1AC

1AC
Adv 1 is Public Health

Insurance coverage gaps threaten public health response – makes

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

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

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

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

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

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

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

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

Attacks are coming – motivation and capability exists

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

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

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

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

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

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

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

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

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

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

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

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

According to author G. Kenny, the

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

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

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

Attacks cause international lashout and domestic crackdown---decks

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

Lashout causes global war within a week

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

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

Surprisingly, they wouldn’t. The

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

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

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

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

7. The Lesson

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

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

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

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

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

Bioterror causes extinction

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

Disease causes extinction and no burnout---global transportation

networks
Yaneer Bar-Yam 16, Founding President of the New England Complex Systems Institute,
“Transition to extinction: Pandemics in a connected world,” NECSI (July 3, 2016),
http://necsi.edu/research/social/pandemics/transition
Watch as one of the more aggressive—brighter red  —  strains rapidly expands. After a time it goes extinct leaving a black region.
Why does it go extinct? The answer is that it spreads so rapidly that it kills the hosts around it. Without new hosts to infect it then
dies out itself. That
the rapidly spreading pathogens die out has important implications for
evolutionary research which we have talked about elsewhere [1–7].¶ In the research I want to discuss here, what we
were interested in is the effect of adding long range transportation [8]. This includes natural
means of dispersal as well as unintentional dispersal by humans, like adding airplane routes,
which is being done by real world airlines (Figure 2).¶ When we introduce long range transportation
into the model, the success of more aggressive strains changes. They can use the long range
transportation to find new hosts and escape local extinction. Figure 3 shows that the more
transportation routes introduced into the model, the more higher aggressive pathogens are able to survive and spread.¶ As we add
more long range transportation, there
is a critical point at which pathogens become so aggressive that the
entire host population dies. The pathogens die at the same time, but that is not exactly a consolation to the hosts. We
call this the phase transition to extinction (Figure 4). With increasing levels of global
transportation, human civilization may be approaching such a critical threshold .¶ In the
paper we wrote in 2006 about the dangers of global transportation for pathogen evolution and pandemics [8], we mentioned the risk
from Ebola. Ebola is a horrendous disease that was present only in isolated villages in Africa. It was far away from the rest of the
world only because of that isolation. Since Africa was developing, it was only a matter of time before it reached population centers
and airports. While the model is about evolution, it is really about which pathogens will be found in a system that is highly
connected, and Ebola can spread in a highly connected world.¶ The traditional approach to public health uses historical evidence
analyzed statistically to assess the potential impacts of a disease. As a result, many were surprised by the spread of Ebola through
West Africa in 2014. As the connectivity of the world increases, past experience is not a good guide to future events.¶ A
key point
about the phase transition to extinction is its suddenness. Even a system that seems stable, can
be destabilized by a few more long-range connections, and connectivity is continuing to
increase.¶ So how close are we to the tipping point? We don’t know but it would be good to find
out before it happens.¶ While Ebola ravaged three countries in West Africa, it only resulted in a handful of cases outside that
region. One possible reason is that many of the airlines that fly to west Africa stopped or reduced flights during the epidemic [9]. In
the absence of a clear connection, public health authorities who downplayed the dangers of the epidemic spreading to the West
might seem to be vindicated.¶ As with the choice of airlines to stop flying to west Africa, our analysis didn’t take into consideration
how people respond to epidemics. It does tell us what the outcome will be unless
we respond fast enough and well
enough to stop the spread of future diseases, which may not be the same as the ones we saw in the past. As the
world becomes more connected, the dangers increase.¶ Are people in western countries safe because of higher
quality health systems? Countries like the U.S. have highly skewed networks of social interactions with some very highly connected
individuals that can be “superspreaders.” The chances of such an individual becoming infected may be low but events like a mass
outbreak pose a much greater risk if they do happen. If
a sick food service worker in an airport infects 100
passengers, or a contagion event happens in mass transportation, an outbreak could very well
prove unstoppable .
 1AC
Advantage (_) is the economy
Two Internal links---first is coverage:
US is locked into slow growth crisis now -- upward trends are short-
term
John Ross 17, Senior Fellow at Chongyang Institute for Financial Studies, Renmin University
of China, former Professor at Shanghai Jiao Tong University, 6/12/2017, “Why the US economy
remains locked in slow growth,”
http://ablog.typepad.com/keytrendsinglobalisation/2017/06/why-the-us-economy-remains-
locked-in-slow-growth.html
The latest US economic data confirms the US remains locked in a prolonged period of slow
growth with major consequences for geopolitics and destabilising consequences for US domestic politics. ¶
The latest US economic growth data¶ Almost no international issue is more crucial for economic and
geopolitical strategy than economic trends within the US. It is therefore crucial to have an accurate analysis of
these. Regarding such a serious issue and such powerful forces there is no merit in ‘pessimism’, underestimating US growth, and no
merit in ‘optimism’, overestimating US growth – there is only a virtue in realism.¶ This article therefore analyses the latest US GDP
data. The conclusion is clear. The data
confirms the US fundamentally remains in a period of
medium/long term slow growth which will last for at least a minimum of several years.¶ Strikingly, taking a period
of 15 years after the beginning of the international financial crisis, average US growth will be
slower than after the beginning of the Great Depression in 1929. Analyses which appear in parts of
the media claiming the US is entering a significant new period of rapid growth are fundamentally in
error – for reasons analysed in detail blow.¶ Such slow US growth necessarily has major geopolitical
consequences and provides a backdrop for continuing instability and turns in US politics . The
recent period within US politics has already seen:¶ Trump selected as Republican Party Presidential candidate against the wishes of
that Party’s establishment, and elected President against the opposition of the overwhelming major of the US mass media.¶ Since
Trump’s election sharp clashes have continued within the US political establishment with leaks against the President by the US
security services, the President’s sacking of the FBI head, investigations by the US Congress and US police of close aides to the
President, and open campaigns to force the President to change policies or to remove him from office by major US media such as the
New York Times and CNN.¶ Within the Democratic Party a serious challenge mounted to the Party establishment’s candidate
Clinton by the first figure declaring themselves to be a socialist to receive major US public support for almost a century – Sanders.¶
As US medium/long term slow economic growth will continue sharp turns and tensions in US politics will not disappear but are
likely to continue.¶ The consequences for US relations with China flowing from this situation, and geopolitical tensions between the
US and its traditional allies such as Germany shown for example at the recent G7 summit, are analysed at the end of this article. The
conclusion is that China’s constructive approach to the Trump administration is clearly correct but that the risk of sharp turns in the
situation must be taken into account due to the tensions within the US created by its historically low growth.¶ This prolonged period
of slow growth in the US, and in the advanced economies in general, combines with China’s own transition to ‘moderate prosperity’,
and then to a ‘high income’ economy by World Bank international standards, to create under Xi Jinping a qualitatively new period in
China’s development.¶ The Great Stagnation¶ Starting with the global background to the latest US economic data, a
defining
feature of the present overall international situation is extremely slow growth in the advanced
Western economies.¶ In nine years since the 2008 international financial crisis average growth in the advanced Western
economies is already almost as slow as during the ‘Great Depression’ of the 1930s and by the end of 2017 it will be
significantly slower. By 2016, total GDP growth in the advanced economies in the years since 2007 was only 10.1% and by the
end of 2017, on IMF projections, the growth in the advanced economies after 2007 will be lower than in the same period after 1929 –
total growth of 12.3% in the 10 years after 2007 compared to 15.1% in the 10 years after 1929.¶ Even more strikingly IMF
data
projects that future growth in the advanced Western economies, following the international
financial crisis, will be far slower than in the same period after 1929. IMF projections are that by 2021,
fourteen years after 2007, total growth in the advanced economies will be less than half that in the 14 years after 1929 – average
annual growth of only 1.3% compared to 2.9%, and total growth of 20.6% compared to 49.8%.¶ This data is shown in Figure 1. An
aim of this article is instead to carry out the necessary factual checks that the latest US data does not represent a break with long-
term trends.¶ US GDP growth¶ In the 1st quarter of 2017 US GDP was 2.0% higher than in the first quarter of 2016.[1] To evaluate
this 2.0% growth, given that a market economy inherently displays business cycles, it is necessary to separate purely cyclical trends
from medium/long term ones. Failure to do so leads to false analysis/statistical trickery – comparing a peak of the business cycle
with the trough will exaggerate growth, while comparing the trough of the business cycle with the peak will understate growth. Such
cyclical effects may be removed by using a sufficiently long term moving average that cyclical fluctuations become averaged out and
the long term structural growth rate is shown. Figure 2 therefore shows annual average US GDP growth using a 20-year moving
average – a comparison to shorter term periods is given below.¶ Figure 2 clearly shows that the fundamental trend of the US
economy is long-term slowdown. Annual average US growth fell from 4.4% in 1969, to 4.1% in 1978, to 3.2% in 2002, to 2.2% by 1st
quarter 2017. That is, the most fundamental long term growth trend in the US economy is that it has been slowing for half a century.
The latest US GDP growth of 2.0% clearly does not represent a break with this long term US economic slowdown but is in line with
it.¶ Per capita¶ US per capita GDP growth follows the same falling trend. Figure 3 shows a 20-year moving average for US per capita
GDP growth. Annual average US per capita GDP growth fell from 2.8% in 1969, to 2.7% in 1977, to 2.4% in 2002, to 1.2% by the first
quarter of 2017. The latest US data shows no break with this trend of long term slowdown - it is in line with it and continues these
long term trends.¶ This data
shows clearly claims the US economy is currently ‘dynamic’ driven by a
‘wave of innovation’ are therefore factually false – a pure propaganda myth repeated by US media such as
Bloomberg with no connection with factual trends. US per capita growth has in fact fallen to a low
level.¶ This fall of US per capita GDP growth to a low level clearly has major political implications within the US and underlies recent
domestic political events. Very low US per capital growth, accompanied by increasing economic inequality, has resulted in US
median wages remaining below their 1999 level – this prolonged stagnation of US incomes explaining recent intense political
disturbances in the US around the sweeping aside of the Republican Party establishment by Trump, the strong support given to a
candidate for president declaring himself to be a socialist Sanders, current sharp clashes among the US political establishment etc.¶
Cycle and trend¶ Turning from long term trends to analysis of the current US business cycle it may be noted that a 5-year moving
average of annual US GDP growth is 2.0%, a 7-year moving average 2.1% and the 20-year moving average 2.2%. Leaving aside a 10-
year moving average, which is greatly statistically affected by the severe recession of 2009 and therefore yields a result out of line
with other measures of average annual growth of only 1.4%, US average annual GDP growth may therefore be taken as around 2% or
slightly above. That is, fundamental structural factors in the US economy create a medium/long term growth rate of 2.0% or slightly
above. Business cycle fluctuations then take purely short term growth above or below this average. To analyse accurately the present
situation of the US business cycle therefore recent growth must be compared with this long-term trend.¶ Figure 4 therefore shows
the 20-year moving average for US GDP growth together with the year on year US growth rate. This shows that in 2016 US GDP
growth was severely depressed – GDP growth in the whole year 2016 was only 1.6% and year on year growth fell to 1.3% in the
second quarter. By the 1st quarter of 2017 US year on year GDP growth had only risen to 2.0% - in line with a 5-year moving average
but still below the 20-year moving average.¶ As
US economic growth in 2016 was substantially below
average a process of ‘reversion to the mean’, that is a tendency to correct exceptionally slow or
exceptionally rapid growth in one period by upward or downward adjustments to growth in
succeeding periods, would be expected to lead to a short-term increase in US growth compared to
low points in 2016. This would be purely for statistical reasons and not represent any increase in underlying or medium/long US
term growth. This normal statistical process is confirmed by the acceleration in US GDP growth
since the low point of 1.3% in the 2nd quarter 2016 – growth accelerating to 1.7% in 3rd quarter
2016 and 2.0% in 4th quarter 2016 and 1st quarter 2017.¶ President Trump’s administration may of course
claim ‘credit’ for the likely short term acceleration in US growth in 2017 but any such short-term shift is merely a
normal statistical process and would not represent any acceleration in underlying US growth. Only if growth
continued sufficiently strongly and for a sufficiently long period to raise the medium/long term rate
average could it be considered that any substantial increase in US economic growth was
occurring. The latest US growth data, 2.0% year on year, however does not represent any acceleration in US growth compared to
longer term averages and is therefore in line with the pattern of US slow growth and does not represent a break with it.

Increasing coverage is key to faster growth –it solves workforce

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

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

Coverage gaps threaten economic decline – stabilizing insurance

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

Small businesses solves competitiveness – reverses offshoring

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

Strengthening US growth key to solve global conflicts

Richard N. Haass 13, President of the Council on Foreign Relations, 4/30/13, “The World
Without America,” http://www.project-syndicate.org/commentary/repairing-the-roots-of-
american-power-by-richard-n--haass
Let me posit a radical idea: The most critical threat facing the United States now and for the foreseeable future is not a rising China, a reckless North
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.
Continued slow growth causes diversionary conflict with China
John Ross 17, Senior Fellow at Chongyang Institute for Financial Studies, Renmin University
of China, former Professor at Shanghai Jiao Tong University, 7/10/2017, “Trump's economy -
cyclical upturn and long term slow growth”,
http://ablog.typepad.com/keytrendsinglobalisation/2017/07/trumps-economy-cyclical-upturn-
and-long-term-slow-growth.html

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

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

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

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

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

Faced with these obstacles, the

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

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

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

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

viability of the exchanges.¶ ¶

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

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

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

results suggest that the ACA led to increased self-employment

individuals eligible for insurance subsidies. Taken together, these

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

Strengthening the mandate is key to make insurance markets

financially viable
Paul Demko 16, Healthcare Reporter for Political, former Washington Bureau Chief for
Modern Healthcare, 7/13/2016, Obamacare’s sinking safety net,
http://www.politico.com/agenda/story/2016/07/obamacare-exchanges-states-north-carolina-
000162
Even so, many of those insurers
lost tens of millions of dollars on their Obamacare policies last year —
and now they're seeking big rate hikes.¶ The ACA’s strength and its weakness is that it was built
atop America's private insurance system: rather than creating new government health plans, it depends on
competition among companies to offer affordable insurance to people who need it. In a nation dominated by private-sector health
care players, this made it politically possible–but it
also means the system works only if insurers find
Obamacare to be a desirable business. What has happened instead in North Carolina and many other states is that
insurers are finding the Obamacare business to be a swamp.¶ Nationwide, an analysis by
McKinsey found that insurers lost $2.7 billion on individual customers in 2014, the only year since
Obamacare coverage expansion for which full numbers are available–with 70 percent of carriers sustaining losses.
Those losses are after government payments intended to help plans with high-cost customers.
Preliminary data from 2015 suggest the rate of losses likely doubled, according to McKinsey.¶ The red ink
has led to the collapse of two-thirds of 23 new nonprofit health plans that were
established with federal loan dollars to increase competition in the state exchanges where
customers shop for policies. And UnitedHealth Group is largely getting out of the Obamacare
business because of anticipated losses of $650 million this year. “The individual market is a
mess ,” Brian Webb, health policy manager for the National Association of Insurance
Commissioners, told a recent briefing on Capitol Hill.¶ As Obamacare approaches its fourth season of
enrollment, and prepares to enter the post-Obama era, it's hitting an inflection point—and, in states like North Carolina,
that point could become a crisis. Millions are now being covered through the law, but
they're older, sicker and more expensive to insure than anyone anticipated. To compensate,
health plans are raising premiums, in some cases by a lot—the largest insurer in Texas wants to jack up rates
for individual plans by an eye-popping 60 percent next year.¶ A close look at what's really keeping the exchanges underwater
suggests that some of the problems are self-inflicted wounds by Obama and his administration; others are the handiwork of
Republican saboteurs, who undercut the safeguards intended to help companies weather the uncertainty of the new law. And overall,
the system has been weighed down by one big miscalculation: Health
insurance amounts to a guess about how
much customers’ health care is going to cost in the long run, and in many states Obamacare
health insurers guessed wrong.¶ None of the problems are insurmountable, but if they aren’t fixed, the
law could find itself in a mounting crisis—what observers call a “death spiral”— in
which competition vanishes, costs skyrocket, and a dwindling pool of insurers offer policies so expensive that health insurance is as
out of reach as it ever was.¶ Politically, the repair job isn’t trivial: It requires a bipartisan decision to stabilize the Obamacare
markets, a consensus that has been unattainable in the politically toxic atmosphere on Capitol Hill since the law was passed six years
ago without a single Republican vote. With this year’s enrollment season set to open just one week before Election Day, the
turbulence in the exchanges could be a wildcard in the presidential contest–and threaten Obama’s signature domestic achievement.¶
The gulf between Obamacare's success covering citizens and its failures on the insurance front
isn't just an accidental side effect: It's a direct result of the key selling point of the law, that
coverage is now accessible to all Americans. Health care finance experts point to a handful of policy changes that
could bolster the exchanges and ensure that people in states like North Carolina can still buy health insurance five and 10 years from
now. That would require an honest reckoning with what’s gone wrong–and the legislative resolve to enact fixes. “There’s plenty
to be worried about,” said Don Taylor, a health policy expert at Duke University who has tracked Obamacare in his home
state of North Carolina and across the country. “The answer is more policy—not doing nothing.” ¶ So
just what is that new policy supposed to look like?¶ ANY LAW AS ambitious and complex as the ACA is going to be a work in
progress. Almost from the moment Medicare passed in 1965, Congress has been revising it, and even now it undergoes changes
every year. Most insurance companies say they remain committed to offering Obamacare plans, and as long as they stay in the
business, the exchanges are unlikely to implode.¶ In some states, such as California and Washington, the system is working fine.
More than 9 in 10 health plans made money selling Obamacare policies to individuals during the first year of enrollments, according
to McKinsey’s analysis. But in states like North Carolina, it's becoming increasingly clear that the assumptions the law was built on
just haven't held up. “The pool is far less healthy than we forecast,” said Brad Wilson, CEO of Blue Cross Blue Shield of North
Carolina, in an interview with POLITICO. “We need more healthy people.”¶ North Carolina’s Obamacare story started out just as the
administration hoped it would: More than 350,000 people signed up for insurance the first year it was offered. Just two insurance
companies were offering polices through the state's "insurance exchange"—the marketplace that lets individuals without workplace
coverage buy their own coverage–but in 2015 they were joined by a third carrier, UnitedHealth Group. Sign-ups that year surged
above 550,000. This year, the state saw another 10 percent bump, topping 600,000.¶ But as those customers demanded health care,
costs started to mount. In 2014, medical claims in the individual market for both Blue Cross Blue Shield of North Carolina and Aetna
exceeded 90 percent of premiums paid, according to financial filings. Last year, those costs soared above 100 percent of premiums
for all three carriers competing in North Carolina. Altogether,
medical claims hit $3.2 billion–nearly $100
million more than premiums the insurers collected. Throw in administrative costs on top of that,
and it becomes clear that the insurers lost tens of millions of dollars on their individual market
business, most of it coming through the exchange. This year, all three insurers stopped paying
commissions to brokers for selling individual plans, hoping to suppress enrollments and limit
their losses.¶ The companies are still analyzing how and why their initial estimates for setting their rates and writing policies
were so off the mark. The largest insurer, the nonprofit Blue Cross Blue Shield of North Carolina, has repeatedly stated it can’t
continue to sustain the losses it endured during the first two years of Obamacare enrollment, and it is currently weighing whether it
will continue competing on the exchange at all for 2017. Though the insurer has submitted plans to do business again in every
county in the state, it plans to hike rates nearly 20 percent on average. A final decision on 2017 participation won’t be made until
August.¶ “All options are on the table,” Wilson said—even getting out of the Obamacare business.¶ If Blue Cross Blue Shield does
decide to abandon the North Carolina exchange— which most observers believe is unlikely this year—it would potentially leave just
two companies, Aetna and Cigna, offering Obamacare policies in the state. And neither of those companies intend to compete
statewide in 2017, instead offering policies in select counties. The worst-case scenario is that residents of some North Carolina
counties would be left with just one–or even zero–insurers. Nobody knows precisely what that would mean for consumers at this
point, but at the very least exchange shoppers would have fewer choices and higher prices.¶ “That would be very scary for lots of
people,” said Ciara Zachary, health policy analyst at the North Carolina Justice Center, a liberal advocacy group.¶ The troubles in
North Carolina’s exchanges are not unique. POLITICO’S analysis of financial filings for exchange carriers in a dozen states shows
continued struggles in 2015. Health plans competing on the exchanges in Colorado and Oregon, for
example, collectively paid out at least 20 percent more in medical costs on their individual
customers than they received in premiums, leaving insurers tens of millions of dollars in the
red.¶ In New York, most plans are losing money, including the much ballyhooed startup insurer Oscar, which has attracted
hundreds of millions in venture capital funding by promising to shake up the insurance market with tech-savvy innovations. But
Oscar sustained medical claims of $180 million on its roughly 50,000 New York customers last year. That’s nearly $1.50 paid out in
medical claims for every $1 collected in premiums–a burn rate that is clearly unsustainable.¶ Not all exchange markets have proven
to be financial quagmires. The exchange market in Florida, for example, appears to be on a path toward financial stability. Fewer
than half of competing carriers operated in the black in 2014, according to McKinsey’s analysis. But of the nine competing plans for
which 2015 data were available, just one–UnitedHealth–had medical claims that exceeded premiums on its individual market
business. Among the remaining plans, medical claims accounted for 86 percent of premiums. That’s right where insurers need to be
to at least break even.¶ There are no simple explanations for the huge difference in financial performance for Obamacare insurers
competing in different states. Though it's a national law, health insurance varies widely from state to state: the populations are
different, the medical cultures are different, and each state has its own business landscape. The local political responses have been
different, too, but that's not always the main story: both Florida and North Carolina enrolled a lot of people despite having a state
government that strongly opposed the health law.¶ One likely factor is the amount of competition among hospitals, doctors and
other health care providers, which determines their ability to dictate reimbursement rates. In southeastern Minnesota, for example,
where the Mayo Clinic is the dominant provider, the cheapest midlevel plan available to a 40-year-old through the state’s exchange
this year was $329 per month. That’s roughly 20 percent higher than in the rest of the state.¶ “The more competition you have, the
better the pricing,” said Mario Molina, CEO of Molina Healthcare, which is selling exchange plans in nine states. “In some markets
where there’s very little competition it’s difficult to get the prices that health plans need.”¶ But looming over the whole conversation
is the blunt question of just who signs up for Obamacare in each state, and how sick they are. In the dry language of insurance
companies, customers are called their “risk pool”—and when it comes to Obamacare, the pool is way riskier than they wanted.¶ SO
WHAT WENT wrong? Like all insurance, Obamacare is built on the idea of shared risk: A small number of customers with big
medical bills needs to be offset by a much wider group who pay monthly premiums but rarely access care. Theoretically, they balance
 The biggest problem plaguing the exchanges is that for many
out, and insurers collect their profits off the top.¶
states, the balance has turned out to be way off. Fewer individuals signed up for coverage than
projected, and they’ve proven sicker and more expensive than insurers had expected.¶ Before the
ACA, there were a handful of ways insurers could balance their risk pool. One big tactic was just to avoid covering sick people,
filtering out individual customers who appear likely to need lots of expensive medical care. But Obamacare made that type of
discrimination illegal: One big selling point of the law was that everyone would be eligible to sign up.¶ In
the new insurance
landscape, where carriers must take all comers, no matter how sick and costly, the simplest way
to ensure a viable risk pool is to make it as large and diverse as possible.¶ For Obamacare, that has turned
out to be a bigger problem than anyone anticipated. Three years ago, the Congressional Budget Office projected that 24 million
Americans would be enrolled in exchange plans in 2016. The reality: barely half that number signed up this year–and that number is
certain to erode as people stop paying their insurance bills or find jobs that include coverage. The Obama administration’s stated
goal is now just 10 million enrollments by the end of 2016.¶ Why so low? In part, it's because fewer people got kicked off their work
plans than expected. Initially, the architects of the plan thought many employers would stop offering insurance and let people buy
their own on the Obamacare market. That didn't happen. “Employers have not ‘dumped’ employees to the extent that some people
feared and predicted,” said Ceci Connolly, CEO of the Alliance of Community Health Plans. It was good news for those workers, but
not so good for the exchanges’ actuarial health.¶ And in part the small size of the Obamacare pool is because of a self-inflicted wound
by Obama himself. For years, in selling the ACA, Obama had been repeating a talking point: "If you like your health care plan, you
can keep it." But in late 2013, as the first open-enrollment season loomed, millions of Americans received notices that their plans
were being canceled because they didn’t meet the coverage requirements of the health care law. Republicans relentlessly mocked the
president’s failure to keep his pledge. PolitiFact called it the 2013 “Lie of the Year.”¶ In response to the blowback, the administration
decided that those old plans didn’t have to be canceled after all–people could keep them through 2017, even if they didn’t comply
with the new rules. That move may have quelled the political uproar, but it also cut off a potential flow of millions of customers who
may otherwise have signed up for new plans in the fledgling Obamacare exchange markets.¶ Not all states extended those plans, and
some insurers phased them out on their own. But McKinsey estimates that heading into the 2016 enrollment season, 3.7 million
Americans were still in those old individual plans. And it’s likely that an awful lot of them are quite healthy, given that they were able
to obtain coverage even when health plans were free to discriminate against people with pre-existing conditions.¶ A viable risk pool
also needs healthy customers. The most desirable customers are young, from 18 to 34—the so-called young invincibles—who might
not want to sign up at all, because they don't think they'll need health care.¶ To
encourage all Americans to sign up,
Obamacare includes a cudgel: You have to pay a tax penalty if you aren't covered in a qualified
health plan. In reality, there are numerous exemptions–and the penalty has proven too low to
induce younger Americans to buy insurance. The fine maxed out this year at $695, or 2.5
percent of income, whichever is higher. Healthy, younger people (some of whom may be eligible
for subsidies but not realize it) often figure it’s cheaper to pay the fine than shell out money on
health insurance that they don’t think they’ll need. That may or may not make financial sense for them as
individuals, but it's hurting the broader system. For markets to be sustainable financially, experts estimate
that 35 percent of customers should be between the ages of 18 and 34. In reality, right now, just
28 percent of customers fall in that group.¶ Obamacare also includes a restriction on timing: Exchange customers are
supposed to sign up only during the annual open-enrollment period. That’s designed to prevent people from gaming the system and
getting insurance only when they need medical care. But there are exceptions to the timing rule--you can sign up for Obamacare
when you've switched jobs and lose your work coverage, for instance. And insurers complain that these exceptions are far too
numerous and easy to game. Most troubling to insurers, there’s been no rigorous verification process to corroborate that Obamacare
customers are truly eligible for special enrollment periods—that they really did change jobs, that they weren’t just claiming to have
done so because they had just gotten a scary diagnosis or banged up their knee and now wanted health care. Many health plans have
found that customers who come in through special enrollments run up bigger medical bills than other people. Pennsylvania’s
Independence Blue Cross, for example, says people who enroll outside the standard window have 30 percent more medical
expenses.
 Plan
The United States federal government should:
- significantly increase penalties for the requirement to maintain
minimum essential health coverage
- appropriate out-of-pocket financial assistance for the Health
Insurance Marketplace
- expand premium financial assistance on the Health Insurance
Marketplace
- commit enforcement and outreach resources to these actions.
 1AC---Solvency
The plan solves – strengthening the mandate, funding cost-sharing
and increasing subsidies is key to a balanced risk pool, higher
enrollement, competition, and lower premiums– working through
the ACA framework is key to stability
Cori Uccello 17, Senior Health Fellow at the American Academy of Actuaries, MA in Public
Policy from Georgetown University, Deep Banerjee, Director at Standard & Poor, 5/5/2017, The
Individual Market at a Crossroads Transcript, http://www.allhealthpolicy.org/the-individual-
market-at-a-crossroads-5/
Let’s talk about the future a little bit. So, I’m
going to talk about two kinds of forecasts. One is business as usual.
What we mean by that is, everything stays with obviously some changes, but no big overhaul to the rules
of the marketplace. If that is the case, what do we expect? Well, we expect 2017 to be a year when more
insurance companies get to break even margin. So, break even, zero percent, so no loss, break even
margin. And then continued improvement in 2018 where they get to small, single digit margins in this
line of business. It is still a very fragile market and it needs time to stabilize.

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

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

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

So first, I will talk about what

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

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

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

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

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

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

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

Millions are paying the penalty now – strengthening the mandate

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

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

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

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

extinction
Anthony Barrett 13, PhD in Engineering and Public Policy from Carnegie Mellon, Director of
Research @ the Global Catastrophic Risk Institute (GCRI), Fellow @ the RAND Stanton Nuclear
Security Fellows Program, and Seth Baum, PhD in Geography from Pennsylvania State
University, Executive Director @ the GCRI, Research Scientist @ the Blue Marble Space
Institute of Science, and Kelly Hostetler, Research Assistant @ the GCRI, “Analyzing and
Reducing the Risks of Inadvertent Nuclear War Between the United States and Russia,” Science
and Global Security 21(2): 106-133, online
War involving significant fractions of the U.S. and Russian nuclear arsenals, which are by far the largest
of any nations, could have globally catastrophic effects such as severely reducing food production for
years, 1,2,3,4,5,6 potentially leading to collapse of modern civilization worldwide and even the
extinction of humanity . 7,8,9,10 Nuclear war between the US and Russia could occur by
various routes, including accidental or unauthorized launch; deliberate first attack by one nation; and
inadvertent attack. In an accidental or unauthorized launch or detonation, system safeguards or procedures to maintain
control over nuclear weapons fail in such a way that a nuclear weapon or missile launches or explodes without direction from
leaders. In a deliberate first attack, the attacking nation decides to attack based on accurate information about the state of affairs.
In an inadvertent attack, the attacking nation mistakenly concludes that it is under attack
and launches nuclear weapons in what it believes is a counterattack. 11,12 (Brinkmanship
strategies incorporate elements of all of the above, in that they involve deliberate manipulation
of the risk of otherwise unauthorized or inadvertent attack as part of coercive threats that “leave
something to chance,” i.e., “taking steps that raise the risk that the crisis will go out of control
and end in a general nuclear exchange.” 13,14 ) Over the years, nuclear strategy was aimed primarily at
minimizing risks of intentional attack through development of deterrence capabilities, though numerous measures were also taken
to reduce probabilities of accidents, unauthorized attack, and inadvertent war. 15,16,17 For purposes of deterrence, both U.S. and
Soviet/Russian forces have maintained significant capabilities to have some forces survive a first attack by the other side and to
launch a subsequent counter-attack. However, concerns about the extreme disruptions that a first attack would cause in the other
side’s forces and command-and-control capabilities led to both sides’development of capabilities to detect a first attack and launch a
counter-attack before suffering damage from the first attack. 18,19,20 Many people believe that with the end of the Cold War and
with improved relations between the United States and Russia, the risk of East-West nuclear war was significantly reduced. 21,22
However, it has also been argued that inadvertent nuclear war between the United States and Russia has
continued to present a substantial risk . 23,24,25,26,27,28,29,30,31,32,33 While the United States
and Russia are not actively threatening each other with war, they have remained ready to launch
nuclear missiles in response to indications of attack. 34,35,36,37,38 False indicators of nuclear
attack could be caused in several ways. First, a wide range of events have already been mistakenly
interpreted as indicators of attack, including weather phenomena, a faulty computer chip, wild animal activity, and control-
room training tapes loaded at the wrong time. 39 Second, terrorist groups or other actors might cause attacks on
either the United States or Russia that resemble some kind of nuclear attack by the other nation
by actions such as exploding a stolen or improvised nuclear bomb, 40,41,42 especially if such an event
occurs during a crisis between the United States and Russia. 43 A variety of nuclear terrorism scenarios are possible. 44 Al
Qaeda has sought to obtain or construct nuclear weapons and to use them against the United
States. 45,46,47 Other methods could involve attempts to circumvent nuclear weapon launch control safeguards or exploit holes
in their security. 48,49 It has long been argued that the probability of inadvertent nuclear war is
significantly higher during U.S.-Russian crisis conditions, 50,51,52,53 with the Cuban Missile Crisis
being a prime historical example of such a crisis. 54,55,56,57,58 It is possible that U.S.-Russian
relations will significantly deteriorate in the future, increasing nuclear tensions. 59 There are a
variety of ways for a third party to raise tensions between the United States and Russia, making
one or both nations more likely to misinterpret events as attacks. 60,61,62,63
2AC
 AT: No bioterror
It’s accesible
John B. Foley 17, retired Lieutenant Colonel in the U.S. Army, M.S. in WMD Studies from the
National Defense University, 8-2-17, “A Nation Unprepared: Bioterrorism and Pandemic
Response,” http://thesimonscenter.org/wp-content/uploads/2017/05/IAJ-8-2-2017-pg25-
33.pdf

A lack of a strategic vision as to what exactly biodefense seeks to accomplish is the greatest
barrier to the success of interagency efforts at biodefense. The old maxim that “defense does not
win wars” should not be ignored by biodefense planners. History is replete with examples of strategies that
circumvented known defenses. If the nation is well protected against, for example, anthrax or smallpox, an
intelligent adversary would not attack with anthrax or smallpox when nature is replete with a
wide range of pathogens that could be considered for use against humans. Novel viruses and
new disease continue to emerge, and advances in biotechnology make it possible to
manipulate how a virus behaves. Biological weapons programs, once only the domain of state-
sponsored research organizations, are now within the reach of non-state actors . An individual
with a graduate-level degree has all the tools and technologies to implement a sophisticated
program to create a bioweapon.14 The costs associated with the setup and operation of facilities
to explore, develop, and cultivate biological hazards are within the reach of well-funded
terrorist organizations . A terrorist organization with several hundred thousand dollars, a
dedicated group of graduate-level students, and a space of several hundred square meters could
establish a small-scale biological weapons program.15
 Topicality
We meet---ACA reform is government financed and administered

Counterinterpretation – NHI requires two things – a legal

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

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

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

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

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

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

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

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

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

government-financed health insurance can be divided into

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

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

Medicare is a social insurance program,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yet stormy weather

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

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

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

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

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

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

Any national health insurance program must interact with existing

Effects on Medicare, Medicaid, and Private Insurance¶

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

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

National health insurance proposals have vastly disparate methods

access gains must be balanced with cost control measures.¶

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

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

Throughout the history of US national health insurance proposals, reformers

Reform of Health Care Delivery¶

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

The ACA goes farther than previous reform efforts

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

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

The concept of n ational h ealth i nsurance

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

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

Ground – the most balanced topic is centered on whether greater

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

Reasonability -- centering debates on the best interpretation of the

topic creates a moral hazard to go for topicality
 OPM CP
Perm do both
OPM links to both---federal policy that Trump would take credit for, it’s an executive agency
Midterms---seen as a GOP fix for healthcare

Doesn’t strengthen the mandate which means even if insurers are on State exchanges, people
don’t have to enroll which means risk pools remain sick and causes death spiral

Status quo failure on health care destroys Trump’s international

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

The collapse of the Republican effort to reform Obamacare has international

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

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

Congressional inaction on Obamacare was clearly a defeat for the president, but having only
been in office less than 100 days, he certainly has time to recover. There question is whether he, or his
advisors, will recognize that blaming the speaker of the House is not the solution, and that the true “art of the deal,” is
to tone down the rhetoric and begin to find real ways to find common ground with the
Congress, including moderate Democrats , at least insofar as international security is concerned. This
will not be an easy transformation for President Trump. Nevertheless, unless he stops reveling in his outsider image, his fate will be
that of that other outsider president — Jimmy Carter, whose record in the White House was nothing short of dismal. It is a prospect
that the president and his aides surely will wish to avoid at all costs.

All those crises risk global nuclear escalation

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

Within months of taking office, President Donald Trump

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

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

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

It’s true that the changeover

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

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

Although with Russia, unlike Iran, Trump has promised to improve relations, there’s no escaping the fact that Vladimir Putin’s
urge to restore some of his country’s long-lost superpower glory could lead to confrontations
with NATO powers that would put the new American president in a distinctly awkward position. Regarding Asia, Trump has
often spoken of his intent to punish China for what he considers its predatory trade practices, a stance guaranteed to clash with
President Xi Jinping’s
goal of restoring his country’s greatness. This should, in turn, generate additional
possibilities for confrontation , especially in the contested South China Sea. Both Putin and Xi, moreover, are
facing economic difficulties at home and view foreign adventurism as a way of distracting public attention from disappointing
domestic performances.
These factors alone would ensure that this was a moment of potential international crisis, but something else gives it a truly
dangerous edge: a growing strategic reliance in Russia and elsewhere on the early use of nuclear weapons to overcome deficiencies in
“conventional” firepower.

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

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

With that in mind, consider the four most dangerous potential flashpoints for the new Trump administration.

North Korea

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

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

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

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

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

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

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

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

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

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

The Baltic Sea Area

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

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

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

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

The Middle East

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

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

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

Going on Watch

Starting on January 20th, as Donald Trump takes office, the clock will already be ticking in each of these flashpoint regions. No one
knows which will be the first to erupt, or what will happen when it does, but don’t
count on our escaping at least
one, and possibly more, major international crises in the not-too-distant future.

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

which destroy depth, logical advocacy, and 2AC strategy --- reject the
team because the damage is already done
States CP
 Fed Key – Uncertainty
States fail---can’t predict Trump actions or solve CSRs, they cover less
people, and perception of repeal creates uncertainty
Nathaniel Weixel 17, Health Reporter at The Hill, 8-13-2017, "States enter the breach to
protect ObamaCare," The Hill, http://thehill.com/policy/healthcare/346256-states-enter-the-
breach-to-protect-obamacare

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

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

Making matters worse, the

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

Some large states like New York or California could theoretically offer their own subsidies or pass a
state-level individual mandate, just as Massachusetts did under Romneycare. But state budgets are
already tight, and legislators will already have to grapple with the cuts to Medicaid that the
GOP is planning. Will pols in Albany or Sacramento be willing to raise taxes to preserve the Obamacare status quo? I wouldn't
necessarily count on it. And if not, their only other choice may be to apply for a waiver.
Tax Reform
 UQ---Will Pass
Only warrant in UQ ev Trump hasn’t done outreach to dems---he did
three days after their ev was written
Laura Davison 9/13, Capitol Hill tax reporter at Bloomberg, “Trump Talks Tax With
Democrats as Budget Deal Remains Elusive,” https://www.bna.com/trump-talks-tax-
n57982087783/

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

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

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

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

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

Reconciliation Road

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

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

Their ev says the plan’s spending means no one votes for tax reform,
and it’s not a win for Trump
NU = Blue

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

In the roiling debate over the plan to replace the A ffordable C are A ct, there’s a lot more at stake
for President Trump than whether the bill can be saved: Its fate could also determine how muchelse he can
get done on Capitol Hill in the early stages of his presidency. With the bill facing strong resistance on multiple
fronts, Trump’s effort to shepherd it through Congress is shaping up as a pivotal test of an unortho-

dox president’s ability to wield influence in Washington, a growing number of Republicans say. A
win on an
issue as fractious as health care could serve as a rallying point
for even tougher fights ahead, including some Trump agenda items
that wouldn’t otherwise be GOP priorities and others that would
likely require Democratic support. But falling short on a marquee campaign promise — when
both chambers are controlled by the president’s party — would almost certainly sap momentum for Trump’s agenda.
Moreover, Republicans are counting on cuts from former president Barack Obama’s health-care law to make
the budget math work on other Trump priorities, particularly major tax reductions . “It’s difficult to see
the kind of aggressive agenda that they’ve outlined for the rest of this year without some sort of repeal-and-
replace success,” said Michael Steel, a former senior aide to former House Speaker John A. Boehner (R-Ohio), referring to the
House bill that seeks to scale back the health-care law, often called Obamacare. The coming weeks, Steel said, “will show whether the
Trump administration can use the tools of the White House to move legislation forward.” As a candidate for president, Trump
promised that he would work with Congress to pass legislation that would dramatically cut taxes, spur $1 trillion in
infrastructure investments, significantly expand school choice and make it easier to afford child care. And he promised he
would get started on all that — and six other pieces of legislation — in his first 100 days, according to a “Contract with the American
Voter” released shortly before Election Day. Now past the 50-day mark, only one of those bills — the House GOP health-care
plan — has been introduced. And its path has grown more treacherous by the day, with mounting concerns
about the millions of Americans projected to lose coverage, including many who supported Trump in last year’s election.
 No Trump PC – Lame Duck
No PC – Trump is functionally a lame duck president – party defiance,
controvery, exodus of staffers, approval
David A. Graham 17, Staff Writer at the Atlantic, “Donald Trump Is a Lame-Duck
President”, The Atlantic, https://www.theatlantic.com/politics/archive/2017/08/is-trump-
already-a-lame-duck/537198/

Whatever the turning point, thinking

about Trump as a lame-duck president seems a better rubric
for making sense of his administration than most. Consider the things that happen in a lame-duck period.¶ A
lame-duck president’s legislative agenda starts to stall out. Members of Congress are just no longer interested in following the
president’s lead, especially where it might create a political liability for them. Big bills start to waste away on Capitol Hill, and where
a new president would bring both political capital and novelty to bear, a lame duck just doesn’t have the juice. So it is with Trump.
His various attempts to repeal and replace Obamacare have all failed, and while he was able to force both houses of Congress to take
them back up before, largely through sheer force of will, his more recent pleas have fallen on deaf ears. Senate Majority Leader Mitch
McConnell has indicated he has no interest in heading into the breach once again, and GOP members have largely agreed with him.¶
A lame-duck president gets caught in a vicious cycle. Once legislators start refusing to follow his
lead, he begins to look like a paper tiger, so they follow his lead even less. Now that Republican senators
have defied Trump once, why should they get in line on other controversial bills, like tax
reform?¶ By the time a president reaches his lame-duck period, scandals have begun to pile up. Sometimes they are minor and
varied; sometimes they’re blockbusters, from Iran-Contra to Monica Lewinsky. Either way, the taint of controversy tarnishes
the president, diminishes his political capital, and starts to absorb time and energy that once
would have been spent on constructive rather than defensive actions. Trump is already facing an
open-ended investigation, unmatched in breadth by anything except the Clinton-era Whitewater
scandal—taking in allegations of money-laundering, of espionage, and of violations of campaign-
finance laws, and potentially reaching into Trump’s own personal financial dealings prior to
becoming president. It’s already proving a large distraction, as demonstrated by Trump taking time while
returning from a trip to Europe to dictate a statement on behalf of his son, Donald Trump Jr. The statement he dictated turned out
to be an obfuscatory disaster that only made the matter worse. Meanwhile, Trump’s personal lawyer is busy sending defenses of
Trump’s Charlottesville comments to conservative journalists.¶ As
controversy and inaction set in during a president’s
lame-duck period, he starts to lose staffers who see no reason to stick around for a final stretch of
inaction. Others stick around but grumble to the press about lack of discipline and lack of progress—and as they look ahead to
their next job, they often put preserving their own reputations ahead of advancing their boss’s
agenda. Trump’s West Wing has a busy revolving door—he’s already lost two communications
directors, one press secretary, one chief of staff, and a national-security adviser, among others—
and the tenor of leaks about the White House, once largely a chronicle of internecine warfare, is increasingly full of statements of
disappointment and frustration about the president himself.¶ Another problem for a lame-duck president is that exhaustion sets in.
It’s the seven-, or in some cases, three-, year itch, as someone who was a fresh and exciting face at the start of his term has become
tired, boring, or irksome. Trump benefited from his outsize media personality during the campaign, but now he’s paying for it.
Barely a day goes by without a new Trump-involved controversy. The public, and even the journalists paid to care, have become
numb. Some of Trump’s aides and allies want him to take a less public approach, but that’s beyond him. He has one mode: on, and
public-facing. Just take his alleged vacation over the last week or two, which has produced a surfeit of presidential news even by
Trump standards.¶ As a result, most—though not all—presidents
see a slow slide in their approval rating
toward the end of their terms. Trump’s presidency has been one long slide, with his numbers
now resting in the mid-30s.

PC is backwards for Trump because he hasn’t passed anything, congress is trying to cajole him
into supporting their plans
 AT: Reshoring Bad
Their impact evidence concludes aff right after they stopped cutting
it---tons of checks to a sino-india war
Lalwan 17 (Sameer, Deputy Director for Stimson's South Asia program. From 2014-15,
Lalwani was a Stanton Nuclear Security Postdoctoral Fellow at the RAND Corporation. He
completed his Ph.D. in political science at MIT and remains a Research Affiliate at MIT's Center
for International Studies. His research interests include grand strategy, counterinsurgency, civil-
military relations, ethnic conflict, nuclear security, and the national security politics of South
Asia and the Middle East "Signs of a Thaw in India, China Border Dispute," 7/25, Cipher Brief,
https://www.thecipherbrief.com/signs-thaw-india-china-border-dispute/)
Finally, India may seek to boost international perceptions of its toughness after a series of
diplomatic setbacks at the hands of Beijing. These include India’s failed bid for permanent
membership in the Nuclear Suppliers’ Group, unsuccessful efforts to designate Jaish-e-
Mohammed chief Masood Azhar a global terrorist (whom India holds responsible for major terrorist attacks), and
unheeded objections to construction of a China-Pakistan economic corridor through disputed territory
in Kashmir. That the recent alleged PLA incursion coincided with Indian Prime Minister Narenda Modi’s visit to the United States
brinksmanship is driven by
could be construed as another attempt to embarrass India. Both sides allege the current
the other’s domestic politics and pugnacious nationalist audiences . Chinese analysts believe Modi
pursued a hardline China policy to appease his hawkish base amidst lagging economic
growth . Indian analysts contend Chinese President Xi Jinping is deliberately courting a crisis to consolidate power just ahead of
the 19th Congress of the Chinese Communist Party this fall. TCB: What has been the track record for attempting to resolve this
dispute and what does that say about the urgency of the new situation? Lalwani: The track record for mitigating border tensions
between China and India is normally quite good. Most low-level flare-ups subside in a matter of weeks. The last major stand-off in
1986 lasted for 10 months and involved a dispute over the Sumdorong Chu valley in what is now the Indian state of Arunachal
Pradesh. This crisis was ultimately resolved through higher level talks. However, a couple aspects of the current standoff set it apart
from previous crises. Bhutan’s silence regarding Indian troops in its territory has further complicated the dispute. India argues its
troop deployments constitute assistance to their friend Bhutan in the face of PLA aggression. Beijing, however, contends that during
a diplomatic visit, Bhutan failed to confirm its request for Indian military assistance, suggesting discomfort in Thimphu with India’s
actions. An explicit statement from Bhutan or formal invitation to Indian troops would clarify matters, but Bhutan likely needs to
proceed cautiously when dealing with its two major-power neighbors. Additionally, media commentary on both sides—some state
sanctioned—has adopted a much more strident and belligerent tone than in the past, increasing the potential costs to leaders
China has claimed it will not engage in
backing down. TCB: Where does this lead? Lalwani: In recent statements,
dialogue with India until India unconditionally withdraws from Dolam. Apart from reputational concerns, such a
demand will be difficult for India to follow, given that the resumption of the road-building project would represent a fait accompli
with dire security implications. While China faces less severe security concerns in this region and is arguably less vulnerable to
domestic pressures than a noisy democracy like India, China, is also unlikely to back down unprompted. This leaves three scenarios
that could unfold in the coming weeks and months. The first possibility is escalation. Since neither side wants to
capitulate first, the situation could escalate through miscalc ulation or misperception .
India may have outmaneuvered China for the time being through what border dispute expert Professor Dan Altman terms
“advancing without attacking,” pushing the ball into China’s court. Aggressive signals of resolve, like live fire drills by a Chinese
front-line combat brigade, could then be misperceived as actual mobilization for war. Since India has the geographical and logistical
advantage in Dolam, Beijing may press its advantage in another sector of the India-China border, or even another domain like
cyberwarfare.

Trinity’s evidence ends

Another possibility is that the standoff could endure for some time, tense but relatively stable.
The crisis could eventually de-escalate by default as winter sets in and both forces choose to
quietly withdraw from the region. Unfortunately, unruly domestic audiences and media outlets
in both countries may be unsatisfied with this unassuming end and pressure their governments
to take more aggressive action. Another scenario is that both sides could dig in take up
permanent positions a couple kilometers back from the existing standoff location. The wait-and-
see approach becomes all the more risky given that confidence-building measures designed to
manage such crises—such as hotlines, flag meetings, and mutual military visits—have been
conspicuously absent in this standoff.
A third possibility is direct dialogue to consciously de-escalate the standoff. Former and present
Indian national security officials have expressed support for dialogue even while Beijing holds to
its position of unconditional withdrawal. Thus, one option might be a backchannel agreement,
which is reportedly already being pursued, similar to the resolutions of the 2013 and 2014
standoffs. This might involve a potential freeze in Chinese road-building for an Indian
withdrawal. India could also consider softening its stance on China’s One Belt One Road
initiative by warming to projects that could benefit India, like the Bangladesh-China-India-
Myanmar forum.

The signs of a thaw may already be evident. In a prepared speech in Singapore on July 11,
Indian Foreign Secretary Subrahmanyam Jaishankar suggested India-China relations were an
anchor for stability and that the two rising powers “must not allow differences to become
disputes.” Some reading the tea leaves of Chinese state-sanctioned media suggest there may be
some openness to Jaishankar’s message. The more temperate tone of recent Chinese analysis
and op-eds, U.S. encouragement of direct dialogue, and the Indian National Security Advisor’s
upcoming visit to Beijing may all provide the necessary space for both sides to ease tensions.
 2AC – Link Turn – Delay

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

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

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

Crammed congressional calendar

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

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

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

"Time's the most precious commodity they have," said Liam Donovan, a former top aide at the National
Republican Senatorial Committee who is now legislative director for Associated Builders and Contractors.
Midterms
 2AC – GOP Win
Dems can’t win back the House or the Senate – eroding support
Douglas E. Schoen 9/8, pollster and political consultant, was an adviser to President Bill
Clinton Andrew Stein, “Democrats’ top problem in 2018: the math’s still against them”,
http://nypost.com/2017/09/08/democrats-top-problem-in-2018-the-maths-still-against-
them/
In 2018, Democrats only need a net gain of 24 seats to gain control of the lower body. Based on
history, that should be a piece of cake. Yet , 2018 could be different. Republicans may wind up retaining
control of both chambers.¶ Why? Primarily, Democratic support has eroded substantially since 2009.¶ In 2009,
the Democrats held 256 seats in the House and 55 seats in the Senate. Today they hold 194 and 46 respectively. In that time, Dems
lost 21 House seats in the key Midwestern states of Pennsylvania, Ohio, Michigan, Wisconsin
and Indiana, while Republicans gained 17 seats in these five states.¶ Failing to appeal to working-
class voters in key states won by Bill Clinton and Barack Obama was a key part of Hillary
Clinton’s downfall. But Hillary’s problem went well beyond swing states; it was national. Overall,
Trump won 2,622 counties, while Clinton only carried 490.¶ Why does this matter? Because there are simply not
enough coastal seats to be won for Democrats to win the House.¶ Current data from the Cook Political
Report support this conclusion. The data show that 10 districts nationwide are “toss-ups” and 22 districts
“lean Republican,” meaning Democrats must win virtually every competitive seat to take back
the House.¶ Despite historical trends, today’s polarizing political climate makes it appear practically
impossible . Given the Republican geographic advantage, the Democrats could gain 20 seats at
best. On the Senate side, Democrats are more likely to lose seats than gain them. Of the 33
Senate seats that are up for grabs, 23 belong to Democrats. Ten of these blue seats are in states
President Trump carried. ¶ What, then, is the path forward for Democrats? Right now, there is a clear
division between the moderate wing of the party and the left-wing “revolution

52 percent of
” led by Sens. Bernie Sanders and Elizabeth Warren. Yet the Democrats need a clear, unified message beyond obstruction and resistance.¶ A recent Washington Post poll showed that

Americans believe the party doesn’t have a message other than resisting President Trump — and
more than 25 percent of Democrats agree.¶ Dems need a pro-growth economic agenda coupled
with a reassertion of traditional values, fiscal discipline, cultural conservatism and, most of all, a
set of inclusive policies designed to unify, not divide.¶ They need to be more inclusive on social
issues, like abortion. The “litmus test” promoted by Planned Parenthood and Tom Steyer
alienates a vast moderate base.¶ A values-based agenda has historically been a pillar of Democratic success when coupled with pro-growth economic policies that appeal to the
political center.¶ This has been the case from John F. Kennedy’s inaugural address to Bill Clinton, who

turned around a failing presidency and won reelection in 1996 because of an assertion of
traditional values and fiscal conservatism. Adopting a centrist platform helped Clinton win
states like Tennessee, Kentucky, Arkansas and Louisiana — states now out of reach for the
Democrats in any election.¶

Too early---no way to predict every race and black swans wreck the link
Each race is different, if they don’t have evidence for each race, they don’t have a coherent vision
of the elections---it’s a neg burden
Trump has doesn’t have an agenda---no impact
DA not intrinsic, logical policy maker can do the plan and X can pass the bill the impact relies on
Dem turnout locked in---they hate Trump
 Link Turn – GOP Base Turnout
Turn – dem turnout is inevitable but strengthening the ACA causes
GOP base backlash – swings the midterms
Jonathan Martin 17, Political Correspondent for the NY Times, co-author of the New York
Times best seller “The End of the Line: Romney vs. Obama: The 34 Days That Decided the
Election”, 2018 Dilemma for Republicans: Which Way Now on Obamacare?, The New York
Times, https://www.nytimes.com/2017/03/28/us/politics/2018-dilemma-for-republicans-
which-way-now-on-obamacare.html
WASHINGTON — As they come to terms with their humiliating failure to undo the Affordable Care
Act, Republicans eyeing next year’s congressional campaign are grappling with a new dilemma:
Do they risk depressing their conservative base by abandoning the repeal effort or anger a
broader set of voters by reviving a deeply unpopular bill even closer to the midterm elections?¶ The question is
particularly acute in the House, where the Republican majority could be at risk in 2018 if the
party’s voters are demoralized, and Democratic activists, energized by the chance to send a
message to President Trump, stream to the polls.¶ Sifting through the wreckage of a disastrous week, Republican
strategists and elected officials were divided over the best way forward. Some House Republicans pressed to move on to other issues
and notch some victories that could delight their own loyalists while not turning off swing voters.¶ “We’ve got a lot of time to do real
things on infrastructure, to do real things on tax reform, on red tape reform, and really get the American economy moving,” said
Representative Steve Stivers of Ohio, chairman of the National Republican Congressional Committee, the House campaign arm. “We
do those things and we still have a lot of time to recover.”¶ “If you’re going to fumble the ball,” he added, “better to do so in the first
quarter of a football game.Ӧ Devising
health care legislation that could appeal to both wings of the
House Republican Conference — the hard-line conservatives and more moderate members —
would require a nearly superhuman feat, added Representative Billy Long, Republican of Missouri.¶ “Not unless
Harry Houdini wins a special election to help us,” Mr. Long said about the prospects of cobbling together a coalition that could agree
on how to repeal and replace the health care law.¶ But other longtime Republicans warned that if
the party did not address
what they have derided as Obamacare, an issue that has been central to their campaigns for the
last seven years, they would incur a heavy political price in the midterm elections.¶ Midterm
campaigns have increasingly become akin to parliamentary elections — referendums on the
party in power rather than on individual candidates, where turnout by dependable partisan
voters is the deciding factor.¶ “If they fall on their sword on this, they’re going to get slaughtered,”
said former Representative Thomas M. Davis III, a Virginia Republican who himself was once at the helm of the House campaign
committee.¶ “Where
parties get hurt in midterms is when their base collapses,” Mr. Davis said.
“Democrats are going to show up regardless of what you do. If our voters don’t see
us fulfilling what we said we were going to do, they’ll get dispirited.” ¶ What troubles
many Republican strategists is the specter of the party’s most reliable voters being bombarded
by reminders of their leaders’ failure to address the health law. Th ey fear a recurring story
line sure to pop up every time insurance premiums increase, providers leave local networks, or , most
worrisome, Republicans fund President Barack Obama’s signature achievement.
 Single Issues Not Key
Opposition isn’t based on a single issue – the plan can’t swing the
election
Edward-Isaac Dovere 9/13, Chief Washington correspondent, 9/13/2017, “Teflon Don
confounds Democrats”, http://www.politico.com/story/2017/09/13/teflon-trump-democrats-
messaging-242607
“People would like more of a sense of reassurance … than we’ve had so far,” Hart said. “For the
Democrats, part of that is recognizing that it’s not that there’s an overwhelming agenda
item on the part of the American public — it’s not the economy or health care or some single issue
— but it is the sense that somehow things are very out of sorts, and it touches so many
different issues.”¶ That’s the main difference between 2018 and 2006, when Democrats’
strategy primarily consisted of running against an unpopular president, George W. Bush, and an
unpopular war.¶ “It may have worked then,” said former Rep. Steve Israel, the DCCC chair in the
2012 and 2014 cycles and the leader of messaging for House Democrats last year. “I’m not sure
it’s going to work now, because the middle class is clamoring for help. Just saying we’re not
Trump isn’t going to help.”¶ More and more, Democratic operatives are gravitating toward pushing for an argument that
Trump is just out to make his rich friends richer, at the expense of everyone else. They believe they could include all sorts of attacks
on his decisions under that umbrella, from stripping regulations on credit cards to trying to end Obamacare to pushing for corporate
tax breaks.¶ DCCC polling showed that on the question of who “fights for people like me,” Trump and Democrats were split at 50
percent each in February but that Democrats are now ahead by 17 points.¶ “Everything is a trade-off,” said Guy Cecil,
reflecting polling done by his Priorities USA super PAC. Republicans “want to give tax cuts to
the rich, and they want to screw the rest of us. This is a quintessential question of whose side are
you on.”¶ Bill Burton, a former Obama aide now at SKDKnickerbocker, said he’s worried Democrats are still not making a
convincing
 AT: Dodd-Frank
GOP won’t repeal Dodd-Frank
David Dayen 17, Writer at Salon, 6/7/2017, “Republicans Can’t Really Repeal Dodd-Frank”,
https://www.thenation.com/article/republicans-cant-really-repeal-dodd-frank/
Republicans have no interest in bending on principle. The House has spent half a year making
the same kinds of messaging votes they did when they knew Barack Obama would veto the
finished product. There’s probably a bill out there that would reduce Dodd-Frank rules for
community banks (although there’s plenty of tailoring in bank supervision already) that could pass Congress; in fact,
here is that bill. But Republicans don’t want to make the choice of getting that done without freeing
the big banks as well. So they pass the CHOICE Act, and it falls into the ether, and they can say
to their lobbyist pals that they tried.
This is ultimately why congressional Republicans have full legislative control in Washington but
no legislative accomplishments.

It’s highly unusual for a dominant political party to do nothing with that power. But
Republicans in Congress are more interested in making speeches than in making laws. And that
cedes the playing field for governing almost entirely to Donald Trump.

In the case of financial regulation, the administration’s goals align with the intentions of the
Choice Act. Trump has continually selected a rogue’s gallery of bank executives and corporate
lawyers to oversee the industries where they used to work. Just this week, he picked Joseph Otting, the former
CEO of OneWest Bank, to run the Office of the Comptroller of the Currency. So both OneWest CEOs in the bank’s ignominious
history, Otting and Steve Mnuchin, command top regulatory positions. SEC chair Jay Clayton, former law partner at Sullivan and
Cromwell, just hired Steven Peikin, former law partner at Sullivan and Cromwell, to run the agency’s enforcement division.

These personnel moves are playing out exactly as you’d expect. Enforcement is expected to be
light to nonexistent. Rules are expected to exist in name only. Banks are expected to run wild.
But this repeal by neglect is temporary by design. A new administration would carry new priorities. Only statutory law can maintain
policy continuity. But Republicans
don’t want to do the work. Instead they write the Choice Act and
other sparkle-pony wishes for industry that have no chance of success, abdicating their
lawmaking role. They might as well not exist. And when the current White House occupant has a scattershot
relationship to reality, that’s downright dangerous.
 AT: Mexico Impact
Immigration impact doesn’t make sense---Trump deportations would accompany increased
border security---solves spillover
DACA deal proves mass deportation won’t happen---all campaign rhetoric
Metz says that violence is already at horrific levels, should have happened
Overstretch evidence is in the context of large great power war, not border skirmishes
1AR
 T
We meet -- mandates that actually achieve universality are NHI
OECD 4 – Organisation for Economic Cooperation and Development, Study on Private Health
Insurance, June 2004, “PROPOSAL FOR A TAXONOMY OF HEALTH
INSURANCE,”https://www.oecd.org/els/health-systems/31916207.pdf

A simplified classification of health insurance schemes into mandatory and voluntary is proposed :

Mandatory health insurance includes schemes where individual participation is compulsory by

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

Voluntary health insurance includes insurance where insurees participate on a voluntary basis,
or where employers can choosethemselves whether to offer health insurance cover to their employees either voluntarily
or per effect of collective agreements.
Case
 Econ UQ
Econ slowing – multiple indicators
Rebecca Ungarino 17, Associate Producer at CNBC, former Editor in Chief at Dollars &
Sense, 8/7/2017, Here’s why US growth could wither this year, CNBC,
https://www.cnbc.com/2017/08/04/heres-why-u-s-economic-and-earnings-growth-could-
wither-this-year.html
Several signs are pointing to soft earnings and economic growth, according to Gina Sanchez, CEO
of Chantico Global.¶ "I'm specifically looking at the divergence between the soft data, like
consumer confidence, and the hard data, like retail sales. Consumer confidence was pacing well
above retail sales for many months now, and we are starting to see that start to slow and come
back to the reality that retail sales numbers never picked up pace," Sanchez said Friday on CNBC's "Trading
Nation."¶ Indeed, the most recent retail sales missed expectations, and other data points such as
personal income and auto sales have recently missed expectations.¶ All of this signals to Sanchez that the
economy is in a recovery mode, but that recovery is "likely going to continue to be modest."¶ "We believe that
expectations have, as usual, gotten ahead of reality. We think that we are still in 2 percent growth
mode, going through the rest of the year," she said.¶ Specifically, sectors that could under-deliver toward the end of
the year are consumer-related areas such as consumer discretionary. A relatively weak U.S. dollar also adds to Sanchez's less-than-
optimistic outlook.¶ "We
see a weak dollar, and that weak dollar is likely to be inflationary. That is
going to be a challenge when wage growth has not matched pace with the rest of inflation," she said. The
dollar index on Friday logged its biggest daily performance since January, though the greenback is still weak on a year-to-date basis
against many foreign currencies.¶ In the monthly employment situation released Friday, average hourly wages rose in line with
expectations, but remained sluggish on an annual basis. Unemployment ticked down to 4.3 percent.¶ "We think, given the outlook
for growth, earnings could under-deliver at the end of the year. That, in combination with what we think is a high [price-to-earnings
ratio] relative to all the external risks to [price-to-earnings ratio], could create a situation where investors should be considering
consolidating their positions and getting into wait-and-see mode for the end of the year," Sanchez said.
OPM CP
 AT: Trump Ends Heg
Trump doesn’t doom US hegemony---Long term foundations of
American power are intact, and willingness for global engagement
will bounce back
Hal Brands 17, the Henry A. Kissinger distinguished professor of global affairs at Johns
Hopkins University’s School of Advanced International Studies. With Charles Edel associate
professor of strategy and policy at the U.S. Naval War College. 7/14/17, “The Gathering Storm
vs. the Crisis of Confidence” http://foreignpolicy.com/2017/07/14/the-gathering-storm-vs-the-
crisis-of-confidence-trump-1930s-1970s/

In many ways, this was an accurate reflection of the national mood at the end of the 1970s. During that decade, the United
States faced a raft of serious challenges — severe economic competition from other leading powers, the rise of the
Soviet Union as a global peer competitor in military terms, the stagflation and national humiliation caused by the oil shocks. There
were concerns that the U nited S tates was turning inward in the wake of Vietnam, as leading
congressional observers even sought to withdraw significant numbers of U.S. troops from
Europe. Economic nationalism was on the rise. Richard Nixon’s first treasury secretary, John Connally, artfully expressed the
ethos: “Foreigners are out to screw us. Our job is to screw them first.”

In these circumstances, doubts

about the staying power of the United States and the postwar
international system were pervasive. Defenders of that system fretted that the American era was
coming to a close; enemies of the free world were often exultant. “The retreat of American power” could “become a rout,”
James Schlesinger, the former secretary of defense and secretary of energy, wrote in 1979. “The trend could well become irreversible
in many respects.” “Imperialism is not able to face the crises,” Leonid Brezhnev had told Warsaw Pact leaders the year prior.

And yet the 1970s proved not to be the death knell for American power and the free world
system erected after World War II, but simply a difficult moment that served as prelude to renewal. By the
late 1970s, the world was again turning in America’s direction — democracy was spreading,
globalization was racing ahead, America’s primary great-power competitor was sliding into
irreversible decline. And by the early 1980s the United States was pursuing assertive and broadly effective strategies for re-
establishing its global ascendancy and pushing the positive trends along. Within a decade, the Cold War had ended on American
terms, as democracy and markets were advancing — with U.S. assistance — further than ever before.

If focusing on the 1930s analogy thus leads one to fear that the end of the international order is nigh, looking at the 1970s
encourages the conclusion that perhaps the future is relatively bright after all. In this view, the United States and the international
system it anchors still have tremendous and unmatched strengths vis-à-vis the competition, the long-term trends are working in
Washington’s favor, and America
is simply experiencing one of its periodic moments of doubt and
introspection rather than a more fundamental turn away from internationalism — just as
occurred during the 1970s.

So how well does this analogy fit? In some ways, emphasizing the 1970s comparison risks understating the difficulties and
challenges America faces today. For all the disillusion occasioned by Vietnam, America did not elect a president who repudiated key
traditions of U.S. foreign policy as vehemently and frequently as Donald Trump did during the 2016 campaign. American “soft
power” took a beating amid the domestic upheaval of the 1970s, but that weakness may ultimately prove to be minor compared with
the loss of prestige the United States is already suffering as a result of Trump’s presidency.

From a global perspective, the Soviet Union may have been an authentic military peer rival during the 1970s, but even at its peak its
sclerotic, command economy never threatened U.S. economic primacy as China does today. And in the 1970s, the United States was
able deftly to play China and the Soviet Union against each other; today, Washington has fraught and deteriorating relations with
both powers as they challenge international norms and geopolitical arrangements to which they were never genuinely reconciled.
The 1970s were a difficult period, no doubt, but the comparison may — at least in some ways — encourage too rosy a view of what
America confronts today.

Yet if the 1970s are far from the perfect analogy, the period does nonetheless illuminate important aspects of the contemporary
moment. It reminds us that, today as in the past, America’s competitors face long-term challenges that make ours look relatively
modest by comparison. Russia is, after all, a declining economic power and a demographic basket case; its military power thus rests
on extremely precarious foundations. China is already dealing with slowing economic growth, a rapidly aging population, and a
massive debt bubble, and its sense of geopolitical self-confidence hardly conceals its leadership’s transparent nervousness about
growing social unrest and other signs of dissatisfaction with a corrupt and ruthlessly authoritarian political system.

Similarly, the
1970s analogy reminds us to take into account long-range U.S. strengths that no
adversary can match and to factor in emerging trends that may play to America’s advantage.
Washington’s unequaled collection of allies, its relatively healthy demographic profile, its culture of innovation, and its
repeated resilience in the face of macroeconomic shifts falls into the first category; an energy revolution that is giving America new
economic and geopolitical leverage is but one example of the second.
Moreover, the experience of the 1970s underscores that assertive challengers often overplay their hand, thereby risking overreach
and exposing vulnerabilities for the United States and its allies to exploit. An overconfident Moscow took on numerous Third World
commitments during the 1970s, allowing Carter and then Reagan to punish that overextension through support to anti-communist
guerrillas. Should Russia and China continue their revisionist behavior today, they are similarly likely to encourage geopolitical
blowback, if only by driving their rivals toward closer cooperation with one another and with the United States. Additionally, we
can learn from the 1970s that our current traumas are neither unprecedented nor particularly
severe by historical standards. In its effects on U.S. political stability and American power, the
Vietnam War was far worse than anything the country has experienced in Iraq or Afghanistan
over the past 15 years.
Finally, the experience of the 1970s also cautions us not to panic about the state of American
internationalism. Yes, the Trump phenomenon is deeply disturbing for those who wish to see
a globally engaged America contributing constructively on issues including international trade
and combating climate change. But we have lived through periods of American disillusion with
the world before, as the experience of the 1970s reminds us, and the logic of global engagement
and activism has generally reasserted itself after a fashion — usually in response to threatening
developments abroad. Indeed, the fact that public opinion polling on support for U.S. alliances
and honoring America’s overseas commitments actually looked much worse in the mid-1970s
than it does at present (after the U.S. withdrawal from Vietnam, for instance, only 36 percent of Americans felt that “it was
important for the United States to make and keep commitments to other nations”) provides some antidote to
pessimism today.
Midterms
 UQ---GOP Win

Urban clusters, gerrymandering---makes turnout irrelevant

Rebecca Shabad 8/8, Reporter, 8/8/2017, Report: Political map doesn't look good for
Democrats in 2018, https://www.cbsnews.com/news/report-political-map-doesnt-look-good-
for-democrats-in-2018/
The political map doesn't look very good for Democrats ahead of the 2018 midterm elections,
according to a new analysis published by FiveThirtyEight.

The analysis, written by Cook Political Report's David Wasserman, says that if
Democrats were to win every single
House and Senate race next year in places that Hillary Clinton won or that President Trump by less
than 3 percentage points last November, they could still lose the House and lose five Senate
seats .

Democrats, for example, hold six seats in the Senate out of the 26 Republican-leaning states and six
are at risk next year, the report notes. Democrats will have to defend 25 of the 48 seats they
currently occupy in the upper chamber while Republicans only have to defend eight of
their 52 seats.

The political map, Wasserman wrote, is a product of Democratic clusters in urban areas and
Republican gerrymandering.

Their odds don't look strong: the last time the Senate had such a strong Republican bias, it was
1913 when direct Senate elections were ratified, the report said. Democrats, however, did win back control of the
House and Senate in 2006 when a GOP bias existed that year.

Democratic elitism has turned off campaign donors

Ryan Cooper 8/25, Natl Correspondent at The Week, 8/25/2017, “Democrats' unexpected
money problem,” The Week, http://theweek.com/articles/720424/democrats-unexpected-
money-problem
The trainwreck presidency of Donald J. Trump continues, as it must. Most recently, the president is preparing to ban transgender
soldiers from the military, and has picked a big fight with Senate Majority Leader Mitch McConnell for no reason. With all the
failure, bigotry, infighting, and Trump's crashing popularity, Democrats are anticipating big pickups in the 2018
midterms — possibly big enough to overcome Republican electoral shenanigans.¶ But they are
running into a money problem , and from an unexpected source: small donors. Overall, the Republican National
Committee is out-raising the Democratic National Committee by roughly 2-1. Some of that is probably to be expected,
given the Republican advantage among the ultra-rich — but the RNC is also winning among small donors by
nearly 50 percent. It's a problem driven by the blinkered elitism of the Democratic establishment.¶
Still, it is particularly odd given the fact that Bernie Sanders — who has effectively become the party's main figurehead through lack
of competition, if nothing else — got tremendous amounts of small dollar fundraising during his primary campaign. At the time,
Democratic Party officials were slavering over that fact, figuring that if he would just give up his email list, they could get in on the
party (and keep those consultant contracts flowing).¶ But they failed to understand the reason why Sanders got so much small donor
cash. The reason is trust.¶ The
fundamental political characteristic of the moment is overwhelming
backlash to the status quo. People hate both parties, they hate the leadership of both parties, and they hate the sitting
president — whoever it may be. Some of this is pure racism, misogyny, or xenophobia, especially in reaction to the first black
president. But at least an equal portion is due to the abysmal economic performance of the last eight years. Wall Street banks
wrecked the economy and got hundreds of billions in free cash and trillions in cheap loans; ordinary homeowners got nine million
illegal foreclosures and a lousy job market.¶ To this day the Great Recession has not ended. Growth since the crisis
has been the worst in postwar history, inequality and corporate profits remain at or near record highs, while wages are growing
slightly if at all. Somewhat akin to Russia after the collapse of the Soviet Union, much of America is seized with an epidemic of
"diseases of despair" — alcoholism, opioid addiction, suicide, and concomitant increasing mortality.¶ That sort of abysmal situation
is highly risky to an incumbent party. (Witness the 2010 Democratic wipeout, or any of a dozen European parties in power during
the eurozone crisis.)¶ President Obama managed to skate over the backlash and win re-election through a few key policies, an easy
opponent, and the fact that he is the greatest American political talent in generations. By contrast, Sanders (who is not so talented)
actually validated the backlash and ran a campaign promising to overturn the status quo — and backed it up with a highly unusual
voting history that was just as heterodox as his promises. As a result, he is by most measures the most popular working politician
today.¶ Therefore, one major factor hurting the DNC fundraising is how Democratic Party elites,
especially President Obama, connived behind the scenes to keep Sanders' ally Keith Ellison out of the
DNC chair. That frankly dirty and underhanded maneuvering signaled to Sanders' left-wing
supporters that elite Democrats were only interested in them insofar as they were an obedient
source of votes and cash. So they took their money elsewhere.¶ Democrats' strategic blindness is perhaps even
more visible in the cynical contempt that saturates their fundraising emails and mailers, as Michael Whitney (who helped with
Sanders' primary fundraising) argues. Democrats' elitism combined with their fetish worship of
empiricism has produced the most obnoxious fundraising asks in American history, with endless
histrionic declarations of MAJOR COLLAPSE and WE'RE DOOMED, because that gets people
to open the mailing and donate. Recently, they've taken it even further, by sending emails and letters at the end of the
month that are marked to look like late bills.¶ Apparently this kind of horrifying stuff works pretty well on an individual basis. But it
is an overtly manipulative strategy that signals contempt for the donor as a witless chump to be
pumped for cash and then ignored, instead of a fellow citizen deserving of an honest argument.
Using fear tactics for quick cash also tends to foreclose putting forth a positive vision for what
Democrats will do to fix the country's problems.¶ Republicans have tried such manipulation
before, but as Whitney demonstrates, under Trump they have mostly ditched such tactics and copied from
the Sanders playbook, to their manifest benefit. (And in any case, Republicans rarely struggle to raise money.)¶ If
Democrats want small donors to join up en masse (let alone vote or volunteer for campaigns), they must earn their trust. The
Democratic leadership is among the all-time greatest political failures in American history, and the Democratic Party brand remains
in the toilet. Recognizing that toxic association with the despised status quo, and giving American citizens the dignity of an honest
argument about how they will fix it — instead of treating them like sheep to be sheared — is a good place to begin.
 GOP Demoralization---1AR
The link turn outweighs – angering the base by flipping on repeal is
worse than alienating other voters
Jonathan Martin 17, Political Correspondent for the NY Times, co-author of the New York
Times best seller “The End of the Line: Romney vs. Obama: The 34 Days That Decided the
Election”, 2018 Dilemma for Republicans: Which Way Now on Obamacare?, The New York
Times, https://www.nytimes.com/2017/03/28/us/politics/2018-dilemma-for-republicans-
which-way-now-on-obamacare.html
WASHINGTON — As they come to terms with their humiliating failure to undo the Affordable Care
Act, Republicans eyeing next year’s congressional campaign are grappling with a new dilemma:
Do they risk depressing their conservative base by abandoning the repeal effort or anger a
broader set of voters by reviving a deeply unpopular bill even closer to the midterm elections?¶ The question is
particularly acute in the House, where the Republican majority could be at risk in 2018 if the
party’s voters are demoralized, and Democratic activists, energized by the chance to send a
message to President Trump, stream to the polls.¶ Sifting through the wreckage of a disastrous week, Republican
strategists and elected officials were divided over the best way forward. Some House Republicans pressed to move on to other issues
and notch some victories that could delight their own loyalists while not turning off swing voters.¶ “We’ve got a lot of time to do real
things on infrastructure, to do real things on tax reform, on red tape reform, and really get the American economy moving,” said
Representative Steve Stivers of Ohio, chairman of the National Republican Congressional Committee, the House campaign arm. “We
do those things and we still have a lot of time to recover.”¶ “If you’re going to fumble the ball,” he added, “better to do so in the first
quarter of a football game.Ӧ Devising
health care legislation that could appeal to both wings of the
House Republican Conference — the hard-line conservatives and more moderate members —
would require a nearly superhuman feat, added Representative Billy Long, Republican of Missouri.¶ “Not unless
Harry Houdini wins a special election to help us,” Mr. Long said about the prospects of cobbling together a coalition that could agree
on how to repeal and replace the health care law.¶ But other longtime Republicans warned that if
the party did not address
what they have derided as Obamacare, an issue that has been central to their campaigns for the
last seven years, they would incur a heavy political price in the midterm elections.¶ Midterm
campaigns have increasingly become akin to parliamentary elections — referendums on the
party in power rather than on individual candidates, where turnout by dependable partisan
voters is the deciding factor.¶ “If they fall on their sword on this, they’re going to get slaughtered,”
said former Representative Thomas M. Davis III, a Virginia Republican who himself was once at the helm of the House campaign
committee.¶ “ Where
parties get hurt in midterms is when their base collapses ,” Mr. Davis
said. “Democrats are going to show up regardless of what you do. If our voters don’t
see us fulfilling what we said we were going to do, they’ll get dispirited.” ¶ What
troubles many Republican strategists is the specter of the party’s most reliable voters being
bombarded by reminders of their leaders’ failure to address the health law. They fear a
recurring story line sure to pop up every time insurance premiums increase, providers leave local networks, or,
most worrisome, Republicans fund President Barack Obama’s signature
achievement.
 No Link
Dem outrage is inevitable and they fail at creating momentum on
healthcare
Jeet Heer 17, Senior Editor at the New Republic, PhD Candidate at York University, writing a
dissertation on cultural politic, 6/14/2014, The Russia Scandal Is Distracting Democrats From
Trumpcare, New Republic, https://newrepublic.com/article/143321/russia-scandal-distracting-
democrats-trumpcare
Gillibrand and Murphy are speaking to a simple point: Attention and outrage are limited resources for an
opposition party trying to mobilize the masses, and right now, the Russia story is dominating
headlines. But not long ago, the Republicans’ Obamacare repeal efforts did command the media’s attention and public’s
outrage—specifically when the House first attempted to pass the AHCA, and when it succeeded in its second attempt. Republican
congressmen were literally running scared from angry constituents, and the press couldn’t get enough of the raucous town hall
meetings.¶ This, undoubtedly, is why Republican senators have decided to keep their own bill secret—to deprive the media of details,
and thus deprive the public of fuel for outrage. By all appearances, their strategy is working.¶ Gillibrand and Murphy’s rhetoric
notwithstanding, Democrats in the Senate seem to be treating healthcare as a secondary concern .
A top Senate aide told Stein that “not going nuclear on AHCA also allows them to hammer out bipartisan Russian sanctions deal.”
From a parliamentary point of view, this is a defensible position. The Democrats have few cards to play; they can’t filibuster the
legislation, but they can hold a vote-a-rama. They might want to wait for a later emergency to grind the Senate to a halt. Also, “going
nuclear” might make more sense once the details of the bill are public, giving the Democrats a more specific enemy to rally against. ¶
Still, whatever the logic behind the Democrats’ strategy, some activists are starting to panic,
believing that the fight is being lost due to complacency and disengagement. “There’s no
shortage of passionate opposition to Trumpcare, but there’s a profound shortage of
awareness that the beast is back,” Ben Wikler, Move On’s Washington director, told the New Republic’s Graham Vyse. “Big
chunks of the American public have been lulled into a dangerous belief that Trumpcare is not going anywhere. The fact is, we’re in a
code-red emergency.” Stopping the Senate’s health care bill will require massive mobilization, he said. “ A biblical flood of
phone calls is necessary but not sufficient to stop Trumpcare. At this point, for Republican senators to vote
against the bill they would have to feel like supporting it is an existential threat to their political careers, and that means surround-
sound, defending resistance. It means phones ringing off the hook. Emails being jammed. Protesters shouting at them when they go
to the grocery store.Ӧ The
ubiquitous Russia story is a barrier to this type of political mobilization. For
all the attention the scandal deserves, it is also, from the point of view of resisting the Trump
agenda, counterproductive and politically demobilizing. The Russia story is high political
theater, with senators grilling top government officials and damaging information leaking
almost daily from the White House and law enforcement agencies. There’s very little room in
this drama for activists. At best, if the Senate or some other branch of the government is seen as failing to do its duties,
protestors might play a role in raising a stink. But on the whole, the Russia investigation is one where the system proceeds according
to its own rules, while the public looks on.¶ The
battle over health care, by contrast, requires enflaming mass
passions. Democrats and activists were able to do so earlier this year, mobilizing voters to attend
town halls and call their congressional representatives. But as the Republicans started working
in secret and the Russia story started dominating the news, it’s been hard to sustain the
needed level of outrage. While there have been massive rallies over the last few months
focused on women, climate change, immigrants, and impeachment, attempts to organize large
marches around healthcare have fizzled . ¶ Which brings us back to the question: What is the goal of the
Resistance? If the goal is to defeat Trump, then it makes sense to a focus on finding an impeachable offense. If the goal is to defeat
Trumpism, the battle should focus on dislodging Trump’s ideological allies, like Steve Bannon and Stephen Miller, from power. And
if the goal is to fight the Republican Party, then the highest priority has to be issues like health care, where the divide between the
Democrats and the GOP is stark. If the Republican health care bill becomes law, Democrats must take some of the blame. They
are too narrowly focused on opposing Trump—on trying to take him down over Russia—rather
than opposing the policies he’s pursuing, which couldn’t get anywhere without the Republican
Party.
The link turn outweighs – dems have a number of things that will
turnout out the base but the GOP doesn’t – Obamacare is key
Michelle Cottle 9/2, Editor at the Atlantic, 9/2/2017, Republicans Need a Villain for the
Midterms, https://www.theatlantic.com/politics/archive/2017/09/republicans-need-a-villain-
for-the-midterms/538689/
Like most politics of late, the 2018 elections promise to be wild and weird. For starters, midterms typically serve as a referendum on
the sitting president—which should be fabulous news for Democrats, given that Donald Trump’s favorability numbers are now
smaller than his waistline. Except! When
one peruses the actual electoral map, the House, Senate, and
gubernatorial landscapes all favor Republicans. ¶ As for turnout, while the GOP’s base (read: old,
white folk) is usually far better about voting in non-presidential years than the Democrats’
(read: young ‘uns and minorities), Dems are unusually exercised (read: apoplectic) about this president. And
while hardcore Trumpkins are expected to stand by their man, a growing number of “soft” Trump voters are expressing buyer’s
remorse. There’s no telling how this cohort will vote (or not) come next November.¶ Which ultimately renders this oh-so-peculiar
political dynamic subject to an oh-so-commonplace political law: Whichever team more furiously fires up its base
will carry the midterms.¶ For Democrats, the mission looks pretty basic : Keep pointing at
Trump and asking voters in horrified tones, “Do you really want this guy running around unchecked?” Expect Democratic
campaign ads to make liberal use of photos featuring Trump smirking alongside Paul Ryan or
Mitch McConnell. Message: What cozy peas in a pod!¶ The path forward for Republicans is much less
clear . Mobilizing one’s base involves aiming for the gut, spotlighting a proper villain—be it
person (Hillary) or policy (Obamacare)—that makes the masses see red and reach for their pitchforks. But
with Republicans currently running everything (including the botched repeal of Obamacare), coming up with a suitably
electrifying bogeyman could prove challenging.