Neg - Arizona Debate Institute



NegSolvencyM4A failsExpanding Medicare increases wasteful spending, reduces worker productivity, and prevents new tech developments in HCPipes, 15 [Sally Pipes, president, CEO, and Thomas W. Smith Fellow in Health Care Studies at the Pacific Research Institute, a San Francisco-based think tank. As a native Canadian and naturalized American, I have a unique understanding of how government-run single-payer healthcare systems actually operate -- and why such ideas are wrong for America. I have published five books: Miracle Cure: How to Solve America’s Health Care Crisis and Why Canada Isn’t the Answer (2004), The Top Ten Myths of American Health Care: A Citizen’s Guide (2008), The Truth About Obamacare (2010), The Pipes Plan: The Top Ten Ways to Dismantle and Replace Obamacare (2012), and my latest, The Cure for Obamacare (2013)]. Bernie Sanders' 'Medicare For All' Would Be A Disaster For All. 19 October 2015. MHBut a closer look demonstrates that single-payer -- in Denmark or anywhere else -- devastates a nation's healthcare system. Sanders's plan would do nothing but guarantee exploding costs, long wait times, and low-quality care. Consider Medicare, the federal healthcare program for seniors. Last year, Medicare wasted $60 billion -- about 10 percent of its budget -- on improper or fraudulent payments. That money went to non-existent healthcare providers with phony addresses and doctors with suspended licenses. And the government was none the wiser. Because of its massive size and inability to adequately monitor its spending, the Government Accountability Office first labeled the program "high risk" in 1990 -- meaning especially susceptible to fraud and abuse. Unsurprisingly, the program is headed toward bankruptcy. Medicare's latest annual report revealed that its main Part A trust fund -- for Hospital Insurance -- will be exhausted in 15 years. The feds will then have to sharply cut benefits, raise the payroll taxes used to fund it -- or raid the rest of the federal budget to cover seniors' care. Canada's single-payer health system is the last thing the United States needs. Canadians looking for treatment must wait for care, even if they're in desperate need. Alberta Health Services, for example, reports that 90 percent of patients who need back surgery have to wait up to almost nine months. Hundreds have fled to clinics in the United States to get treatments that their government health programs have been denying them. Fraser estimates that Canada's healthcare system costs patients nearly $1 billion a year in lost productivity. Innovation has suffered as well. Companies have little incentive to develop new technologies for the Canadian market, as they know that the government will immediately slap price controls on their services. Between 2001 and 2013, for example, research and development within the country's pharmaceutical industry dropped 29 percent. Denmark's single-payer system, which Sanders wants to copy, has also failed to help patients. The Commonwealth Fund recently evaluated the quality of healthcare in 13 major industrial nations. While the United States had one of the lowest rates of death from cancer, Denmark had the highest. Normally, policy proposals by a self-proclaimed "Democratic Socialist" wouldn't merit much attention. But Sanders has been drawing big crowds -- and posting big poll numbers -- with an agenda that includes single-payer health care. If Sanders wins the presidency, patients will lose. M4A reduces coveragePlan reduces pay-outs – means less coverage for treatmentMegan McArdle, 6-9-17. (McArdle: Columnist for Bloomberg View. Degrees and what not from Uchicago, UPenn, etc. “Why not Try ‘Medicare for All’? Glad You Asked.” The Denver Post. Accessed 7-18-17 JSD.)In fact, economists generally assume that sellers are charging each buyer as much as they can. Having one customer refuse to pay so much doesn’t make your other customers more willing to pay, so there’s no reason to think that you’ll be able to raise the price you charge them. However, there remains an undeniable fact: Medicare pays significantly less than private insurers. And this can’t simply be explained by the fact that Medicare covers a huge number of people, because so do Aetna and Humana and Anthem and Blue Cross. There’s some evidence that Medicare reimbursements don’t quite cover the average cost of having a patient in the hospital. The hospital’s fixed costs are mostly getting covered by higher reimbursements from private payers. (Though this varies by hospital, and is difficult to tease out, and therefore disputed.) Note that this isn’t necessarily somehow “cheating.” There are plenty of people flying around the country whose fares don’t cover the average cost of their flight. It still makes good economic sense to sell them tickets at low fares, because the airlines are getting more revenue from a cheap ticket than from an empty seat. Ditto hospitals deciding whether to have empty beds. In businesses like this, people often look at the prices paid by marginal-cost consumers, and conclude it would be great if everyone got that price. But someone has to cover those fixed costs, or the seller goes bankrupt. Data from the Medical Expenditure Panel Survey suggests that people on Medicare account for about a third of all national health expenditures; folks 44 to 65 for another third; and the rest of us for the final third. And those folks are the ones most likely to use hospitals, because they’re more likely to be really sick, not just getting an annual checkup and a few pills.Plan makes doctors cut corners – can’t solve health/disease/etcMegan McArdle, 6-9-17. (McArdle: Columnist for Bloomberg View. Degrees and what not from Uchicago, UPenn, etc. “Why not Try ‘Medicare for All’? Glad You Asked.” The Denver Post. Accessed 7-18-17 JSD.)Like the critics of the cost-shifting thesis, I doubt that hospitals could simply turn around and jack up rates to private payers. On the other hand, I do kind of wonder what the hospitals would do to cover the now gaping holes in their budgets. Hospital profit margins are in the low-to-mid single-digits, which is probably not enough to absorb a large loss. One thing they might do is go bankrupt. Ha! I’m kidding. Hospitals are politically powerful. They’d ask for, and get, a bailout from the government, because no lawmaker is going to let the local hospital close. But that would make this program pretty expensive, because that bailout would most likely involve moving all Medicare reimbursements closer to what private payers pay. Or they also might refuse to handle so many Medicare patients (a phenomenon you see among doctors, though doctor opt-out is nowhere near as bad as it is with Medicaid, which basically tries to pay doctors in cigar bands). Of course, you can’t turn away someone who’s having a heart attack. But you could, say, decide that you’re only doing so many Medicare-funded knee replacements a year. That would fix the budget problem. But all those folks with bad knees are apt to get pretty cranky while waiting for a hospital bed. And of course, hospitals could cut costs. There’s evidence that this is what they have done, in response to previous cuts in Medicare reimbursement. Unfortunately, there’s also some evidence that mortality might have gone up as a result, as hospitals cut back on service quality. That may be a tradeoff we’re willing to make for lower health care costs, but it should be explicitly discussed.**Aff claims of short tf are can-opener claims – Long tf for plan to solveHarold Pollack 15. 8-1-15 (Pollack – Helen Ross professor at Uchicago. Masters and PhD in public policy from Harvard. Heavily published for Public health policy. “Medicare for All – If it were Politically Possible -Would Necessarily Replicate the Defects of Our Current System.” Journal of Health Politics, Policy & Law [peer-reviewed, associated with Duke]. Accessed 7-19-17. JSD.) For all of these reasons, my argument with Seidman comes from someone who shares the goals of universal coverage and inclusive social insurance but who wonders whether Medicare for All is really the best fix. My point is not (merely) that Medicare for All seems politically out of reach for the foreseeable future. More to the point, if Medicare for All actually were enacted, it would necessarily replicate many of the defects its proponents associate with both the ACA and our pre-reform financing system. Seidman writes what must be called one of the great assume-the-canopener openings I’ve seen: “It is striking how many problems facing the Affordable Care Act . . . would disappear if the nation were instead implementing Medicare for All.” To state the obvious, the short-term political obstacles (where short-term is defined in units of decades rather than years) make this a distant proposition. If our current problems vanish, they will do so only through one of the most prolonged vanishing acts in American history. During the 1970s and 1980s, a broad liberal-left coalition, including many single-payer advocates, came to recognize that Medicare for All was unlikely to get through the US Congress within our lifetimes. Our political system demanded a more incremental model, one less disruptive to the status quo, less frightening to the myriad of “protected publics”— veterans, senior citizens, and others who hold implicit political veto power over what can be done (Starr 2013). After the Clinton health care debacle, alliances exemplified by Health Care for America Now (HCAN) (Kirsch 2012) negotiated the ambitious but incremental reform that became the ACA.**Aff estimates of cost miss a big factor – deadweightTim Worstall, 15. 9-21-15. (Worstall: Contributor. Fellow at Adam Smith Institute. “Bernie Sanders’ Medicare for All Plan Misses the Largest Cost of the Plan – Deadweight Costs.” Forbes. Accessed 7-19-17 JSD.)What's being missed is the deadweight costs. If you levy a tax, any tax, then you will prevent some economic activity from taking place. If we tax incomes then some people will decide that working ain't for them, at the margin, and they'd rather go fishing. Tax consumption and people will consume less. Tax capital or investment and people will save and or invest less. This doesn't mean we should never tax anything, of course it doesn't. What it does mean is that we should only tax where what we spend the revenues on is worth more than what we've lost by imposing the tax. So, taxing in order to make sure the military can stop the Canadian hordes from swarming over the border is fine: that's worth more than the losses from collecting the taxes to fund it. Who knows, maybe more should have been collected to fund this to make sure Mark Steyn never made it South? However, this is still a test that any taxation has to pass: is the benefit of spending the money greater than the deadweight losses from taxation to fund said spending? I'm sure we all have our favourite bits of government spending that don't pass this test but it's not actually obvious that the Medicare for all proposal passes it either. The general rule of thumb is that deadweight costs are 20% of the sum raised in taxation. And in current advanced world economies this rises into the 30-40% range for marginal taxation increases. Given how much we tax already then the extra taxes to do more spending have higher deadweight costs than the average of all taxes so far: not an unusual or odd assumption. And we also need to note that there are no deadweight costs from voluntary activity: if people are happily paying their health care insurance premiums (or even unhappily but voluntarily) there are no deadweight costs. But the moment we move over to taxation as a way of funding the same costs then there are deadweight costs. Because no longer are people voluntarily purchasing with their own money: we are now taxing some economic activity to produce that revenue. And thus we will get less of that economic activity. Think about it for a moment: say we pay for all of this through the taxation of incomes. That will obviously be a proportional tax on our incomes, it's not going to be a flat tax. So, before, I had to go out and make $5,000 (just an example number) to pay for my insurance. Now, with it being paid for from tax, there needs to be a 10% tax on my $50,000 a year (again, just an example, to make the math easy) income to pay for that same insurance. Before, I had to do the work to earn the money to pay for the insurance. Now though, I could cut back on my work a bit, work fewer hours, get an easier job, whatever, and I'd still have my insurance for that 10% of my income. But if I'm off fishing a bit more because my marginal ta rate has gone up then there's less income to tax. This is how deadweight costs work. By taxing an economic activity, instead of charging a price for a good or service which people pay for voluntarily, we reduce the amount of economic activity that is going on. And at the margin those deadweight costs are substantial: 30-40% of the tax being raised. And 30-40% of $15 trillion ain't chopped liver: it's $4.5 to $6 trillion. And that number isn't there in the estimation of the costs of Medicare for all. But it needs to be. And when we do put it in we find that it doesn't actually save us any money at all.M4A doesn’t reduce medical costsMedicare 4 All can’t reduce health care spendingHarold Pollack 15. 8-1-15 (Pollack – Helen Ross professor at Uchicago. Masters and PhD in public policy from Harvard. Heavily published for Public health policy. “Medicare for All – If it were Politically Possible -Would Necessarily Replicate the Defects of Our Current System.” Journal of Health Politics, Policy & Law [peer-reviewed, associated with Duke]. Accessed 7-19-17. JSD.) Although Senator Joseph Lieberman was the most vocal Democratic opponent, the public option faced quiet and powerful opposition from much of the supply side of the medical care economy. Then there is the minor matter of raising taxes by perhaps 8 percent of gross domestic product (GDP) as we move health care spending more fully onto public budgets. To Seidman’s credit, he acknowledges the need for a large tax increase to bring health care onto the public budget. This is a subject that often attracts embarrassed hand-waving among single-payer advocates. Seidman identifies important elements that should be in the mix: a payroll tax, a valued-added tax, an income tax surcharge. That is a heavy lift. It may be an even heavier lift. Seidman’s essay claims that we might reduce health care spending from 18 percent to 15 percent of GDP. I find this politically implausible. We’re not going to wring nearly one-fifth out of our health care economy while we simultaneously impose radical changes to health care financing. Such contraction is the precise opposite of what we did in establishing Medicare. It will be a miracle if we hold medical spending steady at 18 percent given our aging population. In one 2013 analysis, Michael E. Chemew (2013: 861) calculates that “if the gap between inflation-adjusted per beneficiary Medicare spending and GDP growth per capita drops to zero— a level never sustained for a significant period— Medicare spending will rise from 3.7 percent of GDP to 5.1 percent in 2035.” Under any financing system, we will probably require substantially greater revenue to prevent health care from deeply damaging the federal budget. Neither political party has acknowledged this reality. Although the electorate and its congressional representatives like to believe that they support fiscal discipline, the evidence to back up these protestations is thin. The ACA’s most unpopular elements are those concerned with cost control or deficit reduction: the Independent Payment Advisory Board, the Cadillac tax, the employer mandate, reduced subsidies to Medicare Advantage plans, the medical device tax, reduced Medicare reimbursement rates to hospitals, the individual mandate. At least the first five of these items are unlikely, politically, to survive in current form**Medicare historically exceeds cost predictionsSue Blevins, 03 4-11-03 (Blevins: president of the Institute for Health Freedom. “Universal Health Care Won’t Work – Witness Medicare.” Cato Institute. Accessed 7-19-17 JSD.However, before we accept such a drastic shift in national health policy, we should examine how single-payer health insurance could affect all individuals’ health care costs, choices and privacy. If history is any indication, any single-payer initiative will end up costing much more than advocates claim. That, in turn, will lead to higher taxes and/or rationing under which the government will determine which medical treatments will and will not be covered. How do we know this will happen? Because single-payer health care has already been empirically tested on seniors in the United States. Many people may not realize it, but the Medicare program is one of the largest single payers of health care in the U.S. and in the world. An examination of Medicare’s 38-year-old track record provides evidence of what happens when the government controls the financing of health services for millions of U.S. citizens. Consider the following facts. When Medicare was debated in 1965 (the year it was signed into law), business and taxpayer groups were concerned that program expenditures might grow out of control. However, single-payer advocates assured them that all seniors could easily be covered under Medicare with only a small increase in workers’ payroll taxes. The federal government’s lead actuary in 1965 projected that the hospital program (Medicare Part A) would grow to only $9 billion by 1990. The program ended up costing more than $66 billion that year. Just three years after Medicare was passed, a 1968 Tax Foundation study found that public spending on medical care had nearly doubled in the first few years of Medicare. In subsequent decades, Medicare payroll taxes and general taxes have continued to rise to pay for skyrocketing health care costs.General circumventionGovernment controls the funds, can restrict all HC accessRashi Fein, 03. (Fein: PhD. Department of Social Medicine, Harvard Medical School. “Universal Health Insurance – Let the Debate Resume.” The JOURNAL. Accessed 7-22-17. JSD.)While some "dangers" are inherent in the proposal, these dangers most likely can be met by the exercise of democracy. If the money that fuels the system flows through government, it means that government may choose to spend too little and then try to compensate for that shortfall by reducing reimbursements, classifying drugs and procedures as "experimental" and not reimbursable, and engaging in other "shenanigans" designed to shift responsibility to others for the queues for appointments, decline in quality of nursing care, lack of capital investment, and so forth that may occur. That outcome is as true in medicine as it is in every facet of US society, including education, highways, national parks, bioterrorism defense, and the like. The ballot box is the answer. Given the dollars that now enter into election campaigns and the low voter turnout, that may not be an especially strong rod. Even so, it is a stronger rod to lean on and is likely to be more effective than an appeal to the kindness and generosity of the market that, in a quest for profits, may also "underspend."Government admin is inefficient / wastefulMedicare wastes their budget and single payer/Medicare for all in different countries has not fared well.Pipes 15 (Sally, 10/19/15, “Bernie Sanders' 'Medicare For All' Would Be A Disaster For All”, Forbes, ) SCThis month, Bernie Sanders took his vision for the future of American health care to a national television audience in the first Democratic presidential debate. "We should look to countries like Denmark, like Sweden and Norway and learn from what they have accomplished,"?Sanders said. He wants the United States to copy Denmark's single-payer healthcare system. This idea electrifies his supporters. Under a Sanders presidency, he promises, there'd be no more spiraling insurance premiums or high drug prices. But a closer look demonstrates that single-payer -- in Denmark or anywhere else -- devastates a nation's healthcare system. Sanders's plan would do nothing but guarantee exploding costs, long wait times, and low-quality care. Consider Medicare, the federal healthcare program for seniors. Last year,?Medicare wasted $60 billion?-- about 10 percent of its budget -- on improper or fraudulent payments. That money went to non-existent healthcare providers with phony addresses and doctors with suspended licenses. And the government was none the wiser. Because of its massive size and inability to adequately monitor its spending, the Government Accountability Office first labeled the program "high risk"?in 1990?-- meaning especially susceptible to fraud and abuse. Unsurprisingly, the program is headed toward bankruptcy. Medicare's latest annual report revealed that its main Part A trust fund -- for Hospital Insurance --?will be exhausted in 15 years. The feds will then have to sharply cut benefits, raise the payroll taxes used to fund it -- or raid the rest of the federal budget to cover seniors' care. Seniors themselves are increasingly rejecting traditional Medicare in favor of a privately administered alternative called Medicare Advantage. This program lets seniors choose private insurance plans that contract with Medicare to provide benefits. These Medicare Advantage plans often provide better benefits than traditional Medicare. For example, seniors don't have to purchase supplementary "Medigap" insurance policies -- policies that enrollees need to plug gaps in coverage under standard Medicare plans. Enrollment in Medicare Advantage plans has?nearly tripled since 2004. As a result, one in three seniors on Medicare has enrolled in a private Advantage plan compared with just 1 in 10 a decade ago. That doesn't say much for the program Sanders wants to impose on everyone. Nor does his plan's?$15?trillion?price tag. Other countries that have adopted single-payer systems haven't fared any better than Medicare. Take Canada. As someone who was born there, I can tell you firsthand that Canada's single-payer health system is the last thing the United States needs. Canadians looking for treatment must wait for care, even if they're in desperate need. Alberta Health Services, for example, reports that 90 percent of patients who need back surgery have to?wait up to almost nine months. Hundreds have fled to clinics in the United States to get treatments that their government health programs have been denying them. The Fraser Institute, a Canadian think tank, calculates that residents of our northern neighbor have to?wait an average of two months?to get an MRI -- and almost a year if they need orthopedic surgery. One in three is waiting to see a primary care doctor. Part of the problem is a lack of capacity. For example, the province of Ontario has fewer hospital beds per capita --?just 1.4?per 1,000 people -- than other industrialized nations. The average in eight similarly developed nations is?3.4 beds?per 1,000 people. And while Ontario officials brag that this is a sign of how efficiently they run their healthcare system, medical professionals say that this shortage has caused the hospital equivalent of gridlock. "This means the hospital's beds are full. Surgeries have to be cancelled and there are no beds in which patients can recover,"?noted the Ontario Health Coalition, which is trying to ward off still more spending cuts as the province deals with a?$10.9 billion?budget gap. Fraser estimates that Canada's healthcare system costs patients?nearly $1 billion?a year in lost productivity. Innovation has suffered as well. Companies have little incentive to develop new technologies for the Canadian market, as they know that the government will immediately slap price controls on their services. Between 2001 and 2013, for example, research and development within the country's pharmaceutical industry?dropped 29 percent. Denmark's single-payer system, which Sanders wants to copy, has also failed to help patients. The Commonwealth Fund?recently evaluated?the quality of healthcare in 13 major industrial nations. While the United States had one of the lowest rates of death from cancer, Denmark had the highest. Normally, policy proposals by a self-proclaimed "Democratic Socialist" wouldn't merit much attention. But Sanders has been drawing big crowds -- and posting big poll numbers -- with an agenda that includes single-payer health care. If Sanders wins the presidency, patients will lose.Administrative costs for private insurance are worth it – better efficiency delivering careMangan, 15 [Dan Mangan is a reporter covering health care and other issues for . Mangan has been a journalist for more than 20 years.] Health insurance coverage paperwork wastes $375 billion. 17 January 2015. [New York's Single Payer Official Website, a statewide clearinghouse for all single payer/medicare-for-all initiatives and events throughout our very active state. In medical billing, companies that function as intermediaries who forward claims information from healthcare providers to insurance payers are known as clearinghouses.]Ed Haislmaier, a senior research fellow of health policy studies at the conservative Heritage Foundation, said “there’s a whole lot of reasons” not to move to a single-payer model. “Basically, you’re allocating health-care resources based on politics and not necessarily on needs, and that ends up introduce[es] all kinds of inequities and inefficiencies into the system,” Haislmaier said. “The thinking is you want to provide a system that provides better values. … You’re not going to achieve that through government administration, you’re only going to achieve that through a competitive private model” in which[where] superior providers are given more customers and consumers get lower prices, he said. However, the Heritage Foundation’s Haislmaier said that even if one accepts the estimates of savings in the paper, “the savings do not come anywhere near what you’d have to come up with for effectively nationalizing the system.” “You would still, as a practical matter, and this is a problem that Vermont ran into, tax people substantially,” Haislmaier said. “At the end of the day, as a practical matter, I don’t see them having the ability to sell the necessary tax increases.” Haislmaier also noted that not all administrative billing and insurance-related costs are bad. “Some are good,” he said, pointing to how such mechanisms in the private sector can ensure that procedures are warranted before they’re paid for. In contrast, Haislmaier said, the government-run Medicare and Medicaid systems had less administrative costs because they also have a policy of “pay first and chase later,” which leads to billions of dollars in fraud. “There’s a significant cost to not having the right administrative controls,” he said.Adv AnswersEcon Adv AnsEcon decline does not lead to conflict – Recession ProvesDrezner 14 [Daniel W. Drezner is an American professor of international politics at The Fletcher School of Law and Diplomacy at Tufts University, “The System Worked: Global Economic Governance during the Great Recession,” World Politics, Vol. 66, No. 1, January 2014, p. 134 ] BJThe final significant outcome addresses a dog that hasn’t barked: the effect of the Great Recession on cross-border conflict and violence. During the initial stages of the crisis, multiple analysts asserted that the financial crisis would lead states to increase their use of force as a tool for staying in power.42 They voiced genuine concern that the global economic downturn would lead to an increase in conflict—whether through greater internal repression, diversionary wars, arms races, or a ratcheting up of great power conflict. Violence in the Middle East, border disputes in the South China Sea, and even the disruptions of the Occupy movement fueled impressions of a surge in global public disorder. The aggregate data suggest otherwise, however. The Institute for Economics and Peace has concluded that “the average level of peacefulness in 2012 is approximately the same as it was in 2007.”43 Interstate violence in particular has declined since the start of the financial crisis, as have military expenditures in most sampled countries. Other studies confirm that the Great Recession has not triggered any increase in violent conflict, as Lotta Themnér and Peter Wallensteen conclude: “[T]he pattern is one of relative stability when we consider the trend for the past five years.”44 The secular decline in violence that started with the end of the Cold War has not been reversed. Rogers Brubaker observes that “the crisis has not to date generated the surge in protectionist nationalism or ethnic exclusion that might have been expected.”45Impacts don’t go global – other countries are resilient without the USArgitis and Robinson 5/19/17 [Theophilos Argitis and Blaise Robinson report and provide political analysis for Bloomberg, “Global Expansion Is in Sync, Even If Everything Else Is in Chaos”, Bloomberg News, May 19, 2017, ] BJA synchronized expansion means the global economy doesn’t need to rely as much on the U.S. for growth. That limits the emergence of imbalances that could destabilize global growth, such as an abrupt change in the U.S. dollar that leaves emerging markets vulnerable. And global economies have rarely been so in sync. The variation of growth rates this year Group of 20 economies will be the lowest since at least 1980, according to Bloomberg calculations and IMF data. In fact, no G-20 economy is expected to post a decline in output this year, which would be the first time since 2010. Growth rate differences are diminishing even as the global expansion accelerates, with G-20 growth forecast to average 2.4 percent in 2017, from 1.8 percent last year. It’s the same trend -- more synchronization at a faster rate -- for inflation rates as well. That’s led chief executives to strike an optimistic tone. “We’re encouraged by signs of momentum in the global economy,” said Gregory Hayes, chief executive of United Technologies Corp., which builds everything from aircraft engines to elevators, on an April 26 earnings call. “We’ve seen really good strength here in the U.S. We’ve seen recovery in Europe. Even in China, we saw good economic growth in the first quarter.”A2: Racial inequality AdvCan’t solve racial inequality -- Economic inequality is rampant along racial linesHiltzik 16’ (7/11/2016)(Pulitzer Prize-winning journalist Michael Hiltzik writes the daily blog "The Economy Hub." His business column appears every Sunday and Wednesday. As a member of the Los Angeles Times staff, he has been a financial and technology writer and a foreign correspondent. He is the author of five books, including “Dealers of Lightning: Xerox PARC and the Dawn of the Computer Age” and “The New Deal: A Modern History.” Hiltzik and colleague Chuck Philips shared the 1999 Pulitzer Prize for articles exposing corruption in the entertainment industry) eruption of community protests that followed the killings of Alton Sterling and Philando Castile last week placed the spotlight once again on racial disparities in American society. But one aspect that again received less attention than it deserved is economic disparity. That’s important because it’s pervasive in the U.S. and arguably lies at the core of our racial conflicts. Progressive economist Jared Bernstein put his finger on the issue, observing that “the systemic racial injustice embedded in the economy” is among the “institutional prejudices” America needs to consider deeply. I examined this issue after the Ferguson outrage of 2014, noting the persistent economic harassment that afflicted the residents of that city — racial profiling leading to a proliferation of nuisance fines and court fees that would grow exponentially. As a local legal-aid organization documented, clients were “jailed for the inability to pay fines, losing jobs and housing as a result of the incarceration, being refused access to the Courts if they were with their children or other family members.” Black unemployment is consistently higher than the white rate, black homeownership rates consistently lower. In virtually every economic metric, black households are mired behind white households. The further behind they fall, the harder it becomes to get a leg on the income ladder and to keep climbing. As Bernstein and Valerie Wilson of the Economic Policy Institute also observed, black unemployment is more volatile than that of whites — it rises faster in slack times and falls faster as the economy moves toward full employment: “Between 1979 and 2014, the average annual black unemployment rate changed by 1.7 percentage points for every 1-percentage-point change in the national unemployment rate,” Wilson wrote. Real wage growth for black households will also grow faster than in white households, albeit marginally. One disquieting finding is that black unemployment exceeds white unemployment across all levels of educational achievement. The disparity shrinks as educational attainment rises — it’s largest for those without a high school diploma and smallest for those with college degrees — but it never goes away. The average unemployment rate in 2015 for blacks with a college degree (4.1%), was higher than the rate for whites who had not completed college (4.0%). Indeed, college graduates are the only black workers with lower unemployment than the national average; whites with no high school diploma are the only whites whose average unemployment rate exceeds the national average. “Persistent disparities in unemployment are constant reminders of how race continues to have an undue influence on life in this country,” Wilson has written. These are arguments in favor of placing full employment at the forefront of policy goals, Wilson says. That means keeping interest rates low, despite pressure on the Federal Reserve “from monetary hawks to raise short-term interest rates as a guard against price and wage inflation.” Income disparities are just the tip of the iceberg in racial economic injustice. The racial gap in wealth is even greater. The Pew Research Center found in 2014 that the wealth of white households had reached 13 times the median wealth of black households, compared with eight times the wealth in 2010. That was the largest gap since 1989, when it was 17-to-1. The gap between white and Latino households was smaller, but still significant. Pew’s study showed that white household net worth had held steady after the recession, while that of black households continued a slide dating back to 2004. Latino family net worth peaked in 2007 and has declined since then. Underlying this gap in wealth is a gap in homeownership, according to Thomas Shapiro and colleagues at Brandeis University’s Institute on Assets and Social Policy. They determined that the racial gap in median net worth tripled from 1984 to 2009, expanding to $236,000 from $85,000. Much of the difference was home equity, which gave home-owning families a leg up in helping relatives with down payments, lowering the cost of borrowing and improving access to credit, Shapiro found. And though some of these advantages were eroded by the housing crash, many long-term homeowners were still able to weather the storm better than renters.The divergence in home ownership rates was stark, Shapiro’s team found using 2011 figures: About 73% of white households owned their homes, compared with only 45% among black households and 47% among Latinos. If black and Latino homeownership rates matched whites,' they would experience a huge increase in household net worth. (Thomas Shapiro, Demos) Had homeownership rates merely matched each other, black household net worth would be 450% higher and Latino wealth 350% higher. “If public policy successfully eliminated racial disparities in homeownership rates,” Shapiro and his colleagues observed, “median Black wealth would grow $32,113 and the wealth gap between Black and White households would shrink 31 percent.” Reducing the homeownership and thereby the wealth gap can be done, but requires aggressive federal policies. Among those spotlighted by Shapiro are strict enforcement of housing anti-discrimination laws; segregation limits the value gains in homes in black neighborhoods, while black and Latino families still face obstacles to moving into predominantly white areas. Fannie Mae and Freddie Mac should be encouraged to reduce principal and make other modifications to homeowners struggling with mortgage burdens in the wake of the housing crash; black and Latino families would be beneficiaries of such policies, which would help them preserve their home equity.The most important step for Americans in coming to grips with the nation’s racial heritage is recognizing that its social aspects are intertwined with its economics. As long as we fail to recognize the profound obstacles confronting black and Latino Americans in finding jobs and accumulating wealth, the social disparities will never disappear.A2: Income Inequality AdvSickest, politically weakest Americans will suffer under expanded MedicareHogberg, 15 [Dr. David Hogberg was a Washington Correspondent for Investor's Business Daily, specializing in his coverage of health care and Medicare. Prior to IBD, he worked as a policy analyst studying health care and other issues for various think tanks, including the National Center for Public Policy Research. He is a senior fellow at the National Center for Public Policy Research. He is author of Medicare’s Victims: How the U.S. Government’s Largest Health Care Programs Harms Patients and Impairs Physicians]. Why Medicare for all is a terrible idea. 30 July 2015. MHAnd what is Reich’s solution to this? As he states at the beginning of the article, “Medicare offers a way to reduce these underlying costs—if Washington would let it.” Well, Washington won’t let Medicare make such changes because it is filled with groups such as hospital and physician associations that have a vested interest in keeping a cash cow like Medicare largely the way it is. Those vested interests don’t care for the competition that would arise if Medicare started changing what it paid for. That problem would only be exacerbated if Congress opened up Medicare to everyone. Treatment under Medicare wouldn’t necessarily be determined by what was best for the patient but by who had sufficient political power to influence Congress on Medicare policy. As I argue in my new book, Medicare’s Victims, it is often the sickest patients who suffer the most under Medicare because they are the most likely to lack political power. Consider the Medicare patients who, as Reich complains, have to return to the hospital 20 percent of the time. There are probably too few of them to have much impact on Congressional elections, one of the most important ways of influencing Congress. Additionally, many of them may be quite ill and thus in no condition to be organizing, protesting, getting media coverage and other things that can get the attention of Congress to change Medicare policy. Those with political power would get good care, while those without such power—often the sickest—would lose out. That would be the nightmare result if Reich’s dream ever became a reality. Vermont proves Single Payer relies on massive tax hikes that exacerbate inequalityKliff, 15 [Sarah Kliff is one of the country's leading health policy journalists, who has spent seven years chronicling Washington's battle over the Affordable Care Act. The Supreme Court cited Sarah's work in their 2012 decision upholding the health care law.?She is the recipient of multiple reporting awards, including fellowships from the Association of Health Care Journalists and the Annenberg School of Journalism at the University of Southern California.Sarah is a frequent television guest and has appeared on CBS, PBS, Fox News, CNN, and MSNBC]. How Vermont's single-payer health care dream fell apart. 22 December 2014. MHThe models Gruber was running were meant to project the cost of Vermont's plan under different scenarios. What if the health plan covered 80 percent of the typical Vermonter's health care costs? What about 94 percent? But as the numbers got more concrete — as they closed in on the plan the governor actually wanted — the financial foundation began to crack. Lunge knew by that Friday that the single-payer system Vermont wanted to build would require about $2.5 billion in additional revenue in its first year. Each new packet of Gruber data was essentially the same as the old Gruber data. It kept showing that a single-payer system would be more costly than initially expected. "It was really over the weekend that we started to realize this might be too big an obstacle to surmount," said Lunge. But by moving all the financing to the government, a single-payer health plan like the one Vermont considered would lay naked the incredible costs of our health care system. Vermonters would certainly notice the 9 percent income tax hike and 11.5 percent payroll tax that the Shumlin administration concluded would be necessary to raise enough funds. What's more, single-payer would not have just changed how Vermont pays for health care — it would have changed who *pays, shifting more of the burden onto large companies. Right now, the way workers pay for health insurance is regressive: a private insurance company sets a price for their policy, and a worker who earns $30,000 has to put a bigger share of her paycheck towards buying it than someone who earns $100,000. Single-payer systems often rely on taxes, rather than set premium contributions. And that links the price of health insurance to how much someone earns. The proposed 9 percent income tax, for example, would be far more expensive for that $100,000 worker than the $30,000 earner. That new taxes are unpopular, even in Vermont, is not a surprise. But if Shumlin could have told Vermont businesses, "You'll pay slightly less than you used to for health care — it'll just be a tax rather than a premium," his plan may have just barely squeaked by. But he couldn't: the proposed taxes would ask higher earners to spend more on health care than they do now — in some cases, far more. "An 11.5 percent tax would look great if I'm a low-wage employer," said Schoen. "But I'm a high-wage employer, 11.5 percent is going to be way higher than what I used to pay to buy insurance." "You'd think that, if there was any state where this could fly politically, it should have been Vermont," said Matthew Dickinson, a political science professor at Middlebury College. "But in this case, the price was so big that even a state as solidly blue as Vermont wasn't able to swallow it." SP Would Increase Taxes On Low-Middle Income Individuals Starr 16 (Paul Starr?is co-founder and co-editor of the The American Prospect. and professor of sociology and public affairs at Princeton University. A winner of the Pulitzer Prize for General Nonfiction and the Bancroft Prize in American history, he is the author of seven books), The American Prospect, “The Larger Problems of Sanders Single Payer Plan”, February 29, 2016, Even if we accept Friedman’s lowball estimates of the cost, the Sanders plan would require staggering increases in federal taxes. Those increases raise two kinds of questions—about the feasibility of the taxes and about the opportunity costs of using so much tax revenue to substitute for private health expenditures. Sanders calls for six different increases to fund single-payer. Two of the changes—a new payroll tax of 6.2 percent and a new income tax of 2.2 percent—would affect everyone. The other four increases fall primarily on high-income households (higher income tax rates, taxing capital gains as ordinary income, eliminating deductions, higher estate taxes). Both sets of tax increases create serious political problems. As a result of the first set, the post-tax income of Medicaid beneficiaries (who now receive coverage for free) would fall 8.4 percent. Other low- and middle-income people, to be sure, would get coverage worth more than 8.4 percent of their income, but they might not think so. For households with incomes between $18,550 and $75,300, for example, marginal tax rates (payroll and income tax combined) would rise from 30.3 percent to 38.9 percent. That will be a hard sell. Whether people at that income level with employer-provided insurance would objectively be winners or losers under the Sanders plan depends on whether Friedman’s or Thorpe’s cost estimates are right. (Thorpe estimates that 70 percent of the privately insured come out losers.) But, subjectively, even many winners would see themselves as losers because they don’t feel that their employer’s health-insurance payments were their money to begin with. Perceptions bias calculations against a tax-financed alternative. The tax increases affecting high-income households raise other problems. I am in favor of more progressive taxes, but there is no peacetime precedent in American history for increases of the magnitude Sanders is talking about. In his health care and other proposals, Sanders proposes raising the top marginal rate on earnings (income taxes and payroll tax combined) to 77 percent—higher than in Sweden (67 percent), Denmark (55.6 percent), or any other European country. The capital-gains tax rate that Sanders is proposing (64.2 percent, not counting his financial transaction tax) would so high as to be counterproductive. At that level, the tax wouldn’t generate the expected revenue. People would hold on to appreciated assets rather than sell them, and capital would be locked into present uses, depressing new investment.Alt cause – US tax system is regressiveBerman 13’ (6/7/2013)(Jillian BermanAssociate Business Editor, The Huffington Post Associate Business Editor, The Huffington Post)2013/06/.../income-inequality-tax-system_n_3454216.htmlIncome for the country’s top 1 percent has soared by 275 percent over the past 30 years, while growth for the rest of us has stagnated. A new study finds that policymakers’ decisions to make the tax code less progressive played a large role in widening that gulf. About 30 percent of the expansion of the after-tax income gulf between the rich and not-so-rich between 1979 and 2007 was due to tax and budget policies becoming less redistributive, according to a recent paper from the Economic Policy Institute, a left-leaning think tank. In addition, the boost in income for the top 1 percent and the top 0.01 percent of households is correlated with tax cuts, the study found. In short: Policymakers’ decisions to slash taxes — especially on the rich — contributed to income inequality. Andrew Fieldhouse, the paper’s author and a budget policy analyst at EPI, said that while market forces are largely to blame for the growth in income inequality, the government bears responsibility for making it worse. “This is just another piece of evidence, at the broadest level, that Washington’s model for tax reform is completely divorced from economic research,” Fieldhouse told The Huffington Post. “Federal budget policy not only failed to push back these market forces, but exacerbated income inequality.” While EPI’s analysis is one of many to find that keeping taxes low — especially for the rich — widens the gap between the haves and have-nots, that hasn’t stopped policymakers from fighting tax increases. The budget President Barack Obama proposed earlier this year boosted taxes on the wealthy — but still by not has high of a margin as he originally promised — and it was met with opposition by leading Republicans. Recent research has found that slashing taxes on the rich doesn’t lead to the boost in economic growth promised by many proponents. And while some have argued that raising taxes on the rich will disincentivize them to work hard, another EPI study that rich households don’t respond to increases by being less productive — rather, the study found, they simply shift their income to categories that are taxed at lower rates (like investment income). Indeed, the jump in income inequality over the past few decades is correlated with a simultaneous boost in investment income, which is largely concentrated in the hands of the rich and is taxed at lower rates than the income earned from good old-fashioned work, according to EPI. The preferential tax treatment of investment income has increased over the past few decades, a factor which “almost certainly played a role” in widening the income gulf, the EPI paper found. More income inequality has consequences for Americans at all places along the income ladder. The large gap between the rich and the poor is slowing the nation’s recovery from the recession, Nobel Prize-winning economist Joseph Stiglitz wrote in a New York Times op-ed earlier this year. And reducing income inequality could prolong periods of economic growth, a 2011 study from the International Monetary Fund found.A2: Better Care AdvSP/MFA Would Lead to Shortages/Waitlists for healthcarePaige 15 (Leigh Page is a veteran writer with over 20 years of solid, proven experience, Leigh communicates, interprets and analyzes all aspects of healthcare for all types of media – from newsletters to brochures to annual reports and beyond. “Single-Payer System: Why It Would Ruin US Healthcare” Medscape. Date accessed 7-17-2017. ) ZWIn a pure single-payer system, doctors can only contract with the one payer available. Currently, in the United States, physicians have some choice of insurers to work with, and even in Medicare or Medicaid, doctors can opt out. But they couldn't do so in a pure single-payer system. "Providers remain ostensibly independent, but the single payer exercises significant controls," such as determining what services are "necessary," wrote John McClaughry, founder of the Ethan Allen Institute, a free market think-tank in Montpelier, Vermont. The single payer is a "monopoly HMO," he added. Critics say the single-payer program might start with acceptable reimbursement rates as a way to get physician buy-in, and then ratchet them down because there is no alternative. As Dr Accad has already pointed out, the single payer can reduce reimbursements with impunity, because it has a monopoly. Rather than restrict choices further, opponents of a single-payer system want to open up choices in the current system. "We should strike down state barriers to insurers and allow their products to be sold nationally," says Jim Geddes, MD, a trauma surgeon near Denver. Noah N. Chelliah, MD, a cardiologist in Grand Forks, North Dakota, agrees. "Auto insurance premiums are low because insurers had to compete with each other nationwide," he says. "The same could be done for health insurance." "When physicians become essentially employees of the government, which is what happens in a single-payer system, then everything pretty much breaks down," Dr Geddes says. "Only physicians are the best position to determine the quality of care. We're the number-one patient advocates." However, Dr Geddes does not believe that the United States would allow complete termination of commercial insurance. He thinks there would probably be private plans that people could purchase on their own, as is the case in the United Kingdom. However, "this would lead to a two-tiered system," he says. "I've seen it in the United Kingdom, and it's not what we should have here." Waiting lists are a familiar feature of single-payer systems, especially for higher-cost or cutting-edge healthcare. According to a report[ HYPERLINK "javascript:void(0);" 2] by the Fraser Institute, an independent think-tank in British Columbia, Canada, the median waiting time to get treatment from a specialist has doubled in the past 20 years, to 18.2 weeks. Canadian patients wait the longest for orthopedic surgery (42.2 weeks), neurosurgery (31.2 weeks), and plastic surgery (27.1 weeks). Dr Chelliah—whose North Dakota practice is 80 miles from the Canadian border—says that many Canadian patients on waiting lists come to him and other providers in the area for care. He thinks the waiting lists are intentional. "The way I see it, the Canadian system saves money by delaying care by rationing," he says. "The net result is that people die before they finally can get their care. I know that sounds provocative, but I think it's true." A few years ago, he noticed that a Canadian friend of his was huffing and puffing and told him he needed to get a stress test. His Canadian family physician was initially reluctant to order one but finally agreed, and then it took 3 months to get the stress test done. Even though the results were strongly positive, the man wasn't scheduled for an angiogram until the following year. The angiogram found a 99% blockage, called a "widow-maker," and he finally got a stent. "This patient could easily have died," Dr Chelliah says. Dr Accad pointed to a recent news report[ HYPERLINK "javascript:void(0);" 3] from Canada, in which a leukemia patient had a bone marrow donor, but she couldn't get the transplant because there wasn't a hospital bed available for her. Though the problem sounds crazy, "patients in these systems tend to accept waiting lists," he said.In Great Britain, the National Health Service (NHS), operating separately in England, Scotland, and Wales, not only finances healthcare but also owns hospitals, physician practices, and the practices of other providers of care. However, about 10% of Britons have access to private facilities paid through private insurance. Those who want to have expedited care buy private insurance. Dr Geddes recalls that his nephew had an anterior myocardial infarction while working in London. He was first transported to a nearby NHS hospital, but they didn't have a catheter lab to treat him, so he was sent to a catheter lab at a private hospital covered by his private insurance. "He probably would have died at an NHS hospital," Dr Geddes says. Dr Geddes believes strict government controls and impossibly long waiting lists have created a fatalistic attitude among many British doctors, and this makes the waiting lists even longer. Many years ago, he traveled to the United Kingdom to watch a British surgeon operate. The surgery team showed up at 8:00 AM and had two cases for the day. "The first case took a little too long, and afterward we had a leisurely lunch," he says. "The second patient was an open-heart case and had already been prepped, but they decided they wouldn't have enough time." The operation was postponed. "In the United States, we would have gone ahead with the second case and just stayed late," Dr Geddes said.Impact—Gov Picks and Chooses Who Gets HealthcareCampell 17 (Denis Campbell is health policy editor for the Guardian and the Observer. He has written about the NHS, public health and medicine since 2007) “Doctors forced to plead with NHS for treatments for patients, BMJ finds”, The Guardian, July 4, 2017, Growing rationing of healthcare is forcing more doctors to plead with the NHS to fund treatments patients need, including cataract removals, new hips and knees, and removal of varicose veins. GPs and hospital consultants in England submitted 73,927 exceptional requests on behalf of patients in 2016-17 in a bid to persuade the NHS to fund drugs or surgery they were initially denied, an investigation by the BMJ has found. That was almost 50% more than the 50,188 individual funding requests (IFRs) doctors put in to clinical commissioning groups (CCGs), the bodies that hold the NHS budget in local areas, in 2013-14. The revelations have prompted fresh concern among doctors and health experts that the cash-strapped NHS is increasingly denying patients treatments that were routinely available until recently. The sick “have misguidedly become soft targets for NHS savings”, the Royal College of Surgeons (RCS) has said. Impact—Patients Dying on WaitlistsPope 13 (Christopher M. Pope, PhD, is a Graduate Fellow in the Center for Health Policy Studies at the Heritage Foundation, “Legislating Low Prices: Cutting Costs or Care?”, The Heritage Foundation, August 9, 2013) Until recent-ly, the Netherlands had a similar system of price regulation and was lauded as a model for the United States to follow.[38] Yet state-regulated pricing led to shortages throughout the Dutch health care system and failed to control spending. Following an electoral backlash against growing waiting lists and deteriorating standards of care, the government deregulated prices. The resulting competition has since driven down costs and substantially improved quality. In the 1980s, after decades of expanding public entitlements to health care, the need to limit the growth of spending had become pressing. Rather than allowing cost sharing to constrain demand, the government sought to regulate the supply side, gradually imposing budget caps and price controls on hospitals and physicians according to “agreed upon expected output.”[39] Yet these reforms undermined incentives for efficiency and innovation. Shortages ensured that even the worst providers were oversubscribed, and the system became unresponsive to patient needs. Those needing heart transplants were hit particularly hard, with only one-third as many operations undertaken per capita as in the United States, and approximately 100 cardiac patients died every year while on waiting lists.[40] Despite steadily expanding government subsidies, shortages were widespread, and those needing long-term care faced particularly long waiting lists.MFA/SP Would De-incentivize Doctors and Hurt Quality of CareBook 9 (Robert A. Book, Ph.D., is Senior Research Fellow in Health Economics in the Center for Data Analysis at The Heritage Foundation.) “Single Payer: Why Government-Run Health Care Will Harm Both Patients and Doctors”, The Heritage Foundation, April 3, 2009, physicians, quite reasonably frustrated by the cost and hassle of dealing with billing multiple insurance companies-not to mention the time lost appealing seemingly arbitrary denials of payment-often conclude that the solution lies in a "single-payer" system along the lines of a "Medicare for all" concept. A single payer-a government agency-would at a minimum eliminate the duplication of effort associated with signing on and maintaining relationships with multiple private insurance companies. It would standardize billing processes and coverage rules and perhaps even establish clearly defined rules to reduce the frequency of apparently arbitrary "downcoding" and denials of payment. What many fail to appreciate, however, is the extent to which the existence of multiple, competing payers prevents government payers such as Medicare from reducing their payment levels to much lower levels than prevail now. As it stands, a reduction in Medicare payment rates can induce physicians to drop Medicare patients and try to make their living from a higher percentage of (or even only) privately insured patients. This would inevitably result in reduced access to care for Medicare patients-and thus political pressure from those patients for increased Medicare payments to improve access. If Medicare or something like it were the "single payer"-the sole purchaser of health care-no such pressure would exist. If the single payer established lower payment rates, by definition physicians could not drop out and make their living from other patients, because there wouldn't be any other patients.[3] The only alternative for a physician would be to cease the practice of medicine and either retire or find another profession. While this would certainly happen to some degree, a large percentage of physicians-who have invested many dollars and years of training in their practices-would be unable to find an alternative profession that is nearly as satisfying or as remunerative. The inevitable result would be much lower payment rates and lower income for physicians.[4] Patients would suffer as well, especially in the long run. Because fewer highly talented people would be willing to undergo the years of training (under difficult working conditions and low pay) to become physicians, patients would suffer decreased access to health care and longer wait times. Lower payments would mean that physicians would invest less in advanced medical equipment and would likely spend less time with each patient. In addition, with fewer people undergoing the training necessary to conduct medical research, new treatments and cures would be developed at a slower rate, costing many lives. Medicare Payment Levels Medicare determines the level of its payments to physicians based on a complex formula involving crude estimates of the relative costs of providing different services,[5] annual adjustments based on estimates of demand for services, and growth in the Medicare population and the overall economy. The annual adjustment process is expressed in the "Sustainable Growth Rate" (SGR) rule[6] which attempts to constrain the growth in Medicare spending and "make up" for the differences between previous years' estimated and actual utilization. Each year since 1999, the SGR calculation has called for a reduction in the Medicare payment levels (a "negative update") for physician services, because actual use outstripped previous forecasts, and forecasted future utilization outstripped the growth rate of the Medicare population and gross domestic product (GDP). And each year, physicians' representatives have gone to Congress to argue that reducing payments will cause some physicians to drop out of the Medicare program, reducing elderly Americans' access to health care. Negative updates were allowed to go into effect in only three of the last 11 years-in the other eight years, after intensive lobbying from physician groups, Congress has intervened and passed legislation either freezing payments or providing a positive update.[7] Competition Among Buyers The basis for the physicians' now-annual argument to Congress is that reducing Medicare payments will cause more physicians to drop Medicare patients and make their living from privately insured and self-paying patients only. Indeed, anecdotal evidence indicates that some physicians have already done so,[8] as Medicare payments are already significantly below those of private insurance by almost 20 percent for physician services overall and by 12 percent for primary care.[9] As if to demonstrate the effects of lower payments, in most states Medicaid payments are even lower than Medicare's, and far fewer physicians participate in Medicaid. Not surprisingly, states with relatively lower Medicaid payments compared to other states have lower rates of physician participation in Medicaid.[10] Access Issues Physician advocacy groups make the reasonable-and believable-argument that every reduction in the Medicare payment rates will result in a further reduction in the number of physicians who find it worthwhile to take Medicare patients and instead try to make their living from patients with private payers. A survey found that in response to a proposed 10 percent cut in Medicare rates, 28 percent of physicians would stop accepting new Medicare patients, 8 percent would stop treating Medicare patients already under their care, and much higher percentages would discontinue nursing home visits, reduce available hours, or defer investment in medical and health IT equipment.[11] Obviously, this would not affect physicians in all specialties equally. Most pediatricians have very few if any Medicare patients[12] and would hardly be affected at all, but cardiologists and oncologists, for example, would be hit hard, since a large percentage of their potential patients are over age 65. The impact on nephrologists would be especially severe, because anyone with end-state renal disease is covered by Medicare regardless of age. Yet for every reduction in the payment level, a few more physicians would find it better to drop Medicare than to stay in. The absence of other payers would give the "single payer" the freedom to reduce payments far more than Medicare can in the presence of a large percentage of privately insured patients. The result would be substantially lower payments-the "single payer" would be a "stingy payer." Physicians' income would be substantially reduced. Indeed, in countries with single-payer health systems, the average income of physicians is substantially lower than in the United States. For example, physicians in the Britain and Canada have incomes more than 30 percent lower than their U.S. counterparts.[13] The existence of multiple private payers limits not only the ability of Medicare but also that of private payers themselves to reduce payment levels. Although physicians usually face "take it or leave it" contracts from insurance companies, and most physicians have little ability to actually negotiate, a health plan that sets payment rates too low will find that many physicians choose to "leave it." When enough physicians leave, patients have difficulty obtaining access to care and eventually leave the health plan.A2: Disease OutbreaksInternational cooperation on outbreaks solvesBoard on Global Health 04 [The Board on Global Health?monitors and reports on global health issues and policies, “Learning from SARS: Preparing for the Next Disease Outbreak”, National Academic Press, 2004, pg. 208 ] BJAs the world becomes more conscious of microbial threats to health, countries are increasingly recognizing the necessity of reporting outbreaks promptly and cooperating fully in international efforts to contain them. Indeed, if there is one piece of good news to be noted from last year’s epidemic, it is the fact that—as David Heymann and Guenael Rodier observe in this chapter—an array of diagnostic and surveillance tools, coordinated strategies of containment, and international collaboration among scientists and public health authorities were in this case able to control the outbreak of SARS, even in the absence of curative drugs or vaccines. Nevertheless, last year’s experiences further reinforce the lessons that HIV/AIDS, influenza, Ebola, malaria, and a host of other persistent and emerging infectious diseases have already made clear—that the health of any one nation cannot be isolated from the health of its neighbors, and that public health challenges in any locality have the potential to reverberate swiftly around the globe. Karen Monaghan’s paper for the National Intelligence Council, which concludes this chapter, summarizes the continuing threat that SARS may still pose, as well as the challenges that lie ahead for attempting to contain any further deadly outbreaks of SARS or other infectious diseases in the future.The U.S already has initiatives in place to monitor outbreaksSun 14 [Lena Sun is a Pulitzer Prize winning journalist for the Washington Post, focusing on health issues, “U.S. launches new global initiative to prevent infectious-disease threats”, Washington Post, Feb. 13, 2014, ] BJ Faced with what they describe as a perfect storm of converging threats from infectious-disease epidemics, U.S. officials launched a global effort Thursday with more than two dozen countries and international organizations to prevent deadly outbreaks from spreading.The goal is to prevent, detect and respond to infectious-disease threats where they start. That’s more effective and less costly than treating sick people after diseases spread. The new initiative is ?intended to bolster security at ?infectious-disease laboratories, strengthen immunization programs and set up emergency response centers that can react to outbreaks within two hours.Despite advances in medicine and technology, Americans are at greater risk than ever from new infectious diseases, drug-resistant infections and potential bioterrorism organisms, said Thomas Frieden, director of the Centers for Disease Control and Prevention, which is spearheading the initiative.On Thursday — even though federal offices in Washington were closed because of a major snowstorm — Health and Human Services Secretary Kathleen Sebelius welcomed officials to a meeting held at department headquarters to launch the effort. “Global health security is a shared responsibility. No one country can achieve it alone,” she said. “A threat anywhere is indeed a threat everywhere.”Lisa Monaco, assistant to the president for homeland security and counterterrorism, said biological threats can “emerge quickly, travel quickly and take lives.” She cited the H7N9 bird flu virus, a virus first reported in China last year, and Middle East respiratory syndrome (MERS), first reported in Saudi Arabia in 2012.Virulent diseases burn themselves out – No extinctionCarlson 07 [Shawn Carlson has a PhD in nuclear physics and is a MacArthur Fellow, “Top Scientist Advocates Genocide for 90% of World Population”, ISKCON, August 26, 2007, ] BJ The data stand utterly against this idea. Plagues have run rampant through human populations throughout time. Millions have died. Huge fractions of some populations have been wiped out. But the net death rate has never come close to the fractions that Pianka envisions. Virulent diseases that kill quickly tend to burn themselves out. Natural selection creates less lethal varieties because an organism can't spread if it kills its host before it can propagate. The flu pandemic of 1918 (the influenza virus is championed by Pianka) may have killed 50 million people, but that was only about 5 percent of those infected. Moreover, every year sees medical advancements—screening techniques improve, as do our methods of creating new vaccines and treating illness of all kinds. Not only that, a desperate situation would be met by desperate measures, including the implementation of martial law, the halting of all air and ground traffic except for emergency vehicles and so on, to stop contagion.Disease pandemics are unlikely to arise – specific conditions must be metAdalja 16 [Amesh Adalja is an infectious-disease physician at the University of Pittsburgh. “Why Hasn't Disease Wiped out the Human Race?”, The Atlantic, June 17th, 2016, ] BJ Any apocalyptic pathogen would need to possess a very special combination of two attributes. First, it would have to be so unfamiliar that no existing therapy or vaccine could be applied to it. Second, it would need to have a high and surreptitious transmissibility before symptoms occur. The first is essential because any microbe from a known class of pathogens would, by definition, have family members that could serve as models for containment and countermeasures. The second would allow the hypothetical disease to spread without being detected by even the most astute clinicians.The three infectious diseases most likely to be considered extinction-level threats in the world today—influenza, HIV, and Ebola—don’t meet these two requirements. Influenza, for instance, despite its well-established ability to kill on a large scale, its contagiousness, and its unrivaled ability to shift and drift away from our vaccines, is still what I would call a “known unknown.” While there are many mysteries about how new flu strains emerge, from at least the time of Hippocrates, humans have been attuned to its risk. And in the modern era, a full-fledged industry of influenza preparedness exists, with effective vaccine strategies and antiviral therapies.HIV, which has killed 39 million people over several decades, is similarly limited due to several factors. Most importantly, HIV’s dependency on blood and body fluid for transmission (similar to Ebola) requires intimate human-to-human contact, which limits contagion. Highly potent antiviral therapy allows most people to live normally with the disease, and a substantial group of the population has genetic mutations that render them impervious to infection in the first place. Lastly, simple prevention strategies such as needle exchange for injection drug users and barrier contraceptives—when available—can curtail transmission risk.Ebola, for many of the same reasons as HIV as well as several others, also falls short of the mark. This is especially due to the fact that it spreads almost exclusively through people with easily recognizable symptoms, plus the taming of its once unfathomable 90 percent mortality rate by simple supportive care.Beyond those three, every other known disease falls short of what seems required to wipe out humans—which is, of course, why we’re still here. And it’s not that diseases are ineffective. On the contrary, diseases’ failure to knock us out is a testament to just how resilient humans are. Part of our evolutionary heritage is our immune system, one of the most complex on the planet, even without the benefit of vaccines or the helping hand of antimicrobial drugs. This system, when viewed at a species level, can adapt to almost any enemy imaginable. Coupled to genetic variations amongst humans—which open up the possibility for a range of advantages, from imperviousness to infection to a tendency for mild symptoms—this adaptability ensures that almost any infectious disease onslaught will leave a large proportion of the population alive to rebuild, in contrast to the fictional Hollywood versions.A2: Avian FluAff is fearmongering, H7N9 shows no threatening singsMcNeil 3/1/17 [Donald G. McNeil Jr. is a science and health reporter specializing in plagues and pestilences. “China’s Bird Flu Surge Is a Low Epidemic Threat, W.H.O. Says,” New York Times, March 1st, 2017, ] BJAlthough there has been a surge in human infections with H7N9 avian flu in China this winter, the risk of an epidemic remains low, a World Health Organization official said on Wednesday. But the virus — which has killed about a third of the people known to have caught it — has now split into two distinct strains. That will probably force development of a second small stockpile of emergency vaccine to be rolled out if the virus becomes more transmissible and threatens to turn into a pandemic, a scientist at the Centers for Disease Control and Prevention said. Flu specialists from around the world gathered in Geneva this week to assess the global influenza situation and discuss with vaccine companies which viral strains should be in next winter’s flu shots. China has had 460 lab-confirmed human cases of H7N9 bird flu this winter, said Dr. Wenqing Zhang, head of the W.H.O.’s global influenza program. That is the most in any flu season since the first human case was found in 2013. The new strain kills more birds, which may make China’s poultry industry more willing to shut live bird markets and do more to protect poultry farms from infection. Almost all cases have been caught directly from birds. A few cases have been passed from a victim to a family member or caregiver, but there is no evidence of “sustained human-to-human transmission,” Dr. Zhang said. A2: BioterrorBioterrorism is not likely to occur - too many barriers to acquisitionKrauss 12 [Lawrence Krauss is a theoretical physicist at Arizona State University and has a PhD in Physics from MIT, he is Co-President of the Bulletin of the Atomic Scientists, "Countdown to the Man-Made Apocalypse," Slate, March 16, 2012, ] BJSince then, we have run three “Doomsday Symposia,” during which key scientists and policymakers assess ongoing global threats to humanity in three areas: nuclear proliferation and nuclear weapons, climate change, and biotechnology and bioterrorism. The last issue has raised a lot of heat in the media in recent years, and the specter of new lethal viruses that might wipe out populations suggested to us that there might be compelling new reasons to move the clock forward again. Indeed, as biotechnology has undergone in the past 35 years the same explosive growth that physics technology underwent in the previous period, the emerging possibility of biologically induced weapons has increased. We now have the ability to artificially recreate genetic sequences, including viruses. DNA “hacking” has become a pastime at institutions such as MIT, among the same kind of people who used to be so enamored with computer hacking. Finally, the holy grail of genetic manipulation now involves the frontiers of synthetic biology, wherein researchers are attempting not merely to build up genetic sequences base-pair by base-pair, but also to explore the possibility of building novel life forms from scratch. These developments are thrilling for scientists and technologists who love to take things apart and put them back together. But there remains the terrifying prospect that smart pranksters, DIYers, a laboratory, or more sinister groups could, either by accident or intentionally, accidentally create a new supervirus with the potential to wipe out all other life on Earth. (Hence the furious debate that has surrounded experiments into artificially developing forms of the avian flu virus H5N1 that is transmittable between mammals.) Indeed, just this week, a host of external watchdog organizations have called this week for a moratorium on synthetic biology. We should encourage the vigilance and rigorous discussion that has accompanied these developments. Happily, however, the bulletin’s experts, including Harvard biologist Matthew Meselson and human genome pioneer and synthetic biologist Craig Venter, suggest the above scenarios are in the near term unlikely at best, pure fiction at worst. In the first place, the synthetic-biology industry is well-aware of the dangers of unmonitored genetic hacking and is responding on its own. Appeased by the group’s self-policing thus far, the Presidential Commission for the Study of Bioethical Issues determined in 2010 that “there is no reason to endorse additional federal regulations or a moratorium on work in this field at this time.” In the second place, while manufacturing dangerous biological compounds may be possible, weaponizing them is not so easy. While it might be possible to inflict significant terror locally, dispersing biological agents over broad regions to create global crises is far more challenging. Next, there is the difficulty of reproducing appropriate technology. The field is as much an art as a science, and it is difficult to reliably reproduce results in a field where the financial benefits are likely to be so great that proprietary technology is not readily shared. We can all (at least those of us who, unlike some of the dominant presidential candidates, accept the reality of both evolution and an old earth) take solace in the robustness of life itself, evolved over 4.5 billion years in the presence of remarkably ingenious viruses, which have also competed for survival. It is unlikely that a new organism, without the benefit of all of this “learned experience,” could outmaneuver all the mechanisms that life has developed to outwit constant biological invaders. All of this suggested to those of us who have the unenviable task of regularly revisiting the possibility of Doomsday in order to help humanity adjust its thinking appropriately, that the current revolution in biotechnology is, for the moment, more likely to benefit humankind than destroy it. Bioterrorism Also Has Several Barriers To ImplementationKeller 13 [Rebecca Keller is a Senior Science and Technology Analyst at Stratfor, Dr. Keller holds a doctorate in organic chemistry from Colorado State University, “Bioterrorism and the Pandemic Potential”, Strafor, March 7, 2013, ] BJThe risk of an accidental release of H5N1 is similar to that of other infectious pathogens currently being studied. Proper safety standards are key, of course, and experts in the field have had a year to determine the best way to proceed, balancing safety and research benefits. Previous work with the virus was conducted at biosafety level three out of four, which requires researchers wearing respirators and disposable gowns to work in pairs in a negative pressure environment. While many of these labs are part of universities, access is controlled either through keyed entry or even palm scanners. There are roughly 40 labs that submitted to the voluntary ban. Those wishing to resume work after the ban was lifted must comply with guidelines requiring strict national oversight and close communication and collaboration with national authorities. The risk of release either through accident or theft cannot be completely eliminated, but given the established parameters the risk is minimal. The use of the pathogen as a biological weapon requires an assessment of whether a non-state actor would have the capabilities to isolate the virulent strain, then weaponize and distribute it. Stratfor has long held the position that while terrorist organizations may have rudimentary capabilities regarding biological weapons, the likelihood of a successful attack is very low. Given that the laboratory version of H5N1 -- or any influenza virus, for that matter -- is a contagious pathogen, there would be two possible modes that a non-state actor would have to instigate an attack. The virus could be refined and then aerosolized and released into a populated area, or an individual could be infected with the virus and sent to freely circulate within a population. There are severe constraints that make success using either of these methods unlikely. The technology needed to refine and aerosolize a pathogen for a biological attack is beyond the capability of most non-state actors. Even if they were able to develop a weapon, other factors such as wind patterns and humidity can render an attack ineffective. Using a human carrier is a less expensive method, but it requires that the biological agent be a contagion. Additionally, in order to infect the large number of people necessary to start an outbreak, the infected carrier must be mobile while contagious, something that is doubtful with a serious disease like small pox. The carrier also cannot be visibly ill because that would limit the necessary human contact. As far as continued research is concerned, there is a risk-reward equation to consider. The threat of a terrorist attack using biological weapons is very low. And while it is impossible to predict viral outbreaks, it is important to be able to recognize a new strain of virus that could result in an epidemic or even a pandemic, enabling countries to respond more effectively. All of this hinges on the level of preparedness of developed nations and their ability to rapidly exchange information, conduct research and promote individual awareness of the threat.Ptx LinksPlan is popular – demsDems like the planSuzy Khimm, 7-15-17. (Khimm: Freelance writer in Washington. “’Medicare for All’ Isn’t Sounding so Crazy Anymore.” NYT. Accessed 7-18-17. JSD)Single payer is now poised to become the standard position for the Democratic base. More elected Democrats are following suit as Republicans struggle to get their deeply unpopular health care bill past Congress. The prevailing assumption is that the G.O.P. effort will ultimately implode, clearing the way for a bold alternative. Senator Dick Durbin [would], the upper chamber's second-highest-ranking Democrat, told me that he'd happily sign onto a single-payer bill - and might even bring one to the floor himself. But while liberals have spent decades pining for single payer - Ted Kennedy drew up a bill in 1970 - there are surprisingly few detailed proposals. M4A causes democratic legislative momentumPlan gives dems needed momentum Brad Bannon, 7-11-17. (Bannon: Democratic Pollster and CEO of Bannon Communication Research. Political analyst for CLTV. “4 Reasons why Democrats Support Medicare for All.” The Hill. Accessed 7-21-17. JSD)Medicare for all is good politics Democrats must push aggressively on issues where we have a big advantage. A survey conducted in June by NBC News and the Wall Street Journal indicates that the biggest advantage Democrats have over Republicans is on health care. Americans think Democrats do a better job on healthcare than Republicans by a margin of 43 percent to 26 percent. President Andrew Johnson once said Washington is 12 square miles surrounded by reality. The conventional wisdom in the swampland is that Medicare for all is a health hazard for Democrats. But a national survey last month by the Kaiser Family Foundation found American supported the expansion of government run healthcare. So, what are Democrats afraid of anyway? A Fight for Medicare for all Demonstrates Democratic Determination Trump won because he sounded and acted like a bull in a china shop which is what angry voters wanted. In contrast, Democrats walk on eggshells and don't sound angry enough to shake things up in Washington. A push for universal health insurance is a great way for Democrats to prove that they’re not intimidated by D.C. conventional wisdom and a tough fight. Leadership means Dems need more than blind opposition to Trump. Republicans including Trump win with all sorts of push the envelope issue stands. During the campaign last year Trump and most successful GOP candidates pushed for repeal of ACA, even though few voters wanted to destroy Obamacare. A poll conducted for National Public Radio last month showed that only a quarter of the public favored repeal while everybody else either wanted to fix Obamacare or even extend it. Taking unpopular stands on issues demonstrates leadership and boldness to Americans who are frustrated with the status quo. The good news for Dems is that Medicare for all is more than twice popular than Trumpcare.Federalism LinkM4A violates federalismMedicare 4 All violates FederalismHarold Pollack 15. 8-1-15 (Pollack – Helen Ross professor at Uchicago. Masters and PhD in public policy from Harvard. Heavily published for Public health policy. “Medicare for All – If it were Politically Possible -Would Necessarily Replicate the Defects of Our Current System.” Journal of Health Politics, Policy & Law [peer-reviewed, associated with Duke]. Accessed 7-19-17. JSD.) This is telling. Medicare for All would require a serious rewrite of state-federal relations, radical surgery to the Employee Retirement Income Security Act (ERISA), the digestion of various Medicaid functions now performed by state governments, and a myriad of other granular details. Then there are the legal and constitutional challenges. Some would argue that Medicare for All avoids the ACA’s constitutional minefields exemplified by the individual mandate. It doesn’t. The basic issues in National Federation o f Independent Business v. Sebelius, 132 S. Ct. 2566 (2012), went beyond whether a mandate is a tax or other niceties. The real fight concerned the constitutional propriety of a post-New Deal expansive federal government that seeks to regulate and humanize our national health care market. Medicare for All would stake an even greater claim to contested views of federalism and the reach of national government. At this writing, one awkward sentence of the ACA has produced a specious but dangerous Supreme Court challenge in King v. Burwell (759 F.3d 358 (4th Cir. 2014), cert, granted, 135 S.Ct. 475 (2014)). I’m confident that constitutional conservative advocates and judges would identify more plausible concerns and glitches in any single-payer plan. Many of the most sensitive challenges that now bedevil the ACA would be sensitive challenges to a Medicare for All system, as indeed they long have been within Medicare and Medicaid. Within any financing system, we would require new care models for complex patients. We would face the economic, organizational, and human challenges of end-of-life care. We would make difficult decisions about network adequacy and patient cost sharing and face difficult questions in designing essential health benefit provisions for autism, substance use disorders, and cancer. We would face difficult questions regarding safety net reimbursement rates. We would face our society’s tenuous commitment to the well-being of our most disadvantaged citizens. Federalizing care for dual-eligible Medicare-Medicaid recipients might be done in a way that resembles states with the most expansive Medicaid programs. Just as plausibly, national policies could resemble the policies of far less generous statesCp ideasBolster ACA, solves affFixing ACA paves the way for Medicare for All eventuallyHarold Pollack 15. 8-1-15 (Pollack – Helen Ross professor at Uchicago. Masters and PhD in public policy from Harvard. Heavily published for Public health policy. “Medicare for All – If it were Politically Possible -Would Necessarily Replicate the Defects of Our Current System.” Journal of Health Politics, Policy & Law [peer-reviewed, associated with Duke]. Accessed 7-19-17. JSD.) For the foreseeable future, the main health policy challenge is to make the ACA work. One challenge is to make the new marketplaces more attractive, accessible, and useful for ordinary people who seek affordable coverage that will actually protect them if they need it. Consumers need more human and automated decision supports to help them navigate the different-tiered plans and to match available offerings to their individual circumstances. We need to pursue comparative effectiveness research and explore new delivery models required to improve care under any broad financing system. We need new revenue sources to stabilize the federal budget in the event that health expenditures rise more quickly than we expect to see We should also explore ways of making health coverage less burdensome and costly to employers. Seidman— and many conservatives— are right to note the toxic impact of employer-based coverage from many perspectives. The employer mandate has been modestly helpful in easing the transition to an exchange-based health care system. Over time, it seems wise to weaken and perhaps abandon this requirement once the new marketplaces function effectively. We would also be wise in supporting politically generative measures within the general framework of the ACA I hope that the public option returns in some form as a viable choice within the new marketplaces. One 930 Journal o f Health Politics, Policy and Law possibility would be to allow individuals over the age of sixty the option of purchasing public insurance coverage. Many Americans would welcome this option, which would also provide needed competition and market discipline of providers. Policies like this may someday pave the way to a Medicare for All system. More likely, these would allow the possibility of public insurance carving out a complicated coexistence with private coverage. This may be the best outcome. If we keep our shoulder to the wheel in pursuing the messy, frustratingly incremental process of health reform, we can create a more humane and disciplined health system. That’s no small accomplishment. I’m not sure what else we can do either.All-payer rate setting CPCP solves, reduces costsEzra Klein, 14. 1-9-14. (Klein: Bloomberg columnis. “What Liberals Don’t Get About Single Payer.” Bloomberg. Accessed 7-18-19 JSD.)A health-care system that followed international best practices would direct the government to set rates. Or it would let insurers band together and negotiate rates collectively -- a practice called “all-payer rate setting.” But it wouldn’t need to eliminate private insurers. It’s good for consumers to have a choice of insurers, who have real incentives to innovate and devise better ways to keep customers healthy and costs down. It’s health-care providers -- not insurers -- who have too much power in the U.S. system. As a result, they have the most to lose if health-care prices fall. But, as is often the case, political power flows in part from popularity. So politicians who routinely rail against for-profit insurers are scared to criticize -- much less legislate against -- for-profit hospitals, doctors or device manufacturers (though drug companies come in for a drubbing now and then). These are the people who work every day to save our lives, even if they make us pay dearly for the privilege.Cost transparency CPRestructure of system is key-not more GovernmentKaplan, 11 [Robert S. Kaplan received a B.S. and M.S. in Electrical Engineering from M.I.T., a Ph.D. in Operations Research from Cornell University, and honorary doctorates from several international universities. Elected to the Accounting Hall of Fame in 2006. He currently works with Michael Porter on the HBS Value Based Health Care initiative to introduce time-driven activity-based costing (TDABC) and value-based bundled payments to health care. The goal is to motivate the health care sector to restructure around delivering superior patient outcomes at significantly lower total cost. The Big Idea: How to Solve the Cost Crisis in Health Care. September 2011]. . health care costs currently exceed 17% of GDP (gross domestic product) and continue to rise. Finally, poor measurement of cost and outcomes also means that effective and efficient providers go unrewarded, while inefficient ones have little incentive to improve. Indeed, institutions may be penalized when the improvements they make in treatments and processes reduce the need for highly reimbursed services. Without proper measurement, the healthy dynamic of competition—in which the highest-value providers expand and prosper—breaks down. Instead we have zero-sum competition in which health care providers destroy value by focusing on highly reimbursed services, shifting costs to other entities, or pursuing piecemeal and ineffective line-item cost reductions. Current health care reform initiatives will exacerbate the situation by increasing access to an inefficient system without addressing the fundamental value problem: how to deliver improved outcomes at a lower total cost. Fortunately, we can change this state of affairs. And the remedy does not require medical science breakthroughs or top-down governmental regulation. It simply requires a new way to accurately measure costs and compare them with outcomes. Our approach makes patients and their conditions—not departmental units, procedures, or services—the fundamental unit of analysis for measuring costs and outcomes. The experiences of several major institutions currently implementing the new approach—[the Head and Neck Center at MD Anderson Cancer Center in Houston, the Cleft Lip and Palate Program at Children’s Hospital in Boston], and units performing knee replacements at Sch?n Klinik in Germany and Brigham & Women’s Hospital in Boston]—confirm our belief that bringing accurate cost and value measurement practices into health care delivery can have a transformative impact.K linksInsurance sets an economic value to lifeNHI necessitates the government placing a value on human lifePeter Singer, 09. 7-19-09 (Singer: bioethics professor at Princeton. Laureate prof at Universtiy of Melbourne. “Why We Must Ration Health Care.” New York Times. Accessed 7-22-17. JSD)Though such feel-good claims may have some symbolic value in particular circumstances, to take them seriously and apply them — for instance, by leaving it to chance whether we save one life or a billion — would be deeply unethical. Governments implicitly place a dollar value on a human life when they decide how much is to be spent on health care programs and how much on other public goods that are not directed toward saving lives. The task of health care bureaucrats is then to get the best value for the resources they have been allocated. It is the familiar comparative exercise of getting the most bang for your buck. Sometimes that can be relatively easy to decide. If two drugs offer the same benefits and have similar risks of side effects, but one is much more expensive than the other, only the cheaper one should be provided by the public health care program. That the benefits and the risks of side effects are similar is a scientific matter for experts to decide after calling for submissions and examining them. That is the bread-and-butter work of units like NICE. But the benefits may vary in ways that defy straightforward comparison. We need a common unit for measuring the goods achieved by health care. Since we are talking about comparing different goods, the choice of unit is not merely a scientific or economic question but an ethical one. ................
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