs, because Medicaid has traditionally provided lower reimbursements than other types of insurance.

risk that politicians, policy makers, and the public will believe that the problem of provision of
health services for the poor has been solved by the provision of health insurance. This mistaken
belief has led to the dismantling of other (certainly also inadequate) approaches to charity care (R.
B. Stevens and Stevens 1974) such as charity hospital wards, and after the ACA passed many
hospitals changed their rules about whose debt they would write off and whose they would go to court to
collect (Pearjan 2015). Receiving charity care at the discretion of a doctor or hospital is not, of course, the same as a right to health care. Charity can be withdrawn or withheld for any reason, can discriminate on the basis of almost
any characteristic of the recipient, and is seldom adequate to meet needs. Another area in the ACA that generated concem among advocates for improved health-care access was the so-called Cadillac tax on health plans. The Cadillac tax was designed to address
a long-standing frustration among health economists and some policy makers about the "tax exclusion"• of employer-based health insurance for both employee and employer. This preferentialfax status for employer-based group health insurance originated in
World War II, when wage and price caps temporarily made it impossible for businesses to recruit workers by olfering them bett er wages. After World War II, this tax exclusion ofthe value of health insurance from income tax for workers was made permanent, making
a dollar of health insurance, which is not taxed, more valuable to employees than a dollar in cash compensation, which is taxed, As a consequence, employees or their unions may seek more generous health insurance plans than they might otherwise. Then,
insulated from the direct costs of health care at the point of service, individuals may use more health care than they would if they were paying out of pocket ("moral hazard," in the language of economists). This may be a good thing or a bad thing from the point of
view of health, since patients are not very good at differentiating, or doctors at communicating, which tests or treatments their doctors recommend are essential to protect their health, and which are more discretionary. The aggregation of millions of such choices is
thought to increase health-care cost inflation. Over the past two decades, the standard solution to this problem in the policy discourse has been to giv e patients "more skin in the game," translated as greater exposure to the costs of their health care. Again, this may
be fine for sports injuries that could be repaired or not without affecting day-to-day functioning, but if increased out-of-pocket costs mean that patients stop taking cholesterol medicines or blood thinners to prevent heart attacks, it may be unwise from both a health
and a cost perspective. This systematic shifting of costs from employers to patients and their families has been well documented (Claxton zoo4; Hacker zooê), as has its impact on health-care access for individuals of modest incomes (Richman and Brodie 1oi4;
VVharam et al, 1013; Schoen et al. 2010). For individuals with chronic illnesses, there has been substantial controversy about whether the increasing burden nf copayments and coinsurance for outpatient visits and medications leads to preventable and costly
hospital admissions (Li et al. 2014). These findings are hardly new The sociologist Earl Koos showed in the 195os that patients of modest income would think twice about going to the doctor for all but the most severe symptoms, a reticence not shared by those of
greater means in the same community (Koos 1954). The economists and health researchers who ran the RAND Health Insurance Experiment (HIE) in the 197os and 19805 brought quantitative measurement and random assign- ment to questions about the impact
of cost on how and when patients seek medical care, and the HIE findings are cited both by those who believe i.n- surance should be more generous and by policy makers on the other side. In the HIE, families were randomized to several health insurance designs
with a range of coinsurance and copayrnents, from no out-of-pocket care cost to pa- tient costs of 9.5 or 5o percent of charges up to 5, io, or 15 percent ofincome. As cost to the individual went up, health-care utilization went down, Individuals from lower-income
families decreased their use of health care more than those from higher-income tiers did. Moreover, lower health-care utilization did not lead to statistically significant differences in the few health measures they were able to track across all participants (Newhouse
and t.he Insurance Experiment Group 1993). But decreases in health-care utilization in response to cost in- cluded both services that experts deemed discretionary and those that ex- perts ranked as essential. Furthermore, with a 2.016 minimum wage of $7.25 per
hour and a maximum individual health insurance deductible of $6,55o, high-deductible insurance plans offered to employees or sold to individuals under the ACA can have cost sharing of 1/so percent of costs up to 45 percent of a minim\1m~wage workers annual
income, threefold higher than anything contemplated in the RAND Health Insurance Experiment (IRS 2016). The Cadillac tax on health insurance plans risks worsening this pro- cess of income-based rationing. Beginning in 2018, a 40 percent excise taxis scheduled
to be imposed on the value of health insurance benefits exceeding $10,100 for individual coverage and $27,500 for f amily coverage (indexed to inflation). The law specifies that the thresholds can increase for individuals in high-risk professions and for employers
that have a disproportionately older population For employer-based plans, there are certainly "execuvive"• health plans' oifered by some companies to their most highly compensated execu- tives, including in sectors such as manufacturing, computing, and Hnance.
But the primary determinants of a health insurance premium besides benefits are the age and health status ofthe covered population. Analysts and advocates for older, unionized worlcforces in manufacturing, transportation, and other sec- tors raised tbe concern
during the health reform debate that their plans might be taxed under the Cadillac tax not becaus e ofthe richness of tl1ei.r benefits, but because ofthe health of their workers. I.n an era of growing inequality and stagnating wages, these workers are already facing an

). THE LOT OF THE WORST-OFF: HEALTH-CARE ACCESS AND

increasing burden from their out-oiipocket health-care costs (Fletcher 1014

SAFETY-NET PROVIDERS Even by th9Congressional Budget OHice's latest ten-year projections from
April 1014, in 2016 to 2024, there will remain 19 million to 31 million non- elderly uninsured individuals in
the United States. That fact alone demon- strates the ongoing need for additional systems of health-care
provision. Furthermore, geographic clustering ofthe uninsured in urban communities where many poor
residents live, and in rural areas with both low incomes and few health-care providers, will create a
continued need for health institu- tions with a special mission to serve the disadvantaged. Ru ral critical-
access hospitals across the plains, the rural South, and in other areas ofthe country continue to receive
preferential payment rates from Medicare and Medicaid. 'These hospitals are also given other kinds of
administrative flexibility; such as the ability to bill for rehabilitation and posthospitalization nursing care,
generally because those services are otherwise not available in sparsely pop- ulated regions of the
country and because these services contribute to the financial viability of these small facilities. While the
expansion of public and private insurance under health-Care reform might appear to reduce the need
for traditional safety-net institutions to provide health care, there will continue to be substantial
need for low-cost providers due to the persistence of large numbers of uninsured individuals.
Those excluded from health insurance after reform include undocumented immigrants
(categorically excluded under the law), and individuals under 100 percent ofthe poverty line who would
qualify for Medicaid under reform but who live in states that have chosen not to expand Medicaid eligibility
Finally individuals can be exempted from the individual mandate to buy insurance if there is no affordable
plan available to them, defined in the law as a plan that costs less than 8 percent of annual income (Hall
and Rosenbaum aoiz; Hall zoiib; Hall zona; M. H, Katz zoio; M. H. Katz and Brigham zou; Wang, Conroy
and Zuckerman zoog; McKethan et al. zoog). However, the IRS has followed the Congressional _]oint
Committee on Taxation's deliberations on this aifordability provision to apply the deinition of "affordable"•
employer- based coverage to the cost of employee-only coverage, not family coverage, which usually
costs considerably more (Health Aifairs zo14). Under the "family glitch,"• if the employee may have
access to employer-based insurance, then the family is ineligible for tax credits to buy a policy through
the ACA marketplaces even if family coverage costs 15 percent, zo percent, or more of family income.
Nonworking spouses, or Working spouses whose employers dorf t oder coverage, and children are those
most likely to be uninsured due to the "family glitch? As a result of all of these groups ineligible for
coverage under the ACA or existing health policies and programs, community health centers for
primary care, government hospitals, and mission-oriented non-profit hospitals will continue to be
needed for those who remain uninsured despite health-care reform. Safety-net providers will also
remain essential to those whose cost-sharing requirements remain burdensome and for services
that may not be covered, such as vision, dental, and disability rehabilitation (Hall and Rosenbaum
zoiz). For example, Sarah Horton and Judith Barker (chapter 5, this volume) explore dental inequalities
and their impact on Latino children. The Massachusetts health reform enacted in 2.006 under Governor
Mitt Romney became the template for the national Aifordable Care Act of 2010 (Gruber 1008). The
politics in Massachusetts were quite different than na- tionally as Massachusetts is not typical ofthe rest
of the country in terms of income, demographics, or political environment; instead it represents a high-
social service / high-tax state that is amenable to expansion of health programs. Reform in
Massachusetts showed that a system of near-universal health care can expand access but still
undercut the care of the most vulnerable (Hanchate et al, 1012; Andrulis and Siddiqui zou; Ku et al.
2011; M. H. Katz zon). Experiences in Massachusetts demonstrated some of the promise (Gruber zoo8)
and some of the challenges that the ACA may present to safety-net institutions. Massachusetts health-
care reform increased coverage of the uninsured, but nearly bankrupted safety-net hospitals that
had long served the most vulnerable because it failed to account for the clustering of the
remaining uninsured at a few facilities (Himmelstein and Woolhandler 1010; Maxwell et al. zou; Pande
et al. 2011). These hospitals suffered from high levels of Medicaid insurance among their patients, which reirnburses hospitals at rates below their costs. They also continued to see many patients without insurance despite health-care reform,
while at the same time reform was paid for in part by withdrawing of subsidies for caring for the poor that these hospitals had long received from Massachusetts under its Free Care pool and the Medicaid Disproportionate Share program (Thompson zoiz). This
dynamic is now being repeated in national health reform (Neu- hausen et al, 1014). Hospitals in states that have not expanded Medicaid face a similar but even more diilicult dynamic, with continued high rates of unin- sured patients (Price and Eibner 2013; Glied
and Ma 2013). As in Massachu- setts, subsidies to care for the uninsured are scheduled to phase out over the first few years of national health reform, but unlike in Massachusetts, these hospitals will not see the same level of increases in insurance coverage for
their patients, meaning they will be worse oif than before reform unless there is a last~n1i.nute change in either coverage or subsidies, Furthermore, insur- ance coverage expansion may not benefit hospitals and other providers as much as anticipated: individuals
with incomes below ioo percent of the fed- eral poverty line are not eligible for tax subsidies on the insurance exchanges, because the dralters ofthe Alfordable Care Act assumed all individuals under 138 percent ofthe poverty line would be covered by the Medicaid
expansion included in the law Finally many exchange plans contract with only a few hospitals and doctors, using a so-called narrow network design, which is par- ticularly l.il<ely to cause problems for regional referral hospitals to which a patient may be brought by
ambulance even if their insurance does not cover that hospital. Neither economists nor policy makers have really come to grips with the clustering of disadvantaged patients within and across the health-care system, whose insurance frequently reimburses at or

below providers' costs, just because there is enough money in the system as a whole does not mean that "it all averages out" in terms of the financial viability of health-care institutions , This is a long-standing problem and is a principal reason many health-care
providers do not accept Medicaid insurance. "Payer mix" is a cru- cial determinant of the profitability of hospitals, doctors, and other health- care providers: in other words, a provider can afford to care for some patients with Medicaid or no insurance if they have
enough other patients with pri- vate insurance to "cross-subsidize"• them. As private insurers have become more and more skilled since tl1e i98os at negotiating with providers for dis- counts and reviewing expensive tests and procedures, providers have had less
leeway to cross-subsidize "poor payers"• such as Medicaid (Montague 1995). The calculations are complex, since each health-care provider and institution contracts with hundreds if not thousands of insurers. But usually Medicaid pays below the cost to provide
the service, while Medicare pays at about cost or a little more, and most ofthe time private insurers pay between 150 percent and 3oo percent ofthe Medicare rate. This varies by insurer, provider, region, and even which service the patient r eceives. Over the past
four decades in cities like New York, Philadelphia, Washington, Los Angeles, and Detroit, hospitals have not generally closed due to a lack of patients, but due to a lack of money-usually high rates of uninsured and Medicaid patients whose care costs more to
provide than the hospitals receive in reimbursements (Landry and Landry zoog, 2.71-72), Residential segregation by income has ensured that due to their geographic catchment areas, hospitals can be as unequal as our neighborhoods and schools, One solution to
this problem, in which caring for the poor insured by Medicaid can drive a hospital to bankruptcy is to increase Medicaid reimbursement rates to at least cover hospitals' and doctors' costs. This discretion belongs to the state-level policy makers who set Medicaid
rates, and the legislatures that allocate taxpayer funds between health care and other priorities. Finally; some patients are finding that their insurance plans under the ACA make it difficult to afford care at the point of service because of high de- ductibles,
copayments, and coinsurance, and because of limitations in which hospitals, physicians, and pharmaceuticals are covered by the plans 1014; Gottlieb 1014). This was also seen in Massachusetts, where the poor- est patients found that copayments under the new
system were scaled to the standards for private insurance, often in the range of $10-50, higher than the copayments they had previously faced, which had been scaled to the limited incomes ofMed.icaid recipients, on the order of $1-5 (McCormick et al. zon.;
Mulvaney-Day et al. zon.; Clark et aL zou; Zhu et al. zum). Modifications to Massachusetts's programs have addressed these initial shortcomings of the program, but notably problems with funding of safety-net institutions and levels of copayments and cost sharing
for the poorest recipients are being repeated in many other states as they roll out national reform. QUALITY, ACCOUNTABILITY, AND SERVING VULNERABLE POPULATIONS Innovations that improve access and qualit y of care in the aggregate have frequently
been shown to have less benefit or even harm to vulnerable populations. Improvements in quality of care frequently have the ironic consequence of widening disparities, either because the populations who had the worst outcomes to start with are more difficult to
reach with improved care, or because the mechanisms designed to increase access and quality destabilize institutions that have long served the poor. For instance, cardiac surgery report cards were started in New York in the 19805, and within a decade it became
clear that it was harder for patients with severe disease and multiple comorbidities to iind a surgeon, because they could be predicted to have a higher risk of poor outcomes, but the physicians "grade"• was not adjusted to account for the baseline risk of his or her
patients (Brown, Clarke, and Oak- ley zen.; Shahian et al. 2011). Report cards in New York were associated with widening of racial and ethnic disparities, likely because surgeons perceived mi nority patients as at higher risk for poor clinical outcomes (Werner, Asch,
and Polsky zoo5). Under Medicare's policy of denying payment for readmis- sions (Naylor et al. 2011; Bhalla and Kalkut zoio) or hospital-acquired urinary tract infections and decubitus ulcers, hospitals have incentives to avoid elderly and disabled patients who are
at high risk for these complications (Saint et al. zoog; Meddings, Saint, and McMahon 2010; Meddings et al. zoiz; Morgan et al.2o12). Finally variation in outcomes is fr equently attributable to the quality of facilities where patients are treated rather than the
characteristics of indi- vidualpatients or providers (Heisler et al. 1003; Weinick and Hasnain-Wynia 1011), But the payer mix and reimbursements for a particular hospital deter- mine the resources it has to bring to any given patients care, including in the
documentation ofthe aualitv of care nrovided (Millett et al, moo). Using payments to create incentives for high-quality health care seems simple on its face, and paying more for high-quality care is a sensible strat- egy, especially compared to simply paying by
volume of medical procedures whether they produce good outcomes or had ones, The challenge is whether incentives can be structured around factors within the control of the health- care provider. What is fair to providers in these schemes is highly contro- versial
(Bogdan-Lovis, Fleck, and Barry 1011). The question of whether one should adjust, in health-care pay-for-perfomiance, for severity of illness of the population served, income, geography and many other factors known to affect outcomes mirrors the contentious
debates over education reform (Carrier et al. 1011; Mehta et al. 10 08). Are those who educate poor children, or provide health care to poor pat ients, responsible for those individuals' poorer-than-average outcomes, or are they due to poverty; living conditions,
stress, or other factors outside of the control of those professionals? Or even more basic, is the sample size ofa teacher's students or a doctor's patients too small to make meaningful distinctions i.n quality of care (Hofer et al. 1999; Krein et al. 1oo1)? This is a
critical question in the design and implemen- tation of pay-for-performance because health outcomes are known to vary with poverty The question remains unresolved whether one can separate the perfor- mance of service providers from the other influences on the
health outcomes that are being ranked and scored in pay»for-performance programs. Ifwe can- not, instead of providing incentives to improve health outcomes, the programs risk leading providers to cherry-pick healthier patients and possibly to "Ere" their sicker,
noncompliant patients (Hayward and Kent 1008). Analyses that adjust provider scores by known confounders-risk adjustment for the pop- ulation served is one-can also be important in assessing health outcomes seen for physician practices or facilities such as
hospitals, nursing homes, and rehabilitation centers. In contrast, in the debates over Medicare and Medicaids programs for payment for outcomes and nonpayment for complications, the decision has been made explicitly not to adjust for expected health of the
population served. The argument that no one should receive second-class care is a reason- able one. But the simple measurement of outcomes does not address whether the outcomes are due to poor care which case penali zing providers finan- cially makes
sense), inadequate resources to provide the care (perhaps due to poor reimbursements from Medicaid), or risk factors present in the patients or community (which might be better addressed through individual or com- munity public health interventions).
Assessments of teachers and schools based on student outcomes face a similar problem of differentiating quality of instruction, differences in resources provided for instruction, and greater needs of poor students. The assumption underlying some heal th reforms is
that ineflicient or low-qualityproviders will go out ofbusiness, just as in Ll-le private sector. But if the goal is to serve a population, not a customer base, then one has to ask who will replace these service providers. The existence of large urban and rural areas with
inadequate health service access demonstrates that this prob- lem has not yet been solved, and many ofthe hospital bankruptcies that have led to closures in the past thirty years have been due more to a poor payer mix (too many uninsured and Medicaid patients)

Hman to inadequate clinical demand. HEALTH CARE FOR UNDOCUMENTED IMMIGRANTS: THE LIMITS OF SELF-INTEREST IN HEALTH POLICY The decision to exclude undocumented
immigrants from national health reform was seen as critical to passage and is consistent with
other recent legislation and policy initiatives at national, state, and local levels (Park zoii). This
choice is problematic because of the long-established links between the United States and the countries
of origin of the bulk of undocumented immigrants, including South America, Central America, and the
Caribbean, as well as China by virtue of its size (Ngai 2.oo4), Migrant labor is integral to many economic
sectors of our economy, including agriculture, construction, and personal services. In addition to these
economic ties, many undocumented immigrants are the spouses or children of U.S. citizens. Further,
there are self-interest arguments in favor of universal health care, from reduced risk of infectious diseases
to improved economic efficiency of workers to the de facto universal care we already provide at great
expense in emergency departments and hospitals (Churchill 1994). These arguments-that it is in the
interest of everyone that the entire population receive health care, to reduce the spread of disease
and the direct or indirect cost of emergency care to taxpayers-have had little sway in the American
political system. The universal health-care systems of Europe, as well as those of Asia, Africa, and
Latin America, are fundamentally based on solidarity among citizens. Exclusion of noncitizens
from health-care systems is not unique to the United States, and immigrants have become political
flash points in health and welfare policy in many countries, including France, Germany and South
Africa (see, e.g., Ticktin zou). In the United States, the burden on safety-net institutions in immigrant
communities is likely to combine reduced funding, similar or increased need, and increased political
vulnerability, as their patient population both appears to be and is composed of a larger fraction of
undocumented immigrants than before reform (Matthew 2012).
 Solvency

Extinction outweighs even with low probability

Bostrum 12 (Nick, Professor of Philosophy at Oxford, directs Oxford's Future of Humanity Institute and
winner of the Gannon Award, Interview with Ross Andersen, correspondent at The Atlantic, 3/6, “We're
Underestimating the Risk of Human Extinction”,
http://www.theatlantic.com/technology/archive/2012/03/were-underestimating-the-risk-of-human-
extinction/253821/)

Bostrom, who directs Oxford's Future of Humanity Institute, has argued over the course of several papers that human extinction risks are poorly
understood and, worse still, severely underestimated by society . Some of these existential risks are fairly well known, especially the
natural ones. But others are obscure or even exotic. Most worrying to Bostrom is the subset of existential risks that arise from human technology, a subset that he expects to
grow in number and potency over the next century.¶ Despite his concerns about the risks posed to humans by technological progress, Bostrom is no luddite. In fact, he is a
longtime advocate of transhumanism---the effort to improve the human condition, and even human nature itself, through technological means. In the long run he sees
technology as a bridge, a bridge we humans must cross with great care, in order to reach new and better modes of being. In his work, Bostrom uses the tools of philosophy and
mathematics, in particular probability theory, to try and determine how we as a species might achieve this safe passage. What follows is my conversation with Bostrom about
some of the most interesting and worrying existential risks that humanity might encounter in the decades and centuries to come, and about what we can do to make sure we
outlast them.¶ Some have argued that we ought to be directing our resources toward humanity's existing problems, rather than future existential risks, because many of the

latter are highly improbable. You have responded by suggesting that existential risk mitigation may in fact be a dominant moral
priority over the alleviation of present suffering . Can you explain why? ¶ Bostrom: Well suppose you have a moral
view that counts future people as being worth as much as present people . You might say that fundamentally it doesn't
matter whether someone exists at the current time or at some future time, just as many people think that from a fundamental moral point of view, it doesn't matter where
something. A human life is a human
somebody is spatially---somebody isn't automatically worth less because you move them to the moon or to Africa or

life. If you have that moral point of view that future generations matter in proportion to their
population numbers, then you get this very stark implication that existential risk mitigation has a
much higher utility than pretty much anything else that you could do. There are so many people that
could come into existence in the future if humanity survives this critical period of time---we might live for
billions of years, our descendants might colonize billions of solar systems, and there could be billions
and billions times more people than exist currently. Therefore, even a very small reduction in the
probability of realizing this enormous good will tend to outweigh even immense benefits like
eliminating poverty or curing malaria, which would be tremendous under ordinary standards.

We can predict our DAs--the reason traditional approaches to conflict prediction

fail is because they’re based on systemic theories---but predicting specific
conflicts using analysis of particular motives and conditions empirically
succeeds
Kristian S. Gleditsch 12, Department of Government, University of Essex & Peace Research Institute
Oslo, and Michael D. Ward, Department of Political Science, Duke, “Forecasting is difficult, especially
about the future: Using contentious issues to forecast interstate disputes,” Journal of Peace Research,
50(1) 17–31, Sage Journals

There have been remarkably few efforts to generate global forecasts or risk profiles for interstate
conflict. Moreover, the most prominent efforts to consider the predictive ability of models of interstate
conflicts have based their research on models that were not actually proposed with forecasting in mind. A
notable example here is Beck, King & Zeng (2000), who essentially adopt the so-called liberal peace
model of Russett & Oneal (2001). Certainly, nothing akin to the Political Instability Task Force’s now
annual projections (beginning with Gurr, Marshall & Khosla, 2000) exists for international conflicts.
Perhaps not surprisingly, many observers are very skeptical of the ability of academic researchers
to anticipate conflict between states, at least beyond very short time horizons.

Research in recent decades has seen a large number of hypotheses generated to explain under what
conditions militarized interstate conflict is more or less likely. This avenue of research has been primarily
inspired by research on the so-called democratic peace, or the absence of conflict between democracies.
Indeed, there are thousands of scholarly works mentioning the term militarized interstate dispute
(MID), most of which use these data for some kind of empirical examination of a proposition about
disputes. Yet, the evidence suggests that the ability of this body of work to forecast conflict out-of-
sample is decidedly disappointing . Ward, Siverson & Cao (2007) found that most of the recent
statistical studies of militarized interstate disputes in prominent political science and international
relations journals were unable to predict the outbreak of a single dispute out-of-sample (see also
Beck, King & Zeng, 2000).

Many researchers have sought to improve on the ability to forecast militarized interstate conflict by turning
to alternative statistical methods. Beck, King & Zeng (2000), for example, find that neural networks
perform marginally better than generalized linear regression models in forecasting conflict from the same
input factors.1 Changes in estimation methods or statistical techniques per se, however, have at best led
only to limited improvements in out-of-sample predictive ability.

Our argument is that simply identifying inappropriate methods as the key source of the problem in
forecasting conflict may give us the wrong diagnosis and lead us down less productive avenues.
A more fundamental problem is models that provide a poor basis for forecasting by disregarding the
motives for conflict to arise, or by only considering motives in a relatively superficial manner. Models that
have been proposed for research on the democratic peace, notably the work of Russett & Oneal
(2001), are primarily intended to examine whether certain characteristics of liberal institutions,
such as democracy and trade, make conflict on average less likely relative to baseline risks of conflict.
Although these approaches may be appropriate for testing the original propositions of interest, they
essentially ignore the contentious issues that might cause states to resort to violence and instead
treat these contentious issues as exogenous features, typically hidden inside a so-called ‘black box’ of the
baseline risk of conflict. Our own initial foray into out-of-sample prediction for a state-level model indicates
that spatial information about other conflict events can help to improve forecasts (see Ward & Gleditsch,
2002). Although this allows predictions of conflict to be conditional on other observed events rather than
treating each conflict as an independent observation, the approach still ignores the issues over which
such conflicts may have arisen initially.

We believe that greater attention to the specific reasons for the occurrence of conflicts and the
incompatibilities that may generate the use of violence can help improve our ability to forecast
conflict. Although we recognize that different models may be appropriate to evaluate particular
propositions and to forecast events, in our view the enterprise of prediction has great potential for
winnowing bad ideas out of theories on the causes of conflict and avoiding the problem of
retrospective biases in conventional hypothesis testing on the data used to develop the hypotheses in
the first place (see Ward, Greenhill & Bakke, 2010).

In fairness, much of the existing work on the statistical modeling of conflict has bypassed
motivation since it is genuinely difficult to establish what states fight over and what their possible
motivation for fighting might be. Nevertheless, the fact that something is difficult to evaluate does not
mean that simply ignoring it is the best course of action . Another tradition in research on conflict has
sought to identify incompatibilities in terms of contentious issues, such as territorial or maritime claims
(Diehl, 1992; Mansbach & Vasquez, 1981). Recent efforts to examine these propositions empirically have
found considerable evidence that cases where such claims exist are more likely to see militarized
activities (Hensel, 2001; Hensel et al., 2008; Hensel & Mitchell, 2010). Even so, at present this line of
research has primarily engaged in testing hypotheses about whether coefficient estimates are
significantly different from 0 or the in-sample post-diction of conflicts, and has not yet examined if
information on contentious issues may be helpful for forecasting dyadic conflict out-of-sample. Here we
explicitly consider whether taking into account information on contentious issues and conflict
management can help improve on forecasting interstate conflict and our understanding of conflict
dynamics.

Although we focus on statistical approaches to interstate conflict in this article, many of our arguments
also apply to problems in traditional theories of conflict and qualitative approaches to prediction
or anticipating political events (see Tetlock, 2005). Traditional theories of interstate conflict tend to
focus on structural features presumed to influence the opportunities for conflict such as the
distribution of power in the international system or relative balance of power (see e.g. Waltz, 1979).
These theories display little interest in the specific incompatibilities that may motivate the use of violence.
However, structural factors rarely change rapidly, but violent conflict tends to be episodic, and hence
cannot be adequately explained merely by reference to permissive conditions (see Fearon, 1995).
Likewise, our core argument applies to studies of civil war, which tend to emphasize opportunities for
conflict rather than motivations for conflict (see Cederman, Weidmann & Gleditsch, 2011), and where
evidence for the predictive ability of existing statistical efforts seems similarly disappointing (see Ward,
Greenhill & Bakke, 2010). Many political and area study experts, typically using informal methods for
deriving predictions, often have strong confidence in their ability to forecast events. However, the
comprehensive series of studies by Tetlock (2005), who asked experts to rate a series of outcomes which
could then be compared against the historical record, provide little support for the forecasting ability of
political experts.

Yes great power war – realism, fear of worse alts, failed political processes, violent
human nature – their evidence twists definitions to exclude our scenarios
-On point answer to Mueller, Pinker and Mandelbaum

Lyon 14 ---- Rod, director of the strategy and international program at the Australian Strategic Policy
Institute, executive editor of The Strategist, “ No, Great Power War Isn’t Obsolete ,” The Diplomat, 8/22,
http://thediplomat.com/2014/08/no-great-power-war-isnt-obsolete/

August has seen a wave of reflection on major war. It’s a question we seem to revisit every time the key anniversaries of WWI and WWII roll around,
but especially this year because its the 100th anniversary of the outbreak of WWI. Some pundits are keen to draw parallels
between 1914 and 2014—though on its face it’s not apparent to me why 2014 should be more like
1914 than 2013.¶ Academic strategists familiar with their disciplinary history will know that the issue of whether major war’s
obsolete received a detailed coverage back in Survival magazine in the late 1990s. To save readers the trouble of digging
through their archives, one contributor, John Mueller, argued that it was obsolete—gone the way of slavery and dueling—while others
wrestled partly over how to define obsolescence and even more over how to define major war. Was the Vietnam War “major?” Was the Cold War a
“war?” Michael Mandelbaum argued that perhaps major war was just a poor policy option nowadays—because of
the steep rise in the costs and the thin rewards for success.¶ It’s intriguing that the question about the
obsolescence of war is typically qualified by the adjective “major.” No one seems particularly keen to

claim that nasty little wars—in particular, nasty little wars in faraway places—are obsolete, perhaps because they
patently aren’t . From memory, Mueller didn’t want to call those conflicts “wars,” though; he saw those more as “opportunistic
predation” (That’s the reason the cover of his book, The Remnants of War, features an image—from the Balkan conflict in 1991—of a thug swigging
from a bottle.)¶ Then 9/11 came along and sideswiped that whole debate. The nasty little wars of the
1990s didn’t stay in faraway places. A superpower got up and marched off to war —albeit a war against al
Qaeda, its supporters, and all its works. Somewhere along the line the mission became conflated with a host of other
problems, and Washington ended up obsessing about the Global War on Terror for longer than it probably
should have done. But Washington’s behavior at least answered one question related to the Big One: did great

powers still go to war? Yes. Now, the question still unanswered—unanswered since 1945 if you think major war has
to be hot; unanswered since 1991, if you think major war can be cold—is whether or not major powers still go to war with
each other.¶ Psychologist Steven Pinker has recently argued that the better angels of our nature are making
us turn away from violence. I’m not wholly convinced by his argument—the better angels of our nature seem
pretty militant to me, and always have been. (See Ephesians, 6:12.) But academic research from a few decades back suggests
that great-power wars against each other aren’t common. Jack Levy in his research on war in the international system between 1495 and 1975 found
only nine of what he would call “world wars”—wars where almost all great powers were involved. Much more commonly, he found “interstate wars”—
113 of which engaged a great power.¶ I cite those figures to underline two points. First, if world wars are rare, maybe we don’t need special
explanations to say why there hasn’t been one since 1945 (hot) or 1991 (cold). Second, that definition of major war is still a problem.¶ Let’s put
aside the academic arguments and look straight at the case that most worries us. Is a great-
power war between the U.S. and China possible? I think we could answer that question directly: possible, yes ; likely, no.
Great powers, especially nuclear-armed ones, don’t go to war with each other lightly. But sometimes wars
happen . And they aren’t accidents. They’re about international order. They’re about, as Raymond Aron
said, the life and death of states. And the principal reason for fighting them is that not doing so

looks like a worse alternative.¶ Moreover, the paths to war—including rare major-power war—are
not reserved solely for conventionally-armed states. Where both powers are nuclear-armed we
should expect a conflict, even one at the lower rungs of the escalation ladder, to be fought with a high degree of political control, and
an understanding that the objectives of the conflict are limited. Naturally, it would help if both sides shared a common
understanding of where the firebreaks were between conventional and nuclear conflict, and already had in place a set of crisis-
management procedures, but it’s possible that neither of those conditions might exist . (Neither would prevent a war,

but both would provide a better sense of the likely escalation dynamics of a particular conflict.) Indeed, it’s because major war is

possible that we retain such a keen interest in war termination. Unconstrained escalation doesn’t
lead to a happy place.

Right to health causes increases structural inequality---courts would grant

wealthy individuals with the ability to bring claims to court access to drugs at the
expense of subjugated populations
Lenoardo Cubillos 16, Resident in Psychiatry & Senior Policy Advisor at Dartmouth College. With
Rebecca Dittrich et al. 2016, “The International Right to Health: What Does It Mean in Legal Practice and
How Can It Affect Priority Setting for Universal Health Coverage?”
http://www.tandfonline.com/doi/pdf/10.1080/23288604.2016.1124167

THE ETHICS OF ALLOCATING RESOURCES

Priority setting confronts a critical question: how does society ethically allocate scarce
resources? Patients utilizing Article 12 of the International Covenant on Economic, Social and
Cultural Rights, or similar rights, in their right to health claim could argue that they have a right to
their “highest attainable standard” of health, for example.9,17 However, states cannot guarantee a
carte blanche highest attainable standard of health to every citizen without consideration of
resource constraints . Attempting to meet the maximal healthcare needs of every individual would
overwhelm a society’s capacity to provide other social goods, such as education anddefense.21
The question, then, is: what is a reasonable principle for allocating resources, and to what body is
the decision maker accountable in applying such a principle?

Equity and ethics should be critical considerations to ensure proper priority setting. Governments
should consider whether the interests of some groups are unfairly promoted over those of
another. Attention to the principle of equity in access to care, quality of care, outcomes, and financial
protection can promote a fair distribution of benefits across different population and disease groups.22

When seeking to maximize population health, the government should not disregard its ethical obligation
to secure benefits for, and reduce harms to, individuals.22In some instances, attention to population-
level health may disregard the individualized needs of a highly vulnerable disease group. The
government may wish to develop policies to recognize and offer protections for these highly individualized
needs. It is important to give particular attention to the needs of society’s most vulnerable and
marginalized inhabitants. Even if an intervention is not the most cost-effective, it maybe necessary to
ensure vulnerable disease groups an equal opportunity to their right to health. Court decisions to over-
turn a coverage decision may maximize individual health only for those with the resources to
bring a claim but not those in vulnerable disease groups. An equitable benefits package generally
excludes healthcare products that cannot be provided to everyone for whom that product is medically
indicated.22 A court’s decision to grant a patient access to the product she demands typically
applies only to that patient.5 Thus, decisions granting individuals access to the interventions they
demand can create horizontal inequity because others having the same need for the intervention
are treated differently.6If we understood the right to health strictly on an individual level the
outcome is likely to be an unequal, subjective access to the highest attainable health standard. To
prevent this, courts could seek to uphold priority setting decisions when they are in reason-able alignment
with the evidence and the social value judgments of that broader society.21,23

The highest attainable standard of health of a citizenry can only be determined within the confines
of what the country can fairly afford. This is true as long as the government is already allocating a fair
percentage of its total budget to health care. By granting access to products based on an individual’s
right to health without carefully considering that the product may have been rationally denied,
courts could secure one individual access to a product unaffordable for all who would need it. In
doing so, the courts threaten the broader population right to health .24

Courts will allow non-enforcement using resource constraint excuses

Stephen P. Marks, Professor, Health and Human Rights, Harvard University and Faculty of law and
Economics, University of Nice, “Normative Expansion of the Right to Health and the Proliferation of
Human Rights,” GEORGE WASHINGTON INTERNAITONAL LAW REVIEW v. 49, 2016, p. 136-138.

From the ontological perspective, British philosopher and academic, Jonathan Wolff, takes a radically different approach to $=P137 human rights as
legal rights. It can be argued, according to Wolff, that
there cannot be a human right to health because "the content of
the human right to health cannot be coherently specified." n242 Wolff questions whether General Comment Number 14 has
provided adequate specificity and argues that "to some degree it has avoided the main question," namely, "when is failure to supply medical care or
other determinants of health nevertheless not a human rights failure." n243 Wolff worries that courts would need to determine "when is it acceptable
not to supply something that would be likely to improve health." n244 However, he overlooks that fact that in
major cases courts have
made such determinations (despite having analyzed such case law elsewhere). n245 For example, in Soobramoney v. Minister of Health,
the South African Constitutional Court let stand a government denial of dialysis for a man with failing kidneys, because the constitutionally-mandated
right to emergency medical treatment did not require the state to provide it. n246 Referring to the constitutional provisions on health and similar rights,
the court stated: What
is apparent from these provisions is that the obligations imposed on the state ... are
dependent upon the resources available for such purposes, and that the corresponding rights themselves are limited
by reason of the lack of resources . Given this lack of resources and the significant demands on them ... an unqualified obligation to
meet these needs would not presently be capable of being fulfilled. n247 The court further reasoned that: [Providing dialysis] would also have the
consequence of [prioritizing] the treatment of terminal illnesses over other forms of medical care and would reduce the resources available to the state
for purposes such as preventative health care and medical treatment for persons suffering from illnesses or bodily infirmities which are not life
threatening. n248 Justice Sachs eloquently added, "In all the open and democratic societies based upon dignity, freedom and equality with which I am
$=P138 familiar, the rationing of access to life-prolonging resources is regarded as integral to, rather than incompatible with, a human rights approach
to health care." n249 Thus, the right to health, as defined internationally, does allow a "failure to supply
medical care" due to resource constraints not to be "a human rights failure." n250 Wolff is correct to warn that "used the
wrong way a human right to health approach can prioritize the claims of the powerful , vocal,
troublesome and well organized, leaving the most vulnerable unprotected ." n251 The example of the use of health

rights litigation in South and Central America suggests that the courts might distort health resource priority
setting and national health planning. n252

Insurance doesn’t improve health outcomes --- most comprehensive studies.

Megan Mcardle, March 2010. Bloomberg View columnist. She wrote for the Daily Beast, Newsweek,
the Atlantic and the Economist and founded the blog Asymmetrical Information. She is the author of "“The
Up Side of Down: Why Failing Well Is the Key to Success.” “Myth Diagnosis: Everyone knows that people
without health insurance are more likely to die. But are they?” The Atlantic.
https://www.theatlantic.com/magazine/archive/2010/03/myth-diagnosis/307905/

The possibility that no one risks death by going without health insurance may be startling, but
some research supports it. Richard Kronick of the University of California at San Diego’s Department
of Family and Preventive Medicine, an adviser to the Clinton administration, recently published the
results of what may be the largest and most comprehensive analysis yet done of the
effect of insurance on mortality. He used a sample of more than 600,000, and controlled
not only for the standard factors, but for how long the subjects went without insurance,
whether their disease was particularly amenable to early intervention, and even whether
they lived in a mobile home. In test after test, he found no significantly elevated risk of death
among the uninsured.

This result is not, perhaps, as shocking as it seems. Health care heals, but it also kills. Someone
who lacked insurance over the past few decades might have missed taking their Lipitor, but also their
Vioxx or Fen-Phen. According to one estimate, 80,000 people a year are killed just by
“nosocomial infections”—infections that arise as a result of medical treatment. The only
truly experimental study on health insurance, a randomized study of almost 4,000 subjects done
by Rand and concluded in 1982, found that increasing the generosity of people’s health
insurance caused them to use more health care, but made almost no difference in their
health status.
If gaining insurance has a large effect on people’s health, we should see outcomes
improve dramatically between one’s early and late 60s. Yet like the Kronick and Rand
studies, analyses of the effect of Medicare, which becomes available to virtually everyone in America at
the age of 65, show little benefit. In a recent review of the literature, Helen Levy of the University
of Michigan and David Meltzer of the University of Chicago noted that the latest studies
of this question “paint a surprisingly consistent picture: Medicare increases consumption of
medical care and may modestly improve self-reported health but has no effect on mortality, at least
in the short run.”
Of course, that might be an indictment of programs like Medicare and Medicaid. Indeed, given the
uncertainties about their impact on mortality rates—uncertainties that the results from Sorlie et al. don’t
resolve—it’s possible that, by blocking the proposed expansion of health care through Medicare, Senator
Lieberman, rather than committing the industrial-scale slaughter Klein fears, might not have harmed
anyone at all. We cannot use one study to “prove” that having government insurance is
riskier than having none. But we also cannot use a flawed and conflicting literature to
“prove” that Lieberman was willing to risk the deaths of hundreds of thousands.
Government insurance should have some effect, but if that effect is not large enough to be
unequivocally evident in the data we have, it must be small.
2NC
T
 V: Gov’t Financed
They don’t meet:
Self-financing rules means it’s functionally just another private plan- no real
change from the status quo
Rodberg, 9 -- Queens College Urban Studies professor
[Leonard, Research Director of the NY Metro Chapter of Physicians for a National Health Program, "More
of the Same Is Not Health Care Reform, It's a Placebo," PHNP, 7-23-9,
www.pnhp.org/news/2009/july/more_of_the_same_is_.php, accessed 9-11-17]

Would the existence of a “public option” change this? The public plan that the Congress has designed
is required to be financially self-sustaining, just like the private insurance with which it competes.
Why would such a plan be attractive to consumers, other than perhaps its “public” label and its likely
lower cost, estimated by the CBO to be about 10% below the cost of comparable private plans? The
proposed public option will provide three kinds of plans — “basic, enhanced, and premium plans”
just like private insurance. Since the public option has to operate under the same financial rules
as private insurance, it is, in fact, just private insurance masquerading as a public entity.

Doesn’t meet universal- public option will only affect 10% of the population,
employed will be barred, keeps tens of million uninsured
Rodberg, 9 -- Queens College Urban Studies professor
[Leonard, Research Director of the NY Metro Chapter of Physicians for a National Health Program, "More
of the Same Is Not Health Care Reform, It's a Placebo," PHNP, 7-23-9,
www.pnhp.org/news/2009/july/more_of_the_same_is_.php, accessed 9-11-17]

The “health insurance exchange” and its “public option,” the only new structural features of these plans,
will affect little more than 10% of the population and will have no significant impact on the overall
health care system. Those who receive insurance through their employer are not permitted to
access the exchange or the public option. The “public option” must be self-sustaining and follow the
same rules as private insurers. Once set up, it will receive no government funds. The subsidies for
low- and moderate-income individuals and families are completely inadequate. Many will find insurance
unaffordable, and underinsurance will continue. Tens of millions of people will continue to be
uninsured . These plans are not reform; they are little more than a placebo, a detour from the path to true
reform of our health care system.
 A2 aff creativity

people spend their entire careers on just one version of single payer—the lit is
full of defenses and criticisms of each of 25 distinct single payer models
Brook, 17-- Robert H. Brook, MD, Professor of Medicine, and Health Policy and Management, UCLA
Jodi L. Liu, PhD, RAND, 2017, What is Single-Payer Health Care? A Review of Definitions and Proposals
in the U.S., J Gen Intern Med 32(7):822–31

Table 2 shows the 25 proposals reviewed. The Physicians for a National Health Program (PNHP) proposal17 and the HealthInsurance Solution18 are
very different approaches . PNHP recommends universal comprehensive benefits without cost sharing. The H ealth- I nsurance
S olution would have incomerelated (means-tested) deductibles and out-of-pocket maximums to prevent catastrophic financial losses for

all citizens and legal residents not covered by Medicare or Medicaid. Medicare and Medicaid would continue, and private insurance would not be restricted. The three federal bills were the Medicare For All Act, American Health Security Act, and National Health
Insurance Act.19–22 Versions of these bills have been repeatedly introduced in Congress. All three propose coverage of comprehensive benefits. The Medicare for All Act and the American Health Security Act are similar and include combinations of taxes, payment
reform, no cost sharing, and banning of private insurance duplicating the single-payer plan. We identified 20 state proposals from across the country (6 Northeast, 3 South, 4 Midwest, 7 West).4, 23–37 All offer universal coverage of comprehensive benefits, except
the Connecticut bill, which is solely a statement of purpose. The proposals vary in the level of detail and the extent that provisions would be determined at a later date, as well as how cost sharing, provider choice, supplemental insurance, quality of care, and cost
controls are addressed. We compared the proposal contents to components of single-payer definitions (Table 2). All the proposals indicate the payer and relevant geography. All except the Connecticut bill specify the eligible population, benefits, and financing. Most
discuss the types of providers that could participate in the system and how they would be paid. Administrative costs, cost controls, and the role of private insurance are discussed in many proposals, but as with the definitions, these components are not consistent
across proposals. In the following sections, we describe the breadth of the proposals and access, quality, and cost provisions. Based on key distinguishing features, we categorize the proposals as traditional, cost sharing, high-level, and catastrophic (Table 2 and
online Appendix Tables A.1-.4). The traditional proposals provide coverage of comprehensive benefits with no cost sharing (free care for all). The cost-sharing proposals also offer comprehensive benefits but may allow cost sharing; in addition, these proposals tend
to be cost-conscious and would study or later implement cost-containment strategies. The high-level proposals are less detailed and contain fewer access, quality, and cost provisions. The sole catastrophic proposal diverges from the others by offering income-

related benefits. Breadth Across Health Care System Functions Figure 2 shows the percentage of proposals containing provisions relating to health care system functions.
Nearly all (23 proposals, 92%) include provisions spanning the four main functions. The collected funds are typically taxes, premiums, and federal funds. The eligible population

proposals vary in how funds would be allocated to providers. Some include fee-
is typically defined by residency. The

for-service, global budgets, population-based payments, or combinations thereof; others call for studies
on payment models. The provision of services is characterized by the covered services and how they would be determined. Within these 23 proposals, all except the Maryland
bill discuss the type of providers eligible to participate in the program. The two exceptions that do not address all four functions are the Connecticut bill (statement of purpose
only) and the Health-Insurance Solution. The Health-Insurance Solution details fund collection and pooling for a specified population, but does not include specific changes to
provider payment, covered services, or provider eligibility. Access, Quality, and Cost Provisions Figure 3 shows the most common provisions addressing access, quality, and
cost. Access.With the Health-Insurance Solution and the Connecticut bill constituting the two exceptions, 23 proposals (92%) would provide eligible residents with
comprehensive benefits. BAll medically necessary health care^ is mentioned in 11 proposals (44%). Twelve proposals (48%) specify no cost sharing (deductibles, copayments,

In 17 proposals (68%), patients have free choice

and coinsurance); six proposals leave cost sharing to be determined following analyses.

of providers; this extends only to primary care providers in five proposals that require referrals for specialty care.
The role of private voluntary health insurance is discussed in 16 proposals (64%), ranging
from prohibiting substitutive and/or supplementary insurance to no mention of restrictions. Of these, nine
proposals allow some type of private insurance. None prohibit complementary private insurance. Other access-related provisions include the establishment of an

enrollment system (e.g., with minimal language and literacy barriers), ensuring adequate resources in underserved
areas, addressing state issues (e.g., reimbursement for out-of-state services, reciprocity agreements with other states), and
monitoring access (e.g., annual reviews of unmet needs). Quality. Health care provider guidelines, standards, and monitoring are included in 16 proposals
(64%). Ten proposals (40%) include review and modification of the benefits package based on value and safety; four proposals (16%) mention reducing the use of ineffective or
inappropriate care. The establishment of electronic systems for records and payments has implications for both quality and cost, and is included in 14 proposals (56%). Also
spanning quality and cost, 13 proposals (52%) include formularies for prescription drugs and medical supplies to allow for standardized use of efficacious and cost-effective
medications and to support bulk purchasing and price negotiations. Other quality-related provisions include studies on new models of care, ensuring a workforce able to deliver
quality care (including adequate payments to support the workforce), care coordination, promotion of preventive care, and public reporting of quality ratings and prices. Cost.
The most common cost provision is global budgets for total expenditures (17 proposals; 68%). The global budget is typically set based on prior-year expenditures and projected

Provider
growth in gross domestic (or state) product. A threshold for administrative costs is set as a proportion of total expenditures in 13 proposals (52%).

payment is addressed in 12 proposals (48%): nine would have hospitals and h ealth m aintenance o rganizations operating
under institutional global budgets, and three mention additional studies of payment models. Nine proposals (36%)
specify the authority to implement cost-containment strategies if necessary; five proposals (20%) plan to study cost-
containment approaches. Other cost-related provisions include medical fraud investigations, migration effect studies, and

eliminating the tax exclusion for employer-sponsored insurance premiums.

These debates are meaningful—those distinctions are crucial to the success of a

proposal – solves aff creativity args
Snell, 16-- Kelsey Snell, staff writer, citing Sherry Glied, dean of the Wagner School of Public Service at
NYU
 3-15-2016, "The many mysteries surrounding Bernie Sanders’s single-payer health care plan,"
Washington Post, https://www.washingtonpost.com/news/powerpost/wp/2016/03/15/the-many-mysteries-
surrounding-bernie-sanders-health-plan/?utm_term=.45277f7173c9

said Sherry Glied, dean of the Wagner School of Public Service at New
“It is not just a problem of the politics,”

York University. “ The devil truly is in the details in designing single payer – you have to define
what you are going to give up, the trade offs, and once you do that [single payer] isn’t a simple elegant thing anymore.” Experts say
Sanders’ plan might decimate the health-insurance industry and force hundreds of thousands of Americans to find new jobs, or it might

simply force insurers and their employees to cater more to the rich. It might bust the
federal budget and stall economic growth , or it might supercharge the economy . It might give
Americans the best, most affordable health care in the world , or it might sentence them to
long waits, substandard care and a system that works much better for the wealthy than
everyone else.
Econ
 OV

Econ turns the coverage advantage

Basu et al. ‘13 (Sepideh Modrek, PhD, David Stuckler, MPH, PhD, Martin McKee, MD, DSc, Mark R. Cullen, MD, Sanjay Basu, MD, PhD, “A
Review of Health Consequences of Recessions Internationally and a Synthesis of the US Response during the Great Recession”, Public Health
Reviews, Vol. 35, No 1)

There are at least two major pathways by which recessions might adversely affect health
outcomes (see Figure 1 for conceptual model). One pathway by is through economic shocks. These
include unemployment, loss of savings, foreclosure and eviction, and unpayable debt. In the US, each of
these factors has been found to trigger health problems such as suicides, substance abuse, and
deferment of medical care due to losses of income or increasing debt. There is a large literature debating
variously why crude mortality rates often decline during recessionary periods, and recent advances in this
area are presented below. However, from the perspective of public health agencies there appear to be
vulnerable populations that are often “hidden” from public health surveillance.4 For example, while
average drinking rates have typically declined during the recession (presumably as most people can
afford less alcohol), a subpopulation has increased binging; this population appears to disproportionately
include those at risk for unemployment.5 Hence, crude mortality rate declines may mask hidden public
health problems. There is also some limited evidence that changes in housing tenure (e.g., foreclosures)
and savings affect health during fiscal crisis. Knowing the effects of recessions on health, it should be
possible to target interventions toward the most vulnerable, but discussion of what should be done in
practice is nearly absent from the public health literature. A second pathway through which
recessions may affect health outcomes is their effect, and that of fiscal austerity measures ,
on healthcare delivery systems and social safety nets. Many newly-unemployed people
entered into public health insurance programs such as Medicaid (US government health insurance program for families and
individuals with low income) at precisely the moment when government programs received less

funding, due in large part to declines in income and associated tax-based revenues.6 Hence,
healthcare programs had to decide what programs to continue funding as their revenue streams
evaporated . Major insurance companies also made changes to their policies on deductibles ,
lowering the probability that even individuals with coverage would seek timely care .7,8 Depending on how
healthcare delivery changes, amenable mortality—deaths that are avoidable with timely and effective healthcare—might be amplified or averted. Other types of safety net
interventions also affected health by, for example, preventing or protecting the newly-impoverished from loss of nutritional support (“food stamp” Supplemental Nutrition
Assistance Program) or becoming homeless (housing assistance programs), which itself modifies disease risk.
 L: PO—Top 2NC

Insurance company margins are extremely thin – there’s hardly any profit to
squeeze out of them, so the AFF would put them out of business.
Posen 17 (6/30, Alexis, professor of Health Economics at CUNY School of Public Health and a co-author of the textbook "Navigating Health Insurance." “Five
myths about health insurance”, https://www.washingtonpost.com/outlook/five-myths/five-myths-about-health-insurance/2017/06/30/0136f34e-5cd2-11e7-a9f6-
7c3296387341_story.html?utm_term=.83e2a745dfae)

MYTH NO. 3 Health insurance companies make massive profits by cheating consumers.
To strengthen the case for reform, proponents of the ACA scapegoated private insurers in
the debate leading up to its passage, blaming outsize premiums and skimpy coverage on unethical behavior. In a 2009 radio address, Obama cited
insurers’ undue “profits and bonuses.” Insurers, however, were not earning particularly high
profits then . A 2010 Congressional Research Service study showed that among large, publicly traded health insurers,
profits averaged 3.1 percent of revenue . In comparison with other health-care players, that put them in the middle of the pack — well
below pharmaceutical and biotech companies and medical-device manufacturers, on par with pharmacy companies, and above hospitals. Yet this rhetoric has
persisted in both liberal and conservative outlets. “The ACA gets blamed for rising premiums, while insurance companies are reaping massive profits,” a Salon article
declared in October. A Weekly Standard piece published around the same time pointed to rising profits among the health insurers on the Fortune 500 as “another
fine example of the natural alliance between Big Government and Big Business.” But the
beginning of the ACA coincided with
the end of the recession. From 2007 to 2009, 8 of the 10 largest insurers had double-digit
losses , and one — WellCare — had triple-digit losses. In a phenomenon economists call “regression to the
mean” and financial analysts call “the business cycle,” profits across all industries
recovered around the same time the ACA was implemented. A nationwide study of
insurers supports the argument that their profits are more aligned with economic growth
than anything else . In 2013, when GDP growth was slower, insurers on average operated at
a loss; but they recovered by 2014 when growth picked up. Moreover, the bulk of insurer profits
were from investments rather than enrollees .

The plan collapses the health care industry instantaneously---causes financial

crisis
Paul Starr 9, professor of sociology and public affairs at Princeton University, 6/26/9, “Debating the
Public Option,” http://prospect.org/article/debating-public-option

Robert Reich seems to consider the "apoplectic" opposition of private insurers and other health care
interests as proof that the public option, in whatever form, is a good idea. The industry is genuinely
scared of a public plan that would pay doctors and hospitals Medicare rates, which run 20
to 30 percent below what private insurers now pay providers for the under-65 population.
According to the most widely cited estimate, a public plan on those lines, if offered to all employee
groups and individuals , could enroll more than 100 million people who now have private
insurance.

But what would happen in that event? The resulting sudden drop in the flow of funds to the
health-care sector would cause a monumental financial crisis throughout the system . There is
no way that Congress is going to bring on that kind of a crisis, which would immediately discredit reform.
So if a public plan is introduced, it is going to have to pay rates that are closer to those of private insurers.
The ability of a public plan to constrain growth in prices -- that is, its ability to control costs through its
bargaining leverage -- could only be exerted gradually. But the public option may never be able to get to
that point if it first becomes a dumping ground for high-cost people.

Causes cost-shifting where providers will charge private insurers more to

compensate for low payments by the public plan---causes an insurance death
spiral
D. Mark Wilson 9, Vice President of Health and Employment Policy and Chief Economist for the HR
Policy Association in DC, 07/12/09, “CREATING A NEW GOVERNMENT HEALTH PLAN WILL
SIGNIFICANTLY INCREASE THE COST SHIFT TO PRIVATE SECTOR PAYERS,”
http://www.hrpolicy.org/downloads/2009/09-48%20Final%202009-
3%20AES%20Cost%20Shift%20for%20Public%20Plan%20Policy%20Memo.pdf

Our Finding

Creating a new government health insurance plan that uses Medicare provider reimbursement levels
and is only open to individuals, the self-employed, and small businesses will shift an additional $43.0
billion per year in costs to private payers, an increase of 75.0 percent from the current cost shifting
level of $57.3 billion that comes from Medicaid, Medicare, and the uncompensated care provided to
the uninsured. Further, this higher level of cost shifting will be passed on to fewer private sector
payers as small businesses move into in the new government plan. If all employers are allowed to
participate in the government health plan, the additional cost shifting to private payers will be $124.5
billion per year – a dramatic increase that will likely drive even more employers who provide private
health insurance into the government plan as their health insurance premiums rise, which could
ultimately lead to the end of private, employer sponsored plans and create a defacto single payer
system dominated by the government health plan.
Background

Since October 2008, several studies have described how a government health insurance plan would work
and what implications it would have on employer provided plans, private health insurance providers, and
the uninsured.3 Most recently, the Lewin Group published a study estimating the cost and coverage
impacts of a government health plan under a variety of assumptions.4 It found that from 32.0 million to
119.1 million Americans who already have private sector health insurance would switch into a
government health plan that uses Medicare payment levels, depending on who can participate in the
government plan. This is largely due to the fact that a government plan would likely have lower costs than
private plans if it paid providers using Medicare fee schedules, which are substantially lower than the fees
paid to providers in private insurance plans.

Although the Lewin Group study estimated the cost and provider impacts associated with a new
government health insurance plan, it did not estimate the changes in cost-shifting that would occur
between Medicare, Medicaid, the uninsured, and private health insurance providers if such a plan were
put in place. This Policy Memorandum was prepared at the request of HR Policy Association, which
brings together the chief human resource officers of more than 260 of the largest corporations in the
United States, to help its members evaluate the implications of proposed reforms within our nation’s
health care system. This memorandum estimates the additional cost shift that will occur to private
payers if a new government health insurance plan were put in place that excludes large employers
at $43.0 billion per year, or about $253 per beneficiary per year for those that remain enrolled in
private health plans. If the government plan allows all employers to participate the cost shift would
be $124.5 billion per year or about $1,502 per beneficiary per year for those that remain enrolled in
private health plans.
The Evidence of Cost Shifting

During the past 20 years, documentation has accumulated in the health service research literature of
hospital cost shifting to private payers due to uncompensated care for the uninsured and
Medicare and Medicaid reimbursement levels that do not cover the cost of providing those
services.5

Empirical research strongly supports the conclusion that cost shifting does occur – especially for
hospital services.6 Further, according to the Congressional Budget Office, since the late 1990s, the
consolidation of hospitals and pressure on private insurers to broaden their provider networks
appear to have strengthened hospitals’ bargaining position, raising the possibility that more cost
shifting will occur than was observed in the 1990s.7 Recent research has found that under managed
care, physicians have less ability to set prices and shift costs.8

A 2006 study of 311 California hospitals found that for 2001 the total annual cost shift from
Medicare and Medicaid to private payers was $210 million.9 The state of Vermont estimates that in
2008, hospitals shifted $91.5 million in Medicare costs and $94.4 million in Medicaid costs to
commercial insurance and self-payers.10 A 2006 study of Washington state hospitals found that in
2004, hospitals in that state shifted $510 million in Medicare costs and $227 million in Medicaid
costs to commercial insurance.11 These state level studies strongly suggest that any government
plan that has “administered” prices similar to Medicare or Medicaid, instead of market-determined
prices, will result in additional and substantial cost shifting to private sector payers.

Nationwide, a recent Milliman study found that in 2004 hospitals shifted $34.8 billion in Medicare
costs and $16.2 billion in Medicaid costs to commercial payers, or a total of $51.0 billion per
year .12 This amounts to a cost shift of $926 per person covered by Medicare and $429 per person
covered by Medicaid.13

Cost shifting also occurs when the cost of uncompensated care for the uninsured is passed on to
private health insurance providers. In 2008, Americans uninsured for any part of the year received
approximately $57.4 billion in uncompensated care – $35.0 billion from hospitals.14 In 2008,
hospitals received $28.7 billion in funding from Medicare, Medicaid, and state and local
governments that offset all but $6.3 billion of their uncompensated care costs that was likely
shifted to other payers.15 This amounts to a cost shift of $138 per uninsured person.16

The total existing cost shift for hospital services for Medicare, Medicaid, and the uninsured
without the creation of a new government plan is $ 57.3 billion per year (see Table 1).

The Coverage Shift That Will Occur With A Government Health Plan

The Lewin Group recently estimated the cost and coverage impacts for two variations of a government
health insurance plan.17 Specifically, Lewin assumed a new government health insurance plan would:

• Be modeled on Medicare and reimburse using Medicare payment levels;

• Be available to individuals and the self-employed;

• Provide benefits that are the same as the BlueCross/Blue Shield Standard Option offered to federal
workers under the federal employees health benefit plan (FEHBP).

The two variations for who would be eligible for coverage under a government plan that Lewin analyzed
were:18

1. The government plan would only be open to small firms and individuals, large employers would be
excluded; or
2. The government plan would allow all employers to purchase coverage for their workers through the
new government plan.19

Based on these assumptions and the two coverage variations, the Lewin study estimated that private
health insurance coverage would fall by 32.0 million if large employers were excluded from
participating in the government plan and 119.1 million persons if all employers were allowed to
participate in the government plan. Enrollment in the government plan would be 42.9 million
(individual/small employer option) or 131.2 million persons (all employer option) as presented in Table 2
below.

Although the Lewin study estimated the coverage changes that would occur with the adoption of a
government plan in a national health insurance exchange, it did not estimate the net increase in cost-
shifting that would occur between a new government plan that utilizes Medicare payment levels and
private sector payers.

A New Government Plan Will Lead to a Significant Increase in Cost-Shifting To Private Payers

Creating a new government health plan that utilizes Medicare payment rates will significantly
increase the cost shift to the private sector payers that can not, or do not participate in the
government plan. Utilizing the Lewin Group estimates of the changes in coverage that will occur under a
government health plan and the Milliman cost shift estimates presented above yields the net change in
the cost shifts from government sector health plans to private sector payers that are likely to occur with
the implementation of a new government health plan.

Specifically, creation of a government health plan will reduce the number of uninsured by 27.4
million to 28.0 million (see Table 2). This will reduce the current cost shift associated with the
uncompensated care that is provided to the uninsured by $3.8 billion to $3.9 billion per year
depending on whether or not large employers are offered the option to enroll their employees in the new
government plan (see Table 3 below). However, the use of Medicare payment rates by the new
government health plan will increase the cost shift to private sector payers by $39.7 billion or
$121.5 billion per year (see Table 3 below). If large employers are excluded from participating in
the government plan, the already large cost shift that is associated with the Medicare program – $34.8
billion per year – will increase by $43.0 billion because of the new government health plan.

If large employers are allowed to participate in the new government plan, the added cost shift
increases to $124.5 billion . Further, the larger cost shift will be spread over even fewer private
sector payers as businesses of all sizes enroll in the government health plan. Moreover, a cost
shift of this size would likely drive more and more employers who provide private health
insurance into the government plan as their health insurance premiums rise, which could
ultimately lead to the end of private, employer sponsored plans and create a defacto single payer
system dominated by the government health plan.

The public option would accelerate the Obamacare death spiral and displace
private insurance.
Smith 16 (Noah Smith: Bloomberg View columnist, assistant professor of finance at Stony Brook
University, “Don't Be Scared of a Health-Insurance Public Option,” 8/30/16,
https://www.bloomberg.com/view/articles/2016-08-30/don-t-be-scared-of-a-health-insurance-public-
option)

I see the public option as a back-door route to full

Like many others on both the left and right,
nationalization of most of the U.S. health-care system. The reason is that Medicare is capable of providing the
 the government can just
same quality of care to most customers at a lower price than any private insurer.¶ Part of this is because
subsidize Medicare if it wants -- no private company can compete on price with a
government service that doesn't need to make a profit. But even without any subsidies, Medicare can probably
undercut private services through a variety of natural advantages. It can use its leverage as a very big purchaser to
negotiate lower prices with providers. It has also lower administrative costs and doesn’t
have to spend money on marketing.¶ You can easily see this in the data. Here, via the Kaiser Family
Foundation and the Wall Street Journal, is a graph of health-cost growth and growth projections for government and private insurance:¶ That stands in
stark contrast to other industries -- for example, parcel delivery, where the U.S. Postal Service has struggled to compete with private rivals like UPS
With this kind of cost advantage,
and FedEx. The economics of health care simply seems to be very different from other markets.¶

a public option will probably push all private insurers off of the Obamacare exchanges . Of course, it
could choose not to do so, and set its price equal to whatever the private companies charge -- but that would negate the point of the public option in the
government-provided health care goes on the exchanges and stays there, it’s
first place. So if
likely that it will eventually be the only option. After that, it would be only a matter of time
until the public option displaced most private health care in the country , except for premium services offering
high-end or specialized care that the government would find too expensive to cover.
 IR: U—Fed Action Thumpers 2NC

Reforms don’t hurt profit – ACA maintains a sufficiently competitive market

structure – selectivity within companies improves competition and growth
opportunities
O’Connell, 10-24-17-- Brian O’Connell, journalist, US News & World Report, 10-24-2017, "Gauging
the 'Trump Impact' on Health Care Stocks," https://money.usnews.com/investing/stock-market-
news/articles/2017-10-24/gauging-the-trump-impact-on-health-care-stocks-and-funds

Some of the changes in the ACA were expected, other experts say, and thus will minimize any
volatility in health care industry stocks, especially among insurers.
"While there is potential for longer-term meaningful changes in how consumers access health insurance,
we believe that for the diversified managed care organizations, these announcements have
been anticipated and adjustments have been made," says Scott Yuschak, equity strategy analyst
at SunTrust Advisory Services.

Yuschak says the diversified managed care organizations have "added to their revenue
base" by offering ancillary services like administering prescription drug benefits,
modernizing health care delivery through technology and offering other supplemental
insurance products both domestically and abroad.
"Many companies have moved away from the public exchanges and have become more
selective on where they offer Medicaid plans," he says. "For the companies with disproportionate
exposure to the public exchanges and/or Medicaid, we believe investors must accept more volatility in the
stock prices. We think legislation could ultimately come out that addresses these changes, but this is not
guaranteed so the stocks could remain volatile."

Overall, Yuschak says his firm remains positive on the diversified large-cap health insurance space.
"While valuations clearly are elevated, we like the stable growth rates these companies
provide," he says. "Medical cost trends remain benign, and growth opportunities appear
robust. We also believe that managed care organizations can present solutions to these policy
challenges which could be accretive to growth rates."

Some industry observers note the impact specifically from Trump's announcements aren't "direct hits" to
the largest insurers. "Companies like UnitedHealth Group (UNH) and Aetna (AET) have already
limited their exposure to volatility in the individual ACA market by pulling out of the
market altogether last year," says Howard Yeh, co-founder of HealthCare.com.
"Of the insurers that remain, the individual segment is, for the most part, a relatively small
percentage of their overall business, which is driven by group health insurance and
Medicare," Yeh says. "In addition, most insurers who submitted 2018 rates to the various state
insurance departments have factored in pricing if CSRs were not going to be paid."

Several of the large national insurance companies have benefited from the ACA and,
despite the Trump executive orders, will continue to do so. "That's not just in terms of gaining
greater numbers of plan subscribers, but also because fewer plans that have the needed
scale and resources to compete yield more market sway in different communities, able to
better push their preferred pricing structures and plan offerings," says Timothy Hoff, a
management professor at Northeastern University.
 A2: “TR”

Slow and steady from the fed—only increases from here hurt the market
Avallone, 8-14-17-- Mark Avallone, 8-14-2017, "Why An Interest Rate Hike Will Not Stop The Stock
Market Rally," Forbes, https://www.forbes.com/sites/markavallone/2017/08/15/why-an-interest-rate-hike-
will-not-stop-the-stock-market-rally/#147d93c67a98

While it seems implausible for stocks to continue to rise after such a historic run up since 2009, the
data explains why stocks have been able to defy the emotional worries of a stock market
correction, the fears of global instability, and a potential rise in interest rates. Earnings are the biggest
determinant of stock prices—not news headlines, nor tweets, nor fears about what might happen.
Interest rates matter, but for a variety of reasons, a rapid rate climb is unlikely for the remainder of
2017. To be sure, we see some pressure on rates as a result of stronger economic growth from the U.S.
and other major economies; but the stock market also continues to benefit from relatively low and
stable oil prices, low inflation, and low interest rates. The Federal Reserve Bank (The Fed) has
spoken about slowly unwinding some of its “Quantitative Easing,” which could have the effect of raising
interest rates—but that is not scheduled to start until October. One of The Fed’s mandates is to
control inflation. Currently we don’t see any hint of runaway inflation; so The Fed has
less pressure to control prices and raise interest rates. The Fed’s other mandate relates to
employment. We currently have low unemployment and an improving labor market, but since wage
growth has only recently ticked up, The Fed is not likely to dramatically change its course at this
time.

Fed action and the stock market are literally perfect—only the aff messes that up
Burgess, 9-19-17-- Robert Burgess, journalist, 9-19-2017, "The Daily Prophet: Fed Has Markets Right
Where It Needs Them," Bloomberg, https://www.bloomberg.com/news/articles/2017-09-19/the-daily-
prophet-fed-has-markets-right-where-it-needs-them-j7s2048n

The Daily Prophet: Fed Has Markets Right Where It Needs Them Could things get any better for
the Federal Reserve ? Central bank officials on Wednesday are widely expected to reaffirm
their plan to raise interest rates again before year-end and announce that they will start
shrinking the $4.7 trillion balance sheet in October. Rather than panicking and sending
markets in a tizzy, investors are taking it all in stride. U.S. stocks are record highs , 10-year
Treasury yields are near the lows of the year, corporate credit spreads are at about all-time lows and the
dollar has weakened. Taken together, these variables are helping to keep the economic
expansion on track while putting to rest -- at least for now -- fears that Fed tightening and
balance-sheet tapering would be a disaster for markets. While some would say investors are
complacent, and Fed officials have indicated that they feel financial conditions may be too easy,
markets are clearly responding to a Goldilocks-like environment where the economy is neither
too hot nor too cold and inflation is under control. As such, the betting is that the Fed continues to
remove the punchbowl ever so slowly.
Institutional investors are heavily invested in health care – they seek high returns
from drug and insurance companies – means the link outweighs any link turn but
providers.
Button ’13 [Keith Button, Institutional investors drawn to health-care sector, July 16, 2013,
http://www.pionline.com/article/20130716/ONLINE/130719926/institutional-investors-drawn-to-health-
care-sector]

Opportunities in health-care investing through hedge funds, private equity funds and long-only equity
strategies seem to be drawing increasing interest from institutional investors. But not all
areas of the sector are flourishing. One indicator of the interest is the growth of U.S. health-care
mutual funds for institutional investors over the last 12 months. According to Morningstar, total
net assets for those funds have increased to $1.8 billion as of May 31, up from $1.2 billion as of Nov. 30,
2012, and from $1 billion as of June 30, 2012. Institutional investors are very interested in the
health-care sector now, especially because of excellent returns in health-care subsectors,
including the stocks of drug manufacturers, insurance companies and providers, said Roderick
Wong chief investment officer and managing partner of RTW Investments LLC, a health-
care hedge fund firm in New York with $60 million in assets under management. For some sectors, the
returns are about 20% so far in 2013, Mr. Wong said. RTW's offshore fund (RTW Master Fund Ltd.) was
up 26.8% for 2013 through June and up 21.9% for 2012, both net of fees, according to the firm. The HFRI
EH: Sector — Technology/Healthcare Index is up 8.92% for 2013 through June. In comparison, the HFRI
Fund Weighted Composite Index is up 3.55% for the same period. Health-care reform also is driving
institutional investor interest in the space, Mr. Wong said. The Affordable Healthcare Act will add up to 30
million people to the insured rolls. The ACA is “clearly a short- and medium-term net positive for many
players in health care,” Mr. Wong said. Carter Neild, a general partner at health-care investment firm
OrbiMed Advisors LLC, New York, said he sees institutional investor interest in the health-care
sector driven more by innovation in the industry and drug launches, and less by the ACA
changes. Last year, for example, the U.S. Food and Drug Administration approved 39 new drugs, a 15-
year high. OrbiMed is considered the largest health-care investment manager in the world, with about $7
billion under management. That includes about $2.5 billion in hedge funds, $2.5 billion in long-only equity
funds, $1.5 billion in private equity funds and $500 million in health-care royalty funds. Within health care,
investor interest has varied according to wide disparities in returns. Royalty funds, the illiquid investment
vehicles that monetize royalties for drugs or medical devices, are “white hot” and wildly oversubscribed
because they provide great returns and steady cash flow in a low/no-interest environment, Mr. Neild said.
And only a handful of health care royalty fund managers exist, including OrbiMed, DRI Capital Corp. of
Toronto, Royalty HealthCare Partners of Stamford, Conn., Capital Royalty L.P. of Houston and Royalty
Pharma of New York Venture capital an exception In contrast, the returns for health-care venture capital
funds are tanking, along with investor interest in the space, Mr. Neild said. Health-care venture capital,
primarily investing in the biopharmaceutical or medical device space, has typically made up about 25% of
the total venture space. Awful returns for the space are killing fundraising. “Those funds are just dying;
there's massive attrition,” Mr. Neild said. “Many of these groups that have been in business for a long,
long time will just disband.” Among the established venture capital firms that have publicly indicated they
will not raise another health care venture fund are Skyline Ventures of Palo Alto, Calif.; Scale Venture
Partners of Foster City, Calif.; Essex Woodlands Health Ventures of Palo Alto; and Prospect Venture
Partners, also of Palo Alto. For long-only health-care strategies and long-short equity health-care hedge
funds, returns have generally reflected the healthy returns of health-care public equities. And the Nasdaq
Biotechnology index, for one benchmark, is up about 40.7% for 2013, through July 15. Whether the
health-care sector in general experiences a long-term, sustainable profit boost as a result of ACA reforms
will depend on what mechanisms are created to control prices and health-care utilization, Mr. Wong said.
But the drug and biotech sectors are well-positioned for long-term profitability, he said. The current
productivity boom in drug discovery will translate into “real value creation” through important new drugs
that have a significant impact on disease, Mr. Wong said. “We are in the early stages of a research
productivity boom that should fill pipelines for the next decade or more,” he said. Endowments and
foundations in the $500 million to $3 billion range and larger family offices seem to have a real appetite
for the health care investment strategies followed by RA Capital Management LLC, said Michael Calore,
director of investor relations for the hybrid hedge/private equity fund manager. The Boston-based
manager runs more than $500 million, investing in small-cap, development-stage biotech companies.
Uncorrelated alpha Health care has become attractive for institutional investors in part because
uncorrelated alpha, which is harder to find in other segments, is available from the good
managers in the space, Mr. Calore said. And with health care product development companies
developing technologies at faster rates and deep-pocketed big pharmaceutical
companies looking to acquire technologies through mergers and acquisitions, fund managers
have a lot of opportunities in the space, he said. Ferenc Sanderson, a partner in PrevInvest, a
pension fund advisory a pension fund consultant and research firm based in Cleveland and Rome, Italy
said institutional investor interest in health care has definitely received a boost from the ACA. Over the
first five months of the year, long-short equity hedge funds have moved more into health-care stocks, Mr.
Sanderson said. Through April, year-to-date stock prices in the health care sector of the S&P 500 were
up 18.4%, second only to the utilities sector. Another factor has been the high level of consolidation in the
health-care industry, especially with hospitals in urban areas, mostly driven by pressure to reduce costs,
he said. A third factor has been the boom in retirement and specialty health-care facilities, such as those
that treat Alzheimer's patients, as occupancy rates have increased. Because this sector is characterized
by steady returns over the long term, a lot of private equity firms and some institutional investors, such as
university endowments with large real estate portfolios, are jumping in, Mr. Sanderson said. Other
exposure A lot of the hedge fund money invested in health care is through multistrategy funds, not pure
health care plays, rather in stocks of large companies that are outside of the sector but stand to benefit
from changes in technology platforms, insurance and pharmaceuticals that ACA will bring. “That's the
opportunity. It's the big picture which is the real alpha story, I think,” Mr. Sanderson said. “When you've
got consolidations of companies, there's going to be winners and losers. When you've got consolidation of
data, there's opportunities if you can capture that data and manage it.” Institutional investors also
might have more riding on health-care investments than what meets the eye. For a typical
global long-short equity hedge fund, health-care sector positions might be less than 5%.
But considering related companies — tech, insurance and real estate investments that will be
affected by the health-care industry changes — the exposure could be more than 20%, Mr. Sanderson
said.
 M: Econ— Trump

Yes diversionary war—Trump

Foster 16 [Dennis Foster, professor of international studies and political science at the Virginia Military
Institute, “Would President Trump go to war to divert attention from problems at home?”, Washington
Post, 12/29, https://www.washingtonpost.com/news/monkey-cage/wp/2016/12/19/yes-trump-might-well-
go-to-war-to-divert-attention-from-problems-at-home/]

If the U.S. economy tanks, should we expect Donald Trump to engage in a diversionary
war? Since the age of Machiavelli, analysts have expected world leaders to launch
international conflicts to deflect popular attention away from problems at home. By stirring
up feelings of patriotism, leaders might escape the political costs of scandal, unpopularity —
or a poorly performing economy. One often-cited example of diversionary war in modern times
is Argentina’s 1982 invasion of the Falklands , which several (though not all) political scientists
attribute to the junta’s desire to divert the people’s attention from a disastrous economy. In a 2014
article, Jonathan Keller and I argued that whether U.S. presidents engage in diversionary
conflicts depends in part on their psychological traits — how they frame the world, process
information and develop plans of action. Certain traits predispose leaders to more belligerent
behavior. Do words translate into foreign policy action? One way to identify these traits is
content analyses of leaders’ rhetoric. The more leaders use certain types of verbal
constructs, the more likely they are to possess traits that lead them to use military force.
For one, conceptually simplistic leaders view the world in “black and white” terms; they develop
unsophisticated solutions to problems and are largely insensitive to risks. Similarly, distrustful leaders
tend to exaggerate threats and rely on aggression to deal with threats. Distrustful leaders typically favor
military action and are confident in their ability to wield it effectively. Thus, when faced with politically
damaging problems that are hard to solve — such as a faltering economy — leaders who
are both distrustful and simplistic are less likely to put together complex, direct
responses. Instead, they develop simplistic but risky “solutions” that divert popular
attention from the problem, utilizing the tools with which they are most comfortable and confident
(military force). Based on our analysis of the rhetoric of previous U.S. presidents, we found that
presidents whose language appeared more simplistic and distrustful, such as Harry Truman, Dwight
Eisenhower and George W. Bush, were more likely to use force abroad in times of rising inflation and
unemployment. By contrast, John F. Kennedy and Bill Clinton, whose rhetoric pegged them as more
complex and trusting, were less likely to do so. What about Donald Trump? Since Donald Trump’s
election, many commentators have expressed concern about how he will react to new challenges and
whether he might make quick recourse to military action. For example, the Guardian’s George Monbiot
has argued that political realities will stymie Trump’s agenda, especially his promises regarding the
economy. Then, rather than risk disappointing his base, Trump might try to rally public opinion to his side
via military action. I sampled Trump’s campaign rhetoric, analyzing 71,446 words across 24 events from
January 2015 to December 2016. Using a program for measuring leadership traits in rhetoric, I estimated
what Trump’s words may tell us about his level of distrust and conceptual complexity. The graph below
shows Trump’s level of distrust compared to previous presidents. These results are startling. Nearly 35
percent of Trump’s references to outside groups paint them as harmful to himself, his allies and friends,
and causes that are important to him — a percentage almost twice the previous high. The data suggest
that Americans have elected a leader who, if his campaign rhetoric is any indication, will be historically
unparalleled among modern presidents in his active suspicion of those unlike himself and his inner circle,
and those who disagree with his goals. As a candidate, Trump also scored second-lowest among
presidents in conceptual complexity. Compared to earlier presidents, he used more words and
phrases that indicate less willingness to see multiple dimensions or ambiguities in the decision-making
environment. These include words and phrases like “absolutely,” “greatest” and “without a doubt.” A
possible implication for military action I took these data on Trump and plugged them into the
statistical model that we developed to predict major uses of force by the United States
from 1953 to 2000. For a president of average distrust and conceptual complexity, an economic
downturn only weakly predicts an increase in the use of force. But the model would predict that a
president with Trump’s numbers would respond to even a minor economic downturn with
an increase in the use of force. For example, were the misery index (aggregate inflation and
unemployment) equal to 12 — about where it stood in October 2011 — the model predicts a
president with Trump’s psychological traits would initiate more than one major conflict per
quarter.
1NR
Adv
 Access S: No Coverage—2NC

NHI overloads existing care and lack of new health workers mean any increase
hurts quality
Anderson 14 (Amy, Graduate Health Policy Fellow in the Center for Health Policy Studies at The
Heritage Foundation and an Assistant Professor of Nursing at the University of Arkansas at Little Rock.
[“The Impact of the Affordable Care Act on the Health Care Workforce” http://www.heritage.org/health-
care-reform/report/the-impact-the-affordable-care-act-the-health-care-workforce])

The Affordable Care Act of 2010 (ACA) is projected to expand health insurance coverage to an estimated
30 million to 34 million people. However, expansion of coverage is not an expansion of actual care,
and the distinction is becoming clear.[2] When Congress enacted the national health law, it unleashed
a potential tsunami of newly insured patients, flooding a delivery system that was
already strained and fragile. The American health care infrastructure has had workforce
shortages for decades and is not prepared to meet such a vast influx of patients effectively or
efficiently. Training new physicians, nurses, and other health professionals takes years,
sometimes decades. Without more graduates from nursing and medical schools and increased innovation
in shared roles and responsibilities among doctors, nurses, and other medical professionals, individuals
and families will face longer wait times, greater difficulty accessing providers, shortened time with
providers, increased costs, and new frustrations with care delivery. A system overload is inevitable.
Pent-up demand from those waiting for a plastic card and attracted by the promise of “free” or heavily
subsidized services is expected. Of course, doctors, nurses, and other medical professionals want to help
people in need, but the sheer logistics of expanded care delivery, the current and growing
shortage of personnel, and limited resources will certainly undercut the good intentions of the
policymakers who crafted the national health law. In fact, the “transformational” changes touted by the
law’s champions will likely complicate and negatively affect health care workers and their ability to provide
care. These changes will increase regulatory burdens, increase already heavy workloads,
reduce payments, impose new penalties, and disregard personal preferences and values.
The increased stress will further destabilize the health care industry. These factors combined will
threaten access and quality of care for all Americans, thus breaking the President’s promises and the
stated intentions of those in Congress who enacted the national health law. Making a Bad Situation
Worse Despite the best efforts of medical professionals and educators to increase the workforce over the
past few years, shortages are projected in every health care profession. The projected supply of workers
fails to meet the demand associated with population growth and aging of the population. With the new
demand for medical services for the millions who are expected to enroll in Medicaid and the federal and
state insurance exchanges, the workforce shortages could become catastrophic. Based on a 2012
compilation of state workforce studies and reports, every state clearly needs more physicians.
There are shortages of primary care physicians and specialists.[3] All health professions are facing
personnel shortages: dental, mental health, pharmacy, and allied health—to name a few. Before the
ACA’s enactment, a confluence of pressures had contributed to labor force problems. The ACA will
impose additional strains on the health care workforce. Population Demographics. The current U.S.
population is more than 315 million and growing.[4] By 2030, 72 million Americans will be 65 or older, a
50 percent shift in age demographics since 2000.[5] The shift is mostly due to the aging baby boomers,
who were born at the conclusion of World War II. Americans are living longer than ever before
with the help of breakthroughs in medical technology and advanced care management. Seniors currently
account for 12 percent of the population but will account for 21 percent by 2050. This growing, aging
population will ensure more chronic disease and additional stress on the health care
workforce.[6] Distribution Shortfall. A maldistribution problem already exists. In much of the nation,
health professionals are highly concentrated in urban locations.[7] The federal government
established Health Professional Shortage Areas (HPSAs) in 1976, pursuant to congressional enactment
of the Health Professions Educational Assistance Act, to increase the number of health care workers in
rural and underserved areas. However, 37 years later, access to care is still unequal between
urban and rural locations throughout the United States.[8] The U.S. Department of Health and
Human Services (HHS) projects the need for 7,987 primary care physicians in rural areas and shortages
of dentists and psychiatrists as well.[9] Nationally, only 10 percent of physicians and 18 percent
of nurse practitioners (NPs) practice in rural locations, yet one-fourth of America’s
population resides in rural areas.[10] Rural populations are poorer and more likely to participate in
government assistance, creating the potential for high demand due to the Medicaid expansion in 26
states.[11] Geographical challenges affect the health of rural Americans through longer
wait times, difficulty accessing care, long-distance travel, and limited resources. The ACA
reauthorized loan repayment and forgiveness, scholarships, increases in Medicare-funded Graduate
Medical Education (GME) residency slots, funding for workforce planning, and increased funding for the
Public Health Service. These are intended to reduce the rural shortages, but these programs have
historically achieved only limited success. Yet they have been the only initiatives to address
maldistribution. The danger is that these shortages will result in increased morbidity and mortality
for rural Americans. Solving the problem will likely require a paradigm shift in educational admission
practices, recruitment of more personnel with rural experiences, payment reform in the public and private
sectors, and a much friendlier regulatory environment for medical practice, including tort reform.
Disproportionate Ratios. Another personnel supply problem is the disproportionate ratio of primary care
physicians to specialists. Research suggests that the ideal ratio of specialists to primary care physicians
is 40 percent to 50 percent in the healthiest nations.[12]A large gap in this ratio currently exists, with only
one-third of physicians working in primary care. In states with higher ratios of specialists
to primary care physicians, research indicates increased costs and decreased quality of
care.[13] The ACA relies heavily on the concept of the Patient Centered Medical Home (PCMH) model
and free preventive care. However, both models require enough primary care providers to deliver
services. This will be difficult given the projected personnel shortages.[14] The ACA’s newly insured
population is expected to require at least 8,000 additional primary care physicians to meet their
needs.[15] Even with the use of nurse practitioners (NPs) and physician assistants (PAs),
projective shortages range from 20,400 to 45,000 primary care physicians over the next
decade.[16]

Alt causes to medical access – insurance alone is insufficient

Becker 14 (Arielle Levin Becker, Connecticut Mirror, “Obamacare got them insurance, but patients still
face barriers to care” 5/15/14 https://ctmirror.org/2014/05/15/obamacare-got-them-insurance-but-patients-
still-face-barriers-to-care/)

The law known as Obamacare helped thousands of Connecticut residents get health care
coverage. But for many, getting coverage eliminated just one of many barriers to getting health
care. That’s something Dr. Luis Diez-Morales knows from the calls his Hartford office gets. There was
the newly insured man looking for a primary care doctor, who’d already found that other
physicians aren’t taking new patients or don’t have an opening for several months. A patient
called after going to the pharmacy to say she couldn’t afford her insulin and wondered if
there was anything else she could take. Another woman wanted an appointment for her
mother, who needs a doctor who speaks Spanish. A 60-year-old man with heart disease called
to cancel his next visit because he realized he couldn’t afford the copayments. And a woman who
works in a convenience store and doesn’t get paid if she doesn’t work called asking for a
Saturday appointment — a rarity in medicine. Diez-Morales, a physician at St. Francis Hospital
and Medical Center and medical director of the St. Francis Center for Health Equity, spoke as part of a
roundtable discussion Wednesday on the barriers the newly insured face in getting health care. It was
sponsored by the Connecticut Center for Patient Safety. Panelists cited a wide range of potential
pitfalls that face the newly insured. Among them: Most people buy insurance without properly
understanding their plans. It can be nearly impossible to find the details about what drugs a
health plan covers. Some new patients feel disrespected by doctors who rush through
their appointments or spend the visit looking at computer screens, making them unlikely to go to
a second appointment. Patients who don’t speak English often have to rely on a
patchwork of inadequate solutions to communicate with a doctor. People who don’t have
access to a car or public transportation struggle to get to medical appointments. And
some patients avoid seeing a doctor because they fear being diagnosed with an illness.
Insurance confusion One of the major challenges, panelists said, is consumers’ lack of
understanding of how insurance plans work. That’s of particular concern because experts believe that
people are increasingly going to be responsible for more of their own health care costs. Many health
plans already have high deductibles. And increasingly, experts believe, companies are likely to shift from
offering their own health plans to giving workers a set amount of money to buy their own coverage on
public or private health insurance exchanges. Steve Glick, president of the Chamber Insurance Trust,
which helps businesses with insurance, is among those forecasting the shift. And he said people need far
more education about insurance than they have now. Research suggests that the vast majority of
people don’t know how to define copayments, coinsurance, deductibles and out-of-
pocket costs, he said. Instead, people often buy insurance based solely on the premiums —
the up-front cost they must pay each month — without realizing how much they might have to
pay when they get care. As a result, Glick said, people who shopped on the exchanges created as
part of the federal health law are realizing that the plans they bought don’t cover a drug they need. Or
they didn’t realize they’d have to pay more than $6,000 toward a deductible before the plan would begin
paying for a service. “I’ve never seen such confusion,” said Glick, who has worked in the industry for 35
years. The federal health law requires that health plans provide a description of benefits in a standardized
format, known as a summary of benefits and coverage. They’re intended to allow people to compare
plans. But Glick said even those summaries are too difficult for most people to understand. Prescription
drugs are a particular challenge, Glick said, because there have been significant changes to
cost-sharing requirements. He cited the case of one client, a single mother who works as a
paralegal and needs infusions that cost $10,000 per month. In her old plan, they were covered with a $40
copay. But her new plan required her to pay $500 per month for the drug. Glick said it’s not an isolated
problem. “Major drugs are not covered the way they used to be, and that’s going to affect many people,”
he said. But figuring out those changes can be tough , said Doris Peter, director of the Consumer
Reports Health Ratings Center. In trying to find the list of covered drugs for one of the plans sold by
Connecticut’s health insurance exchange, Peter had to navigate through multiple websites. “It took me
about 11 clicks, and I knew what I was looking for,” she said. “This is just outrageous, I think, for people to
be able to manage.” Often, understanding a health plan’s drug coverage comes down to experiments,
Peter said: People get a prescription, go to the pharmacy, and end up with a bill. “Fast food drive through”
medicine The families Jacqueline Ortiz-Miller works with face even more barriers. Many are below the
poverty level. Some are not in the country legally. Often, they have several generations living in a small
apartment or are homeless. “It’s really important to understand that life’s struggles make a huge impact in
accessing health care,” said Ortiz-Miller, a community health worker in Hartford who works on a childhood
obesity program. Many of the families she works with don’t have cars or the money for public
transportation, so they walk to appointments. When a primary care center moved out of walking distance,
many patients were left to figure out how to get there, she said. In the Hispanic and African-
American communities, Ortiz-Miller said, she often sees a psychological barrier : a fear of
diagnosis. “For many of my families, because of that fear , they won’t see a doctor,” she said.
She believes it contributes to the high rates of diabetes, heart disease and obesity in
their communities. And among those who go to the doctor, the experience isn’t always
positive, she said. Because of changes in insurance, many have been told they can’t see the primary
care doctor they’ve developed a relationship with, Ortiz-Miller said. Others complain that their
appointments are rushed and feel “like a fast-food drive through type of service.”
Sometimes, doctors tell them at the start that there’s a 10 or 15 minute limit to the appointment. Many
doctors now use electronic medical records, and Ortiz-Miller said patients perceive their
doctors spending more time entering information into the computers and making sure
they can bill for services than making eye contact and talking to the patient. “A lot of my
families have been sharing how they feel like they’re not valued and they feel like they don’t matter when
they’re at their appointments,” she said. Venton B. Forbes, executive director of FaithCare, which aims to
integrate faith and medicine and helps connect people to free care, said he hears similar complaints from
patients who say their doctors spend more time on computers or trying to ensure they get reimbursed
than they do learning about their patients. Patients who don’t speak English face particular
challenges. Because qualified interpreters are overbooked, medical offices often revert to
having staff interpret, even if they’re not qualified to translate medical terminology, Ortiz-
Miller said. There is a language line that people can call for translation, but she said
patients often find it cumbersome and uncomfortable to share personal medical
information with someone over the phone.
 Safety Nets: 2NC

Safety nets like Planned Parenthood are uniquely key to women’s healthcare –
accessibility and quality of care that public providers can’t solve
Hasstedt 17, Kinsey – Senior Policy Manager in the Guttmacher Institute, MPH focusing on sexual and
reproductive health policy and disparities from Johns Hopkins, 2017 (“Understanding Planned
Parenthood’s Critical Role in the Nation’s Family Planning Safety Net,” Guttmacher Institute, January 12,
2017, accessible online at https://www.guttmacher.org/gpr/2017/01/understanding-planned-parenthoods-
critical-role-nations-family-planning-safety-net)

Attacks on Planned Parenthood seek to undermine a network that has capably served millions of women
for decades. Although proponents of defunding Planned Parenthood argue that other
providers—namely health departments and federally qualified health centers (FQHCs)—
would easily be able to fill the overwhelming hole torn in the safety net, evidence suggests
otherwise.1 Planned Parenthood health centers consistently perform better than other
types of publicly funded family planning providers on key indicators of accessibility and
quality of contraceptive care.2 Plus, Planned Parenthood serves a greater share of women
who obtain contraceptive care from safety-net health centers.3 And in some communities
and for many women, Planned Parenthood is the predominant source of publicly funded
contraceptive care.4 It is simply unrealistic to expect other providers to readily step up
and restore the gravely diminished capacity of the family planning safety net were
Planned Parenthood defunded.
Women can often obtain care more quickly from Planned Parenthood. Sixty-two percent of
Planned Parenthood health centers offer same-day appointments, a proportion similar to FQHCs
(58%), but higher than health departments (42%).2 Moreover, the average wait for an initial
contraceptive appointment at a Planned Parenthood health center is 1.2 days, while the
average wait time for such a visit is 2.5 days at sites operated by FQHCs and 4.1 days for
health department sites.
Planned Parenthood health centers are also by far the most likely to accommodate clients
who have difficulty taking time off from work or family responsibilities to obtain care: Seventy-
eight percent of Planned Parenthood health centers offer extended evening or weekend hours versus
57% of FQHCs and just 18% of health departments.2

Planned Parenthood health centers facilitate women’s timely access to a wide range of
methods. Planned Parenthood is particularly good at ensuring a woman can choose the
contraceptive method that will work best for her, and helping clients to start and
effectively use their chosen method (see chart 1).2
Solvency
 RtH Courts: Equity—2NC

A judicial right to health worsens structural inequality—helps middle-class

individuals and further erases awareness of marginalized populations—also hurts
implementation of other health measures due to budget constraints—Brazil
proves
Ferraz 09, Octavio – Assistant Professor in the School of Law at the University of Warwick, 2009 (“The
right to health in the courts of Brazil: Worsening health inequities?,” Health and Human Rights Journal
volume 11 no. 2, accessed October 21, 2017, accessible online at
https://www.hhrjournal.org/2013/08/the-right-to-health-in-the-courts-of-brazil-worsening-health-inequities/)

Does the Brazilian model of litigation give priority to the health needs of those at the
bottom of the ranking of health achievement, consequently diminishing the vast health
inequalities that persist in the country? In order for the model to have this effect, the majority of
litigants would need to belong to the lower socioeconomic groups of Brazilian society, such
as the first and second quintiles of income shown in Table 1.41 But this is not the case. Access to
the courts in Brazil (as in most places) is significantly easier for those with resources and
social attributes that are more predominant in higher socioeconomic groups. Such
resources and attributes, to quote Siri Gloppen, include “rights awareness; organizational strength and
ability to mobilize; and access to legal assistance, technical expertise, and financial resources.”42
Several recent empirical studies on the phenomenon of health litigation confirm, predictably, that a
significant portion of successful litigants do not belong to the most disadvantaged layers of society, but
rather the opposite. Indirect indicators: Legal representation and health services used The two most
common indirect indicators of litigants’ socioeconomic status are the type of legal
representation used by claimants (private vs. public legal services) and the origin of the
medical prescription that supports the claim (public vs. private health services). The
plausible assumption is that representation by a private lawyer and use of the private
health system, especially when they occur together, would strongly indicate a high
socioeconomic profile of the litigant.43 Indeed, given that the two poorest quintiles of the Brazilian
population, that is, cumulatively the poorest 40%, have an average monthly per capita income of 0.42% of
the minimum wage, it is unlikely that they would be able to afford the services of private lawyers and
doctors.44 Table 2 compiles information on the use of private and public legal and health services
available from studies conducted in the municipality of São Paulo and in the states of São Paulo, Rio de
Janeiro, and Santa Catarina. As Table 2 shows (see next page), all studies to date except one
demonstrate that the majority of claimants are represented by private lawyers, and a
significant percentage of prescriptions originate in the private health system.45 The
exception is an early study of litigation in the state of Rio de Janeiro.46 Yet one must not assume that this
study indicates that, at least in Rio de Janeiro, litigation is benefiting the worst off and improving health
equity. Although most claimants represented by public lawyers are indeed often
comparatively worse-off than those represented by private lawyers, public representation
does not mean that the claimants come from the lowest income quintiles of the Brazilian
society.47 On the contrary, factors such as flexible means criteria for qualifying for public
legal services, higher rights awareness, office location, and available transportation lead
an increasing number of middle-class claimants to be represented by public lawyers,
especially in cases involving expensive medication.48 In a recent study of litigation in the state
of São Paulo, for example, Daniel Wang found that the median household income of claimants
represented by public lawyers from June 2008 to January 2009 was just below the minimum salary.49
That is, more than half of the claimants were above that level, and thus did not represent the two lowest
quintiles of the population.50 In another study, it was observed that the public lawyers’ offices in the state
of Bahia are located in a middle-class district that is difficult to access by public transportation.51 The
higher prevalence of prescriptions issued by physicians of the public system in the Rio de Janeiro study
should also be interpreted with caution. Whereas the poorest patients will rarely use private doctors, it is
not difficult for richer patients to occasionally use the public system, for instance to get a prescription to
support a judicial claim.52 Direct indicators: Residence, income, and education More precise
information on the socioeconomic profile of claimants can be gathered through direct
indicators such as residence, income, and education. A few studies have used innovative
methods to gather this information. Fabiola Vieira and Paola Zucchi, for instance, analyzed claimants’
addresses and found that 63% in their sample lived in the areas of the city with the lowest
levels of social exclusion.53 In a more recent study, Ana Chieffi and Rita Barata used the São Paulo
Index of Social Vulnerability (which divides the city into six homogenous areas) and found that 74% of
the claimants lived in the three areas with the lowest social vulnerability rates.54 Fernanda
Terrazas confirmed these findings by interviewing a random sample of 160 successful claimants
in the state of São Paulo.55 Over 70% stated that they lived in their own house in an upper-
class, middle-class, or lower-middle-class neighborhood, and more than 58% stated that
they lived in households with an income over the minimum wage per capita. A significant
percentage of respondents had incomes well above that level, with 23.75% reporting incomes two to five
times the minimum wage and with 11.8% reporting an income more than five times the minimum wage.
Perhaps more striking, over 80% of Terrazas’ sample had completed secondary education or higher,
whereas in 2006, only 39.2% of the state’s population had completed this level of education.56
Conclusion The emerging evidence gathered in the available studies on right to health litigation
conducted in Brazil indicates that a significant proportion of litigants do not come from the
most disadvantaged socioeconomic groups in society. For many, these findings are notable
but not surprising. They are also consistent with other studies, such as the recent comparative study by
Gauri and Brinks of social rights litigation in Asia, Africa, and Latin America. Such research shows that
the direct effects of litigation benefit predominantly those individuals “in the middle of the social
spectrum,” that is, “neither the most disadvantaged nor the wealthiest citizens.”57 It is clear, thus, that
the model of litigation currently prevalent in Brazil is not improving health equity. But does
it worsen health inequities? I suggest that it does, although the extent to which this occurs is difficult to
determine with any precision without further research on the opportunity costs of such litigation. It is likely
that the increasing amount of resources spent to fund the health benefits granted to
successful claimants (hundreds of millions of dollars in some states, mostly consumed to purchase
expensive new drugs) is diverted at least in part from current or future health programs that
would benefit larger and more disadvantaged groups who cannot easily access the
courts to protect their interests. Take as an example the case of the state of São Paulo, where data
is more easily available and comprehensive. In 2008, the state spent approximately R$400 million
(approximately US$200 million) to comply with court orders benefiting around 35,000 successful
claimants, mostly to purchase expensive drugs, many of which have to be imported and are not
even registered for use in Brazil.58 This is roughly the same level of resources that the federal
Ministry of Health has recently announced will be invested in a program of vaccination
against pneumococcal bacteria to cover all 3.2 million children born every year in Brazil. But
this program will not be fully implemented until 2010 due to resource limitations of the
health budget.59 Further research on the opportunity costs of right-to-health litigation will be very
important in assessing health equity.
 RtH Courts: Non-Enforcement—2NC

Resource constraints kill enforceability

Richard D. Lamm, Director, Center for Public Policy & Contemporary Issues, University of Denver and
former Governor, State of Colorado, “The Case Against Making Healthcare a ‘Right’,” HUMAN RIGHTS v.
25 n. 4, Fall 1998, Ebsco.

It is wonderful rhetoric to claim on the political stump that all citizens ought to have a " right to healthcare." But it is not good
public policy. Medical policy and ethics focus mainly on the individual, and urge--under the pain of a lawsuit--to do everything that is
"beneficial" or will "add value" to that patient. This standard soon runs into the law of diminishing returns and simultaneously distributes limited
resources ineffectively. The price of modern medicine is to decide what to cover among the smorgasbord of treatments available. The healthcare
system can no more afford to do everything "beneficial" for every patient than the education system can do everything "beneficial" for every student,
nor the police department do everything "beneficial" for every citizen, nor every parent do everything "beneficial" for their children. We are judging
much of what we do and expect in health from an unsustainable yardstick. No matter how we organize and no matter how we fund healthcare, we will
find our medical miracles have outpaced our ability to pay. It is hard to change our thinking after years of blank check medicine--but necessary. As
David Eddy said, "We will need to accept, once and for all, that resources are limited. It is the limitation on resources that
both necessitates and justifies the strategy of getting more for less." This is painful, but unavoidable. We are inventing the unaffordable and spending
the unsustainable. We need to focus limited resources on where they will buy the most health for society. A decent and just society is a structure with
many important pillars. Healthcare is one of those pillars but so is education, justice, welfare, decent infrastructure, and liveable environment. My
generation has been mesmerized by the concept of rights because the concept was so useful in expanding freedom and justice. But "rights" are not a
universal tool applicable to every social need. Conclusion I am increasingly skeptical that human rights is a useful platform for the public distribution of
social goods. Like the statue in the park, its
pose is heroic but it is not practical or useful except as an
unattainable symbol. One can declare endlessly and idealistically that "human rights" include not
only freedom but also food, housing, healthcare, a liveable wage, and a chicken in every pot. Beyond being laudable goals, they
are not achievable in the world of public budgets.
 Extinction: 2NC

Low probability extinction scenario still outweighs—irreversible

Michael Anissimov, founding director, Immortality Institute, “Immortalist Utilitarianism,”
ACCELERATING FUTURE, 5—04,

www.acceleratingfuture.com/michael/works/immethics.htm

They fear social ostracization if they focus on "Doomsday scenarios" rather than traditional extension.
Those are my guesses. Immortalists with objections are free to send in their arguments, and I will post
them here if they are especially strong. As far as I can tell however, the predicted utility of lowering the
likelihood of existential risk outclasses any life extension effort I can imagine. I cannot emphasize
this enough. If a existential disaster occurs, not only will the possibilities of extreme life extension,
sophisticated nanotechnology, intelligence enhancement, and space expansion never bear fruit, but
everyone will be dead, never to come back. Because the we have so much to lose,
existential risk is worth worrying about even if our estimated probability of occurrence is
extremely low. It is not the funding of life extension research projects that immortalists should be
focusing on. It should be projects that decrease the risk of existential risk. By default, once the probability
of existential risk is minimized, life extension technologies can be developed and applied. There are
powerful economic and social imperatives in that direction, but few towards risk management. Existential
risk creates a "loafer problem" — we always expect someone else to take care of it. I assert that
this is a dangerous strategy and should be discarded in favor of making prevention of such
risks a central focus.