1AC

1
Advantage 1 is the economy
Two internal links---first is coverage:
US is locked into slow growth crisis now -- upward trends are short-term
John Ross 17, Senior Fellow at Chongyang Institute for Financial Studies, Renmin University of China,
former Professor at Shanghai Jiao Tong University, 6/12/2017, “Why the US economy remains locked in
slow growth,” http://ablog.typepad.com/keytrendsinglobalisation/2017/06/why-the-us-economy-
remains-locked-in-slow-growth.html

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

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

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

Coverage gaps threaten economic decline – stabilizing insurance markets is key

Sara Rosenbaum 10, JD from Boston University, Jonathan Gruber, Buying Health Care, the Individual
Mandate, and the Constitution, The New England Journal of Medicine,
http://www.nejm.org/doi/pdf/10.1056/NEJMp1005897
From an economics standpoint, pose of the ACA is to regulate how Americans buy health care, which is clearly economic conduct. Above all, the
ACA’s fundamental goal is to stabilize the vast U.S. market for health care services — which accounts for 17.5% of the gross domestic product,
according to Congress — along with the health insurance system on which nonelderly Americans rely as a principal means for financing their
health care. The law’s goal is revealed through extensive legislative findings that are set forth in the ACA. The goal
also can be seen in
the act’s provisions that collectively are aimed at making the insurance market work for millions of
Americans who, because of their income, health status, or both, have been locked out of affordable,
accessible, and stable coverage and must therefore try to pay for care at the point of service.¶ The
existing system has broad economic implications for both the insured and the uninsured. Far from being passive
and noneconomic, the uninsured consume more than $50 billion in uncompensated care, the costs of
which are passed through health care institutions to insured Americans. Moreover, medical expenses not
covered by insurance are one of the leading causes of bankruptcy in the United States, and the costs of
resolving those bankruptcies are borne throughout the U.S. economy. In addition, the lack of health
insurance leads to poorer health, which can, in turn, reduce workplace productivity. Even the possibility
of losing health insurance makes many workers afraid to leave their jobs for more productive positions
elsewhere, so the current system reduces the over all productivity of the U.S. labor force.¶ The changes made
by the ACA to stabilize the insurance market are fundamentally economic. The legislation’s core is its mandate to end pervasive discriminatory
insurance practices while making care affordable. But such change
is not possible without an individual mandate. If
people who are in better health can opt out of the market and effectively gamble that they can pay for
whatever health care they need at the point of service, prices rise for those who are in poorer health,
leading to an “adverse selection” spiral that raises insurance prices for all. This is not an idle conjecture.
Five states have tried to undertake reforms of the nongroup insurance market like those in the ACA without enacting an individual mandate;
those five states are now among the eight states with the most expensive nongroup health insurance.¶ In the end, the
ACA is all about
altering individual economic conduct, and its importance lies in the way it changes the when and how of
health care purchasing. By ensuring access to affordable coverage for most Americans, the law seeks to
rationalize our economic behavior while providing the regulatory and subsidization tools to make this
rationalization possible. To characterize the ACA as a law aimed at anything other than individual economic conduct is to
fundamentally miss the point of the legislation.

Second is small businesses:

Uncertainty and poor ACA implementation threatens job lock and crush small
businesses – they’re key to the economy
Jeanne Shaheen 17, MA in Political Science from the University of Mississippi, 6/29/2017, Small businesses
are collateral damage in healthcare chaos, http://www.nhbr.com/July-7-2017/Small-businesses-are-
collateral-damage-in-healthcare-chaos/
The Republican plan to overhaul our healthcare system is causing anxiety for millions of Americans and
uncertainty for small businesses and entrepreneurs who are the backbone of our economy.¶ The Senate bill
was drafted in secret by Republican senators with no input from the public, no testimony from doctors or hospitals and no public hearings. This
backroom maneuvering follows passage of the House Republican healthcare plan, which even President Trump has called “mean.”¶ These bills
roll back protections for people with pre-existing conditions, raise out-of-pocket costs and strip coverage from millions of people. They also
slash Medicaid — our nation’s program for insuring children, people with disabilities, seniors in nursing homes, and people with substance use
disorders — by nearly half.¶ I recognize that the
Affordable Care Act needs changes. I believe we should focus on
improving the law, keeping what works and fixing what’s not working, while helping to level the playing
field for small businesses.¶ But instead of fixing it, the Trump administration is systematically undermining the
ACA by cutting outreach and enrollment efforts, suggesting it won’t enforce the law and refusing to
commit to making cost sharing reduction payments essential to the ACA-created health insurance
marketplaces for more than a month at a time. President Trump has made clear his desire to see the system fail, saying: “The
best thing we can do politically speaking is let Obamacare explode.”¶ That’s irresponsible, and treats small businesses as collateral damage.¶
While some small businesses buy health insurance in the small group market, many entrepreneurs, sole proprietors and people working for
small firms purchase their insurance on the individual market through an ACA marketplace.¶ According to the nonpartisan Congressional
Budget Office, the
chaotic, incoherent and secretive process in Washington is creating “substantial
uncertainty about how the new law would be implemented [and] could lead insurers to withdraw from
or not enter the non-group [individual] market” for insurance purchased individually on ACA
marketplaces.¶ In 2014, one in five individuals who purchased healthcare on an ACA marketplace was a small business owner, self-
employed, or both. Before passage of the ACA, small businesses paid an average 18 percent more for coverage than large businesses.¶ Data
from the Centers for Medicare and Medicaid Services says the average yearly premium increase in the small group market was 10.4 percent
between 2008 and 2010 (pre-ACA), but dropped by half between 2011 and 2015. The number of uninsured small business employees (those
working at firms with fewer than 50 workers) dropped by more than four million between 2013 and 2015.¶ The
ACA also enabled many
Americans to consider entrepreneurship by ending the disincentive known as “job lock,” which kept
many Americans in jobs they didn’t want because they feared losing their health insurance.¶ David Lucier,
owner of Claremont Spice & Dry Goods in Claremont, said: “Before the ACA, insurance costs were more than a third of my business expenses.
Now, they’re less than an eighth. The ACA made it possible for me to go out on my own and realize my dream of starting a small business.”¶
Citing the uncertainty and the general unpredictability of the legislative process in Washington, insurers
are departing the exchanges. This is especially damaging for sole proprietors and small businesses that
rely on the ACA and its affordable insurance options.¶ Without the ACA, millions of Americans will lose
their insurance, and small businesses will face the prospect of closing or shifting health costs to
employees.¶ New Hampshire is a small business state. Small businesses employ more than half our private
workforce and are a job creating engine. They need certainty so they can make prudent decisions about
payroll, budgets and product development.¶ Running a small business is hard enough. The current chaos in
Washington makes it that much more difficult.¶ Instead of tearing down the ACA and taking health coverage
away from people and small businesses, we should be building on the gains and achievements of
healthcare reform and work together on a bipartisan basis to fix what’s not working.¶ The ACA has had a
positive impact all across America, but it needs commonsense repairs and strengthening. My message to Republican
leaders in Congress and President Trump is: stop undermining the ACA, and let’s work together to improve America’s healthcare system.

Small businesses are key to reverse economic stagnation – solves weak job growth
and labor outflows
Boyd Nash-Stacey 16, Economist at BBVA Compas, MA in Economics from the University of Houston,
6/22/2016, Running on fumes: remaining gap in Beveridge Curve a matter of structural forces,
https://www.bbvaresearch.com/wp-content/uploads/2016/06/160622_US_EW_RunningOnFumes.pdf

As the U.S. economy enters its 28th consecutive quarter of expansion (4th longest since the great
depression), there is ongoing debate as to whether labor markets, and for that matter, the broader
economy is nearing the end of the expansion cycle. While there is evidence that expansions do not die of old age, there
are signs that the labor market recovery is nearing retirement, similar to a growing share of the labor
force. 1 For example, a recent report from the BLS suggested that job growth was the lowest in six and half
years. Moreover, the auspicious signs of strong flows back into the labor force reversed course dramatically.
While these measures can be volatile, there are many signs that cyclical recovery is nearing its peak at a moment
when conditions remain below the economy’s pre-crisis potential.¶ That being said, a broad view of the labor market
suggests that conditions could not be better. The economy has added an average of 226K jobs per month since 2014, and the unemployment
rate now stands at 4.7%—the lowest rate in nine years. In addition, the number of people choosing to re-enter the labor force and begin work
was at an all-time high in April, pushing up the labor force participation rate, a trend that had coincided with wage gains and tighter labor
market conditions. ¶ To assess if there is remaining slack in the labor market or if the remaining headwinds are structural in nature, we exploit
the empirical relationship between the unemployment rate and jobs vacancies, known as the Beveridge Curve (BC), and a time-series derivation
of the gap in the BC referred to as the “curve shifter.” Theory suggests that higher levels of unemployment (larger pool of job seekers) is
associated with a lower number of vacancies given that a higher supply of job seekers and greater demand for employees will increase the
likelihood of employers finding a match for their vacant positions. As a result, traditional business cycles produce movements along the curve.
However, during the recession and recovery, there has been a persistent outward shift in the curve, which
is unlikely to be explained by normal cyclical forces.¶ To put this into perspective relative to the pre-
crisis, for any given job vacancy rate, there was a 2pp higher unemployment rate (UR). For sectors most
acutely impacted by the crisis, such as construction and transportation and utility, the gaps were 5.1pp
and 2.3pp larger, respectively. Although there have been some indications of improvements, based on a
derivation of this gap or shift in the BC, there appear to be remaining frictions.¶ Using this reduced form
representation of the curve shifter, we confirm previously established relationships between productivity (Lubik 2012), uncertainty (Liu & Leduc
2015), and secular shifts in labor force activity a la Bova et al (2016). However, we find that access to credit, in addition to significant fiscal
policy tightening, are the key elements in the breakdown of labor market matching. Moreover, we find heterogeneous impacts across firm size
and age, and industries. In fact, the reduced form representation of the factors that can “shift the curve” a la Pissarides (2000) and Liu & Leduc
(2015) shows that despite a handful of cyclical indicators suggesting vast improvements in the labor market, there remain significant structural
forces at play.¶ Usual suspects explain remaining gap in labor market¶ After controlling for changes in unemployment benefits (extension of
unemployment insurance claims) due to the financial crisis, we found that there were three key factors that explain the significant and
persistent outward shift in the BC: labor force outflows of those 55 and older, cyclical fiscal policy tightening and credit availability. In fact, over
a four year cycle, increased willingness of banks to lend in the commercial and industrial (C&I) and commercial real estate loans (CRE) spaces
explains 35% of the shift, while cyclical fiscal policy shocks explain 31% of the movement, productivity explains 15%, and retiree outflows from
the labor force explain an additional 13%. Unlike Liu & Leduc (2015), we find that policy uncertainty explains only a small portion of the shift
(3.0%). On a short time horizon (four quarters), however, productivity plays a more important role in matching, explaining nearly 50% of the
shift, with labor force outflows explaining an additional 17%.¶ These results imply that factors that are cyclical by nature
can have lasting effects on broader labor market activity. A process sometimes referred to as hysteresis. For example,
fiscal policy shocks and credit availability tend to ebb and flow with the business cycles, leading to predictable movements along the BC.
However, without offsetting shocks to other determining factors, e.g. lower uncertainty or higher productivity, the impact can persist for years,
and in some cases never fully recover. In addition, to the extent that credit and fiscal policy have experienced a permanent shift, and the fact
that monetary policy is becoming a less effective tool, it will be hard to envisage any significant reduction in the gap in the medium-term. ¶ In
addition, we tested the impact hiring rates have on BC across firm age, size and industry. In the short run, large and incumbent firms have the
largest impact on the BC. However, after six quarters, the
impact that startups and small firms have on the BC is more
significant and persistent. In fact, at 16 quarters, the impact that startup hiring has on BC compared to old
firms is 10 times greater; for small firms, in a similar vein, the impact is 250% greater at 16 quarters
versus four quarters from the initial shock. With this in mind, creating an environment that encourages small
business formation and risk taking could counteract headwinds plaguing the labor market. ¶ Firms at all levels
are susceptible to credit cycles and cash flow volatility. However, these factors are amplified for new entrants or small firms, imparting a larger
influence on the broader labor market, particularly in keystone sectors such as retail, real estate and construction. In other words, hiring
slowdowns in these sectors have the largest and most persistent effect on the BC shifter. For instance, a one standard deviation drop in the
hiring rates in these sectors would shift the BC outwards by approximately 10%. To put this into perspective, in the aftermath of the crisis, the
BC shifter increased by 30% from peak-trough. Moreover, unlike other industries that are more apt at weathering cycles and have greater
access to credit such as manufacturing, these industries are generally slow to respond and as a result, accumulate losses over a longer time
period, and in some cases, never recover.¶ This finding has substantial implication for the health of the broader
economy given the fact that small and new firms are the dominant force in net job creation in the U.S.; whereas,
larger (500+ employees) and older (11+ years) firms are historically net job destroyers. Moreover, startups and small businesses
hire at a rate between 1 to 2.5 times higher than older and larger firms. Labor-intensive service sectors such as retail
also have persistently higher levels of hiring, in some cases 50-75bp higher than other sectors. More specifically, startup hiring rates in
industries such as finance and insurance, manufacturing and information are 380%, 330% and 270% higher, respectively, than their industry
peers. Small and young firms in arts and entertainment, agriculture and accommodation hire at rates 200%-400% higher than the national
average. Researchhas also shown that only 3% of businesses can be classified as “high growth businesses,”
but they are responsible for a disproportionate share of growth. Moreover, small businesses are
essential parts of U.S. supply chains given that can lower logistical costs, are nimble problem solvers and
are better equipped to partner on joint innovations. ¶ There is additional upside to targeting small
businesses and startups given that as outflows from the labor market intensify, there could be adverse
effects for aggregate productivity as new entrants take time to develop skills. As a result, focusing on new
business hires could help to accelerate the demographic transition.

Small businesses solves competitiveness – reverses offshoring

Karen Mills 13, MBA from Harvard Business School, SBA’s Karen Mills: U.S. competitiveness hinges on the
strength of small business suppliers, The Washington Post,
https://www.washingtonpost.com/business/on-small-business/sbas-karen-mills-us-competitiveness-
hinges-on-the-strength-of-small-business-suppliers/2013/05/06/03f517b8-b412-11e2-9a98-
4be1688d7d84_story.html?utm_term=.86664a9b8ab1

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

Strengthening US growth key to US leadership---solves global war

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

and governments around the world are far more likely to become more open if the American model is
perceived to be succeeding. Finally, the world faces many serious challenges, ranging from the need to halt
the spread of weapons of mass destruction, fight climate change, and maintain a functioning world economic
order that promotes trade and investment to regulating practices incyberspace, improving global health, and preventing armed
conflicts. These problems will not simply go away or sort themselves out. While Adam Smith’s “invisible hand” may ensure
the success of free markets, it ispowerless in the world of geopolitics. Order requires the visible hand of leadership to formulate

and realize global responses to global challenges. Don’t get me wrong: None of this is meant to suggest that the US can deal effectively
with the world’s problems on its own. Unilateralism rarely works. It is not just that the US lacks the means; the very nature of contemporary global problems
suggests that only collective responses stand a good chance of succeeding. But multilateralism
is much easier to advocate than to
design and implement. Right now there is only one candidate for this role: the US. No other country has
the necessary combination of capability and outlook. This brings me back to the argument that the US must put its
house in order – economically, physically, socially, and politically – if it is to have the resources needed to promote
order in the world. Everyone should hope that it does: The alternative to a world led by the US is not a world led by China,
Europe, Russia, Japan, India, or any other country, but rather a world that is not led at all. Such a world would almost certainly

be characterized by chronic crisis and conflict. That would be bad not just for Americans, but for the vast majority
of the planet’s inhabitants.

The US-led liberal order is key to solve global conflict – economic foundations are key
Robert Kagan 17, Senior Fellow in Foreign Policy, Project on International Order and Strategy, Brookings
Institution, “The twilight of the liberal world order,” 1/24/17, https://www.brookings.edu/research/the-
twilight-of-the-liberal-world-order/

However, it is the two great powers, China

and Russia, that pose the greatest challenge to the relatively peaceful
and prosperous international order created and sustained by the United States. If they were to
accomplish their aims of establishing hegemony in their desired spheres of influence, the world would return to
the condition it was in at the end of the 19th century, with competing great powers clashing over
inevitably intersecting and overlapping spheres of interest. These were the unsettled, disordered conditions that
produced the fertile ground for the two destructive world wars of the first half of the 20th century. The
collapse of the British-dominated world order on the oceans, the disruption of the uneasy balance of power on the European continent due to
the rise of a powerful unified Germany, combined with the rise of Japanese power in East Asia all contributed to a highly competitive
international environment in which dissatisfied
great powers took the opportunity to pursue their ambitions in
the absence of any power or group of powers to unite in checking them. The result was an unprecedented
global calamity. It has been the great accomplishment of the U.S.-led world order in the 70 years since the end of the Second World War
that this kind of competition has been held in check and great power conflicts have been avoided.

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

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

Faced with these obstacles, the

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

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

Continued slow growth causes diversionary conflict with China

John Ross 17, Senior Fellow at Chongyang Institute for Financial Studies, Renmin University of China,
former Professor at Shanghai Jiao Tong University, 7/10/2017, “Trump's economy - cyclical upturn and
long term slow growth”, http://ablog.typepad.com/keytrendsinglobalisation/2017/07/trumps-economy-
cyclical-upturn-and-long-term-slow-growth.html

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

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

Polina Tikhonova 17, Reporter, MA from Oxford University, citing Bruce G. Blair, the National Bureau of
Asian Research, and Union of Concerned Scientists, 7/27/2017, “If Trump Orders A Nuclear Strike On
China, Here’s What Happens”, https://www.valuewalk.com/2017/07/trump-orders-nuclear-strike-
china/

The fact that Trump now has the obedience of the U.S. Pacific Fleet chief in the hypothetical, yet
possible, decision to launch nuclear strikes against Beijing makes the whole let’s-nuke-China scenario
even faster and easier to execute.¶ Less than five minutes. This is the approximate time that would
elapse from President Trump’s decision to launch a nuclear strike against China to shooting
intercontinental ballistic missiles out of their silos, according to Bloomberg estimations. The publication, citing
former Minuteman missile-launch officer Bruce G. Blair, also estimates that it would take about 15 minutes to fire
submarine missiles from their tubes.¶ While the expert predicts that there might be some minor hiccups in the let’s-nuke-China scenario – like
some of the top brass trying to talk Trump out of launching a nuclear strike – it appears that it
would be easier for the President
to nuke an enemy than expected now that he has the public support from the commander of the U.S.
Navy’s Pacific Fleet.¶ US vs China Tensions Rising, But Is Nuclear War Imminent?¶ The mere thought of a nuclear war between the U.S.
and China – the world’s two biggest militaries – sounds intimidating. Amid strained relations between Washington and
Beijing, and with Trump recently giving U.S. Navy more freedom in South China Sea, the territory that
China considers vital to its national and security interests, the possibility of the two nations going to a
nuclear war cannot be ruled out anymore.¶ With Trump pledging to rein in China’s aggressive territorial
expansion in the South China Sea during his presidential campaign, the Trump administration has made quite a few
moves that could be pushing the two nations to the point of no return. In May, Trump ordered the U.S.
Navy to conduct a freedom-of-navigation operation in the disputed area, which Beijing claims in its
entirety despite the Philippines, Malaysia, Brunei, Vietnam and Taiwan also claiming parts of the
disputed region.¶ Earlier this month, the Trump administration sent an even scarier war message to
Beijing to challenge its military buildup on the artificial islands in the South China Sea. A U.S. destroyer passed
through the international flashpoint in the South China Sea, a move that prompted a furious response from Chinese President Xi Jinping, who
warned his American counterpart of “negative factors” in U.S.-China relations. The Chinese Foreign Ministry lambasted the incident as a
“serious political and military provocation.”¶ US vs China War Would Be ‘Disastrous For Both’¶ Just last week, Trump approved the Pentagon’s
plan to challenge Chinese claims in the South China Sea, where Beijing has been actively building reefs into artificial islands capable of hosting
military planes. Breitbart News’s Kristina Wong exclusively reported that the President approved the plan to check China over its ongoing
militarization of and actions in the South China Sea, a move that will most likely further stain U.S.-China relations.¶ The
latest heated
exchange of hostile gestures between Beijing and Washington cannot but make experts wonder: what
would happen if the U.S. and China went to war? That would be “disastrous for both sides – politically,
economically, and militarily,” according to VICE citing senior vice president for political and security
affairs at the National Bureau of Asian Research, Abraham Denmark.¶ While the two nations continue
working together to prevent a potential nuclear threat from China’s neighbor – North Korea – it seems
like an even bigger nuclear conflict is brewing between Washington and Beijing.¶ ‘Increased’ Possibility of
Nuclear War¶ In ValueWalk’s recent comparison of the U.S., Chinese and Russian militaries, it was concluded that the outcome of any war
involving the U.S. and China is quite impossible to predict, as there’s no telling what would be the scope and duration of the military
confrontation and if nuclear weapons would be used.¶ It’s also unclear if Russia would join forces with its arguably one of the biggest allies –
China. If it did, China’s chances of winning a war against Washington would considerably soar. After all, there are plenty of potential flashpoints
in the relations between Washington and Beijing, notably Taiwan and the South China Sea. The U.S. has in its possession about 6,800 nuclear
warheads – the world’s second largest nuclear arsenal after Russia – while China has only 270 nukes, according to recent estimations by the
Arms Control Association.¶ According to a report by the Union of Concerned Scientists, published last year, the
U.S. going to “nuclear war with China is not inevitable – but the possibility that it could occur has
increased.” However, with Washington and Beijing not being able to find common ground on such a vital issue for China’s national and
security interests as the South China Sea, and with Trump ordering more actions that further strain U.S.-China
relations, the risk of nuclear war between the world’s two biggest militaries could skyrocket.

Cost and certainty on the individual exchanges is key to solve job lock – studies
Bradley T. Heim 17, Professor in the School of Public and Environmental Affairs at Indiana University, PhD
in Economics from Northwestern University, Lang Kate Yang, 4/272017, The impact of the Affordable
Care Act on self-employment, Health Economics, accessed via Wiley Online Library

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

Thus, for an individual contemplating self-

cooperative insurers have become insolvent, 6 which may call into question the long-term viability of the exchanges.¶ ¶

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

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

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

results suggest that the

(when exchanges functioned properly and people had sufficient time to adjust their employment status) among individuals eligible for insurance subsidies. Taken together, these

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

Strengthening the mandate is key to make insurance markets financially viable

Paul Demko 16, Healthcare Reporter for Political, former Washington Bureau Chief for Modern Healthcare,
7/13/2016, Obamacare’s sinking safety net,
http://www.politico.com/agenda/story/2016/07/obamacare-exchanges-states-north-carolina-000162

Even so, many of those insurers

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

Renee-Marie Stephano 12, JD in Health Law, Villanova University School of Law, 7/9/2012, US HealthCare
Reform’s Effect on the US Medical Tourism Marketplace, http://medicaltourismassociation.com/en/us-
healthcare-reform-s-affect-on-the-us-medical-tourism-marketplace-white-paper.html

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

Medical tourism threatens international medical apartheid – exporting care undermines public health
systems in South East Asia specifically
Glenn Cohen 11, Assistance Professor and Co-Director of the Center for Health Law Policy, Biotechnology
and Bioethics, Harvard Law School, JD from Harvard Law, Medical Tourism, Access to Health Care, and
Global Justice, Virgina Journal of International Law, Vol 52(1),
http://www.vjil.org/assets/pdfs/vol52/issue1/Cohen_Final.pdf

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

Market is nascent – further growth key – especially in Asia -- underinsurance drives demand

GMT 16,
Globla Medical Tourism, magazine known as the “voice” of the medical tourism industry,
10/6/2016, http://global-mtm.com/global-medical-tourism-market-to-witness-increasing-influx-of-
medical-tourists-in-asian-countries/

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

Public health inequality causes East Asian instability

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

Instability escalates – domestic pressures are a key determinant of conflict

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

Nuke war

Michael Auslin 17, PhD in History from the University of Illinois at Urbana-Champaign, former associate
professor of History at Yale The End of the Asian Century: War, Stagnation, and the Risks to the World’s
Most Dynamic Region, January 2017, accessed via Kindle for Windows - no page numbers available

How close is Asia to seeing conflict erupt, and where? Not every dispute threatens peace, but today, the Indo-Pacific region is
regressing to a nineteenth-century style of power politics in which might makes right. With the world’s
largest and most advanced militaries other than the United States, and including four nuclear powers, a
conflict in Asia could truly destabilize the global economy and spark a conflagration that might spiral out of
control.¶ If you are lucky, you might be near Pearl Harbor in Hawaii when one of America’s aircraft carriers is in port. One afternoon not long
ago, I watched the USS Ronald Reagan slowly steam out of Pearl Harbor into the vastness of the Pacific Ocean. The Ronald Reagan is an apt
symbol of how security risk has been managed in Asia: the United States has underwritten regional stability since 1945. Today,
however,
the post– World War II order instituted by the United States is increasingly stressed, at the very time
when Washington is finding it difficult to respond to crises in Europe and the Middle East. The economic and political risks
discussed here are not isolated from these security trends.¶ The immediate cause of rising insecurity is simple: as China has grown stronger, it
has become more assertive, even coercive. Beijing has embraced the role of a revisionist power, seeking to define new regional rules of
behavior and confronting those neighbors with which it has disagreements. Japan and Taiwan, along with many countries in Southeast Asia,
fear a risingChina, as does India, though to a lesser degree. That fear,
fueled by numerous unresolved territorial disputes
in the East and South China Seas and by growing concern over maintaining vital trade routes and control
of natural resources, is causing an arms race in Asia. The region’s waters have become the scene of
regular paramilitary confrontations. ¶ These fears and responses are triggering more assertive policies on the part of all states in
the region, which only raises tensions further. At the same time, governments feel pressured at home to demonize
neighbors, encroach on territory, and refuse to negotiate on security disputes. This is clearly what has happened in
recent years in the Sino-Japanese relationship. We have already gone through two turns of a “risk cycle”: uncertainty
and insecurity, driven over the past decade by China’s growing power and increasingly assertive and coercive behavior, and by the
emergence of a de facto nuclear North Korea. A third turn, to instability, could cause conflict and even war.¶ The
“Asian Century” thus may not turn out to be an era when Asia imposes a peaceful order on the world,
when freedom continues to expand, or when the region remains the engine of global economic growth. What it imposes may
instead be conflict and instability. The nations of the Indo-Pacific and the world must prepare for the possibility of
economic stagnation, social and political unrest, and even armed conflict. The emergence of those would mark the
end of the Asian Century.

Failing to invest in public health crushes Indian economy

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

and clean cooking but also for livelihood activities.

Growth solves Indo-pak war

Marshall M. Bouton 10, Adjunct Professor of Political Science at Northwestern University, President –
Chicago Council on Global Affairs, July 2010, America’s Interests in India, CNAS Working Paper,
http://www.cnas.org/files/documents/publications/CNAS_USInterestsinIndia_ Bouton.pdf

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

That escalates

Russ Wellen 14, editor of Foreign Policy In Focus’ ‘Focal Points’ blog for the Institute of Policy Studies,
12/19/2014, “The Threshold for Nuclear War Between Pakistan and India Keeps Dropping,”
http://fpif.org/threshold-nuclear-war-pakistan-india-keeps-dropping/

Most people think that, since the end of the Cold War, chances that a nuclear war will break out are slim to none. Though some
nervousness has surfaced since the Ukraine crisis, it’s true that, barring an accident, the United States and Russia are unlikely to attack each other with nuclear weapons. Southeast Asia is
another matter, as Gregory Koblentz warns in a report for the Council of Foreign Relations titled Strategic Stability in the Second Nuclear Age. Interviewed about the report by Deutsche Welle,
Koblentz pointed out: “The only four countries currently expanding their nuclear arsenals are China, India, Pakistan and North Korea.” China, for example, is developing mobile intercontinental

by 2020, Pakistan
ballistic missiles to prevent its stationery ICBMs from becoming sitting ducks, as well as submarines capable of launching ballistic missiles. Meanwhile,

could have enough nuclear material to build 200 nuclear weapons, about as many as Great Britain currently has. Koblentz told Deutsche
Welle: Altogether, Pakistan has deployed or is developing eleven different nuclear delivery systems including ballistic

missiles, cruise missiles, and aircraft. As if terrorism, such as the Mumbai attacks of 2008, and territorial
disputes, such as over Jammu and Kashmir, don’t make relations between Pakistan and India volatile enough, a new
element has been introduced. Pakistan is now seeking to develop low-yield tactical nuclear weapons (as
opposed to strategic ― the big ones) to compensate for its inferiority to India in conventional weapons and numbers of armed forces.
Koblentz told Deutsche Welle: Since the conventional military imbalance between India and Pakistan is expected to grow thanks to India’s larger economy and higher gross domestic product

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

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

into a grave. To wit: Summary of Consequences of Regional nuclear war between India and Pakistan (from studies
done at Rutgers, the University of Colorado-Boulder and UCLA) If … • War is fought with 100 Hiroshima-size weapons (currently available in India-Pakistan arsenals), which have half of 1
 20 million people die from the direct
percent (0.05%) of the total explosive power of all currently operational and deployed U.S.-Russian nuclear weapons •

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

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

experts predict that ensuing food shortages would cause hundreds of millions of already hungry people, who now depend

upon food imports, to starve to death during the years following the nuclear conflict. When it comes to nuclear weapons, we truly are

all in it together. Many claim that whatever leadership the United States and the West might demonstrate in disarmament would be lost on Asian nuclear-weapon states. But
they fail to take into account how disarmament is becoming a norm all over the world including in Asia.
 3
The United States federal government should:
- significantly increase penalties for the requirement to maintain minimum essential
health coverage
- appropriate out-of-pocket financial assistance for the Health Insurance Marketplace
- expand premium financial assistance on the Health Insurance Marketplace
- commit enforcement and outreach resources to these actions
 4
The plan solves – strengthening the mandate, funding cost-sharing and increasing
subsidies is key to a balanced risk pool, higher enrollement, competition, and lower
premiums– working through the ACA framework is key to stability
Cori Uccello 17, Senior Health Fellow at the American Academy of Actuaries, MA in Public Policy from
Georgetown University, Deep Banerjee, Director at Standard & Poor, 5/5/2017, The Individual Market at
a Crossroads Transcript, http://www.allhealthpolicy.org/the-individual-market-at-a-crossroads-5/

Let’s talk about the future a little bit. So, I’m

going to talk about two kinds of forecasts. One is business as usual. What we
mean by that is, everything
stays with obviously some changes, but no big overhaul to the rules of the
marketplace. If that is the case, what do we expect? Well, we expect 2017 to be a year when more insurance
companies get to break even margin. So, break even, zero percent, so no loss, break even margin. And then
continued improvement in 2018 where they get to small, single digit margins in this line of business. It is still a
very fragile market and it needs time to stabilize.

Probably themore important discussion is business unusual or business interrupted forecast. So, there is
obviously a lot of pricing and insurer participation issues in the marketplace today, going into 2018. One of
the biggest things that we look at, is the CSR, which there is some uncertainty about the future funding
of that. The reason the CSR is important — it’s not because just the dollar amount that goes towards it, but
more importantly it is paid to the insurance companies after the fact. So, the insurance company on day
one, accepts members who are CSR eligible and stop paying out claims based on the fact that they will
receive a CSR. The only receive the federal government funding for the CSR later on. So, insurance
companies don’t want to be in the situation where they find out six months into the year, hey, guess
what, you don’t get that money anymore. What we expect to happen are two options available to insurance companies. One, they would
price with what we are calling an uncertainty buffer. So, let’s say they were expecting to price high single digit premium increases for next year. They will probably
tack on a little bit of this uncertainty buffer, because they don’t know what is going to happen. They can load the silver plan with the CSR that they are not going to
get. So, you will see the silver plan premiums go up. The second option, which is probably a little more drastic, is they get more selective about participating. If

there is greater amount of uncertainty, they could decide to pull out of certain counties or certain
states. And the third one, which is probably important to mention too, that the marketplace has a set of rules. If the rules are changed after
you are already playing the game, it becomes harder to adjust. So, rules like the individual mandate or the
special enrollment periods, enforcement of that will also be critical for the future stabilization of the marketplace .
Perhaps we will talk about (indiscernible) later on, when questions come up.

SARAH DASH: Thank you so much, Deep, and let me turn it over to Cori Uccello. Thanks.

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

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

So first, I will talk about what

is necessary in order to have a stable and sustainable market. First, we need
enrollment levels that are high enough to reduce random fluctuations and a balanced risk pool. In other
words, we need enough healthy people so we can spread the cost of the high cost people over a broader

pool. Second, we need a stable regulatory environment that facilitates fair competition. And that includes
not only a level playing field, but also consistent rules that are known in advance. Third, we need enough
insurers participating to have insurer competition and consumer choice. And as Karen mentioned this, the correct – -the
optimal number of insurers probably varies by area. Last, but no least, because most premiums go toward paying medical claims, it’s important not to overlook the
need for continuing to control healthcare spending and improve quality of care.
So, how is the market doing compared to these criteria? Well, the ACA dramatically reduced uninsured rates and participation in
enrollment in the individual market increased. Nevertheless, in general, enrollment in the individual market was lower than

initially expected, and the risk pool was less healthy than expected. Now, in the market, competing rules do generally face the
same rules. There is pretty much a level playing field. But, the uncertain and changing legislative and regulatory environment

have contributed to adverse experience among insurers. This has led to a decrease in the number of
participating insurers both in 2016 and 2017 and there is an indication there will be a further reduction
of insurers in 2018. Continued uncertainty could lead to more insurer withdrawals, leaving consumers
with fewer plan choices or potentially none at all. And as Deep has alluded to, insurer experience has stabilized, but the market
itself is still fragile.

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

Second, the individual mandate needs to be enforced. The mandate is intended to increase enrollment
and encourage even healthy people to enroll. That’s what’s needed for a balanced risk pool. As Karen mentioned, the mandate
itself is already fairly weak, because the financial penalty is low, many people are exempt from the penalty and enforcement itself is

weak. But further weakening it, would make it less effective and would lead to higher premiums. Strengthening it could improve the risk

profile and put downward pressure on premiums. But enforcement itself isn’t enough. I think there are a lot of people out there who
don’t even realize the mandate is still in play. And so, it also needs to be publicized in order to be effective. Alternatives to the mandate are

being explored, such as the continuous coverage requirements that were in the house passed bill. But
it’s difficult to structure those kinds of mechanisms, so that they encourage healthy people to enroll
sooner rather than later, while still providing protections to people with preexisting conditions.

So, if the mandate is the stick to encourage enrollment, premium subsidies are the carrots. More
external funding in the form of higher
premium subsidies, or funding that will offset the cost of high cost enrollees, such a through high risk
pools or these invisible high risk pools, or reinsurance, could help improve the pool. It’s important to note that there
are many — we use the word “high risk pools” a lot, but there are actually several different ways that high risk pools can be structured. In your packets, there is a
paper from the academy that talks about the different ways that that could be done. Like I said, they could be done in terms of the traditional high risk pools that
were in place prior to the ACA, they could be invisible risk pools so that the person enrolling in the private market stays in that plan, but their claims are paid
through this external funding, and that could be their eligibility for those risk pools, could be based on either having certain conditions or having spending that
exceeds a particular threshold.

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

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

Oliver Wyman 9, international management consulting firm , 10/14/2009, Insurance Reforms Must Include
a Strong Individual Mandate and Other Key Provisions to Ensure Affordability,
http://www.oliverwyman.de/content/dam/oliver-
wyman/global/en/files/archive/2011/Importance_of_Strong_Individual_Mandates_-_Public_Memo.pdf

2. Without a strong mandate, premiums for purchasers in the new marketplace will increase
significantly: ¶ We estimate that without strong individual mandates, average annual medical claims in the reformed
individual market five years after reform are expected to be 50 percent higher compared to today, not
including the impact of medical inflation.¶ This would translate into premium increases of approximately $1,500 for single
coverage for a year and $3,300 for family coverage in today’s dollars for people purchasing new policies. Subsidies will entirely or partially
offset these premium increases for some individuals. Eight million current individual market members and 25 million uninsured earn between
100 and 400 percent of the federal poverty level and will have access to subsidies through the exchange.¶ ƒ Adequate
subsidies help
participation, but are insufficient to drive effective coverage levels—both a strong personal
responsibility requirement and subsidies are needed. Over 18 million people, including both currently uninsured and
existing individual market members, are ineligible for subsidies based on the Senate Finance Committee proposed subsidy schedules. For the
very low income, below 200% of the federal poverty level (FPL), we believe a
large percentage of the uninsured will purchase
insurance because of the generous subsidies. However, take up rates will be much lower for those
above 200% FPL without a meaningful penalty, since subsidies decline at higher income levels.¶ ƒ Weak mandates
result in more uninsured. Requiring insurers to guarantee issue coverage regardless of preexisting
conditions—without an effective mandate—means that people can wait to purchase coverage until they
need it, causing premiums to increase for most new purchasers. We estimate that 12.6 million people will forego
coverage, relative to an effective mandate. ¶ 3. The impact of reform on the individual market will vary significantly by geography. The vast
majority of States have not enacted the reforms proposed in Federal bills. The states where twothirds of the United States population reside
will experience the highest premium increases. In these states, the reformed individual market claims are estimated to be up to 60-73%1 higher
than today with a weak individual mandate.¶ 4. People with existing individual coverage may not see significant impact from rating and benefit
changes. The bills “grandfather” existing coverage, so that people can keep their current coverage. These “grandfathered” policies will not be
impacted by the rating changes described above. However, individuals with “grandfathered” policies will not be eligible for the new subsidies.
We estimate that as many as 4.6 million people will stay in the “grandfathered” blocks after 5 years. However, these individuals would still be
subject to premium increases as a result of insurer fees included in the Senate Finance Committee bill. ¶ Key Findings: Small Group Market¶
Under reform, small group employers (2-50 employees) will experience rating changes similar to those proposed for the individual market. Key
findings include:¶ 1. Average premiums for small employers will increase: Under reform, small employers will experience premium increases as
a result of rating rule changes and minimum benefit requirements. We estimate that small employers purchasing new policies in the reformed
market, with an ineffective mandate, will experience premiums that are up to 19 percent higher in Year 5 of reform, not including the impact of
medical inflation. About 9.5 million small group employees who have coverage today will stay covered under the “grandfathered” block in the
initial post-reform years, but will face premium increases when the grandfathering phases-out.¶ 2. Overall, the number of small employers
offering coverage will decline: Under reform and after accounting for small employer tax credits, premium increases will lead to fewer small
employers offering coverage. We estimate 2.5 million fewer members will be insured through small employer policies. ¶ Overview of Modeling
Approach and Methodology¶ Oliver Wyman has developed a comprehensive model to study the impact of different health insurance reform
proposals on the individual and small employer health insurance markets.¶ The model is based on a database of actual
claims, premium and underwriting information from over 375,000 small groups, representing 4.2 million covered lives, and
1.24 million individual policies, representing 1.6 million covered lives. The database includes blinded information on approximately 1-in-10
purchasers in the individual and small employer markets today. These data are representative of states across the country and reflect the
varying rating rules that are used today. This allows the model to provide insight into the impact of reform at the state level.¶ The
model
differs from other models currently in use because it allows for the analysis of how insurance reforms
will impact actual insurance policies. This is critical because most of the rating reform impact is felt at
the “ends of the distributions.” For example, the medical claims for the healthiest 10 percent of members
are typically less than a quarter of the average claims, and the sickest 10 percent are often four to seven
times more than the average. With actual insurance policy data, we can see how much premiums will shift, and therefore how
enrollment is likely to shift, across the full distribution of policies.¶ Other analyses generally use synthetic health insurance
units developed from survey data to evaluate the impact of reform. Because of this, other models may
underestimate the real-world impact of rating changes, in particular, because they do not evaluate the impact on a
distribution of actual policies.¶ Actuarial analysis is used to determine the premium impact of changes in rating regulations and the
differential impact across geographic regions. The model estimates premium changes and migration among coverage categories over a five year
period after reform is implemented. This multi-year view allows us to capture the impact of adverse selection, which can drive up average
prices in an environment with no or weak mandates. Adverseselection theory holds that healthier individuals are
more likely to drop or switch coverage when faced with cost increases, leaving the remaining pool more
expensive to insure.¶ Our model estimates the costs of different coverage choices available in the market under a given reform
scenario, determines market reaction, and shifts between different potential sources of coverage (e.g., the individual market, small employer
market, large group market, government programs) and the uninsured. To evaluate the market reaction to different reform scenarios, we
apply elasticities of demand for employers, employees, and consumers that are consistent with the
academic literature and ranges used by the Congressional Budget Office and other models.¶ The elasticities, combined with the
estimated cost changes to the employer or individual, allow us to determine how many members will enter or exit the market. We are able to
track the membership inflow and outflow based on the health status and income levels of individuals. In addition to the rating changes, we also
account for the savings individuals realize from subsidies and the cost of declining coverage if an individual mandate penalty is in place. Stated
more simply, we are able to estimate the number of people that will be insured and their expected medical costs for any given reform scenario.
The results we see in the output of the model are consistent with
¶ Results Consistent with Actual Market Experience¶

the experience observed in the market. Among the trends that are readily validated by actual market experience are:¶ ƒ Less
healthy individuals are more likely to take up coverage and less likely to drop coverage when costs
change.¶ ƒ Healthy individuals are more cost sensitive. They are more likely to exit the market if costs
increase and require stronger inducements to take up coverage if they are uninsured.¶ ƒ Premiums will
increase at a rate higher than average medical inflation if the pool enters a risk spiral, which occurs when the
percentage of healthy members in the pool declines.¶ Key Model Variables¶ Our analysis includes the major elements of the Senate Finance
Committee’s proposal, the “America’s Healthy Future Act of 2009” or AHFA, that will impact the cost of insurance in the individual and small
employer health insurance market. These key elements include the following: ¶ [Table Omitted] ¶ The AHFA also includes changes to the
insurance market that were not explicitly evaluated in our model. These include optional risk corridors, which could protect certain plans from
losses in the early years of reform, and the inclusion of a “young invincibles” product that could have higher cost-sharing than permitted for
other products. We do not expect these policy provisions to have a substantial impact on average prices for new purchasers of health insurance
coverage. ¶ The AHFA also includes a number of fees and taxes on the health industry to help finance the proposal. These include a $6.7 billion
annual assessment on insurers, assessments on drug and medical device manufacturers, and other assessments that are likely to impact
premiums in the individual and small group health insurance market. The AHFA also imposed an excise tax on high cost benefit plans offered in
the employer marketplace. The analysis for this report does not include the impact of these fees and taxes on cost and coverage in the
individual and small employer markets. The excise tax on high cost benefit plans does not apply to the individual market and we estimate the
impact on small group policies to be negligible.¶ We have not explicitly modeled the impact of health insurance exchanges. However, Oliver
Wyman issued a report in 2008 on this subject that found that exchanges were unlikely to reduce health insurance premiums for individuals
and small employers2 . The Congressional Budget Office's analysis of the Senate Finance Committee proposal indicates that exchanges could
reduce premiums by 4-5 percent in the individual health insurance market3.¶ We evaluated the impact of health insurance reforms with and
without including underlying medical cost inflation. The results of this report are presented in the absence of medical trend to isolate the cost
impact of specific reforms. While the Senate Finance Proposal includes provisions that are intended to bend the cost curve over the long-term,
the inclusion of medical trend would have increased our projected cost increases over the five-year period we examined.¶ Additional
Methodology Detail—Estimated Medical Costs for the Uninsured Once They Become Insured¶ It is important to have an estimate of the
expected utilization of healthcare services of the uninsured after they become insured. There are a handful of academic studies that have
examined this issue, and the Congressional Budget Office has also estimated the potential cost of the uninsured.¶ Our analysis is generally
consistent with the approach used by CBO. We estimate that the morbidity of the uninsured will be about 85 percent of the level of the current
insured market - meaning the uninsured are generally healthier than the current insured market. However, the insured market is comprised
mostly of members from the employer market. It is well known that the current individual market is generally healthier than the employer
market in the majority of the U.S.¶ We estimate that the average uninsured will have average medical utilization about 20 percent higher than
the current individual market. Given that many of the uninsured are likely to seek coverage in the reformed individual market, we expect that
the average claims in the risk pool of the reformed market will increase as a result. ¶ The uninsured are expected to have higher medical costs
than the current Individual market Expected Claims Cost (Indexed relative to current Individual Market) 100 120 Current Individual Market
Current Uninsured On average, uninsured are estimated to have 20% more medical claims than current Individual market once they become
covered Based on our review of available information, we estimate that the morbidity of the uninsured if given access to insurance would be
essentially 85% of the currently insured. We note that this assumption is roughly consistent with assumptions that the CBO used in its
evaluation of the available data4 . Using premium, claims, and other available information we estimate that the morbidity of those insured
through the individual market is roughly 70% of the morbidity of the entire universe of people insured through the individual, small group, and
large group markets (including self-insured). This 70% factor is the result of the fact that people insured through the individual market, in most
states, are medically underwritten5 . Combining these two estimates, the uninsured will have morbidity that is roughly 20% greater than those
currently covered in the Individual market. ¶ We also used the distribution of claims expenses in the individual market to estimate the
distribution of expected costs for the uninsured. We assume that the sickest 10 percent of the uninsured are estimated to have claims that are
four to six times higher than the average in the current individual market, which translates to annual claims of $9,000 to $10,000. This amount
is similar to the typical range observed in states’ high risk insurance pools. ¶ Impact of Insurance Reform on Today’s Market ¶ In most parts of
the country today, insurers in the individual market are permitted to underwrite and design benefit plans with a variety of price points. This
flexibility enables a stable, competitive insurance market. Perhaps most importantly, it offers the greatest affordability to attract younger and
healthier members and helps encourage wider enrollment in health insurance. ¶ The proposed insurance
reforms will increase
claims costs significantly in the individual insurance market. We estimate the average medical claims for the uninsured
are 20 percent higher than claims in the current individual market. This is because some have not been receiving regular medical care and some
have been unable to obtain coverage at an affordable price as a result of having chronic conditions. ¶ In addition, certain segments with
high medical utilization who are now insured through other arrangements will enter the individual
market as a result of guaranteed issue and modified community rating requirements. This includes people
enrolled in state high risk pools, people on COBRA through their former employers’ coverage and other group conversion policies.¶ Our model
assumes that people will generally act in their economic self-interest.
Although individuals and families cannot predict their
health care needs precisely, they often have a relatively good idea of their short term needs. Insurance
reforms will tend to lower barriers and create stronger financial incentives for unhealthy people to
become insured. As individuals work to optimize the costs and benefits of different coverage options, the market will become
more prone to adverse selection that will increase costs over successive years, especially if insurance
reforms are not coupled with an effective individual mandate.¶ Collectively, these factors will lead to a less
healthy “risk pool” in the individual market which ultimately leads to higher average premiums. The rating
reforms significantly alter the cost-to-value ratio that consumers will experience, and younger members will bear a greater burden of
subsidizing premiums for older members. The
high degree of cross-subsidization in the reformed market makes it
imperative to have high levels of participation among young people to subsidize the older population.¶
Impact of Age Bands¶ Eliminating medical underwriting, requiring guaranteed issue and requiring minimum benefit packages with 65 percent
actuarial value will increase premiums significantly for the youngest, healthiest 30 percent of members in the market today. Based on our
analysis of actual polices, the premium increases will be greater than 50 percent for this cohort in most of the country in the first year of
reform.¶ Forty-two states permit health plans to vary premiums based on age by 5:1 or more, with most of these allowing rates to be based on
actuarial justification. The Senate Finance Committee proposal to limit variations based on age of 4:1 is more restrictive than all but 8 states
today. This would create a strong disincentive for the young and healthy to participate even under the 4:1 age band in the AHFA.¶ In a previous
analysis, Oliver Wyman, Inc. estimated that in most states, premiums for the youngest one-third of the population would increase by 69
percent under a 2:1 age band called for in the House and Senate HELP Committee bills, and by 35 percent under a 3:1 age band (being
discussed as a compromise) relative to 5:1 age band. While these tighter age bands will reduce premiums for older purchasers, at least initially,
most people under the age of 50 will see their rates increase significantly under tighter age bands.¶ The effect of tighter age bands on
premiums compounds over time, and it becomes increasingly difficult to attract younger members into the insurance market. Without
an
effective mandate with meaningful penalties, people with higher expected utilization of medical services
will be much more likely to purchase coverage, driving up premiums and reducing the number of people
who would be covered. On the other hand, the young and healthy will have little incentive to maintain
coverage as they know they can get insurance when they anticipate a need6 . As a result, the risk pool
will deteriorate and premiums will rise without adequate cross-subsidies. This situation is not conducive
to a viable insurance market.¶ Impact of Benefit Changes¶ The bills before Congress would also require that new purchasers buy
health insurance products that meet certain minimum benefit requirements. The Senate Finance Committee proposal requires insurers in the
individual and small group markets to offer “Gold” and “Silver” policies, which have an actuarial value (AV) of 80 percent and 70 percent
respectively. The lowest actuarial value product that insurers could offer in this market would be the “Bronze” package, with an AV of 65
percent.7¶ In addition to the minimum actuarial value of benefit, the bill also includes a range of other changes that will impact the cost of
benefit packages, including requirements to cover certain services (maternity, mental health services, etc.), unlimited annual and lifetime
maximums, and other limitations that will increase costs. These changes do not directly affect the actuarial value of the plan, as described in
the legislation, but will add to the actual cost of the products.¶ Oliver Wyman, Inc. reviewed current benefit offerings in the individual and small
group markets to understand how the requirements proposed by the Senate Finance Committee legislation compare to benefit offerings today,
and to assess the likely impact of the bill’s requirements on premiums. The average actuarial value of coverage purchased in the individual
health insurance market today is close to 65 percent, similar to what the Congressional Budget Office has estimated, however, onehalf of
individual market policies are significantly below the proposed requirement. For the small group market, we estimate that the actuarial value of
products currently purchased is 75 percent, with about 20 percent of small groups having products with actuarial values below the Senate
Finance Committee minimum of 65 percent.¶ We estimate that compliance with the benefit requirements in the Senate Finance Package would
cause premiums for new purchasers to increase by approximately 10 percent in the individual market and 3 percent in the small employer
market nationwide.¶ Reform Scenario Results—Impact of Strong Individual Mandates¶ Each
of the major bills before Congress
require individuals to purchase insurance coverage or face potential penalties. The bills generally also include
requirements for large employers to purchase insurance or face a financial penalty. In general, the bills exempt the smallest employers from
this requirement. In the case of the Senate Finance Committee bill, firms with fewer than 50 employees would be exempt from the
requirement to provide coverage.¶ An amendment accepted during mark-up of the Chairman’s Mark in the Finance Committee substantially
weakened the bill’s individual mandate. This amendment eliminated penalties for not maintaining insurance entirely in the first year insurance
reforms become effective (2013). Modest
penalties are phased in, reaching a maximum of $750 per adult in
2017. This maximum penalty is likely to be only about 15 percent of an average premium in 2017, assuming
current rates of medical cost inflation. The amendment also exempted individuals whose premiums exceed 8 percent of their adjusted gross
income. In 33 states, the average cost of health insurance exceeds eight percent of median state income.8¶ Mandates
with
meaningful penalites are highly effective in encouraging a broad cross-section of the uninsured to
purchase coverage when combined with subsidies. For example, the RAND Corporation’s COMPARE model found that an
individual mandate would have the greatest impact on increasing insurance coverage.9 By itself, an
individual mandate with a penalty of 80 percent of premiums could increase the number of people with
insurance by up to 34 million, a 75 percent reduction in the uninsured. However, RAND estimates the net newly
insured would increase by only 8.7 million if there were no penalties and subsidies up to 200 percent of the federal poverty level.10¶ A recent
survey designed by Professor Joel C. Huber of Duke University, conducted by Knowledge Networks, and funded by the Blue Cross and Blue
Shield Association found that fewer than one third of the uninsured seeking individual coverage and making
between 200 percent and 300 percent of the federal poverty level are likely to purchase coverage given
the maximum penalty of $750 per year in 2017 under the Senate Finance Committee proposal, even after subsidies are
provided. Approximately one in five uninsured making over 300 percent of poverty are likely to purchase
unsubsidized individual coverage with a penalty of $750 per year, according to the survey.¶ To further evaluate the
need for a strong individual mandate, we modeled two reform scenarios with different levels of penalties for the
mandate. The “High Mandate” and “Low Mandate” scenarios illustrate the effect of individual mandates
on affordability and total number of uninsured. The number of uninsured is estimated to be approximately 12.6 million
people higher with the weakened mandate.¶ Further, with weak mandates, the risk pool of the individual market will
be less healthy, have much lower participation among younger members, and experience much higher
premium increases. The average medical claims of members in the reformed individual market will be
50 percent higher than the average in the market today (not including medical inflation). This would translate into premium increases of
approximately $1,500 for single coverage and $3,300for family coverage in today’s dollars.11¶ Younger, healthier members are particularly
vulnerable to rating reform. They will experience premium increases greater than 50 percent relative to the current market in most of the U.S.
With weak mandate penalties coupled with guaranteed issue, it will be less expensive for many people to choose
to buy insurance only when needed. Strong mandates will draw nearly 3 million more young and
healthy members into the reformed individual market. The healthier insurance pool will result in premiums lower than
reform with weak mandates.¶ Mandates serve to complement subsidies. Subsidies will be most effective for individuals with
low income levels. For the uninsured earning 100-200 percent FPL, we estimate that more than 60 percent of them will purchase
insurance because of subsidies. However, more than 60 percent of the current individual market and about 20 percent of the uninsured have
incomes above 300 percent FPL and will realize limited or no subsidy support. Over 18 million uninsured and existing individual market
members are ineligible for subsidies based on the proposed structures. Higher income uninsured individuals are not likely to
take up coverage without a meaningful penalty.

Millions are paying the penalty now – strengthening the mandate changes the
incentive structure
Steve Walker 16, JD from George Washington University, former Vice President of the Healthcare
Investment Banking Division of Merril Lynch, 10/28/2016, Millions choose to pay Obamacare fines
rather than enroll; Simple solution–higher fines or…, Monday Morning,
http://mondaymorning.com/2016/10/28/millions-choose-to-pay-obamacare-fines-rather-than-enroll-
simple-solution-higher-fines-or/

The architects of the Affordable Care Act thought they had a blunt instrument to force people–even the
young and invincible–to buy insurance through the law’s online marketplaces: a tax penalty for those
who remain uninsured. It hasn’t worked all that well, according to The New York Times, and that is at least partly to
blame for soaring premiums next year on some of the health law’s insurance exchanges. The full weight
of the penalty will not be felt until next April, says The Times, when those who have avoided buying insurance will face
penalties in the neighborhood of $700 a person. But even that might be insufficient: For the young and healthy who
are desperately needed to make the exchanges work, it sometimes makes more sense for them to pay
the Internal Revenue Service than an insurance company charging large premiums, with huge
deductibles. “In my experience, the penalty has not been large enough to motivate people to sign up for
insurance,” said Christine Speidel, a tax lawyer at Vermont Legal Aid. Some do sign up, especially those with low incomes who receive the
most generous subsidies, Ms. Speidel said. But others, she said, find that they cannot afford insurance, even with subsidies, so “they grudgingly
take the penalty.” The IRS says that 8.1 million returns included penalty payments for people who went without
insurance in 2014, the first year in which most people were required to have coverage. A preliminary report on the latest tax-filing
season, tabulating data through April, said that 5.6 million returns included penalties averaging $442 a return for people uninsured in 2015.
With the health law’s fourth open-enrollment season beginning next Tuesday, Nov. 1, consumers are fretfully weighing their options, says The
Times. When Congress was drafting the Affordable Care Act in 2009 and 2010, lawmakers tried to adopt a carrot or stick approach: subsidies to
induce people to buy insurance and tax penalties “to ensure compliance,” in the words of the Senate Finance Committee. But the requirement
for people to carry insurance is one of the most unpopular provisions of the health law, and the Obama administration has been cautious about
enforcing it. The IRS portrays the decision to go without insurance as a permissible option, not as a violation of federal law. The law “requires
you and each member of your family to have qualifying healthcare coverage (called minimum essential coverage), qualify for a coverage
exemption, or make an individual shared responsibility payment when you file your federal income tax return,” the IRS says at its website.
Some consumers who buy insurance on the exchanges still feel vulnerable. Deductibles are so high, they say, that the insurance seems useless.
So some think that whether they send hundreds of dollars to the IRS or thousands to an insurance company, they are essentially paying
something for nothing, The Times points out. Obama administration officials say that perception is wrong. Even people with high deductibles
have protection against catastrophic costs, they say, and many insurance plans cover common health care services before consumers meet
their deductibles. In addition, even when consumers pay most or all of a hospital bill, they often get the benefit of discounts negotiated by their
insurers. The health law authorized certain exemptions from the coverage requirement, and the Obama administration has expanded that list
through rules and policy directives. More than 12 million taxpayers claimed one or more coverage exemptions last year because, for instance,
they were homeless, had received a shut-off notice from a utility company or were experiencing other hardships. “The penalty for
violating the individual mandate has not been very effective,” said Joseph J. Thorndike, the director of the tax history
project at Tax Analysts, a nonprofit publisher of tax information. “If it were effective, we would have higher enrollment,
and the population buying policies in the insurance exchange would be healthier and younger.” “If you
make the penalties tougher, you need to make financial assistance broader and deeper,” said Michael
Miller, the policy director of Community Catalyst, a consumer group seeking health care for all. Steve’s Take: With the exception of the “repeal
and replace” camp, practically
everyone agrees that insurance companies are a necessary ingredient in the
exchanges for the ACA to function the way it was intended. And, for insurance companies to remain in the
exchange, they need more healthy people,

fewer sick people or a combination of the two. Both sides of the aisle agree that insurance companies
should not be able to reject people with pre-existing conditions, which means sick people in need of
care will remain, according to Forbes. That means a stronger mandate is required to get healthy people
into the insurance pools. Unfortunately, neither party seems to be discussing this possibility.

Now is key -- insurers have to commit to selling plans by September 27 th

Eric Levitz 9/7, Political Reporter at New York Magazine, former Visiting Lecturer at Johns Hopkins
University in writing, 9/7/2017, The GOP Must Make Obamacare Sabotage-Proof by Month’s End,
http://nymag.com/daily/intelligencer/2017/09/the-gop-must-make-obamacare-sabotage-proof-by-
months-end.html
Republicans can’t blame Donald Trump for their failure to repeal Obamacare. The president didn’t force the GOP to adopt heinously unpopular
priorities for health-care policy, or spend years lying to their voters about what those priorities were; nor did the mogul force his party to attach
draconian Medicaid cuts to their (sloppily drafted) Obamacare-replacement bills, or to reduce insurance subsidies in a manner that
disproportionately harmed parts of the Republican base.¶ But Republicans
can blame Trump for sabotaging the
Affordable Care Act so shamelessly that their party must now pass legislation strengthening the law, by
the end of this month, or else suffer political blowback from soaring premiums.¶ Under Obamacare, participating
insurers are required to keep deductibles and co-payments affordable for low-income people. In practice, this means that insurers must
underprice the risk of covering such individuals, and, thus, accept a financial loss. To make that proposition more appealing to these for-profit
companies, Obamacare provides them with “cost-sharing reductions” — subsidies that defray the insurers’ losses.¶ But for complicated reasons
relating to a lawsuit that House Republicans brought against the Obama administration, Donald Trumpcan cancel those subsidies at
will. And he has threatened to do just that, over and over again, for months.¶ This was disconcerting to insurance
providers. In mid-April, several of them descended on Washington, in hopes of securing the White House’s
assurance that Trump’s rhetoric about withholding the subsidies was just a bluff. Seema Verma, Trump’s
head of Medicare and Medicaid Services, informed the insurers that it could be a bluff — if they agreed to publicly
support the president’s health-care bill. The insurers refused to play ball. And the president has kept a
gun pointed at his hostage ever since.¶ So long as that remains the case, insurers will need to proceed on the
assumption that Trump is going to pull the trigger. Which is to say: They will need to either pull out of the
Obamacare exchanges, or else raise premiums high enough to offset the costs of covering low-income
enrollees without Uncle Sam’s help.¶ This week, two insurers passed through door number No. 1, as Vox’s Dylan Scott notes:¶ First, Optima
Health announced it would stop selling Obamacare plans in some Virginia counties in 2018, citing in part uncertainty around the health care
law’s cost-sharing reduction payments…Optima’s exit is expected to leave tens of thousands of Obamacare customers without insurance
options, unless a new carrier steps in.¶ …Then on Thursday, it was reported that Anthem would leave Maine’s marketplaces if the cost-sharing
reduction payments were not guaranteed for 2018. According to Vox’s tally, that would not leave any counties bare, but it would reduce the
number of plans that customers in the state could choose from.¶ Meanwhile, the Trump administration has decided to slash advertising for
Obamacare open enrollment by 90 percent, and funding for “navigators” who help people sign up by 40 percent — even as Health and Human
Services has spent public funds on advertisements effectively discouraging participation in the law.¶ These
actions exacerbate the
risk of a premium hike. Sick people will seek out health insurance, whether or not they’re exposed to
advertising that encourages them to do so. But many healthy people will not — especially when the administration
has publicly suggested that it will not enforce Obamacare’s individual mandate. And without a critical mass of healthy
individuals purchasing coverage on the exchanges, insurers will need to raise premiums to offset the
costs of covering a disproportionately sick population.¶ All of which is to say: If Congress doesn’t at least take the
gun out of Trump’s hand — and pass legislation guaranteeing that the cost-sharing reductions will be
paid — health care is going to become considerably more expensive next year. And all available polling suggests that
swing voters will blame the ruling party for that development.¶ The good news for the congressional GOP is that Republican senator Lamar
Alexander and Democratic senator Patty Murray have been working on a bill that appropriates those cost-sharing reductions. The bad news is
that, in
order to avoid a spike in premiums, they’re going to need to pass that bill by September 27 — the
deadline for insurers to commit to selling plans through Obamacare in 2018.
2AC
Topicality
 2AC – T Public
We meet---ACA reform is both government financed and administered
Counterinterpretation – NHI requires two things – a legal requirement for insurance
and universality – the ACA currently fails this test but the plan makes it NHI
Thomas Bodenheimer 16, MD, MPH, Founding Director of the Center for Excellence in Primary Care,
University of California-San Francisco; and Kevin Grumbach, MD, Founding Director of the Center for
Excellence in Primary Care, University of California-San Francisco, 2016, Understanding Health Policy: A
Clinical Approach, Seventh Edition, p. 185-196

For more than 100 years, reformers in the United States argued for the passage of a n ational h ealth i nsurance program, a government guarantee that every person
is covered for basic health care. Finally in 2010, the United States took a major, though incomplete, step forward toward
universal health insurance.¶ The subject of national health insurance has seen six periods of intense activity, alternating with times of political inattention. From 1912 to 1916, 1946 to 1949, 1963 to 1965,
1970 to 1974, 1991 to 1994, and 2009 to 2015 it was the topic of major national debate. In 1916, 1949, 1974, and 1994, national health insurance was defeated and temporarily consigned to the nation’s back burner. Guaranteed

with the passage of the Patient Protection and Affordable Care Act, also known as the
health coverage for two groups—the elderly and some of the poor—was enacted in 1965 through Medicare and Medicaid. In 2010,

Affordable Care Act (ACA) or “Obamacare,” the stage was set for the expansion of coverage to millions of uninsured people.

National health insurance means the guarantee of health insurance for all the nation’s residents —what is
commonly referred to as “universal coverage .” Much of the focus, as well as the political contentiousness, of national health insurance proposals concern how to pay for
universal coverage. N ational h ealth i nsurance proposals may also address provider payment and cost containment .¶ The controversies
the four basic modes of health care financing outlined in Chapter 2: out-
that erupt over universal health care coverage become simpler to understand if one returns to

of-pocket payment, individual private insurance, employment-based private insurance, and government
financing. There is general agreement that out-of-pocket payment does not work as a sole financing method for
costly contemporary health care. National health insurance involves the replacement of out-of-pocket payments by one,

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

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

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

government-financed health insurance can

have received government health insurance unless his state added unemployed people to the program. ¶ As discussed in Chapter 2,

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

Medicare is a social insurance

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

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

Many people believed that Medicare

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

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

government-financed national health insurance proposal. The plan came to be known as the “ single-payer ” program,
because it would establish a single government fund within each state to pay hospitals, physicians,
and other health care providers, replacing the multipayer system of private insurance companies
(Himmelstein & Woolhandler, 1989). Several versions of the single-payer plan were introduced into Congress in the 1990s, each bringing the entire population together into one health care financing system, merging the social
insurance and public assistance approaches (Table 15-2). The California Legislature, with the backing of the California Nurses Association, passed a single-payer plan in 2006 and 2008, but the proposals were vetoed by the

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

The essence of the Nixon proposal was the employer mandate,

In 1974, the momentum for national health insurance collapsed, not to be seriously revived until the 1990s.

under which the federal government requires (or mandates) employers to purchase private health insurance
for their employees.¶ Tom Peoples’ cousin Blanche was a receptionist in a physician’s office in 1971. The physician did not provide health insurance to his employees. Under Nixon’s 1971 plan, Blanche’s
employer would be required to pay 75% of the private health insurance premium for his employees; the employees would pay the other 25%.¶ Blanche’s boyfriend, Al, had been laid off from his job in 1970 and was receiving

No longer was national health

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

insurance equated with government financing. Employer mandate plans preserve and enlarge the role
of the private health insurance industry rather than replacing it with tax-financed government-
administered plans. The Nixon proposal changed the entire political landscape of national health insurance, moving it toward the private sector.¶ During the 1980s and 1990s, the number of people in the
United States without any health insurance rose from 25 million to more than 40 million (see Chapter 3). Approximately three-quarters of the uninsured were employed or dependents of employed persons. In response to this crisis

in health care access, President Clinton submitted legislation to Congress in 1993 calling for universal health insurance through an
employer mandate . Like the Nixon proposal, the essence of the Clinton plan was the requirement that employers pay for most of
their employees’ private insurance premiums. The proposal failed.¶ A variation on the employer mandate type of n ational h ealth
i nsurance is the voluntary approach. Rather than requiring employers to purchase health insurance for employees, employers are given incentives
such as tax credits to cover employees voluntarily. The attempt of some states to implement this type of voluntary approach has failed to significantly reduce the
numbers of uninsured workers.¶ THE INDIVIDUAL-MANDATE MODEL OF NATIONAL HEALTH INSURANCE¶ In 1989, a new species of national

health insurance appeared, sponsored by the conservative Heritage Foundation: the individual mandate. Just as many states require motor vehicle drivers to purchase automobile insurance, the Heritage plan

called for the federal government to require all US residents to purchase individual health insurance policies.
Tax credits would be made available on a sliding scale to individuals and families too poor to afford health insurance
premiums (Butler, 1991). Under the most ambitious versions of the individual mandate, employer-sponsored insurance and
government-administered insurance would be dismantled and replaced by a universal, individual
mandate program. Ironically, the individual insurance mandate shares at least one feature with the single-payer, government-financed approach to universal coverage: Both would sever the connection
between employment and health insurance, allowing portability and continuity of coverage as workers moved from one employer to another or became self-employed.¶ Tom Peoples received health insurance through his
employer, Great Books. Under an individual mandate plan, Tom would be legally required to purchase health insurance for his family. Great Books could offer a health plan to Tom and his coworkers but would not be required to
contribute anything to the premium. If Tom purchased private health insurance for his family at a cost of $10,000 per year, he would receive a tax credit of $4,000 (i.e., he would pay $4,000 less in income taxes). Tom’s Uncle

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

Mandate Plan of 2006¶ Nearly 20 years after the Heritage Foundation’s individual mandate proposal, Massachusetts enacted a state-level health coverage bill implementing the nation’s first individual mandate. The
Massachusetts plan, enacted under Republican Governor Mitt Romney, mandated that every state resident must have health
insurance meeting a minimum standard set by the state or pay a penalty. The law provided state subsidies for purchase of private health
insurance coverage to individuals with incomes below 300% of the federal poverty level if they are not covered by Medicaid or through employment-based insurance. The law did not eliminate

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

The pluralistic financing model of the ACA includes individual and employer
Democratic Presidents Roosevelt and Truman.

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

If the ACA were

of income. Because he was not disabled, he did not qualify for Medicaid prior to the ACA despite being poor. In 2014, Job became eligible for Illinois’ Medicaid program. ¶

implemented in its entirety as written into law, it is estimated that 32 million uninsured Americans would receive
insurance coverage—about half through Medicaid expansion and half through the individual mandate.
None of the coverage expansion measures would benefit undocumented immigrants.¶ The ACA has
four main components to its reform of health care financing (Kaiser Family Foundation, 2013).¶ Individual mandate : As discussed in Chapter 2, the ACA requires virtually all US
citizens and legal residents to have insurance coverage meeting a federally determined “essential benefits” standard. This standard would allow high-deductible plans to qualify, with out-of-pocket cost-sharing in 2015 capped at
$6,600 per individual and $13,200 per family. Those who fail to purchase insurance and do not have employer-sponsored insurance, or do not qualify for Medicaid, Medicare, or veteran’s health care benefits, must pay a tax
penalty which would be gradually phased in. In 2016, the penalty would equal the greater of $695 per year for an individual or 2.5% of household income (up to $2,085 for a family). Individuals and families below 400% of the
Federal Policy Level are eligible for income-based sliding-scale federal subsidies to help them purchase the required health insurance. ¶ The ACA established federal and state-based insurance exchanges to function as clearing
houses to assist people seeking coverage under the individual mandate to shop for insurance plans meeting the federal standards. The benefit packages offered by plans in the exchanges vary depending on whether individuals

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

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

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

the
were opposed to the ACA, though by 2015 public opinion was shifting gradually to favor the law. ¶ Two critical Supreme Court rulings dominated the years following the ACA’s passage in 2010. Many expected

Supreme Court to declare the law unconstitutional in its 2012 decision; although the 5–4 vote supported the constitutionality of the individual mandate, it greatly weakened the
Medicaid expansion by making state participation voluntary. The second Supreme Court case was a challenge to the individual mandate provision that
allowed millions of people to obtain low-cost health insurance with government subsidies through the health insurance exchanges. The case was inspired by the seemingly unending, glaring opposition to Obamacare. The plaintiffs

the Court affirmed that both

challenged that only state-based exchanges could offer subsidies; yet millions of people had obtained insurance through the federal exchange. In a June 2015 6–3 decision,

the federal and state-based exchanges could offer subsidies, thereby preventing a huge number of people
from losing their subsidized health insurance.¶ Through all this, the ACA persevered. Though the precise numbers are debated, it appears that 15 million
people have been newly insured under the ACA, about half through Medicaid expansion and half through
the health insurance exchanges. The national uninsured rate has dropped. 87% of those receiving insurance through the individual mandate received a federal subsidy in 2014. 8.2 million
seniors have saved an average of $1,407 in prescription costs due to the ACA’s gradual closing of the Medicare Part D donut hole (see Chapter 2). The ACA is costing the federal government about 20% less than what was projected

in 2010.¶ Yet stormy weather still threatens, mainly centered on the problem of patient cost sharing . Many people insured
 the exchanges face deductibles of $5,000 per year plus 20% or more coinsurance when receiving services. The
through

out-of-pocket limit of $6,600 per individual and $13,200 per family is unaffordable for many people. If the ACA is unable to
generate significant health care cost containment, the costs borne by individuals and families could
seriously threaten the individual mandate portion of the ACA.¶ SECONDARY FEATURES OF NATIONAL HEALTH INSURANCE PLANS¶ The primary
distinction among national health insurance approaches is the mode of financing: government versus
employment-based versus individual-based health insurance, or a mixture of all three. But while the overall financing approach is the headline news of reform
proposals, details in the fine print are important in determining whether a universal coverage plan will be able to

deliver true health security to the public (Table 15-4). What are some of these secondary features?¶ Benefit Package¶ An important feature of any
health plan is its benefit package . Most national health insurance proposals cover hospital care,
physician visits, laboratory, x-rays, physical and occupational therapy, inpatient pharmacy, and other
services usually emphasizing acute care. One important benefit not included in the original Medicare program was coverage of outpatient medications. This coverage was later added in 2003
under Medicare Part D. Mental health services were often not fully covered, a situation in part addressed by the Mental Health Parity Act of 1996 and Mental Health Parity and Addiction Equity Act of 2008 which apply to group
private health insurance plans. Neither the ACA nor most previous reform proposals include comprehensive benefits for dental care, long-term care, or complementary medicine services such as acupuncture. ¶ Patient Cost

Sharing¶Patient cost sharing involves payments made by patients at the time of receiving medical care. It is
sometimes broadened to include the amount of health insurance premium paid directly by an individual. The breadth of the benefit package influences the

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

Any national health insurance program must

sharing as a cost-containment tool are discussed in Chapter 9.¶ Effects on Medicare, Medicaid, and Private Insurance¶

interact with existing health care programs, whether Medicare, Medicaid, or private insurance plans. Single-payer proposals make far-
reaching changes: Medicaid and private insurance are eliminated in their current form and melded into a single
insurance program that resembles a Medicare-type program for all Americans. The most sweeping versions of individual mandate
plans, proposed by the Heritage Foundation, would dismantle both employment-based private insurance and government-
administered insurance programs. Employer mandates, which extend rather than supplant employment-based coverage, have the least
effect on existing dollar flows in the health care system, as do pluralistic models such as the ACA that
preserve and extend existing financing models through the employer mandates and broadened Medicaid eligibility. ¶ Cost Containment¶ By increasing access to medical care, national health insurance has the capacity to cause a

National health
rapid rise in national health expenditures, as did Medicare and Medicaid (see Chapter 2). By the 1990s, policymakers recognized that access gains must be balanced with cost control measures. ¶

insurance proposals have vastly disparate methods of containing costs. As noted above, individual- and
employment-based proposals tend to use patient cost sharing as their chief cost-control mechanism. In contrast,
government-financed plans look to global budgeting and regulation of fees to keep expenditures
down. Single-payer plans, which concentrate health care funds in a single public insurer, can more easily establish a global budgeting
approach than can approaches with multiple private insurers.¶ Proposals that build on the existing pluralistic financing model of US health care, such as the
ACA, face challenges in taming the unrelenting increases in health expenditures endemic to a fragmented financing system. An item contributing to the demise of President Bill Clinton’s health reform proposal, before it could even
be formally introduced in Congress, was a measure to cap annual increases in private health insurance premiums. President Obama eschewed such a regulatory approach in developing the ACA, resulting in weak language about
private insurance plans needing to “justify” premium increases to participate in health insurance exchanges. In an effort to control costs, the ACA limits the percentage of health insurance premiums that can be retained by an
insurance company in the form of overhead and profits (a concept known as the “medical loss ratio,” whereby a greater loss ratio means more premium dollars being “lost” by the company in payments for actual health care
services). The ACA also caps the amount that an employer can contribute toward a health insurance premium as a nontaxable benefit to the employee ($10,200 for an individual policy and $27,500 for a family policy), in an attempt
to discourage enrollment in the most expensive plans. Many savings in the ACA are expected to come from slowing the rate of growth in expenditures for Medicare through measures such as reducing payments to Medicare
Advantage HMO plans. The ACA has benefited by the 2009–2013 slowing of health expenditure growth caused by the severe economic recession of those years, but the ACA cannot take credit for this slowdown (Hartman et al.,

Throughout the
2015). The architects of the ACA put most of their cost-containment hopes in proposals to redesign health care delivery to achieve better value, discussed next. ¶ Reform of Health Care Delivery¶

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

The ACA goes farther than

provinces, where until recently government took great pains to focus on insurance financing and payment rate regulation and not on care delivery reform. ¶

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

purchase high-deductible plans with high cost-sharing, leaving lower- and middle-income families with unaffordable out-of-pocket costs.¶ CONCLUSION¶ The concept of n ational h ealth i nsurance
rests on the belief that everyone should contribute to finance health care and everyone should benefit .
People who pay more than they benefit are likely to benefit more than they pay years down the road when they face an expensive health problem. In the years during and after the passage of the

ACA, n ational h ealth i nsurance took center stage in the United States with fierce debate over “Obamacare.” This debate revealed a wide
gulf between those who believe that all people should have financial access to health care and those who do

not. The fate of the ACA, still in question in 2015, will determine which of those two beliefs holds sway in the
United States.
Employer CP
 Plan Key – Certainty
Solving ACA uncertainty is key – only that solves market contractions
James McCarthy 17, former Senior Editor at Maine Biz, 6/7/2017, Political uncertainty fueling double-
digit ACA individual rate hikesPolitical uncertainty fueling double-digit ACA individual rate hikes,
http://www.mainebiz.biz/article/20170606/NEWS01/170609970/political-uncertainty-fueling-double-
digit-aca-individual-rate-hikes
All three health insurers offering coverage in Maine's Affordable Care Act marketplace are seeking double-digit rate hikes for individual health
insurance plans in 2018.¶ Harvard Pilgrim Health Care is seeking the largest rate increase, proposing an average proposed hike of 39.7%,
followed by Anthem Blue Cross and Blue Shield with 21.2% and Community Health Options with 19.6%.¶ The insurers cite political
uncertainties surrounding the future of the ACA as a key factor in driving up premium rates for the
individual market — most notably, the Trump administration's loosening of the federal government's
enforcement of the mandate requiring individuals who aren't insured to sign up for coverage or face a
financial penalty.¶ "Without enforcement of the coverage mandate, membership is expected to drop,
with the healthier individuals more like to forego coverage," Harvard Pilgrim stated in its submission
filed with the Maine Bureau of Insurance. "This will drive up the average cost of health care for the
individual market. Therefore an adjustment is needed to account for the higher expected claims
costs."¶ The proposed rate hikes in the individual market are for coverage that would begin on Jan. 1, 2018. Proposals also were submitted
by the three insurers and two others, Aetna and United HealthCare, in the ACA-compliant small group market. Hearings on the rate proposals
by the Maine Bureau of Insurance would begin in July.¶ The Portland Press Herald reported that the Bureau of Insurance estimated that of the
85,300 Maine residents covered by ACA-compliant individual insurance plans in the first quarter of 2017, CHO had the largest market share
with 35,100 Mainers, followed by Anthem with 27,700 and Harvard Pilgrim with 21,400.¶ Other factors driving the rate hikes¶ A shrinking
risk pool that would result in a greater percentage of older and potentially less healthy people
remaining in the Maine ACA individual marketplace isn't the only concern expressed by the insurers in
their rate filings.¶ Anthem and Harvard Pilgrim highlighted the political uncertainty surrounding the
continuation of Cost Share Reduction subsidies, which the ACA required insurers to offer enrollees
with incomes 100% to 250% of the poverty level for silver-level plans. The subsidies were intended to
help insurers reduce deductibles and copays for the qualifying customers; to compensate for the
added cost to the insurers, the federal government had promised to reimburse them for the higher
costs.¶ But, like many of the ACA's provisions, the future of those payments — which the Congressional Budget Office estimated would cost
$7 billion in fiscal year 2017, $10 billion in 2018 and $16 billion by 2027 — is uncertain.¶ "A lack of CSR funding introduces a
level of volatility which compromises the ability to set rates responsibly," Anthem stated in the cover letter
accompanying its filing, noting that without CSR funding premium rates for silver plans could increase by an
additional 20% and possibly "necessitate additional adjustments."¶ Among the possible adjustments Anthem cited if
the CSR subsidies are eliminated:¶ "Reducing service area participation"¶ "Requesting additional rate increases"¶ "Eliminating certain product
offerings"¶ "Exiting certain individual ACA-compliant markets altogether."¶ In its filing memorandum, Lewiston-based Community Health
Options noted the major driver of its rate increase is its expectation that the individual risk pool in Maine will shrink.¶ "We
expect that a
weak individual mandate combined with higher premiums in the individual market will lead to
increased market contraction in 2018," CHO's consulting actuary Kathleen E. Ely stated in the insurer's cover letter. "Healthier
people and those whose premiums are unsubsidized will be more likely to not continue to purchase
health coverage."¶ Noting that CHO's individual 2017 risk pool is older and enrolled in "less rich plans" than in 2015-16, Ely wrote that
early 2017 claims through March were running 9% higher than expected.
Dental
 Disease D---1NC
Infectious diseases don’t cause extinction
Owen Cotton-Barratt 17, et al, PhD in Pure Mathematics, Oxford, Lecturer in Mathematics at Oxford,
Research Associate at the Future of Humanity Institute, 2/3/2017, Existential Risk: Diplomacy and
Governance, https://www.fhi.ox.ac.uk/wp-content/uploads/Existential-Risks-2017-01-23.pdf
For most of human history, natural pandemics have posed the greatest risk of mass global fatalities.37 However, there are some reasons to
natural pandemics are very unlikely to cause human extinction. Analysis of the International Union for
believe that
of the 833 recorded plant and animal species extinctions
Conservation of Nature (IUCN) red list database has shown that
known to have occurred since 1500, less than 4% (31 species) were ascribed to infectious disease.38
None of the mammals and amphibians on this list were globally dispersed, and other factors aside
from infectious disease also contributed to their extinction. It therefore seems that our own species,
which is very numerous, globally dispersed, and capable of a rational response to problems, is very
unlikely to be killed off by a natural pandemic.

One underlying explanation for this is that

highly lethal pathogens can kill their hosts before they have a chance
to spread, so there is a selective pressure for pathogens not to be highly lethal . Therefore, pathogens are likely to
co-evolve with their hosts rather than kill all possible hosts.39
Trust DA
 Warming Defense---1NC (Short)
No warming impact---their predictions are wrong and adaptation solves
Oren Cass 17, senior fellow at the Manhattan Institute, Winter 2017, “How to Worry about Climate
Change,” National Affairs, http://www.nationalaffairs.com/publications/detail/how-to-worry-about-
climate-change

Even focusing within that range, estimates

for the expected environmental impacts of warming vary widely. The
IPCC represents the gold standard for synthesizing scientific estimates, and, crucially, its best
guesses bear little resemblance to the a pocalyptic predictions often repeated by activists
and politicians . For instance, the IPCC estimates that sea levels have risen by half a foot over the past century and will rise by another
two feet over the current century. At the high end of the 3-to-4-degree range, it reports the impact on ecosystems
will be no worse than that of the land-use changes to which human civilization already subjects the
natural world .

The responsibility
for translating these and other disruptions into economic costs falls to Integrated
Assessment Models (IAMs). To create its "Social Cost of Carbon," the Obama administration surveyed this economic literature and
focused specifically on three models whose forecasts themselves vary widely, even starting from a common level of warming. For warming of 3
to 4 degrees Celsius by 2100, the middle of the three models estimates an annual cost of 1% to 3% of GDP. The low case estimates 0 to 1%. The
high case estimates 2% to 4%. While
4% is a large dollar amount, arriving at that impact over nearly 100 years
implies almost imperceptibly small changes in economic growth .
The specifics of this high-case model are informative: The Dynamic Integrated model of Climate and the Economy (known as the DICE model)
developed by William Nordhaus at Yale University estimates 3.8
degrees Celsius of warming by 2100 costing an associated
3.9% of GDP in that year. But over time, this cost is the equivalent of slowing economic growth by less than
one-tenth of one percentage point annually. By 2100, regardless of climate change, the world is more
than six times wealthier than in 2015 under this model; global GDP is $500 trillion. The effect of climate change is to reduce that
gain from a multiple of 6.7 to a multiple of 6.5. The economy also continues to grow, so that the climate-change-
afflicted world of 2105 is already much wealthier than a world of 2100 facing no climate change at all.
Such estimates might seem counterintuitively low, especially given the rhetoric often employed. Part of the explanation lies in the almost
incomprehensible economic progress that human civilization is capable of making over the course of a century. The annual cost identified by
Nordhaus in 2100 is $20 trillion — massive by the standards of 2015, manageable by the standards of 2100. Further, that cost repeats every
year even as the impacts are spread over many years. Thus, over the 2090 to 2110 time period, Nordhaus envisions the world spending a
stunning $350 trillion to cope with climate change. One might despair over what else such resources might accomplish over that time period.
But one must also recognize that the
economy of 2100 will likely be able to allocate those resources toward
climate change while also allocating to every other facet of society far more resources than are
available today.

Corroborating these models , the IPCC concludes that "for most economic sectors, the impacts of drivers such
as changes in population, age structure, income, technology, relative prices, lifestyle, regulation, and governance
are projected to be large relative to the impacts of climate change." In other words, other worrying problems have a
far greater capacity to influence progress.

None of this means the dislocations from climate change would be painless or the disruptions cheap. It is merely to observe
that the impacts expected from climate change over the next hundred years look similar to those

through which both civilization and our planet have successfully muddled over the past hundred and
continue to struggle with today. Other worrying problems have their own anticipated but less-severe analogs, too. Whether a
global pandemic strikes, epidemics will inevitably occur like the 2014 Ebola outbreak in West Africa that claimed more than 10,000 lives and
cost the three countries at its center more than a tenth of their GDP. Whether artificial intelligence makes humans superfluous, self-driving
vehicles could throw millions out of work in the years to come. Some countries will default on their debt; some business cycles will spawn deep
global recessions.

These challenges are not existential threats or even ones that require analysis outside the standard
policy process — that is, they are not really worrying problems at all.
EXTREME CASES

If expected climate change represents the most likely outcome, extreme climate change represents
the worst case: Models could be underestimating the warming that emissions will cause; feedback loops could send a 3-degree
increase suddenly careening higher; or even at the expected level the climate could hit a tripwire that collapses global
ecosystems or ocean currents or ice sheets or some other prerequisite of modern civilization.

Any of these things may be true — as is the nature of genuinely forecasted challenges, they are mostly non-falsifiable. But while extreme
climate change is a quintessentially worrying problem, it is also one that has no guarantee or even likelihood of
occurring . Certainly, the "scientific consensus" or even the "scientific mainstream" on climate change does not
extend to confidence in such scenarios .
To compare extreme climate change with other worrying problems, it is helpful to consider the dimensions that make a problem "worrying":
that it is forecasted, irreversible, and pervasive. On all three, climate change appears less worrying than most.

Consider, first, the magnitude of the forecasted impact. Many worrying problems feature the credible
prospect of killing a significant share of the human population or erasing modern civilization. Not
extreme climate change . For instance, even considering higher temperature increases, the IPCC concludes
that:

Global climate change risks are high to very high with global mean temperature increase of 4°C or more above preindustrial levels in all
reasons for concern, and include severe and widespread impacts on unique and threatened systems, substantial
species extinction, large risks to global and regional food security, and the combination of high temperature and humidity
compromising normal human activities, including growing food or working outdoors in some areas for parts of the year.

Obviously, each of those effects would entail enormous economic costs, carry severe consequences for entire
nations, and wreak havoc with the natural environment. But as a worst case, it nevertheless pales in
comparison to catastrophes that might kill a significant share of the human population or erase the
basic physical and economic infrastructure of modern civilization.

Serious efforts to quantify existential threats concur . A 2016 report by the Global Priorities Project at Oxford offered as
its example of a worst case that climate change could "render most of the tropics substantially less habitable
than at present," as compared to hundreds of millions or billions of deaths associated with other challenges.
Another Oxford study from 2008 asked conference participants to estimate the probability of various global
catastrophes leading to human extinction in the coming century, and did not even see fit to include climate
change as an option , while respondents gave molecular nanotechnology, super-intelligent artificial intelligence, and an engineered
pandemic each at least a 2% chance of erasing humanity by 2100.

Some analysts nonetheless place climate change among humanity's genuinely existential threats on the basis
of its "fat tail," arguing that some unknowable but non-zero chance exists at the far-right end of the probability
distribution for an outcome with essentially infinite cost. But this is true of all worrying problems — indeed, the
characteristics of worrying problems might be viewed as those that generate such unknowable non-zero probabilities. Climate
change
cannot be distinguished from other worrying problems on that basis. Rather, the argument begs the
question: What characteristics of climate change make its tail relatively fatter or thinner?

The weight accorded to a worrying problem's forecasted effects depends greatly on the number of causal
steps between the underlying phenomena and worst-case outcomes . Where fewer steps are necessary, or where
steps are relatively more likely to occur, the probability of the worst case arising should increase. For instance, whether an engineered
pandemic devastates humanity depends on development of the necessary technology (highly likely), its use by a malicious actor
(indeterminate), and its spread defying efforts at containment (indeterminate). Generally speaking, technological threats will have the shortest
chains while sociological threats will have the longest ones.

Climate change would appear to sit somewhere in between. It has a very short chain to some impact — indeed, higher
atmospheric concentrations of carbon dioxide are already having effects. But the connection from warmer temperatures to
civilizational catastrophe is highly attenuated . The initial warming must cross thresholds that produce feedback loops.
The ensuing warmth must produce environmental effects that cause unprecedented crises across societies. Those crises must in
turn overwhelm the coping capacity of the entire global community, which must in turn produce wide-scale
breakdowns in social order or trigger military conflict, which must in turn metastasize into...what? Certainly, one

can invent a scenario . But the specifics quickly become hazy, and a worst case entirely outside of
human experience difficult to articulate.
The intent of this analysis is not to dismiss the severity of worst-case climate scenarios or to suggest that "wide-scale breakdowns in social
order" are acceptable. But all worrying problems have worst-case forecasts that look this way, all with
indeterminate probabilities of occurring, which leaves only a few options: We could become overwhelmed with despair, emphasize whichever
problems are most politically useful, or seek out qualitative and quantitative bases for analysis. Too much discussion of climate change adopts
the first or second approach. Efforts at the third approach will inevitably be imprecise and imperfect, but the
burden of proof should
lie on those declaring that climate change stands apart from other worrying problems to explain why
that is so. The suggestion here is not that the forecasted threat of climate change does not belong alongside other worrying problems, only that
the nature of its forecast cannot be what separates it as uniquely worrying.

WORRYING IN SLOW MOTION

In the other ways climate change is a worrying problem, meanwhile, it is less worrying than most. This is especially true
with respect to irreversibility. While President Obama has lamented that climate change is a "comparatively slow-moving
emergency," the one thing worse is a fast-moving one. Most worrying problems have worst-case scenarios that sweep
the globe in a matter of months, days, or even minutes. For climate change, the damage unfolds over
decades or centuries. This has several implications.

First, while climate change is irreversible compared to the typical policy problem, it doesallow for some potential
interventions even once well underway . For instance, natural processes already exist for extracting
carbon dioxide from the atmosphere, and new technologies could be developed that accelerate those processes or
create artificial ones. Alternatively, humans could use so-called "geoengineering" to effect other changes in the climate system that
might counteract an intensifying greenhouse effect. These approaches offer no guarantee or even likelihood of success; turning to
geoengineering might be seen as a disaster in its own right. But they offer more cause for optimism than exists with many other worrying
problems.

Second,time permits adaptation . While the prospect of losing 50% of existing agricultural capacity is daunting,
over a 50-year period only 1% of capacity needs to shift annually. By comparison, over the past 50 years,
total agricultural output has tripled . Similarly, the need for hundreds of millions of people to migrate over a century amounts to
little out of the ordinary on an annual basis. There are, for instance, more than 200 million migrant workers within China, as well as another 200
million international migrants and at least 60 million refugees around the world right now. The United Nations estimates 2.5 billion people will
migrate to cities in just the next 35 years. Further migration, or perhaps the gradual abandonment of some cities or even entire regions, would
obviously be extraordinarily costly and disruptive in human, economic, and environmental terms. But the reason such adaptations are rarely
mentioned in the context of other worrying problems is not that they would be unnecessary, but rather that, in those other cases, they would
be either impossible or else futile.

Purveyors of creatively catastrophic climate cases also face a Catch-22: Developing ever-more extreme
scenarios typically requires ever-longer timescales . Even higher temperatures and risks of further
dominos falling are threatened — by 2300, or after "centuries." Confident forecasts of multi-meter sea-
level rises are issued, to occur over multiple millennia. Harvard University's Martin Weitzman, the leading proponent of
the case that climate change presents a uniquely "fat tail," falls into precisely this trap: The worst case he offers relies on continued
temperature increases over multiple centuries. But if
heightening the threat requires extending the timeframe
further, it becomes diluted threefold: More time becomes available for adaptation, for economic progress and
technological innovation that render the threat irrelevant, or for the model to fail . Any impact forecasted for
200, let alone 2,000, years into the future becomes almost inherently less cognizable than those already under study for 2100.
Cosmo
 2AC –
Framework—the debate should be about the results of the plan—key to fairness
because the plan is the locus of affirmative offense and there are infinite arbitrary
negative frameworks

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

Prefer our framework – prior questions will never be fully settled and can’t guide
health policy
Jennifer Prah Ruger 06, Assistant Professor, Yale School of Medicine, Adjunct Professor at Yale School
of Law, Toward a Theory of a Right to Health: Capability and Incompletely Theorized Agreements, 2006,
Yale Journal of Law & Humanities,
http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1313&context=yjlh

High level principles can have an important role in democratic political life generally and in major social movements
specifically. Decisionmaking in public policy settings, however, requires reasoned agreement on particular
outcomes, regardless of whether there is agreement on political abstractions . Legal decision-making has to
produce agreement on particular outcomes; and because there rarely is agreement on high-level principles, those particular outcomes must be
justified by low level principles. Peoplecan disagree on general principles but agree on concrete cases. Lawyers and
judges are more likely to converge on lower levels of abstraction than higher ones-- dealing with necessary decisions of "what

to do rather than what to think ."' 3 7 This approach is therefore more appropriate for well-functioning legal systems in democratic
societies. ¶ Sunstein's incomplete theorization typology is usefully applied to decision-making about health and health policy. I created
diagrams to capture the three types of incompletely theorized agreements: incompletely specified agreements (Figure 4), incompletely
specified and generalized agreements (Figure 5), and incompletely theorized agreements on particular outcomes (Figure 6) to help illustrate
this point.¶ B. Incompletely Specified Agreements¶ The first type of incompletely theorized agreement occurs when there is agreement on a
general principle, accompanied by sharp disagreement about particular cases. Here, Sunstein argues, people
who accept a general
principle-murder is wrong, for instance-need not agree on what this principle entails in particular
cases--e.g. abortion. 3 8 Similarly, I argue, people who accept the general principle of good health may
disagree on what good health requires in provision of health care and other concrete social services.¶
C. Incompletely Specified and Generalized Agreements¶ The second type of incomplete theorization occurs when people agree on a mid-level
principle, but disagree both about the more general theory that accounts for it and about outcomes in particular controversies. Here, Sunstein
states that the connections are unclear both between the general theory and mid-level principles and between specific cases and mid-level
principles.'3 9 As a health example, I argue, people
might agree on universal health insurance coverage without
settling on a large-scale theory of equality or on a specific health plan. In this model, there is a great deal of
uncertainty and ambiguity leading to more divergence than convergence. 4 0¶ D. Incompletely Theorized
Agreements on Particular Outcomes¶ Incompletely theorized agreements on particular outcomes involves, in a public policy and
human rights context, how people make decisions and come to agreement on particular policy options. In this model, parties reach agreement
on low-level principles that do not necessarily derive from one particular high-level theory. In other words, low-level principles may be
compatible with more than one high-level principle. People may agree on individual judgments while disagreeing on the level of general
principle.¶ E. Incompletely Theorized Agreements and Public Policy¶ While the ITA framework has been applied generally in law, I have argued
that it also has promise as a descriptive and normative analytical framework for public policy,' 4 ' and now for human rights. In applying the ITA
framework in a human rights or public policy setting, at least two points are important: (1) the approach is well suited to human goods that are
plural and ambiguous; and (2) it allows for different but converging paths to the same agreement. In matters of public philosophy concerning
inherently plural and indistinct concepts, and in dealing with collective choice involving numerous views and disagreements, ITA can help bring
participants in a public policy and human rights discussion to agreement on certain specific outcomes.¶ In social decision-making about health
capabilities, health policy, and a right to health, the ITA framework is particularly useful and complementary to the capability approach in at
least three important respects. First, health, and thus health
capabilities are multi-dimensional concepts about
which different people have different and sometimes conflicting views. Complete theorization is thus
difficult to achieve . No unique view of health or health capabilities exists. No view is ideal or unanimously agreed
upon for all evaluative purposes. Second, the incomplete, partial ordering of the capability approach combined with
incompletely theorized agreement on that ordering allows for reasoned public policy decision-making in
particular situations . Third, given the demands of certain evaluative exercises , in particular human rights and
public policy contexts, the flexibility of these approaches allows reasoned agreement on central
aspects of health and capabilities, without requiring agreement on non-central aspects. It also allows for different paths
to the same conclusion . ¶ F. Pluralism, Ambiguity, and Incompletely Theorized Agreements¶ Often in decision-making settings people
"can know that something is true without entirely knowing why this something is true."14 Consider these instances: people might agree that
murder is wrong, that the government should prevent famines, that society should not let people starve and die in the streets, that we should
try to prevent the spread of communicable diseases, and that people should not be subject to forced genital mutilation. People can hold these
in Oregon's Medicaid experiment, 143 there was substantial
views without knowing exactly why. For example,
agreement that cystic fibrosis and viral pneumonia claimed allocational priority in providing medical
care over tooth-capping, acute headaches, and thumb-sucking. But people did not generally agree on
or know exactly why this should be the case. In hospital emergency rooms, physicians will agree on
triage decisions prioritizing life-saving interventions over quality of life enhancements, without fully
theorizing why. And in certain applications of the capability approach, there is considerable
agreement on urgent basic needs without a full understanding of the reason.¶ The need for reasoned
public policy in the face of these ambiguities makes the ITA approach appealing especially in the context of
human rights. Like many concepts in human rights, "health" and "human flourishing" are multidimensional and
ambiguous. Still, people can understand the concepts of "health" or "human flourishing" or "capability" without
fully articulating their details. Through these partially theorized concepts, humans can judge and
evaluate policy as desirable or undesirable.¶ The ITA theory allows people to agree on an outcome despite these ambiguities.
Decision-makers need not fully share a common set of foundations for their beliefs and are allowed
to leave unarticulated the "right" reasons for their respective convictions. When their convergence over a human
right is incompletely theorized, it enables them to obtain some clarity and decisiveness in the result without precisely specifying their reasons
for it.¶ G. Incompletely Theorized Agreements and Capability¶ I return here to obtaining collective agreement on the selection and weighting of
health capabilities for evaluating the right to health. The ITA framework complements the capability approach in this phase because it allows
for collective agreement on a dominance partial ordering of capabilities without requiring that political participants agree on other capabilities.
It can thus obtain agreement on the dominance partial ordering of basic or central capabilities without requiring agreement on non-basic or
non-central capabilities as noted in Part II above. ¶ The ITA framework also assumes pluralism in many forms. Plural value structure and plural
agents do not upset the framework so long as there are at least some areas of consensus. In this sense it allows the capability approach to
apply more widely. As Sunstein notes, "People value things not just in terms of weight, but also in qualitatively different ways. Human goods
are plural and diverse, and they cannot be ranked along any unitary scale without doing violence to our understanding of the qualitative
differences among those very goods." 1"¶ Applying the ITA framework to questions of health, health capability, and
health policy, one sees that people can agree on particular outcomes. Individuals can agree, for instance, on. those health
capabilities that are essential to a right to health and the low-level principles that justify them without agreeing on
complete answers to metaphysical questions, such as "what is human flourishing" or "what is health?"
 AT: Cosmo – Perm
The alternative fails—only the perm solves
Gavin Kendall et al 8, an adjunct professor in sociology at the Queensland University of Technology; Zlatko Skrbis is an Honorary
Professor of Sociology at the University of Queensland; Ian Woodward is an Associate Professor in School of Humanities at Griffith University,
“Cosmopolitanism, the nation-state and imaginative realism”, December 2008, Journal of Sociology 44.4, Sage Journals

What Beck
offers us is a Manichean dialogue between state and cosmopolis, and the danger of accepting this analysis
is that the
state starts to appear irrelevant, exhausted and inimical to cosmopolitan sentiments. Extreme
cosmopolitans, like Beck and Nussbaum, fall into the trap of failing to account for the institution of the state.
Nussbaum’s position is consistent with two underlying assumptions: there are moral bases for politics and each individual should feel primary
loyalty to humanity rather than localness (Calhoun, 2003a: 538–9). The problem with such an
account is that it never engages in
analysis of the large unmediated space between the concrete individual and an abstract category of
humanity. Nussbaum avoids engagement with this question by implying a moral and logical necessity of cosmopolitan
transcendence. This necessity is logically contingent on a normative framework but it is also non-sociological.
Nussbaum’s position, for example, does not explain how people’s judgements (about good and evil) are
generated, how people engage in selfish or altruistic practices, and how and why they perform their
identities within the context of the messiness of social life. The formation of judgements and the politics
of practice are inevitably encumbered by the nature of a particular individual’s location in the context of
groups and institutions, but they are also dependent on identities that are performed by, or attributed to, this person. One does
not become cosmopolitan in a vacuum.
 Sovereignty Inevitable
No one will accept major changes to the structure of sovereignty
Rosa Brooks 12, Professor of Law at Georgetown University Law Center and a Bernard L. Schwartz
Senior Fellow at the New America Foundation, “Strange Bedfellows: The Convergence of Sovereignty-
Limiting Doctrines in Counterterrorist and Human Rights Discourse,” Law and Ethics Summer/Fall

None of these projects would be straightforward; each might be seen as facing barriers so high as to be virtually insurmountable. If the
various institutional and legal “fixes” we might envision are unrealistic in the near term, is there any responsible way forward? The overall thrust of

this essay has been to call for intellectual honesty about the logical implications of emerging
sovereignty-limiting doctrines. But, perhaps, this is one of those areas where discretion—even disingenuousness—is the better part of valor, or at
least the better part of preserving stability. Stephen Krasner makes a variant of this argument in some of his recent work. Krasner famously dubbed

sovereignty “organized hypocrisy,” noting that while the notion of “sovereignty” has long been
associated with clear legal criteria and rules, states have, for just as long, routinely ignored those rules when it suited them to do so.18 To
Krasner, this organized hypocrisy is nonetheless functional—or at least more functional than any available

alternative. In a 2010 essay on “The Durability of Organized Hypocrisy,” Krasner argues that this remains true today.19 He grants that emerging normative or
legal doctrines will continue to challenge and delegitimize traditional notions of sovereignty, and significant “shocks”— such as “the

possibility of mega-terrorist attacks”—might lead to radical change: “Governments in advanced countries would begin to
reconfigure their bureaucratic structures to… [reflect] new rules and principles about responsibilities for territories or functions beyond national borders.” But,

argues Krasner, “Such fundamental challenges to the existing sovereignty regime are not to be welcomed. Any
new set of principles…would be contested. External actors, even if their claims were legitimated…would not find it easy to exercise the authority they had
asserted…there are no formulaic solutions.” Krasner concludes, “Sovereignty
has worked very imperfectly but it has still
worked better than any other structure that decision-makers have been able to envision.”20 In other words:
in the end, perhaps, when it comes to teasing out the implications of emerging sovereigntylimiting
doctrines, organized hypocrisy is the best we can do.

Our conception os sovereiginty is best

Patrick Doherty 13, director of the Smart Strategy Initiative at the New America Foundation, 1/9/13,
“A New U.S. Grand Strategy,” http://foreignpolicy.com/2013/01/09/a-new-u-s-grand-strategy/
A New Grand Strategic Concept

U.S. Foreign Policy: A New Global Partnership

With America’s domestic house in order, the United States will be in a position to lead the global
transition to sustainability. While the United States cannot achieve global sustainability alone, it need not convince its partners of
the challenges we all face. Most of the world’s major economies have already identified economic inclusion
and ecosystem depletion as first-order strategic challenges. With a robust new economic engine
changing America’s global interests, the commitment, scale, and pace of its economic engine will
allow it to convene the world’s major economies in a forum to establish and implement the norms
necessary for an orderly transition to global sustainability. These new norms fall within the following
categories:

Regional convergence: Regional-scale economies, such as the United States, China, India, and Europe, are the primary
actors in today’s global economy. All are unsustainable, and each requires a tailored internal economic strategy to reduce trade imbalances,
manage debt, and reverse overconcentration of global production.
Meanwhile, smaller countries’ economies have often found themselves caught between these giants
— becoming dangerously dependent upon them and drained of their resources, wealth, or human
capital. Without the advantage of scale, most of these countries have little practical chance of achieving the kinds of economic growth that
will meet the expectations of their citizenries. This inadequate, two-tier design is only exacerbating our continued
unsustainability.

Every continental-scale economic region must embark on a decisive sustainability strategy without delay. Working
within existing
norms of the World Trade Organization and the United Nations, America will lead the partnership of
major economies to refashion the global economic system around eight or nine economic blocs, each
boasting the scale necessary to support mature industrial ecosystems. This will mean promoting and
strengthening regional economic blocs such as the Association of Southeast Asian Nations, the Union
of South American Nations, the African Union, the Commonwealth of Independent States, and the
Organization of Islamic Cooperation.

Development: It is not only the United States that needs to get its house in order. Within all regional-
scale economic areas, the country will work with the global partnership to promote a mode of
development that results in prosperity, security, and sustainability for their citizens.

Export-led growth and resource-extraction strategies will no longer suffice. Housing, agriculture, and
resource productivity will be the drivers of sustainable economic development, producing jobs, investment, and
government revenue. While each region will have a unique starting point, global income convergence will unleash substantial trade
opportunities as each region develops robust internal markets. Solutions pioneered in one region will find markets in others. As
multiple
regions create advanced manufacturing capability, global supply chains will become more dynamic
and resilient.

Access and participation: Most

of the world’s population still does not have access to the formal sector of its
local market and therefore cannot participate in this great global project. A whopping 4 billion citizens do not have
access to basic market tools: They do not have identity papers, title to property, or access to courts, banks, credit, or insurance. Until these
people get the economic franchise, we will be unable to realize the goal of global sustainability.

Egypt presents a case study of this phenomenon. In the world’s largest Arab country, 90 percent of
real estate is held outside the formal sector. As a result, there is no effective housing market — and with a bulge of
young people looking to start families, Egypt’s underlying economic crisis will continue to fester.

We cannot allow this to continue. Closed, dysfunctional, or corrupt markets cannot be harnessed to
meet the kind of strategic economic challenges we face today. The United States will work with the
world’s major economies to rapidly extend universal access to basic market tools and establish full
economic participation as a global norm.
Assurance through transition: The great threat to American security in the coming decades of the 21st century stems from the unsustainability
of the international order.

Although addressing this threat is primarily an economic and geopolitical exercise, the U.S. national security establishment must ensure that
economic and political actors have sufficient space and time to adapt the system at home and, in partnership, abroad. The mission of America’s
national security establishment in this new era must be to maintain and extend that space while providing, to friend and foe alike, a credible
assurance that America is committed to, and will actively promote, a rules-based international order.

Multilaterally when possible, unilaterally if necessary, America will work to ensure that borders,
global commons, and basic standards of human rights will be respected by all countries. The transition to
sustainability will be a complex and dynamic undertaking. Its political impact will be unprecedented: Borders, many set during
colonial rule, will come under strain. America will work with its partners to ensure that any borders
that are changed are done so by mutual consent and self-determination, not by violence or coercion. It will
assert its right of access to the global commons as much as it will honor its responsibility to respect them as a sustainable platform for
navigation, commerce, and ecosystem services.
Finally, the United States will continue to insist on all countries’
respect for basic human rights, and it will accept the global responsibility to protect against their
gross and systematic violation.

American policy will be to reduce global demand, over time, for U.S. military intervention by building
capable regional security partners wherever possible — though the United States will maintain and
position expeditionary forces commensurate with objective global risks.
U.S. Governance

Just as America would never fight a 21st-century war with Korean War-era weapons, it should not govern today with institutions devised for a
bygone era. The Founding Fathers established a constitution that allows for the adaptation of the institutions of government to the knowledge,
threats, and opportunities confronting each generation. Americans should make use of that foresight. Under this strategy, the country will
adapt the institutions of its federal government to execute this grand strategy and invest in the American people to ensure that they receive
the opportunities they need to be informed and engaged citizens.

Governing institutions: Today’s executive branch was largely designed to support the country through the Cold War, and it is misaligned to the
requirements of the 21st century. The U.S. national security establishment can barely see the challenges of today, let alone predict the crises of
tomorrow. America’s domestic departments are designed to support an economic strategy that is now weakening the country. Congress is
supposed to oversee this system, but it too cannot rise above the noise. The White House, meanwhile, has not maintained a robust strategic
capacity since 1961.

Just as the 1947 National Security Act adapted the U.S. national security establishment to take on the Cold War, the country will adapt again to
implement and manage this strategy. It will reorganize agencies and departments to execute the elements of this strategy. Congress will be
encouraged to align its oversight committees to the new federal departments.

In peacetime, U.S. foreign-policy agencies — providing defense, diplomacy, development, and intelligence — will align around one map and fall
under integrated civilian control at the global, regional, and country levels. Domestically,
the United States will clear out the
economic policies of the past and ensure that housing, agriculture, and resource productivity are
incentivized and regulated to ensure fair, robust, and open markets with strong consumer
protections.

Opportunity society: When Americans are secure, they are the most productive and engaged in the world. The United
States will recommit itself to making world-leading investments in the American people, the country’s greatest national resource.

Education, health care , retirement security, and scientific knowledge are the cornerstone of the opportunity society. With a
new economic engine providing the private income and public revenue necessary for such investments, and with fiscal health restored,
the country will examine and select the most effective models for ensuring world-class public education, achieving universal health-

care coverage , and earning a worry-free retirement. Funding for basic science and early-stage innovation will be expanded significantly to
keep America the leading research and innovation center in the world.

Minding American Strategy

America has never confronted a global challenge of the type or magnitude it faces today. If it does not change course, the
United States
will be racked by violent storms — both figurative and literal — as the global order breaks down. The
country cannot delay. For a few short years, it has a window in which it can choose an incredibly
prosperous 21st century, but that window will close. It is time once more to lead the world through
difficult change.
The United States must first get its own house in order. It will adapt its industry. It will build a new
American Dream. It will lead the world by example while defining the future and inspiring greatness. And America will do all this while
emerging from an economic depression that is wasting its most precious resource — its citizens’ talents.
 Alt Bad – Bickerton
Alternatives to sovereignty make unaccountable power exercises worse
Christopher J. Bickerton 7, D.Phil. candidate at St John’s College, University of Oxford, Philip Cunliffe,
PhD candidate in the Department of War Studies at King’s College London and Alexander Gourevitch,
PhD student at Columbia University, “Politics without Sovereignty: A critique of contemporary
international relations”, p. 12

First, itis not straightforward that the critique of sovereignty and the proliferation of alternative views of
international politics are the sign of an enhanced sense of political possibility on the global stage. We shall, indeed, argue that, at

present, what we find is the opposite. The retreat of state sovereignty has coincided with diminished

political possibilities throughout the world . Second, the concept of sovereignty is bound up with a
particular idea of responsibility. The idea of a supreme power, subject to no higher law, articulates the idea that human beings are the authors of
their own destiny. Power is always exercised by an agent representing the supreme power of the collective, an agent who, in claiming that power, is therefore at
least in principle accountable for that act. Although
many critics of sovereignty claim to be making power relations
more visible by jettisoning the vexing abstraction of sovereignty, we argue that the result of this is
that one form of power – collective power – is rendered more oblique, and the exercise of power is made
less accountable . If it is not inevitable, it is nonetheless not surprising that the reorganization of political theory and practice
around a fragmented, divisible conception of sovereignty serves to separate the relationship between
power and responsibility. That is to say, political activity still exists, and collective power is still exercised,
but in a mystified and more unaccountable way.
Econ
Trust DA
 1NC No Warming
No warming---temperatures are trending down and negative feedbacks solve any
impact
Fritz Vahrenholt 12, Honorary Professor of chemistry at the University of Hamburg, former
Umweltsenator in the German Ministry for Environment, Scientific Reviewer for the 2010 IPCC, February
8, 2012, interviewed by Welt Online, a German newspaper, online: http://thegwpf.org/international-
news/4932-the-cold-sun-why-the-climate-catastrophe-wont-happen.html

Welt Online: Will it become even colder soon?

Vahrenholt: First of all, the small solar cycles - the Gleissberg and the Suess cycles - are in a
downturn phase. Secondly, the decadal oscillations will be in their negative phase for the next 30
years. And thirdly, we have one of the weakest solar cycles in 80 years. It could be that the next
solar cycle will be even weaker.

All this led us to the the conclusion that we are facing a so-called Dalton Minimum, a cool period, as
it was the case from 1790 to 1830. Warming of the climate, which is caused undoubtedly by CO2
and other greenhouse gases, will be offset by other natural effects to a considerable extent in
coming years and decades. The bottom line is that we will only have global warming of only one
degree by 2100 - provided that the cycles will continue to behave the way they did for the past
7,000 years.

Welt Online: But climate scientists warn that the concentration of CO2 in the atmosphere has
reached such a level that the natural regulatory processes, of which you speak, may not even work
anymore. If that is true, we would have a problem, not?

Vahrenholt: The sun cannot be influenced by the CO2 in the atmosphere, neither can the
stratosphere. The increase in carbon dioxide from 0.028 percent to 0.038 percent in the
atmosphere is nothing earth shattering, after all. Most people do not know that CO2 is only
considered so significant because its climate impact is amplified by water vapor. When the
temperatures rise due to CO2, so the argument goes, then the concentration of water vapor in the
atmosphere also increses. This additional greenhouse gas contributes much more to the greenhouse
effect than CO2.

But fortunately, there are feedbacks that are acting in a correcting way. More water vapor means
more clouds. And clouds shield the radiation from the sun. I believe that Mother Nature is a fairly
stable system, otherwise we would have turned into a hot, waterless planet like Venus a long time ago
in our long geological history.
Computer models vastly overstate warming---the best science shows a lack of
warming for the last decade
Claude Allegre et al 12, former director of the Institute for the Study of the Earth, University of Paris; J. Scott Armstrong, cofounder of
the Journal of Forecasting and the International Journal of Forecasting; Jan Breslow, head of the Laboratory of Biochemical Genetics and
Metabolism, Rockefeller University; Roger Cohen, fellow, American Physical Society; Edward David, member, National Academy of Engineering
and National Academy of Sciences; William Happer, professor of physics, Princeton; Michael Kelly, professor of technology, University of
Cambridge, U.K.; William Kininmonth, former head of climate research at the Australian Bureau of Meteorology; Richard Lindzen, professor of
atmospheric sciences, MIT; James McGrath, professor of chemistry, Virginia Technical University; Rodney Nichols, former president and CEO of
the New York Academy of Sciences; Burt Rutan, aerospace engineer, designer of Voyager and SpaceShipOne; Harrison H. Schmitt, Apollo 17
astronaut and former U.S. senator; Nir Shaviv, professor of astrophysics, Hebrew University, Jerusalem; Henk Tennekes, former director, Royal
Dutch Meteorological Service; Antonio Zichichi, president of the World Federation of Scientists, Geneva; January 27, 2012, “No Need to Panic
About Global Warming,” The Wall Street Journal, online:
http://online.wsj.com/article/SB10001424052970204301404577171531838421366.html

A candidate for public office in any contemporary democracy may have to consider what, if anything, to do about "global warming."
Candidates should understand that the oft-repeated claim
that nearly all scientists demand that something
dramatic be done to stop global warming is not true. In fact, a large and growing number of
distinguished scientists and engineers do not agree that drastic actions on global warming are needed.
In September, Nobel Prize-winning physicist Ivar Giaever, a supporter of President Obama in the last election, publicly resigned from
the American Physical Society (APS) with a letter that begins: "I did not renew [my membership] because I cannot live with the [APS
policy] statement: 'The evidence is incontrovertible: Global warming is occurring. If no mitigating actions are taken, significant
disruptions in the Earth's physical and ecological systems, social systems, security and human health are likely to occur. We must
reduce emissions of greenhouse gases beginning now.' In the APS it is OK to discuss whether the mass of the proton changes over time
and how a multi-universe behaves, but the evidence of global warming is incontrovertible?"

In spite of a multidecade international campaign to enforce the message that increasing amounts of the "pollutant" carbon dioxide will
destroy civilization, large numbers of scientists, many very prominent, share the opinions of Dr. Giaever. And the
number of
scientific "heretics" is growing with each passing year. The reason is a collection of stubborn scientific
facts.

Perhaps the most inconvenient fact is the lack of global warming for well over 10 years now. This is
known to the warming establishment, as one can see from the 2009 "Climategate" email of climate scientist Kevin Trenberth: "The fact
is that we can't account for the lack of warming at the moment and it is a travesty that we can't." But the warming
is only
missing if one believes computer models where so-called feedbacks involving water vapor and
clouds greatly amplify the small effect of CO2.

The lack of warming for more than a decade—indeed, the smaller-than-predicted warming over the 22 years since
the U.N.'s Intergovernmental Panel on Climate Change (IPCC) began issuing projections—suggests that computer models

have greatly exaggerated how much warming additional CO2 can cause. Faced with this embarrassment,
those promoting alarm have shifted their drumbeat from warming to weather extremes, to enable anything unusual that happens in
our chaotic climate to be ascribed to CO2.

The fact is that CO2 is not a pollutant. CO2 is a colorless and odorless gas, exhaled at high concentrations by each of us, and a key
component of the biosphere's life cycle. Plants do so much better with more CO2 that greenhouse operators often increase the CO2
concentrations by factors of three or four to get better growth. This is no surprise since plants and animals evolved when CO2
concentrations were about 10 times larger than they are today. Better plant varieties, chemical fertilizers and agricultural
management contributed to the great increase in agricultural yields of the past century, but part of the increase almost certainly came
from additional CO2 in the atmosphere.

Although the number of publicly dissenting scientists is growing, many

young scientists furtively say that while they also
have serious doubts about the global-warming message, they are afraid to speak up for fear of not
being promoted—or worse. They have good reason to worry. In 2003, Dr. Chris de Freitas, the editor of the journal Climate
Research, dared to publish a peer-reviewed article with the politically incorrect (but factually correct) conclusion that the recent
warming is not unusual in the context of climate changes over the past thousand years. The international warming establishment
quickly mounted a determined campaign to have Dr. de Freitas removed from his editorial job and fired from his university position.
Fortunately, Dr. de Freitas was able to keep his university job.

This is not the way science is supposed to work, but we have seen it before—for example, in the frightening period when Trofim
Lysenko hijacked biology in the Soviet Union. Soviet biologists who revealed that they believed in genes, which Lysenko maintained
were a bourgeois fiction, were fired from their jobs. Many were sent to the gulag and some were condemned to death.

Why is there so much passion about global warming, and why has the issue become so vexing that the American Physical Society, from
which Dr. Giaever resigned a few months ago, refused the seemingly reasonable request by many of its members to remove the word
"incontrovertible" from its description of a scientific issue? There are several reasons, but a good place to start is the old question "cui
bono?" Or the modern update, "Follow the money."

Alarmism over climate is of great benefit to many, providing government funding for academic
research and a reason for government bureaucracies to grow. Alarmism also offers an excuse for
governments to raise taxes, taxpayer-funded subsidies for businesses that understand how to work the political system, and
a lure for big donations to charitable foundations promising to save the planet. Lysenko and his team lived very well, and they fiercely
defended their dogma and the privileges it brought them.

Speaking for many scientists

and engineers who have looked carefully and independently at the science
of climate, we have a message to any candidate for public office: There is no compelling scientific
argument for drastic action to "decarbonize" the world's economy. Even if one accepts the inflated climate forecasts
of the IPCC, aggressive greenhouse-gas control policies are not justified economically.