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SINGLE PAYER 2.0...............................................................................................................................................1 **1AC**..................................................................................................................................................................6 HEALTHCARE 1AC - INH....................................................................................................................................7 HEALTHCARE 1AC – ECON ADV......................................................................................................................8 HEALTHCARE 1AC – ECON ADV......................................................................................................................9 HEALTHCARE 1AC – ECON ADV....................................................................................................................10 HEALTHCARE 1AC – ECON ADV....................................................................................................................11 HEALTHCARE 1AC – ECON ADV....................................................................................................................12 HEALTHCARE 1AC – ECON ADV....................................................................................................................13 HEALTHCARE 1AC – ECON ADV....................................................................................................................14 HEALTHCARE 1AC – ECON ADV....................................................................................................................15 HEALTHCARE 1AC – COMP ADV...................................................................................................................16 HEALTHCARE 1AC – COMP ADV...................................................................................................................17 HEALTHCARE 1AC – COMP ADV...................................................................................................................18 HEALTHCARE 1AC – COMP ADV...................................................................................................................19 HEALTHCARE 1AC – COMP ADV...................................................................................................................20 ...............................................................................................................................................................................20 HEALTHCARE 1AC - PLAN...............................................................................................................................21 HEALTHCARE 1AC - SOLVENCY....................................................................................................................22 HEALTHCARE 1AC - SOLVENCY....................................................................................................................24 HEALTHCARE 1AC - SOLVENCY....................................................................................................................25 HEALTHCARE 1AC - SOLVENCY....................................................................................................................26 HEALTHCARE 1AC - SOLVENCY....................................................................................................................27 **INHERENCY**................................................................................................................................................28 Obama HC Inev.....................................................................................................................................................29 Obama HC Inev.....................................................................................................................................................30 Obama HC Inev.....................................................................................................................................................31 ...............................................................................................................................................................................31 Obama HC Inev.....................................................................................................................................................32 Obama HC Fails - Cost.........................................................................................................................................33 Obama HC Fails - Concessions............................................................................................................................34 Obama HC Fails – Industry Profit.........................................................................................................................35 Obama HC Not Single Payer................................................................................................................................36 Universal Reform Fails - Congress........................................................................................................................37 Universal Reform Fails – Health Politics .............................................................................................................38 ...............................................................................................................................................................................38 ...............................................................................................................................................................................38 **ECON – STATES**..........................................................................................................................................39 2AC AT: Stimulus Solves State Deficits...............................................................................................................40 2AC AT: Kills Econ...............................................................................................................................................41 2AC AT: US Not Key to Global Econ...................................................................................................................42 Medicaid Costs High Now....................................................................................................................................43 ...............................................................................................................................................................................43 Medicaid Drains State Budgets.............................................................................................................................44

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Obama HC Drains State Budgets...........................................................................................................................45 ...............................................................................................................................................................................45 Obama HC Drains State Budgets..........................................................................................................................46 Obama HC Drains State Budgets...........................................................................................................................47 ...............................................................................................................................................................................47 Obama HC Drains State Budgets..........................................................................................................................48 Obama HC Drains State Budgets...........................................................................................................................49 Obama HC Drains State Budgets...........................................................................................................................50 State Deficits Now – No HC..................................................................................................................................52 State Deficits Now – No HC..................................................................................................................................53 State Deficits Now – No Education.......................................................................................................................54 State Deficits Now – No Education.......................................................................................................................55 State Deficits Now – Job Loss...............................................................................................................................56 ...............................................................................................................................................................................56 ...............................................................................................................................................................................56 States Deficit Now—Tradeoffs .............................................................................................................................57 State Deficits Now—Tradeoffs .............................................................................................................................58 State Deficits Now –Tradeoffs ..............................................................................................................................59 State Deficits Tank Econ.......................................................................................................................................60 State Deficits Tank Econ.......................................................................................................................................61 State Deficits Tank Econ.......................................................................................................................................62 More Stimulus Needed - Unemployment..............................................................................................................63 More Stimulus Needed - Insufficient.....................................................................................................................64 More Stimulus Needed - Statistics.........................................................................................................................65 ...............................................................................................................................................................................65 More Stimulus Needed – States Key.....................................................................................................................66 More Stimulus Needed – States Key.....................................................................................................................67 ...............................................................................................................................................................................67 More Stimulus Needed – States Key.....................................................................................................................68 More Stimulus Needed – States Key.....................................................................................................................69 A2: ARRA Stimulus Solves Medicaid Deficits.....................................................................................................70 Trickle Up Stimulus Needed..................................................................................................................................71 Fed Action Key......................................................................................................................................................72 ...............................................................................................................................................................................72 ...............................................................................................................................................................................72 Federalize Medicaid Solves State Budgets............................................................................................................73 Medicaid Reform Solves State Budgets................................................................................................................74 Medicaid Reform Solves State Budgets................................................................................................................75 ...............................................................................................................................................................................75 Single Payer Solves State Deficits.........................................................................................................................76 Kentucky – Medicaid Chopping Block..................................................................................................................77 Louisiana – Medicaid Deficit.................................................................................................................................78 **ECON – FEDERAL DEF**..............................................................................................................................80 Consumer Confidence Low Now...........................................................................................................................81 **ECON IMPACTS**..........................................................................................................................................82 Lashout ! Scenario.................................................................................................................................................83

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China ! Scenario (1/2)............................................................................................................................................84 China ! Scenario (2/2)............................................................................................................................................85 Terror ! Scenario....................................................................................................................................................86 **COMPETITIVENESS**...................................................................................................................................87 Competitiveness K2 Heg.......................................................................................................................................88 Econ K2 Heg..........................................................................................................................................................89 Econ Decline Killing Heg Now.............................................................................................................................90 Econ K2 Obama Agenda.......................................................................................................................................91 HC Reform Key to Econ........................................................................................................................................92 ...............................................................................................................................................................................93 Deflation Coming...................................................................................................................................................93 Deflation Coming .................................................................................................................................................94 ...............................................................................................................................................................................94 Increases Competitiveness.....................................................................................................................................95 Competitiveness K2 Growth..................................................................................................................................96 ...............................................................................................................................................................................96 **Medicaid Reform**...........................................................................................................................................97 Federalize Medicaid Good ....................................................................................................................................98 Medicaid Reform Needed .....................................................................................................................................99 Medicaid Reform Needed ...................................................................................................................................100 Medicaid Reform Needed....................................................................................................................................101 .............................................................................................................................................................................101 Medicaid Reform Needed....................................................................................................................................102 Medicaid Bad.......................................................................................................................................................103 Reform Must Start With Medicaid......................................................................................................................104 Medicare Spill Up ...............................................................................................................................................105 Slow Phase In Key – Medicare & Australia Prove..............................................................................................106 Medicare Subsume Medicaid?............................................................................................................................107 Medicaid Expansion Key.....................................................................................................................................108 **SOLVENCY**................................................................................................................................................109 .............................................................................................................................................................................109 .............................................................................................................................................................................109 Low-Income Uninsured Coverage Needed..........................................................................................................110 Solvency – Medicare Based System Solves........................................................................................................111 Squo Reform Fails – Need Single-Payer.............................................................................................................112 Squo HC Fails......................................................................................................................................................113 Single Payer Solves - Waste................................................................................................................................114 .............................................................................................................................................................................114 Single Payer Solves – Waste & Patchwork.........................................................................................................115 Single Payer Solves – Bureaucracy.....................................................................................................................116 Single Payer Solves – Medical Consensus..........................................................................................................117 Single Payer Solves – Dem Accountability.........................................................................................................118 Single Payer Solves – Fair Wages.......................................................................................................................119 Single Payer Solves – Drug Costs.......................................................................................................................120 Single Payer Solves - Physicians.........................................................................................................................121 Single Payer Solves –Efficient ............................................................................................................................122

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..........................................................................................151 2AC Healthcare Politics (2/3)...128 A2: Bureaucracy........................................................................................................................141 A2: Physician Backlash..........................................................................................................................164 2AC Immigration DA (4/4)....................................................................................................................................131 A2: National Health Program Bad..................................................................................................................................................141 ..............................................143 Small Business Add-on...........................................................166 You’re A Jerk 4 ................146 **2AC**....................................................................................132 A2: Canada Empirically Fails...........................154 2AC CTBT Politics (2/3).....................................................................................................135 A2: Socialized Medicine..............................163 2AC Immigration DA (3/4).....................................................................................................158 2AC Econ DA (3/3).......................134 A2: Socialized Medicine .............................................................................................................................................................................................................................................................................................................125 Uninsured are Poor ........................................................................................................................................................152 2AC Healthcare Politics (3/3)........................................................................................................................................................................................................................................................................162 2AC Immigration DA (2/4).................149 Losers Win?.....................................................................................................................................................................156 2AC Econ DA (1/3)..............................................................................................................................................................................................................124 Uninsured Impoverished ...............................................142 **Add-ons**................................137 A2: Free Market More Efficient.........................161 2AC Immigration DA (1/4)...............................................................................................................................................................................Single Payer 2...........................................................133 A2: Rationing........................................................................................................................................................................................126 A2: High Cost...........................................................................................................................................................127 A2: No Innovation/Wait..................................................................................................................................................................150 2AC Healthcare Politics (1/3).............................................................140 A2: Managed Competition.........................................................................................................................................................................................................................................................................................................155 2AC CTBT Politics (3/3).................................................................................................................................................................................................................160 2AC Military DA (2/2)...........................................................................................................................................................................................................................................................148 Plan Unpop.................................................................123 Single Payer Solves –Empirics...............................................................................................................................138 A2: O’Neill.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................140 ...........................................129 A2: Utopian?.....................165 2AC States CP (1/2)..................................................153 2AC CTBT Politics (1/3).........................................................................................................................................................................................................................................136 A2: MSA/HSA................................147 Plan Pop...............................................................................................................................................................................................................................................................................................................................................................................................................144 Small Business Add-on Ext.............................................................................................................139 A2: Employer-Based HC........................................................................................................................................................................................................130 A2: Scale Up Not Possible............159 2AC Military DA (1/2).......................................................................................145 Equal Protection...........157 2AC Econ DA (2/3)........................................................................................................................................................................................................................................................................................................................................................0 LO 4 Single Payer Solves –Efficient................................................................................................................

..............................................................................................171 ......................170 A2: States CP .................................................................Single Payer 2................................................................................................................168 A2: States CP ...................................................................................................................................................................................................................................................................................................................167 A2: States CP............0 LO 5 2AC States CP (2/2)...........................169 A2: States CP...................................................................................................................171 A2: Pincer CP/Medicaid Expansion CP............................................................................................................................................................................................................................................172 You’re A Jerk 5 ...............................................................................................................................................................169 ....................................................

Single Payer 2.0 LO 6 **1AC** You’re A Jerk 6 .

and stressed that health care reform must help not only Americans who are uninsured.INH Observation One: The Inevitable Some semblance of national health care reform will pass – even if it’s not through before the recess Obama’s political clout guarantees it will pass by the end of the year.” You’re A Jerk 7 . “We have a mandate from the American people to address this issue.Single Payer 2. “This is probably the hardest legislative lift that any of us will make whether we are here for four years or forty. Laura. “The current cost curve cannot be sustained by business owners or by families. “I still believe very strongly that we are going to achieve that goal.” Sebelius said. “If it takes a couple of extra days. and during the August break to try and meld our ideas and bills together in order so that when we return in September we will be prepared. as committed as any president I have ever seen to a single issue.” Dodd said that the President’s leadership on health care reform has been strong.” he said. [President Obama] is committed. news correspondent. Sen. “That does not excuse our committees from doing everything we can during these weeks before the August break. Speaking at a press conference. a week. but we need to get it done. a couple of extra weeks or even a couple of extra months its worth the wait. Woodhead.” “I’m willing to wait. Thomas Carper (D-Del.0 LO 7 HEALTHCARE 1AC . http://talkradionews. do it right.” Dodd said that there would be a bill on the President’s desk by the end of the year. He has said over and over again that he will expand whatever capital in order to achieve the goal of national health care reform in the nation” Dodd said. “We do not have the luxury of not dealing with this.” Dodd said.” said Carper.) explained that the health care bill is moving slowly through committee because of the multitude of problems being addressed.” Health and Human Services Secretary Kathleen Sebelius joined the Senators. a month away from losing it.” Talk Radio News Service. 7/23/09. spend the time. Sen. passing reform is still an urgent priority said top Democrats on Thursday. “Those who have health insurance are a day. the Senate has no excuse to take its time on finding solutions for our nation’s health care problems.com/2009/07/health-reform-still-urgent-despite-no-bill-before-recess-say-senate-dems/ [Mardjuki] Although the Senate may not vote on health care until after the August recess. Chris Dodd (D-Conn. “Health Reform Still Urgent Despite No Bill Before Recess Say Senate Dems.) said while it’s unlikely that a bill would be up for debate on the Senate floor before September. but also those who do already have insurance.

a Democrat.” New York Times. Many. Phil Bredesen of Tennessee. Each of several health care bills coursing through Congress relies on a large increase in eligibility for Medicaid.com/2009/07/20/health/policy/20health. Gov. http://www. New York Times senior journalist. And they said they were convinced that a major expansion of Medicaid would leave them with heavy costs. Medicaid was providing coverage to an average of 50 million people. Sack. they said their deep-seated fiscal troubles made it a terrible time to shift costs to the states . at least partly because half of them did not attend. eating up 7 percent of the federal budget. when stimulus money dries up. the National Governors Association projects that states will face aggregate deficits of $200 billion over the next three years. regardless of political party. Sarah Palin of Alaska. 1/21/09.nytimes. and the governors fear they cannot count on provisions in other bills that they will not bear costs. It was unclear whether the governors would draft a statement expressing their dismay. stayed home to deal with budget crises. The federal government currently picks up about 57 percent of the tab. And they pointed out that Medicaid already suffered from low payment rates to health care providers. as one means of moving toward universal coverage. Tim Pawlenty of Minnesota and Bobby Jindal of Louisiana — were not here. the countercyclical program now faces a grim fiscal paradox: by definition. “Growing Need for Medicaid Strains States. If Medicaid is expanded. benefits or payments to doctors would impose new burdens on the states unless Washington absorbs them. With the recession draining states of tax revenues even as their Medicaid rolls are surging.0 LO 8 HEALTHCARE 1AC – ECON ADV Observation 2: Advantages Advantage 1: Economy A) Instant State Stimulus Medicaid spending already drains state budgets – state legislators are doing everything they can to stay above water. or about one of every six in the United States. demand for Medicaid coverage is highest precisely when states are least able to afford it because of shrinking tax revenues.html [Mardjuki] Eligibility for the income-based program can vary widely by state.Single Payer 2. with Washington roughly matching the spending approved by the states. They are already anticipating large gaps in Medicaid financing after 2010. Rendell of Pennsylvania. states will almost surely have to increase payments to doctors to encourage more of them to participate. two-time Pulitzer Prize winner. and the program is one of the largest drains on every state’s budget. discouraging some doctors and hospitals from accepting beneficiaries.com/2009/01/22/us/22medicaid. In at least one of several bills circulating in Congress. said he feared Congress was about to You’re A Jerk 8 . But at any one time last year. Kevin. The cost of the program — $333 billion in 2007 — is shared by state and federal governments. the states would eventually pick up a share of the new costs. the state and federal insurance program for the poor. and by narrowing eligibility for the program. “Governors Fear Medicaid Costs in Healthcare” http://www. Some of the group’s most notable names — Arnold Schwarzenegger of California. including the group’s chairman. Because the states and the federal government share the cost. 7-19-2009 (two-time Pulitzer Prize winner and correspondent for the New York Times). The governors said in interviews and public sessions that the bills being drafted in Congress would not do enough to curb the growth in health spending. But the sentiment among those who were could not have been more consistent. a Democrat.html?hp Although many governors said significant change in how the nation handles health care was needed. Lawmakers returning to state capitals across the country are preparing to negotiate significant reductions in Medicaid spending by freezing or reducing reimbursements to hospitals and physicians. Kevin Sack and Robert Pear. any increase in eligibility levels. Edward G. As in any economic downturn. Gov. by eliminating coverage options like dental and vision benefits.nytimes. Increased state expenses inevitable – every health care bill debated forces states to pay for massive Medicaid expansion. 2009.

cfm? fa=view&id=711 [Mardjuki] The current situation has been made more difficult because many states never fully recovered from the fiscal crisis of the early part of the decade.chicagofed. At the end of fiscal year 2006. Spending as a share of the economy declined in fiscal year 2008 and is projected to decline further in 2009 and again in 2010. and child care remain in effect. a former health care executive. the available reserves in states with deficits are likely to be depleted in the near future. And a second round of stimulus is needed – federal money to ease state deficits is crucial to stem further recession. This article considers the role of the federal government in helping the states to manage their finances. “As a governor. this aid might help states avoid enacting spending cuts or tax increases that could deepen or prolong the economic downturn.” added Mr. higher education. Most states are required to balance their budgets regardless of the economic environment. Also. and work force training. states have already drawn down much of their available reserves. “It’s a 45-year-old system originally designed for poor women and their children. Lav.” This money has reduced to a degree the depth of state spending cuts and moderated state tax and fee increases. but generally are not sufficient to avert the need for substantial budget cuts or tax increases. Federal assistance can lessen the extent to which states need to take pro-cyclical actions that can further harm the economy. five prominent Democratic governors suggested that the federal government should commit $1 trillion in aid to the states over the next two years. It’s not health care reform to dump more money into Medicaid. Reserves can be particularly important to help states adjust in the early months of a fiscal crisis.pdf [Mardjuki] Like the economy in general . In a number of states the reductions made during the downturn in education. Federal assistance Crucial.” “Medicaid is a poor vehicle for expanding coverage. Mattoon.” said Gov.” Center on Budget and Policy Priorities.org/publications/fedletter/cflaugust2009_265. http://www.0 LO 9 HEALTHCARE 1AC – ECON ADV bestow “the mother of all unfunded mandates. Bredesen was far from alone in his concern.cbpp.” Chicago Federal Reserve Bank Essay Number 265. Iris and Elizabeth. senior economist and economic advisor @ Chicago Federal Reserve. Christine Gregoire of Washington. for which demand rises during a recession. unemployment insurance. State governments face significant constraints in raising additional revenues.5 percent of annual state spending. “State Budget Troubles Worsen. The amount in ARRA to help states maintain current activities is about $135 billion to $140 billion — or less than half of projected state shortfalls. health coverage. The American Recovery and Reinvestment Act recognizes this fact and includes substantial assistance for states. individual state economies are struggling in this recession.org/cms/index. One way states can avoid making deep reductions in services during a recession is to build up rainy day funds and other reserves. my concern is that if we try to cost-shift to the states we’re not going to be in a position to pick up the tab. and for all states combined it still remains below the fiscal year 2001 level. McNichol.” Mr. In this recession. State spending fell sharply relative to the economy during the 2001 recession.Single Payer 2. http://www. but this will not address state budget shortfalls. general fund spending for fiscal year 2008 — six years into the economic recovery — remained below pre-recession levels as a share of the gross domestic product. state budget and tax senior fellow. You’re A Jerk 9 . “Should the Federal Government Bail Out the States? Lessons from Past Recessions. August 2009. Gold award for contribution to state fiscal policy. 6/29/09. California projected a $21 billion deficit after failing to get voter approval for a series of budget balancing fiscal measures. State government budget woes have been much in the news . This heightens the potential impact on public services of the shortfalls states now are projecting. Most of this money is in the form of increased Medicaid funding and a “Fiscal Stabilization Fund.2 The rationale for such financial support is that states (which are generally prohibited from running deficits) need the money to maintain key programs. Richard. Recently. In 18 states. such as Medicaid.1 In January of this year. There are also other streams of funding in the economic recovery act flowing through states to local governments or individuals. These important public services were suffering even as states turned to budget cuts to close the new budget gaps. Bredesen. Federal assistance crucial to stem negative pro-cyclical economic state action. state reserves — general fund balances and rainy day funds — totaled 11. state budget and tax expert.

” Righter said.5 million Illinoisans and cost $12 billion a year in state and federal funds. According to the most optimistic estimates.” Many Republicans also believe there is too much waste in the system and that some people don’t deserve state-provided health care that was made available to more children and parents under former Gov.Single Payer 2.com/taxpayerboard. said Republican fervor for Medicaid reforms appears to be fueled by “the dilemma of raising taxes. the rising cost of Medicaid will take up more and more state resources and “crowd out” other state services while further delaying payments to Medicaid providers. The report.sj-r.” he said. Olsen. He is one of four Republican lawmakers who began meeting privately Friday with four of their Democratic counterparts in the General Assembly and a representative of Quinn to discuss ideas for Medicaid reform. which is available online at http://tinyurl. http://www. “It should be obvious to everyone that if you’re concerned about anything in the budget. But there is disagreement — and outright fear — about the potential ramifications for patients. Republicans say that without changes. hospitals and doctors when it comes to changes in state health programs that cover 2. “I’m not sure there is a clear-enough concept of the consequences of these proposals. says that if costs continue to grow at that rate Medicaid spending will reach $22 billion in 2019 and could represent 50 percent of the state budget.0 LO 10 HEALTHCARE 1AC – ECON ADV Medicaid reform is the only way to solve the state budget crisis. RMattoon. senior reporter.” Medicaid spending has grown an average of almost 8 percent per year between 2003 and 2008. according to a recent report by Gov. Republican votes may be crucial to reduce the impact of the state’s $9 billion deficit through a potential income tax increase. and more in future years. said Michael Gelder. You’re A Jerk 10 . Dean. Quinn’s chief health-policy adviser. Medicaid reforms could save a total of $983 million over the next two years. “Medicaid reform tied to state budget crisis.” “People are almost desperately looking for some kind of ‘silver bullet’ that can get us out of this thing that can be painless. Dale Righter. Republicans in the Democrat-controlled Illinois Senate and House have all but required that long-term Medicaid reform be part of any budget discussions.” State Journal-Register. Howard Peters. more than twice the rate of inflation. you need to be concerned about Medicaid. Rod Blagojevich. Consensus wasn’t reached on any issues after the two-hour meeting in Chicago. 6/20/09.” state Sen. “We want to make as much positive change as possible. reform of Illinois’ Medicaid program — or at least firm plans to make changes in the system — appears to be a key component of any resolution to the state budget crisis. said last week. but the group will meet again Tuesday or Wednesday in Springfield.com/homepage/x488806173/Medicaidreform-tied-to-state-budget-crisis [Mardjuki] Regardless of how much money would be saved this year or next. “It is the 700-pound gorilla quickly turning into the 900-pound gorilla. Pat Quinn’s Taxpayer Action Board. senior vice president of the Naperville-based Illinois Hospital Association.

the House bill would impose a surtax on high-income people and a payroll tax — as much as 8 percent of wages — on employers who do not provide health insurance to workers. said he worried that the new taxes “could cost jobs in a recession. a freshman Democrat from Colorado who voted against the bill approved Friday in the Education and Labor Committee. “The last few miles of any race are the hardest to run. the picture is more complex.” You’re A Jerk 11 . Polis and 20 other freshman Democrats said they were “extremely concerned that the proposed method of paying for health care reform will negatively impact small businesses. reporter. combined with the scheduled increase in tax rates resulting from the expiration of Bush-era tax cuts.html?pagewanted=print [Mardjuki] Three of the five Congressional committees working on legislation to reinvent the nation’s health care system delivered bills this week along the lines proposed by President Obama. Nancy Pelosi.” To help finance coverage of the uninsured. He said he and Congress had made “unprecedented progress” on health care. a crucial goal for Mr. Polis said these taxes. many Democrats were apprehensive. some in their ranks.” On Capitol Hill. were pleading to slow down.” but insisted. He acknowledged a treacherous path ahead. the backbone of the American economy. We will reform health care. It will happen this year.0 LO 11 HEALTHCARE 1AC – ECON ADV B) Federal Deficits Obama’s healthcare proposal fails to curb entitlement spending – increased taxes needed to fund.” New York Times. senior writer. scope and cost of the legislation. Mr. nervous about the prospect of raising taxes or proceeding without any Republican support. nervous and defensive.Single Payer 2.” And he vowed: “We are going to get this done. But instead of celebrating their success.nytimes. “Democrats Grow Wary as Health Bill Advances.” he said. they faced basic questions about whether some of their proposals might do more harm than good. it was clear that Democrats could not meet their goal of passing bills before the summer recess without barreling over the concerns of Republicans and ending any hope that such a major issue could be addressed in a bipartisan manner. The comments suggest that party leaders may not yet have the votes to pass the legislation. I’m absolutely convinced of that. a growing minority of Democrats have begun to express reservations about the size. Mr. the expanded role of the federal government and the need for a raft of new taxes to pay for it all. Democrats had three reasons for concern. Even as Democratic leaders and the White House insisted that the nation was closer than ever to landmark changes in the health care system. “Some successful family-owned businesses would be taxed at higher rates than multinational corporations. would have a perverse effect. 7/17/09 Robert and David. even with House committees working in marathon sessions this week.com/2009/07/18/health/policy/18health. Obama’s deadline of having both chambers pass bills before the summer recess. And while senior Democrats vowed to press ahead to meet Mr. Third. “Now is not the time to slow down. Mr. with even the American Medical Association endorsing the House bill this week. The director of the Congressional Budget Office warned Thursday that the legislative proposals so far would not slow the growth of health spending. Obama as he also tries to extend insurance to more than 45 million Americans who lack it. Herszenhorn. saying. http://www. In a letter to the House speaker. Obama tried Friday to shift the political narrative away from the grim forecasts of the Congressional Budget Office. Representative Jared Polis. Second. Pear.

Most hospitals and clinics would remain privately owned and operated. Physicians could continue to practice on a feefor-service basis. reporter. Douglas W. expanding access to health care You’re A Jerk 12 . Under the current system. with federal subsidies for millions of people. A National Health Insurance Program would save at least $150 billion annually by eliminating the high overhead and profits of the private. on Friday morning. “I think it’s extremely doable to get this done before the end of the year. Doctors and hospitals would be freed from the concomitant burdens and expenses of paperwork created by having to deal with multiple insurers with different rules . which he called “unsustainable. including two members of the Finance Committee.pnhp. Investor-owned facilities would be converted to notfor-profit status. Republicans of Maine.would cover every American for all necessary medical care. hospitals or clinics. “Proposal of the Physicians’ Working Group for single-Payer National Health Insurance. On Wednesday. a bipartisan group of six senators. The vote came eight hours after the House Ways and Means Committee approved a nearly identical bill.php [Mardjuki] We endorse a fundamental change in America’s health care . who also signed the letter. House Democrats who voted no cited various concerns. 13 to 10.” said Senator Joseph I. senior writer. 7/17/09 Robert and David. http://www.” they wrote.which in essence would be an expanded and improved version of Medicare . During the transition to an NHI. receiving a budget from the NHI to cover all operating costs.” Physicians For A National Health Program. “we believe taking additional time to achieve a bipartisan result is critical for legislation that affects 17 percent of our economy and every individual in the United States. Editor of New England Journal of Medicine. But just to try to get it passed in the Senate before we leave for the August recess seems just about impossible. A National Health Insurance Program is the only affordable option for universal. Christine Cassell.” A budget office analysis released Friday said the House bill would “result in a net increase in the federal budget deficit of $239 billion” over 10 years. to change the incentives so reimbursement will be based on the value. Ben Nelson. 2009. http://www. Herszenhorn. The House and Senate bills would require insurers to take all applicants and vastly expand coverage. Peter Beilenson. Lieberman. Quentin Young. the Senate health committee approved a generally similar bill on a party-line vote. Elmendorf. Angell. with 3 Democrats voting no. Three Democrats crossed party lines and voted no. the savings on administration and profits would fully offset the costs of expanded and improved coverage.” The House education committee approved the bill.the creation of a comprehensive National Health Insurance (NHI) Program. testified on Thursday that doing so would come at a steep cost and that the proposals would not curb the rise in health spending by the federal government. It’s just too big a bill. Pear. Obama’s ambitious timetable.Single Payer 2.” The group included three senators.0 LO 12 HEALTHCARE 1AC – ECON ADV Pressure by Senate leaders and Obama to pass healthcare quickly ensures that healthcare reform will be ineffective and costly.” Representative Ron Kind of Wisconsin said. Marcia. Democrat of Nebraska. Senior Lecturer @ Harvard Medical School. Only a single-payer healthcare system is able to solve for perverse incentives and bureaucratic waste. “The legislative process right now is going in the wrong direction. Snowe and Susan Collins. Such a program . “We are not doing enough to reform the health care delivery system. after an all-night session. Obama at the White House this week and urged him not to rush the bill.org/single_payer_resources/proposal_of_the_physicians_working_group_for_singlepayer_national_health_insurance .com/2009/07/18/health/policy/18health. President of American College of Physicians. and their former owners compensated for past investments. 26 to 22. comprehensive coverage. CEO Parkland Health System. Ron Anderson. NHI would make it possible to set and enforce overall spending limits for the health care system. and Olympia J. or receive salaries from group practices.html?pagewanted=print [Mardjuki] And in the latest sign of lawmakers’ chafing at Mr. who met with Mr.often rules designed to avoid payment.nytimes. “Democrats Grow Wary as Health Bill Advances.” New York Times. partly because of an increase in Medicare spending to avert sharp cuts in payments to doctors. slowing cost growth over the long run. of services. investor-owned insurance industry and reducing spending for marketing and other satellite services. Joel Alpert. sent a letter to Senate leaders pleading with them to allow more time. American Public Health Association. 23 to 18. Commissioner of Baltimore City Health. rather than the volume. “While we are committed to providing relief for American families as quickly as possible. the Connecticut independent. American Academy of Pediatrics. MD. But the director of the Congressional Budget Office.

said Obama should have seized the opportunity to pair the stimulus bill with the overhaul of Social Security.0 LO 13 HEALTHCARE 1AC – ECON ADV inevitably means increasing costs." Analysts across the political spectrum agree that the current path is unsustainable. according to the Concord Coalition. the measures could be passed within a year. Obama suggested during his campaign that he might support changing the level of income at which Social Security taxes are calculated. 2-23-09 Budget analysts are worried that a continuing economic crisis will make it impossible to raise sufficient funds from foreign markets to finance the nation's debt.Single Payer 2. "It can either be very nice public relations or move the ball down the road on what is an impending fiscal tsunami. It would squeeze out bureaucratic waste and eliminate the perverse incentives that threaten the quality of care and the ethical foundations of medicine. most prominently by China. the New Hampshire Republican who backed out of his commitment to be Obama's commerce secretary and then voted against the stimulus bill. and reducing costs inevitably means limiting access. however. which would translate into higher costs for US taxpayers. But any measure will be even more controversial than usual because so many Americans have seen their private retirement plans pummeled by the stock market collapse. That is because Gregg is the co-sponsor of the measure that would create a bipartisan commission to put together far-reaching recommendations for an up-or-down vote by Congress. If other nations lose confidence that the United States will pay its debts. Medicare. he said. Boston Globe. Asked about his hopes for the summit. warning him not to repeat what they regard as the mistake of President Franklin Roosevelt. He said he is worried that nothing will happen on the most difficult issues until political leaders "have a gun at our heads. who has been invited to the summit. Unless there is a major budgetary change. who launched the New Deal but eventually heeded calls to curtail deficit spending. the government-run healthcare program for older Americans. The system tends to respond only in the face of unavoidable crisis. You’re A Jerk 13 . In any case. federal spending will go from being about 20 percent of the nation's economy to 42 percent in 2050. the White House believes that he could be one of its most important allies in the overhaul of Social Security. A key player in the summit will be Senator Judd Gregg. which is expected to increase quickly as baby boomers retire. former head of the Congressional Budget Office. Gregg said that under such a procedure. In the last four years. only to see a new recession batter his presidency. Obama is being urged by some analysts to start moving toward a balanced budget as soon as possible to send a signal to the world that deficit spending will abate. is already running a deficit. Medicare." said Reischauer. as long as most of the benefit cuts and tax increases were not slated to take effect until well after the recession is over. Despite the embarrassment caused by Gregg's about-face. some economists fear an international financial crisis could escalate and turn into a worldwide depression. Another frequently mentioned option is raising the retirement age. you have a greater probability of getting people to sign on to some fiscal diet. That is why many analysts are urging Obama to link changes in Medicare with an overhaul of the health system. and tax policy. and the tax code. "When you are shoveling out the goodies. Yet some analysts are offering Obama conflicting advice." Gregg said. Social Security is slated to pay out more money than it receives by 2017. In an interview. a reference to criticism that Obama's stimulus bill was too partisan. Federal entitlement reform is needed to signal long term fiscal solvency and prevent spiraling sell-offs of US debt. Medicare. But an NHI could both expand access and reduce costs. Robert Reischauer. "We need an up-or-down vote on a package that will be unquestionably bipartisan and fair. about three-quarters of US debt was purchased by foreign interests. The major reason is that entitlement programs for older Americans are running short of funds." Some budget specialists are skeptical. it is widely expected that debt purchasers will soon demand higher interest rates.

in turn. religious extremism among both Hindus and Muslims could further polarize Indian politics. Kissinger Senior Fellow in U. The political consequences could include dangerous unrest--and a bitter climate of anti-foreign feeling that blames others for China's woes. talk of a Chinese bid to challenge America's global position reached fever pitch. Success in Iraq--however late.” The New Republic. Doing so will leave China fewer resources for military build-ups and foreign adventures. the World Bank slashed its estimate of China's GDP by 40 percent. as nervous investors moved their money out of the country. building a national health care system. even if the recessions in the West are relatively short and mild.S. a deep economic recession in a country where mass poverty and even hunger are still major concerns could undermine political order. If current market turmoil seriously damaged the performance and prospects of India and China. however undeserved. it has reminded China that its growth remains dependent on the health of the U. say.) And the financial crisis makes it certain that China's growth is likely to be much slower during some of those years. All this means that China's rise looks increasingly like a gradual process. In the worst-case scenario.tnr. The crisis has strengthened the U.Single Payer 2. Beijing will have to devote more resources and more attention to stabilizing Chinese society. Millions or even tens of millions of Chinese will be unemployed in a country without an effective social safety net. It may test the political will of the Obama administration. protection. The crisis has not--yet--led to the nightmare scenario that China-watchers fear: a recession or slowdown producing the kind of social unrest that could challenge the government.) Worse." But suggestions that China could grow at. 10 percent annually for the next 30 years were already looking premature before the economic downturn. and India's economic miracle could be nipped in the bud. citing inaccuracies in the methods used to calculate purchasing power parity. (In late 2007. further slowing growth and. nobody knows what will happen if the growth stops. (Think of Weimar Germany. long-term growth. and India's attitude toward the United States and global economic integration. the current crisis could join the Great Depression in the list of economic events that changed history .S. position in the Middle East as falling oil prices reduce Iranian influence and increase the dependence of the oil sheikdoms on U. but the United States must avoid a protectionist response to the economic slowdown. The United States should stand ready to assist Chinese and Indian financial authorities on an emergency basis--and work very hard to help both countries escape or at least weather any economic downturn. 2/4/09. China has so far been able to manage the stresses and conflicts of modernization and change.com/politics/story. and caring for an aging population. which. In the lead-up to last summer's Beijing Olympics. Every other country in the world has experienced significant financial crises while building such systems. For one thing. For billions of people in nuclear-armed countries to emerge from this crisis believing either that the United States was indifferent to their well-being or that it had profited from their distress could damage U. foreign policy far more severely than any mistake made by George W.html?id=571cbbb9-2887-4d81-8542-92e83915f5f8&p=2) The damage to China's position is more subtle. Support for global integration is a fairly recent development in India. A deceleration in China's long-term growth rate would postpone indefinitely the date when China could emerge as a peer competitor to the United States. Thanks to a generation of rapid economic growth. It's not just the great powers whose trajectories have been affected by the crash. unemployment is rising. The collapse of asset bubbles in the stock and property markets will wipe out the savings of a generation of the Chinese middle class. moves to limit market access for Chinese and Indian producers could poison relations for years. economy. Lesser powers like Saudi Arabia and Iran also face new constraints. instability could lead to a vicious cycle. For another. Already exports are falling. While India's 60-year-old democratic system has resisted many shocks. India's future is also a question. and many serious Indians remain skeptical of it. and China is unlikely to be an exception. At the same time. and the Shanghai stock market is down about 60 percent. thanks to the one-child policy. it has shown that China's modernization is likely to be long. “Only Makes You Stronger. dangerous. if at all. creating and regulating a functional and flexible financial system is difficult. That may still come to pass--the recent economic news from China has been consistently worse than most experts predicted--but. 9 – Henry A. U. even if the worst case is avoided. Bush.-China relations and to American power itself is probably not that China will rise too far. the financial crisis has nevertheless had significant effects. fomenting ever-greater bitterness. the turmoil in the international economy will plunge China into a major economic downturn. will need massive help from the government to support itself in old age.S. as some assumed. The greatest danger both to U. when both Nazi and communist politicians blamed the West for Germany's economic travails.S. providing a social security net.S. The present global distribution of power could be changing slowly. and the inexorable rise of China is one reason why so many commentators are fretting about the "post-American era. however You’re A Jerk 14 .S. too fast. and complex rather than fast and sweet. http://www. Foreign Policy at the Council on Foreign Relations (Walter Russell. The violent Naxalite insurrection plaguing a significant swath of the country could get worse. The Chinese financial system will implode as loans to both state and private enterprises go bad. As the crisis has forcefully reminded Americans. it is that the current crisis might end China's growth miracle.0 LO 14 HEALTHCARE 1AC – ECON ADV Continued economic decline culminates in WWIII Mead.S.

Bad economic times can breed wars. the social forces that support the idea of a competitive market economy within an appropriately liberal legal and political framework are relatively strong. dissent and that allow people of different political and religious viewpoints to collaborate on a vast social project of modernization--and to maintain political stability in the face of accelerating social and economic change. and professionals who want to develop a liberal capitalist society integrated into the world. open system of liberal democratic capitalism even as many former Warsaw Pact nations were making rapid transitions. Crisis can also strengthen the hand of religious extremists. Economists forecast that Iran's real GDP growth will drop markedly in the coming months as stagnating oil revenues and the continued global economic downturn force the government to rein in its expansionary fiscal policy. Beijing. But. Karachi. but thanks in part to the economic crisis. Russia. while international sanctions and other diplomatic sticks have been made more painful and Western carrots (like trade opportunities) have become more attractive. industrialists. The annual inflation rate rose above 29 percent last September. the incoming administration has the chance to try some new ideas and to enter negotiations with Iran (and Syria) from a position of enhanced strength. As a result. Countries that can encourage--or at least allow and sustain--the change. developing countries and countries where capitalism has relatively recent and shallow roots tend to suffer greater economic and political damage when crisis strikes--as.S.0 LO 15 HEALTHCARE 1AC – ECON ADV limited— had already improved the Obama administration's prospects for addressing regional crises. the ability to exploit the advantages of rapid economic development has been a key factor in international competition. So far. None of this makes the Middle East an easy target for U. or the post-cold war leaders who so signally failed to build a stable. less reassuring messages as well. making their workforces ever more productive. the Napoleonic Wars. many countries are only half-heartedly capitalist. Frequently. When crisis strikes. Saudi Arabia and other oil states have become more dependent on the United States for protection against Iran. dislocation. it does. yet. or New Delhi to be born? The United States may not. Meanwhile. upheaval. Meanwhile. to remake the world to suit their own interests and preferences. All this has weakened Ahmadinejad at home and Iran abroad. the Latin world is often drawn to anti-capitalist movements and rulers on both the right and the left. Argentina has lost ground to Chile. imposed by foreign forces and shaped to fit foreign rather than domestic interests and preferences. They are able to invest in education. On either side of the Atlantic. and what other capitalist powers like France. the crisis has weakened the power of the merchants. farther behind the front-runners as time goes by. over time. so has war. the commissars. too. They typically develop liberal political institutions and cultural norms that value. This may be happening yet again. and Japan have done to a lesser extent. in many other countries where capitalism rubs people the wrong way. financial crises often reinforce rather than challenge the global distribution of power and wealth. but. Europe was a pretty peaceful place in 1928. Iranian officials must balance the relative merits of support for allies like Hamas. History may suggest that financial crises actually help capitalist great powers maintain their leads-but it has other. the Seven Years War. while providing their tumultuous market societies with appropriate regulatory and legal frameworks. the collapse in oil prices has put the Iranian regime on the defensive. If financial crises have been a normal part of life during the 300-year rise of the liberal capitalist system under the Anglophone powers. consequently. This is what the United Kingdom and the United States have done in past centuries.Single Payer 2. Every crisis is different. but the Depression poisoned German public opinion and helped bring Adolf Hitler to power. the American Revolution. what rough beasts might start slouching toward Moscow. the two World Wars. such half-hearted experiments not only have failed to work. grow swiftly. according to Iran's Bank Markazi. and they have fewer resources to fund religious extremism as they use diminished oil revenues to support basic domestic spending and development goals. in much of the world. And. capitalism has appeared as an unwelcome interloper. None of which means that we can just sit back and enjoy the recession. if we can't get the world economy back on track. Germany. Since capitalism first emerged in early modern Europe. If the current crisis turns into a depression. inevitably. diplomacy. they have left the societies that have tried them in a progressively worse position. we may still have to fight. or authoritarian traditionalists who are determined to resist liberal capitalist society for a variety of reasons. for example. They produce cutting-edge technologies that translate into military and economic power. populist radicals. Russian development has fallen farther behind that of the Baltic states and Central Europe. financial crises on balance reinforce rather than undermine the world position of the leading capitalist countries. this is not the case. financiers. In these countries. and partly because. but there seem to be reasons why. You’re A Jerk 15 . and pain that capitalism often involves. decline. Now. the companies and banks based in these societies are often less established and more vulnerable to the consequences of a financial crisis than more established firms in wealthier societies. they are quick to decide that capitalism is a failure and look for alternatives. and Syria against domestic needs. up from about 17 percent in 2007. The wars of the League of Augsburg and the Spanish Succession. Hezbollah. the cold war: The list of wars is almost as long as the list of financial crises. has never really taken to capitalism and liberal society--whether during the time of the czars. The vast productive capacity of leading capitalist powers gives them the ability to project influence around the world and. to some degree. or at least tolerate. Partly as a result of these internal cultural pressures.

jobs that have been lost to offshoring--the transfer of business operations across national boundaries to friendlier operating environments. and it's difficult to parse the effects of each factor. Businesses pay higher insurance premiums to make up for the fact that Medicare and Medicaid reimbursements often do not match the total costs hospitals incur treating these patients. for instance. says that judging by data compiled from "fragmentary studies. and Singapore. job drift comes primarily from industries where jobs are most "tradeable. companies do not argue against the employer-based insurance model. By and large. You’re A Jerk 16 . U. Obama's plan may be opposed. GM says healthcare costs add between $1. Americans pay roughly $500 per month. federal employees. however.S. says the amount businesses pay for employee insurance is just one element of their total healthcare costs." -.0 LO 16 HEALTHCARE 1AC – COMP ADV Advantage 2: Competitiveness Skyrocketing health care costs deter companies from hiring in the U. For large multinational corporations. An article in Health Affairs examines Taiwan's National Health Insurance (or NHI) system.S. 3/4/09. Elsewhere in the world.S. For small business owners they can be even more devastating. jobs are "susceptible" to offshoring in a future where technology allows the more efficient transfer of jobs. Teslik. job market. healthcare systems are much less reliant on private sector support--and much less expensive. It is difficult to quantify the precise effect high healthcare costs have had so far on the overall U. he says. Obama's proposal would mandate coverage for children but not adults. they pay for insurance programs through health benefits. industry. and the company says it spent roughly $5." as Blinder puts it. government-run system. footing healthcare costs presents an enormous expense. Moreover. economic expert and assistant editor @ CFR.S. This doesn't mean American jobs will necessarily be lost--jobs can also be brought onshore--but it does mean industry will have to adapt. Not surprisingly. you have small businesses that simply cannot afford to offer coverage. staff writer. where public funds collected through taxes pay for up to 70 percent of healthcare coverage. John Sarbanes Obama does not propose to alter the employer-based system and move to a single-payer. but also a wide and expanding array of other service-sector jobs--will be easier to shift across national boundaries in the future. to buy into a government-sponsored insurance pool similar to the one for insuring U. An article in Cambridge University's Journal of Social Policy looks at what it calls the "remarkable" performance of healthcare systems in Hong Kong.Single Payer 2. “Health Care Costs and U. Jeffrey Rideout. Services that can be delivered electronically--information technology. Second. Instead.S. where the authors argue the legacy of British colonialism has encouraged a strong state role in the healthcare system. Competitiveness. businesses also subsidize the strain on the system wrought by the cost of treating America's uninsured." Sarbanes says. and some have criticized Blinder's approach. "In many places. http://www. have shied away from making such estimates. The proposal also includes a small business tax credit for those that provide coverage to their employees to help with the costs. covers more than 1." it is apparent that "under a million service-sector jobs in the United States have been lost to offshoring to date.Rep. you have small businesses that simply cannot afford to offer coverage. he says. For large corporations they mean the massive "legacy costs" associated with insuring retired employees." Blinder goes on to predict that somewhere between 28 million and 42 million U. the federally supported programs for primarily poor and elderly Americans.6 billion on healthcare expenses in 2006. Malaysia.000 to the sticker price of every automobile it makes. they contend that a wasteful public-private system is pushing costs much higher than they should be. however. he wants to allow people and small businesses. businesses indirectly subsidize Medicare and Medicaid.S. Third.S. For example.cfr. in a 2006 Foreign Affairs article. Rather. General Motors. In contrast. Taiwanese are assessed around $20 a month for full health coverage. Johnson. The Princeton economist Alan S. a "hidden tax" confronted in a health care proposal (PDF) laid out by California's Governor Arnold Schwarzenegger. again through higher insurance premiums. healthcare expenses make it impossible for small business owners to hire candidates they would otherwise desire . implemented in 1995. The authors conclude that savings from the NHI system largely offset the incremental cost of covering the previously uninsured.” Council on Foreign Relations. that healthcare expenses affect every level of U. Lee.500 and $2. – Obama’s health care proposals do nothing to slow rampant job loss. by lawmakers who are against expanding government's role in health care or placing more requirements on the industry. for instance. Often. Chrysler. Health benefits for unionized auto workers became a central issue derailing the 2008 congressional push to provide a financial bailout to GM and its ailing Detroit rival. Taiwan's system is commonly singled out as a model for cost-effectiveness . "In many places. however. It is clear." First. Blinder. Tori. Rideout says. Many other economists. who currently have trouble affording health insurance.1 million employees and former employees. Rideout says businesses incur a "triple tax.S. system costs 83 percent more per capita than the Canadian system. economists disagree on the number of U. the U.S. according to data in a report by McKinsey.org/publication/13325/ [Mardjuki] These ballooning dollar figures place a heavy burden on companies doing business in the United States and can put them at a substantial competitive disadvantage in the international marketplace. A number of East Asian systems also enjoy high quality of care for a much lower cost. a medical doctor and the head of the Internet Business Solutions Group at Cisco Systems' Healthcare Practice. Health care is one of several factors--entrenched union contracts are another--that make doing business in the United States expensive. which provides comprehensive universal health coverage to Taiwan's roughly 23 million citizens.

In the past. American Public Health Association. Joel Alpert. Commissioner of Baltimore City Health. developments such as the agricultural and industrial revolutions produced fundamental changes positively affecting the relative position of those who were able to take advantage of them and negatively affecting those who did not. http://www. 18. 1995. others would try to fill the Vacuum. and abolishing the billing apparatus necessary to apportion costs among the various plans. American Academy of Pediatrics. US Ambassador to the UN. Senior Lecturer @ Harvard Medical School. the competitiveness of U. President of American College of Physicians. Marcia. products would be enhanced. You’re A Jerk 17 . Angell. Khalilzad.S. which will shift the sources of wealth and the relative position of classes and nations. Ron Anderson. As the United States weakened.pnhp. the United States must maintain its technological lead in the economic realm. 2009. the domestic economic and political base for global leadership would diminish and the United States would probably incrementally withdraw from the world.” Physicians For A National Health Program.Single Payer 2. In such an environment. economy declines seriously. Indeed. Tax-based NHI funding might.0 LO 17 HEALTHCARE 1AC – COMP ADV And a single-payer healthcare system radically decreases employers’ health care costs. become inward-looking. The Effect on Corporate America: Firms now providing generous employee health benefits would probably realize savings because their tax contribution to NHI would likely be less than current health insurance costs. “Losing the Moment? The United States and the World After the Cold War. Economic competitiveness is a prerequisite to heg. No. To sustain and improve its economic strength. Its success will depend on the choices it makes. and abandon more and more of its external interests. “Proposal of the Physicians’ Working Group for single-Payer National Health Insurance.” Washington Quarterly. most of the extra funds needed to finance the expansion of care would come from eliminating insurance company overhead and profits. and single source payment is the key to both equal access and cost control. Quentin Young. 2. however increase costs for companies not now providing health benefits. Editor of New England Journal of Medicine.S. CEO Parkland Health System. since public insurance administration is more efficient. If the United States fails to recognize the change and adapt its institutions. Peter Beilenson. Zalmay. Some argue that the world may be at the beginning of another such transformation. Since most firms competing on international markets would save money.php [Mardjuki] The insurance/HMO industry would have virtually no role in health care financing.org/single_payer_resources/proposal_of_the_physicians_working_group_for_singlepayer_national_health_insurance . Spring Vol. [Mardjuki] The United States is unlikely to preserve its military and technological dominance if the U. Christine Cassell. enhancing competitiveness. LexisNexis. MD. its relative position will necessarily worsen.

and especially since the end of the Cold War. In a more genuinely multipolar world. Central Asia. Europe. Were the United States to diminish its influence in the regions where it is currently the strongest power. Americans have insisted on preserving regional predominance in East Asia. Conflict between nations would involve struggles on the oceans as well as on land. with different rules and norms reflecting the interests of the powerful states that would have a hand in shaping it. For instance. the Middle East. But that’s not the way it works. They profess indifference to the world and claim they just want to be left alone even as they seek daily to shape the behavior of billions of people around the globe. The United States. Kagan 7 Senior Associate @ the Carnegie Endowment for International Peace (End of Dreams. A different configuration of power. that great geopolitical miracle. That could make wars between them less likely. for without it the European nations after World War ii would never have felt secure enough to reintegrate Germany. the United States is the dominant naval power everywhere. Even as it maintains its position as the predominant global power. if it ever went away. It is shaped by configurations of power. Even under the umbrella of unipolarity. liberal and conservative. is more of a traditional than a postmodern power. They either happily or grudgingly allow the United States Navy to be the guarantor of international waterways and trade routes. and though Americans are loath to acknowledge it. Finally. International order does not rest on ideas and institutions. increasingly. As a matter of national policy stretching back across numerous administrations. and the Caucasus. http://www. such that other nations cannot compete with it even in their home waters. The jostling for status and influence among these ambitious nations and would-be nations is a second defining feature of the new post-Cold War international system. It is easy but also dangerous to underestimate the role the United States plays in providing a measure of stability in the world even as it also disrupts stability. China. Even when the United States engages in a war.0 LO 18 HEALTHCARE 1AC – COMP ADV US hegemony key to check multiple scenarios for nuclear war. beginning with the first Bush administration and continuing through the Clinton years. The international order we know today reflects the distribution of power in the world since World War ii. Most Europeans recoil at the thought. The current order. and the Caucasus. This was its goal after the Second World War.hoover. that the United States could step in to check any dangerous development on the continent. but even today Europe’s stability depends on the guarantee. intensity. a multipolar world in which the poles were Russia. or it could simply make them more catastrophic. with Iran in the Middle East and Central Asia. Central Asia. and Europe. of the kind used in World War i and other major conflicts. the United States. One novel aspect of such a multipolar world is that most of these powers would possess nuclear weapons. and status. Democratic and Republican. Central Asia. 1” and are equally loath to relinquish it. the United States did not retract but expanded its influence eastward across Europe and into the Middle East. and destructiveness. Nations would compete for naval dominance at least in their own regions and possibly beyond. there is the United States itself. they generally prefer their global place as “No. influence. it would not. Once having entered a region. Return of History. however. it is also engaged in hegemonic competitions in these regions with China in East and Central Asia.Single Payer 2. of course. In a genuinely multipolar world. the Western Hemisphere. it is able to play its role as guardian of the waterways. Such order as exists in the world rests not merely on the goodwill of peoples but on a foundation provided by American power. and since the end of the Cold War. Would that international order be an improvement? Perhaps for Beijing and Moscow it would. the aspects of international order that they like would remain in place. But it is doubtful that it would suit the tastes of enlightenment liberals in the United States and Europe. they are remarkably slow to withdraw from it until they believe they have substantially transformed it in their own image. whether for practical or idealistic reasons. would produce its own kind of order.org/publications/policyreview/8552512. however distant and one hopes unnecessary. honor. Armed embargos. too. Nationalism in all its forms is back. They imagine that in a world where American power was diminished. owes its founding to American power. would disrupt trade flows in a way that is now impossible. the other nations would settle disputes as great and lesser powers have done in the past: sometimes through diplomacy and accommodation but often through confrontation and wars of varying scope. until recently. Even the European Union. is not only far from perfect but also offers no guarantee against major conflict among the world’s great powers. People who believe greater equality among nations would be preferable to the present American predominance often succumb to a basic logical fallacy. and now.html) Policy Review. regional conflicts involving the large powers may You’re A Jerk 18 . and with Russia in Eastern Europe. of international access to markets and raw materials such as oil. India. They believe the order the world enjoys today exists independently of American power. and so is international competition for power. that would not be possible without renewing the danger of world war. American predominance prevents these rivalries from intensifying — its regional as well as its global predominance. Hoover Institution.

The alternative to American regional predominance in the Middle East and elsewhere is not a new regional stability. the future is likely to be one of intensified competition among nations and nationalist movements. nationalist Japan. The rise of Islamic fundamentalism doesn’t change this. no one should imagine that a reduction of American power or a retraction of American influence and global involvement will provide an easier path. one likely to draw the United States back in again. “offshore” role would lead to greater stability there. The region and the states within it remain relatively weak. China. One could expect deeper involvement by both China and Russia. Difficult as it may be to extend American predominance into the future. to expand and fill the vacuum. But even China. forcing the United States and its European allies to decide whether to intervene or suffer the consequences of a Russian victory. and therefore to the need for a permanent American role in Europe. if only to secure their interests. could draw in other great powers. practically ensures a heavy American military presence in the region. That commitment.0 LO 19 HEALTHCARE 1AC – COMP ADV erupt. particularly Iran. The subtraction of American power from any region would not end conflict but would simply change the equation. where most nations agree that a reliable American power has a stabilizing and pacific effect on the region. Although some realist theorists seem to imagine that the disappearance of the Soviet Union put an end to the possibility of confrontation between Russia and the West. It is doubtful that any American administration would voluntarily take actions that could shift the balance of power in the Middle East further toward Russia. Conflict between India and Pakistan remains possible. The world hasn’t changed that much. The vital interest the United States has in access to oil and the role it plays in keeping access open to other nations in Europe and Asia make it unlikely that American leaders could or would under unfavorable circumstances. as does conflict between Iran and Israel or other Middle Eastern states. or Iran.Single Payer 2. But they are more likely to erupt if the United States weakens or withdraws from its positions of regional dominance. In an era of burgeoning nationalism. It only adds a new and more threatening dimension to the competition. faces the dilemma that an American withdrawal could unleash an ambitious. That is certainly the view of most of China’s neighbors. both on the seas and on the ground . paired with the American commitment to protect strategic oil supplies for most of the world. The alternative to American predominance in the region is not balance and peace. It is also optimistic to imagine that a retrenchment of stand back and hope for the best while the powers in the region battle it out. This is especially true in East Asia. and comity in the Middle East. These. It will produce a new instability. Such conflicts may be unavoidable no matter what policies the United States pursues. the departure of the United States from the scene — even if it remained the world’s most powerful nation — could be destabilizing. stability. which neither a sudden end to the conflict between Israel and the Palestinians nor an immediate American withdrawal from Iraq would change. If the United States withdrew from Europe — if it adopted what some call a strategy of “offshore balancing” — this could in time increase the likelihood of conflict involving Russia and its near neighbors. too. It could tempt Russia to an even more overbearing and potentially forceful approach to unruly nations on its periphery. War could erupt between Russia and Georgia. competition for influence among powers both inside and outside the region has raged for at least two centuries. which seeks gradually to supplant the United States as the dominant power in the region. In the Middle East. obviate the need to come to Israel’s aid if its security became threatened. You’re A Jerk 19 . A diminution of American influence would not be followed by a diminution of other external influences. 18 And one could also expect the more powerful states of the region. It is further competition. War could erupt between China and Taiwan and draw in both the United States and Japan. which could in turn draw the United States back in the American position in the Middle East and the assumption of a more passive. including the United States. too. independent. An American withdrawal from Iraq will not return things to “normal” or to a new kind of stability in the region. history suggests that conflicts in Europe involving Russia are possible even without Soviet communism. Nor would a more “evenhanded” policy toward Israel. which some see as the magic key to unlocking peace. In Europe.

That is simply a fact of life in international politics.0 LO 20 HEALTHCARE 1AC – COMP ADV Even if heg will collapse some day we should maintain it now for our protection. the United States is able to defeat its enemies the world over. but that does not detract from the necessity of seeking security. its interests. Thayer 2k7 Associate Professor in Defense and Strategic Studies Missouri State University Bradley A. P. and military power. ideological. These advantages keep the United States. This argument is based on its prodigious economic. Like good health. having events shaped by other countries. and it must strive to maintain its advantages in international politics as long as possible .Single Payer 2. You strive to live as long as possible although you realize that it is inevitable that you will die. In contrast to Layne's argument. Thankfully. From this power also comes respect and admiration. maximizing the power of the United States aids its ability to defend itself from attacks and to advance its interests. thus far the United States recognizes it is much better to be involved so that it may shape events. Knowing that American hegemony will end someday does not mean that we should welcome or facilitate its demise. no matter how grudging it may be at times. Reply to Christopher Layne. rather the reverse. You’re A Jerk 20 . Any involvement—from the extensive involvement of the United States to the narrow activity of Switzerland—in this dangerous realm runs the risk of a backlash. The United States should labor to maintain hegemony as long as possible—just as knowing that you will die someday does not keep you from planning your future and living today. “American Empire: A Debate. The issue is how much participation is right. and then adjusting to what they desire. and its allies secure. International politics is a dangerous environment in which countries have no choice but to participate. to reassure its allies.” Routledge 2k7. Americans and most of the world should welcome American primacy and work to preserve it as long as possible. Due to this power. and to dissuade states from challenging it. rather than to remain passive.105 Each country knows it will never be perfectly secure.

0 LO 21 HEALTHCARE 1AC . You’re A Jerk 21 .Single Payer 2.PLAN PLAN: THE UNITED STATES FEDERAL GOVERNMENT SHOULD IMPLEMENT A FEDERAL SINGLE-PAYER HEALTHCARE SYSTEM FOR ALL UNINSURED PERSONS IN THE UNITED STATES.

and their people are. by most accepted measures.letters200jul20. with an economy in decline. healthier than we are. and millions of older Americans had been enrolled and were getting health care with hardly a hiccup. Global Sourcing Finance Chief at GE Healthcare. why are we giving up on the best solution and settling for something that. is a whole lot less than "next best?" The House plan is not set to go "live" until January of 2013.story [Mardjuki] In a Q-and-A recently posted on the Web site Crooks & Liars (http://crooksandliars. “Why not singlepayer?” Baltimore Sun.nih.pubmedcentral.when we have a single-payer model. including Democratic presidential nominee Barack Obama.but a lot to assist the political careers of more than a few members of Congress who are crafting this "reform" (and making those who need accessible and affordable care the most wait the longest to get it) . Medicare. “A Market for Compassion: Single-Payer Health Insurance”. No. MD/PhD from Northwestern University.com/news/opinion/readersrespond/baled. 9-5-2008. the program was up and running. Currently. thousands of people losing their jobs every month and losing their coverage. that we know works well and could be expanded or duplicated with relative ease and in a much shorter period of time? Single payer harnesses the market’s strength and maximizes efficiency. that is not a typo. dividends. "For 30 years I have supported a single-payer plan. bloated by advertising.le. duplicated bureaucracies. This is paramount because patients need the best healthcare. What's worse. creating a Rube Goldberg-ian system whose biggest benefit will be to insurance companies that have done nothing in the last several decades to improve the current system . A single-payer system will give all consumers the power of choice and open all healthcare providers to the effects of consumer decisions." The question that her response prompts from me is. with more employers changing to plans that cover less and cost the individual more. If I told you that in less than a year after the historic Medicare legislation was signed into law.1114455. Schoonmaker.Single Payer 2. The private health insurance market is inefficient. concede that single-payer insurance is probably our most efficient option.0. Prajwal Ciryamv. Nothing could be further from the truth. providers are insulated from competition because private insurers often restrict coverage to select physicians. consumers can create competition among healthcare providers. and executive compensation. Having a shiny new insurance policy will not help if the out-of-pocket costs are such that people still cannot afford to see the doctor or get the medications they need. from all appearances. is health care.0 LO 22 HEALTHCARE 1AC . and it might not be good for the fortunes of the current president or the senators and representatives up for re-election if a new health care system is not going well or is not all it was advertised to be.gov/articlerender. 7/20/09 Anne. where the focus should have been from the start. but private providers will continue to deliver care. So. All of the major developed nations have some form of single-payer health care. not insurance.[2] But they worry that it lacks the spirit of the American market.SOLVENCY Observation 3: Solvency Only a single-payer system mitigates costs – Medicare proves. maybe. the government will fund health insurance. you wondered if there's a political reason why the plan won't be fully operational until 2013. not the best middlemen to pay for it. how much more dire will things be in four years? What will the insurance companies be doing between now and 2013? How will they be positioning themselves to accommodate the changes that are coming? What will we see from them in the next 3 1/2 years that will signal they have even the slightest interest in improving our access to and delivery of actual health care? What this is really all about.fcgi?artid=2580082 In a single-payer system. Their spending per-person on health care is less than half what we spend here. However. http://www. or dropping coverage altogether.baltimoresun. House Speaker Nancy Pelosi responded to one of the questions by saying. insurance policies are so complex and individuals' future needs so unpredictable that consumers cannot make the informed selections that induce competition between insurers. wouldn't you wonder why it's going to take so long to get essential elements of this version of reform in place? Wouldn't you wonder why the elements that are designed to help the millions of uninsured are the ones that are going to take the longest to implement? Or. the 47 million uninsured Americans[3] have little impact on the market. You’re A Jerk 22 .com/node/29667). In addition. Why are we writing 1. http://www. what will the millions of currently uninsured people do between now and 2013? And. Single-payer works because of the efficiency of specialization. A single-payer system will harness the market's strengths while addressing its limitations. Many Americans. Economies of scale will save the money to make this possible.000-plus-page bills. like the fact that we will have a presidential election in November of 2012. but our next best choice is to support an exchange and a public option.

Single Payer 2. Adam Smith would be proud. You’re A Jerk 23 .0 LO 23 The government will manage the paperwork and private entities will provide the care.

hospitals will probably try to decrease the number of Medicaid recipients they admit (or their lengths of stay in the hospital) and attract more privately insured patients to compensate for the lost Medicare revenue. 1988). Volume 11. Winter 1992. As the payer of the last resort. We have a solid body of research specifically about Medicaid to guide us. While the proposals could lead to some improvements in Medicaid. director of Medical Health Administration. but they do not consider Medicaid reform in the context of radical reform of the American health care system. block grant long-term care and change the federal funding formulas for acute-term care (Holahan and Cohen. offering the lowest reimburse must be expected. at their discretion. more physicians will see private patients and fewer will see Medicaid eligibles. This is a mistake. A more radical package would divide the acute care and long-term care components of Medicaid.SOLVENCY Medicaid reform must be considered in the context of massive healthcare restructuring – Medicaid is the starting point of effective reform. this will likely affect Medicaid recipients. Medicaid already covers a large proportion of the poor and uninsurable. there is a logic to starting with the reform of the Medicaid program. If a change in the Medicare program's reimbursement ra tes lowers hospital profit margins. One package designed to increase Medicaid eligibility and control costs would make poverty the sole criterion for eligibility and rely on managed care to contain costs (Oberg and Polich. If the Medicaid inpatient rates are relatively high.Single Payer 2. such as increased or equalized coverage. If private insurers raise physicians' fees in a state. For just as surely as Medicaid reform proposals that ignore the nation's health care system as whole will have limited success. As it is a government program. You’re A Jerk 24 . If we take this approach. Furthermore. make poverty the criterion for eligibility.” Policy Studies Review. we should include the following elements in our reforms. In the process. These reforms always have several desirable goals. we can also draw on research into the Medicare program and into other nations' public health care systems. Medicaid must compete in a health care system run by market forces. Medicaid is a welfare benefit -not a right-to be granted by the states. Consequently. the hospital will probably try to increase the number of Medicaid recipients they admit (or their lengths of stay in the hospital) to recoup the lost Medicare revenue. If affordable universal coverage is our goal. so proposals to reform the nation's health care that do not fully consider Medicaid will have a less positive impact than they otherwise might. Most of Medicaid's problems can be traced to the principles which characterize the program. “Medicaid’s Role in Moves Toward Universal Health Care. the nation's health care system could be transformed. [Mardjuki] Proposals for reform are usually combined into packages. 1987). Only by changing these principles and combining Medicaid reforms with major structural reforms of American health care system can Medicaid's problems be solved. its reform will not threaten the private health care industry. major problems would remain unsolved. De Alteriis. The Medical Assistance program is greatly affected by the actions of other health care programs.0 LO 24 HEALTHCARE 1AC . Martin. horizontal inequities are not surprising. 1992. If Medicaid inpatient rates are relatively low.

Some politicians. Just as there's a weak and strong version of the public plan. that is. inefficient mess and don't trust Washington to change it. and from the sort of purchasing power that only a large base of customers can provide. pricey. This idea wouldn't take away what anyone has. would be housed on the exchange -. and open to everyone. unaffordable system we have now.html [Mardjuki] The central problem in health-care reform is that good policy and good politics point in opposite directions. except health insurance. and thus the longterm promise of reform. Everything. You make it kinder and gentler. is crude.SOLVENCY Single-payer system for the uninsured would function as a demonstration of a scalable model for the rest of the country – creates impetus for expansion and nation-wide adoption. http://www. But you also build the beginnings of a new. economic and domestic policy expert. “A Market for Health Reform. It's open to only the unemployed." That estimate. and they will bid aggressively to ensure they're included in the market and compete aggressively to make sure they're successful within it. the self-employed and any business. then costs will shoot up. more effective. But there is a tricky political problem: If the exchanges are effective. Sort of an outlet shopping model for health-care. which will in turn give it more scale and bargaining power. But all health insurance exchanges are not created equal. The weak version is state-based. it offers a concrete way that reform could benefit the insured.and employer tax exclusions and all the other points of controversy. you strengthen it with subsidies and regulations on insurers. The largest of these is adverse selection: If you open it to large employers. They are afraid of a Congressional Budget Office estimate that says something like "80 million Americans will transition from employer-based health insurance to the exchange.something health insurers have managed to avoid for far too long. insurers aren't driven to compete.which. It is how we buy everything from books to socks to soup. will come out sounding like "80 million Americans will lose what they have. It would also let those of us with employer-based insurance take the money our employers are paying for our insurance and use it on the exchange instead. With so many potential customers. But put those imperatives together and you have a strange problem indeed: How do you reform a system that you're not allowed to change? The answer that reformers have come up with is that you don't change the current system. translated into political-speak. from an actual. there's a weak and strong version of the exchange. Politicians are very interested in the optics of preserving current insurance arrangements. however. better health-care system off to the side. Ezra. simplicity and standardization (experts say that you need at least 20 million to fully achieve these benefits -. can be deployed to make sure no insurer is penalized for signing up sicker customers and no insurer benefits from signing up healthier customers. which scares politicians. because it is the bridge between the system we have and the system we want. might be in danger. or at least regional. Through consumer choice. and instead exists as a marginal policy to mop up those who aren't covered by employers. It is arguably the single most important element of health-care reform. The huge pool of users gives the exchange tremendous advantages in scale. for a couple of reasons. from direct competition between insurance providers hungry for their business. the self-employed and small businesses. Right now. accessible only to the few able to get there. In the short term. inefficient mess. Germany and every other largely private universal health-care system uses to deal with similar issues. And not through government fiat.washingtonpost. however. that wants to buy in. if it exists at all. in other words. You’re A Jerk 25 . This is what the health insurance exchange is designed to do. structured for consumer convenience. the combination of increased efficiencies and greater competition drive down costs. Klein.com/wpdyn/content/article/2009/07/28/AR2009072802114_pf. and the efficiencies of scale and competition are minimal.” Washington Post. remain uncowed. no matter the size. The strong version is national. They will benefit. 7/27/09. Good politics means. which will lead more employers to use the exchange. You could easily see this exchange slowly emerge as the de facto American health-care system. then workers and employers alike might well decide to use them. But it would allow those of us who don't like what we have to change it. insurers are eager to participate. the weak version is a lot likelier than the strong version. however. as Barack Obama frequently says. ways to address that problem: In particular . the idea behind the health insurance exchange is almost weirdly simple: It's a single market. It gives them a way out of a health-care system that is eating through their wages and limiting their choices. pricey. incidentally. risk adjustment. And there are signs that it. You let it demonstrate its efficiencies and improvements.0 LO 25 HEALTHCARE 1AC . Oregon Democrat Ron Wyden has proposed something he calls the Free Choice Act: It would open the exchanges to all Americans and all businesses. proceeds from the insight that a lot of people rely on this fractured. in which you choose between the products of competing health insurers (both public and private). More so than any other idea in the health-care debate. you get to keep it. but the only large employers who join are those with aging and ill workforces. Over time. There are. And that's no small gain. You let the lure of lower costs and higher quality persuade Americans to migrate over of their own accord. that if you like what you have. from efficiencies of scale. There's risk adjustment to reduce the incentive for cherry-picking. from regulations meant to protect them from deceptive products. The benefits of reversing that bit of accidental exceptionalism are obvious to anyone who has ever stepped inside a Target: Consumers will benefit from more choice. With such a limited pool of applicants. The only way that health-care reform will truly give us a more efficient. Risk adjustment. Good politics. which the Netherlands. But amid the clamor over public insurance options -. It's open to everyone: The unemployed. working market -. ineffective. One is that there are tricky policy problems in a strong exchange. the health insurance exchange is hardly being discussed.Single Payer 2." And that scares people. more affordable health-care system is if it begins to fundamentally change the inefficient. This is not an insurmountable policy problem.easy in a national exchange but harder in a regional or state-based one). Compared with the crazy-quilt system we have now. It never really grows. This is not a new idea. Good policy proceeds from the understanding that our health-care system is a fractured.

and second. whereas others act as the plan themselves. 2009. Since the Reagan administration. has been quietly becoming the most successful program in U. states can increase coverage while shifting much of the cost to the federal treasury. variation in other areas could result in learning and innovation. J. Finally. The congressional proposal to increase SCHIP funding emerged from a bipartisan process and was supported by both Senator Edward Kennedy (D-MA) and Senator Orrin Hatch (R-UT). the very factors that defeated President Bill Clinton’s proposal for universal coverage have actually encouraged expansions of Medicaid. and small business argues persuasively that many “mom and pop” shops simply cannot afford the bill. the debate generally ignores what I see as the most plausible path toward universal coverage: first. Ph. Medicaid. Path to National Health Insurance. programs for the chronically ill. requiring everyone to carry health insurance and allowing people whose incomes are too high for automatic coverage to buy into Medicaid. Institutional providers (hospitals and nursing homes) are supportive. given both the cultural opposition to anything that could be labeled a single-payer program and the fierce opposition of the private insurance industry. Medicaid provides decent health insurance to more than 59 million Americans (including more than 25% of U..000 for a family of three). but if eligibility were standardized and minimum benefits defined. Surprisingly. Columbia University.2 The 2007 battle over Medicaid’s sister program. And Medicaid offers such flexibility within an overarching federal structure. program enrollment has more than doubled (surpassing 59 million). For example. Private insurers support such initiatives because they leave intact the core of the current system and because many states use commercial health plans to serve Medicaid beneficiaries. our political institutions are designed to make it hard to enact comprehensive legislation. I believe that this is the only universal coverage plan with a decent chance of succeeding politically. Even President George W. history for aiding the uninsured.SOLVENCY Expanding Medicaid builds support for universal care – it’s the only way to neutralize political objections Michael Sparer. children). most states deliver benefits through managed care.S. 2009 (Michael Sparer.. Employer mandates face treacherous politics: big business doesn’t want government telling it what sort of coverage to provide.3 Some people complain about interstate variation in eligibility. and outreach and education is a good thing. at the high end. Most Americans would find it fair to require those who can afford insurance to buy it.” January 22. Perhaps most important. and reimbursement.org/?p=300) The 2008 presidential election has rekindled long-simmering hopes for comprehensive health care reform.1 Meanwhile. expanding Medicaid to cover the largest portion of the uninsured. Bush hoped to increase funding. But the same interest groups that would oppose these alternatives would probably support the Medicaid strategy. That’s about as high as moderate Republicans (and the business community) might plausibly be willing to go. the State Children’s Health Insurance Program (SCHIP). states are already experimenting with Medicaid buy-in programs. Reform opponents also take advantage of the anti– big-government ethos that pervades our political culture. since our system of checks and balances provides opponents with numerous opportunities to block legislation. Medicaid is also administered in very different ways by different states.4 Letting the laboratory of federalism work is a better idea than using Medicare or the congressional health plan as the basis for a reformed system — and a much You’re A Jerk 26 . which minimizes complaints about a monolithic national program.Single Payer 2.0 LO 26 HEALTHCARE 1AC . Ironically. benefits. Even less likely to fly are Medicare-expansion proposals. The bone of contention was the income ceiling for eligibility. http://healthcarereform. since they rely on Medicaid dollars. illustrates this broad acceptability. though by less than Congress had proposed. “Medicaid and the U. This history points us to an obvious path toward national health insurance: combine a Medicaid expansion and buy-in with an individual mandate. Moreover. however. Medicaid’s intergovernmental structure encourages expansion: since the program is financed primarily with federal dollars.S. and one state (New Jersey) has even enacted an initiative combining a Medicaid buy-in with an individual mandate for parents to cover children. covers children from families with incomes up to 350% of the federal poverty level.nejm. especially when they can pay into an affordable public insurance plan rather than being forced to buy private policies. New Jersey. The policy debate includes references to new government programs (perhaps a federal program for the uninsured to buy into) and vague formulas for cost containment (usually involving overly optimistic assessments of savings to be generated by using health information technology). softening the impact of the continuing decline in the number of Americans with employer-sponsored coverage. Americans with incomes below 350% of the federal poverty level (around $62. professor of health policy at the Mailman School of Public Health. Business leaders support Medicaid expansions because they relieve the pressure on employers to cover low-wage employees. Medicaid encourages state-based experimentation in responding to local health care needs.D. interstate diversity in cost-containment strategies. Relying on Medicaid is also good policy. Similarly. Previous efforts to enact universal coverage have failed in part because opposition from interest groups such as the business community and the insurance industry is far more influential than is organized support for uninsured low-wage workers.S. the federal–state program designed to provide health insurance for the poor.D. but some rely on commercial insurers and some on nonprofit health plans.

is that intergovernmental financing programs are the most plausible fiscal route to health insurance expansions. and at least in this scenario the cost would be divided among the federal treasury. I see the Medicaid model as providing the most likely path to solving the crisis of the uninsured. though Congress could tie increased federal funding to innovative case management for chronic diseases (or other performance measures). States tried this strategy with some success when implementing SCHIP (hence the “Dr. though increases that are substantial enough to attract physician participation would undermine cost-containment efforts. HEALTHCARE 1AC . the states. especially for a society disinclined to limit the diffusion of new health care technology or to regulate the prices and salaries paid by the private health care sector. since there are states that effectively partner with officebased physicians and have lessons to share.SOLVENCY Many middle-class workers would be reluctant to buy into a “welfare medicine” program. but any effort to simply bypass the physician community will fail. there is the question of paying the bill. But expanding Medicaid in combination with an individual mandate offers a good policy solution that might have enough political appeal to succeed. however. Dynasaur” program in Vermont). and the businesses or individual consumers who buy in. More difficult would be convincing physicians to support a Medicaid expansion and participate in the program. States will complain about having to pay their share. However. Finally. the road to any type of national health insurance is littered with obstacles. Here again. and an individual mandate covering only children. You’re A Jerk 27 . Here. Medicaid agencies could also rely more heavily on nurse practitioners and physician assistants.Single Payer 2. And if the recession and other priorities discourage President Obama from seeking universal coverage in one fell swoop. citing low reimbursement rates and long administrative delays. the laboratory of federalism could help. the model could be phased in. One lesson of the recent Medicaid expansions. it is more typical for office-based physicians to refuse to treat Medicaid patients. but any national health insurance system is going to cost money. Proposals for national health insurance have a long history of failure in this country. there are no easy solutions.5 Medicaid agencies (or the managed-care plans they rely on) will need to pay higher rates.0 LO 27 better idea than creating a brand-new administrative infrastructure. Although Medicaid participation is high in some states. however. Ultimately. starting with a more modest Medicaid expansion. One solution is to give the program a new name and thus a new identity as a middle-class entitlement. too. Federal budget officials will also be skeptical. especially in the midst of an economic crisis. First is the stigma attached to the name. and the “Medicaid for More” model certainly faces barriers. a buy-in program.

Single Payer 2.0 LO 28 **INHERENCY** You’re A Jerk 28 .

and the Democratic brand along with it. they went too far to the left. I tried to tell my more liberal colleagues that this would happen. That's what I think we'll get. It passes. 4. I disagree. they can always say well. If health care reform fails. and they vote against it. And to the extent that their president and their party are damaged. and they vote against it. be hung around my neck when I seek reelection? Outcome 2: Preferable to 1. because now. Members of Congress may not be geniuses. There are four possible outcomes on healthcare. so they can't be held responsible for the toes that get stepped on. the best outcome of all. Having voted against the bill will provide little cover for moderate Democrats. 4. and they vote against it. then Obama is toast.” The New Republic Journal. Fear of the unknown is all-consuming for legislators who think they might be vulnerable to defeat someday. But the distance between the status quo anda perfect bill is so vast that we could have something that's both a massive. It passes.. and they vote against it. and they vote for it.com/tnr/blogs/the_plank/archive/2009/07/21/why-health-care-reform-will-pass. It passes. because it's a big party victory. Specifically.0 LO 29 Obama HC Inev Some type of healthcare reform is inevitable – Democrats must support it to save Democratic face and preserve their own careers even if they’re opposed to it. and they vote for it. given something as large and complex as healthcare. It passes. Few unknowns. If fails. they're going to have to decide whether to pass the bill or not. I can't see them doing it. senior editor. 3. the solon thinks. A perfect bill? No. Outcome 3: The worst possible outcome. You’re A Jerk 29 . But there are lots of unknowns. It fails. 2. for what I should think are obvious reasons. That's also why they're trying to get bipartisan support. http://blogs. which makes it all the more important that people like me stay in Washington. “Why Health Care Reform Will Pass. Democrats will have to decide whether or not to support a filibuster of health care reform that would destroy their president and dig their own grave.tnr. but they're usually pretty good at discerning their own political self-interest. And that's the main difference between now and 1994 -. Outcome 1: Not a bad outcome. from a purely short-sighted and self-interested perspective. Undoubtedly. Outcome 4: In many ways. they can say.health care can't be filibustered without Democratic cooperation. If fails. 2. So let's look at each of these vis-a-vis healthcare the way a centrist legislator might look at them. or any piece of legislation: 1. don't look at me. which is why I supported the provision that would have. which could give them cover. It fails. there are going to be problems and disappointments with the new system. or possibly even the spare votes to allow them to vote against it.aspx [JM] Michael Tomasky analyzes the political logic of red state Democrats: Look at it this way. and they vote for it. They've stuck their necks out for nothing and practically begged to be accused of "being out of touch" with the voters of their conservative state. it's true that you can't pass an effective health care reform without stepping on some toes. And that's why I think we'll end up with a health care bill. from best to worst: 1. Jonathan.. historical improvement and a crushing disappointment. when problems arise with the reforms. That's why the best possible scenario for Democrats is to have the bill pass with them voting against it. But. at the end of the day. 7/21/09. Will those problems. Chait. Now. 3.Single Payer 2. and they vote for it. I'd order the outcomes like so. as the 1994 elections show. hey.

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Healthcare reform inevitable. VOA News 7/14/09
“Obama: Health Care Improvements Inevitable.” http://www.voanews.com/english/2009-07-14-voa2.cfm [Mardjuki] U.S. President Barack Obama says improvements in the American health care system are inevitable. Mr. Obama made his comments in the White House Rose Garden Monday as he nominated an African-American woman, Regina Benjamin, to become the U.S. Surgeon General. The president said "naysayers and cynics" should not bet against the passage of health insurance legislation. He also said inaction on the issue is not an option. Mr. Obama has vowed to sign a health care bill into law this year. Democrats in the House of Representatives say they are nearly ready to unveil their health care reform plan.

Health care will pass – AMA backing. Nasaw, Washington correspondent. 7/16/09.
Daniel. “Powerful doctors groups backs Obama’s healthcare reform plan.” UK Guardian. http://www.guardian.co.uk/world/2009/jul/16/obama-health-plan-ama-support [Mardjuki] American Medical Association, which vigorously opposed Bill and Hillary Clinton's 1990s reform effort, today pledged to work with congressional leaders to ensure legislation is soon passed. The group endorsed the strongest legislation currently on the table, proposed this week by top Democrats in the House of Representatives. The group long opposed government intervention in the healthcare system for fear that its physician members would see their lucrative pay decline. With no universal public programme akin to the National Health Service, Americans rely on a patchwork of employee-provided healthcare, government programmes for the poor, elderly and veterans, and costly private health insurance coverage. Americans spend one out of every six dollars on healthcare - roughly twice as much per capita as other industrialised nations - but lag behind in life expectancy, infant mortality and other health indicators. The medical association's surprise turnaround may be an indication they see reform as inevitable and hope to influence the legislation at the margins. In its letter to Charles Rangel, a powerful New York Democrat, the group said it hoped for "constructive dialogue" during revision of the legislation. "We pledge to work with the House committees and leadership to build support for passage of health reform legislation to expand access to high quality, affordable health care for all Americans," the group wrote in a letter signed by executive vice president Michael Maves.

Healthcare inevitable – Obama pulling out all stops. Murray, White House correspondent. 7/13/09.
Mark. “Obama: Don’t Bet Against Health Reform.” MSNBC. http://firstread.msnbc.msn.com/archive/2009/07/13/1994860.aspx [Mardjuki] But the president also used the announcement as a kind pep talk on health-care reform, as congressional watchers and the press have begun to doubt whether Congress can meet his goal to pass reform bills before it goes on its August recess. "We are going to get this done," Obama said. "Inaction is not a option." He added, "Don't bet against us. We are going to make this happen." And mentioning a sports/exercise metaphor he's used before, Obama said that Washington's muscles for enacting change have atrophied. So: "We are whipping folks back into shape."

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Obama will ram healthcare through Congress – highest odds now. Trende, staff reporter. 7/24/09.
Sean. “Why Obama Isn’t Governing From the Center.” Real Clear Politics. http://www.realclearpolitics.com/articles/2009/07/24/why_obama_isnt_governing_from_the_center_97591.html [Mardjuki] In other words, Obama realizes that the odds are not likely going to improve for the implementation of an aggressively liberal agenda. Right now, he is in the midst of a liberal moment, where he has governing majorities in each House. He wants to get a health care bill through that is the closest to his philosophy, and he knows that future Congresses are unlikely to have similarly hearty Democratic majorities. So he’s “going for it,” knowing that if he can ram a bill through – and with a 80-seat majority in the House I think he ultimately will be able to – it will probably never be repealed, even if Republicans surge back in 2010. If he doesn’t do it now, he will likely be relegated to pursuing an incrementalist strategy, similar to what the Democrats have been pursuing since 1994. If you accept that Obama truly is a solid liberal at heart, not a centrist, and that he’s ultimately at least as concerned about getting this agenda through as he is getting re-elected, then his present approach makes sense.

Health care industry and moderate Republicans negotiating – recognize healthcare inevitable. Pershing, staff reporter. 7/10/09.
Ben. “Is health-care reform inevitable?” Washington Post. http://voices.washingtonpost.com/political-browser/2009/07/is_healthcare_reform_inevitab.html [Mardjuki] Is health-care reform inevitable? That question has come to the fore in recent days, as President Obama and Democratic leaders on Capitol Hill attempt to navigate a maze full of opposition and entrenched interests to arrive at a reform package. Politics is all about leverage, and for now, the pro-reform forces have it. That's why so many potential opponents of the White House's efforts -- drug companies, hospitals, moderate Republicans -- have been willing to sit down and negotiate on the issue. If health-care reform is inevitable, they'd rather make some sacrifices and have a seat at the table then be caught outside the room when the deal is made.

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Crisis coming – allowing Congress to control creation of healthcare legislation dooms reform to failure. Goldman, staff director of Subcommitee on Health and Scientific Research, director @ National Institute of Health, Senior Executive Service. 7/28/09.
Leroy. “A Plan to Rescue Health Care Reform.” Asheville Citizen Times. http://www.citizen-times.com/apps/pbcs.dll/article? AID=/20090728/OPINION07/90723059&template=printart [Mardjuki] The Medicare Trustees have recently reported that its Trust Fund will be exhausted by 2017. Medicaid, as currently configured, is a burden that the several states cannot adequately sustain going forward. The solvency of Social Security will face the same fate in twenty years. And next year the front edge of the 77 million Baby Boomers will be expecting these programs to support their retirement. Those in the know understand that health care costs now amount to $2,500,000,000 000—16% of GDP. They know that these costs are utterly out of control. They know that, unless they are brought under control, they imperil not only the health care system, but also the entire national economy. America faces another 911. But unlike the attack that occurred at the Twin Towers, we know that this one is coming. Allowing it to happen in the face of certain knowledge about its inevitability and the devastation it will cause is unpardonable. But, while the “experts” know what is coming, the American public does not. The President is the only person who can make this case to the nation. He needs to do so immediately. That effort on his part will not only inform the nation. It will create the political will on the part of Congress to enact Health Care Reform and to avert a calamity that will otherwise make the current financial and credit crisis seem tame by comparison. The Administration’s game plan thus far is deeply, fatally flawed. Having turned over the principal responsibility of writing the legislation to the Congress, it has allowed the destructive and polarizing forces that rule on Capitol Hill to take control of the process and doom it.

Senate/House rivalry and lobby influence guarantees that reform will be ineffective. Goldman, staff director of Subcommitee on Health and Scientific Research, director @ National Institute of Health, Senior Executive Service. 7/28/09.
Leroy. “A Plan to Rescue Health Care Reform.” Asheville Citizen Times. http://www.citizen-times.com/apps/pbcs.dll/article? AID=/20090728/OPINION07/90723059&template=printart [Mardjuki] The hard fact of the matter is that the nation faces this crisis because for decades the Congress and previous administrations have been unwilling to forthrightly prescribe the medicine needed to fix this mess. They have been unwilling because doing so involves pain and sacrifice by their constituents. As they have delayed and taken the easy road, the price of the fix has grown to the point that it has paralyzed effective action. If that isn’t a prescription for disaster, what is? So simply expecting the Hill to write the bill the nation needs is foolish and certain to fail. Why? For reasons that are obvious. First of all there is the inherent and overly destructive rivalry between the House and the Senate. Second, the process is largely in the hands of staffers who by instinct base their action on their number one objective—protect the boss. Give me a break. These bosses don’t need protecting. 97% of them win reelection automatically. In addition, they turn for ideas and for affirmation of their ideas to the lobbyists who bankroll their boss’ reelection campaigns. These lobbyists, all of them, do not have the nation’s interest as their agenda. They exist to protect the interests of their clients. These are the folks who have proven that they are not capable of fixing this mess.

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Obama tried Friday to shift the political narrative away from the grim forecasts of the Congressional Budget Office. the picture is more complex. said he worried that the new taxes “could cost jobs in a recession. It will happen this year. 7/17/09 Robert and David.Single Payer 2. saying. senior writer. nervous about the prospect of raising taxes or proceeding without any Republican support. the House bill would impose a surtax on high-income people and a payroll tax — as much as 8 percent of wages — on employers who do not provide health insurance to workers.” he said.Cost Democrats defecting – healthcare proposals on the table don’t cut costs and exacerbate job loss. He said he and Congress had made “unprecedented progress” on health care.html?pagewanted=print [Mardjuki] Three of the five Congressional committees working on legislation to reinvent the nation’s health care system delivered bills this week along the lines proposed by President Obama. some in their ranks. I’m absolutely convinced of that. “Some successful family-owned businesses would be taxed at higher rates than multinational corporations. were pleading to slow down. a crucial goal for Mr. He acknowledged a treacherous path ahead.nytimes. Polis and 20 other freshman Democrats said they were “extremely concerned that the proposed method of paying for health care reform will negatively impact small businesses. combined with the scheduled increase in tax rates resulting from the expiration of Bush-era tax cuts. Mr. Representative Jared Polis. In a letter to the House speaker. scope and cost of the legislation. And while senior Democrats vowed to press ahead to meet Mr. many Democrats were apprehensive. Obama as he also tries to extend insurance to more than 45 million Americans who lack it. Nancy Pelosi. Third. a growing minority of Democrats have begun to express reservations about the size.” And he vowed: “We are going to get this done. Herszenhorn. they faced basic questions about whether some of their proposals might do more harm than good. would have a perverse effect. The comments suggest that party leaders may not yet have the votes to pass the legislation.” but insisted. Even as Democratic leaders and the White House insisted that the nation was closer than ever to landmark changes in the health care system. Mr. Obama’s deadline of having both chambers pass bills before the summer recess. with even the American Medical Association endorsing the House bill this week. The director of the Congressional Budget Office warned Thursday that the legislative proposals so far would not slow the growth of health spending. We will reform health care. Mr. Democrats had three reasons for concern.” New York Times. even with House committees working in marathon sessions this week.” To help finance coverage of the uninsured.” On Capitol Hill. “Now is not the time to slow down. Second.com/2009/07/18/health/policy/18health. Pear. http://www. “The last few miles of any race are the hardest to run.0 LO 33 Obama HC Fails . the expanded role of the federal government and the need for a raft of new taxes to pay for it all. it was clear that Democrats could not meet their goal of passing bills before the summer recess without barreling over the concerns of Republicans and ending any hope that such a major issue could be addressed in a bipartisan manner. “Democrats Grow Wary as Health Bill Advances.” You’re A Jerk 33 . But instead of celebrating their success. nervous and defensive. Polis said these taxes. reporter. a freshman Democrat from Colorado who voted against the bill approved Friday in the Education and Labor Committee. the backbone of the American economy.

rather than the volume. of services. who also signed the letter. “The legislative process right now is going in the wrong direction. But just to try to get it passed in the Senate before we leave for the August recess seems just about impossible. “We are not doing enough to reform the health care delivery system. Douglas W.” Representative Ron Kind of Wisconsin said. Lieberman. the Senate health committee approved a generally similar bill on a party-line vote. 7/17/09 Robert and David. The vote came eight hours after the House Ways and Means Committee approved a nearly identical bill. sent a letter to Senate leaders pleading with them to allow more time.” The House education committee approved the bill.Single Payer 2. including two members of the Finance Committee. partly because of an increase in Medicare spending to avert sharp cuts in payments to doctors. “we believe taking additional time to achieve a bipartisan result is critical for legislation that affects 17 percent of our economy and every individual in the United States.html?pagewanted=print [Mardjuki] And in the latest sign of lawmakers’ chafing at Mr. Obama at the White House this week and urged him not to rush the bill. But the director of the Congressional Budget Office. with 3 Democrats voting no. which he called “unsustainable. 23 to 18.0 LO 34 Obama HC Fails . Republicans of Maine. who met with Mr. to change the incentives so reimbursement will be based on the value.” A budget office analysis released Friday said the House bill would “result in a net increase in the federal budget deficit of $239 billion” over 10 years.nytimes. Obama’s ambitious timetable. “I think it’s extremely doable to get this done before the end of the year. Three Democrats crossed party lines and voted no. Ben Nelson. Snowe and Susan Collins. reporter. “While we are committed to providing relief for American families as quickly as possible. Democrat of Nebraska. You’re A Jerk 34 . Pear. House Democrats who voted no cited various concerns. a bipartisan group of six senators. The House and Senate bills would require insurers to take all applicants and vastly expand coverage.” The group included three senators. 13 to 10.” New York Times. testified on Thursday that doing so would come at a steep cost and that the proposals would not curb the rise in health spending by the federal government. on Friday morning.Concessions Obama’s healthcare rushed – ineffective and too many concessions. “Democrats Grow Wary as Health Bill Advances. http://www.com/2009/07/18/health/policy/18health. and Olympia J. Elmendorf. It’s just too big a bill.” said Senator Joseph I. the Connecticut independent. 26 to 22. On Wednesday.” they wrote. senior writer. Herszenhorn. after an all-night session. with federal subsidies for millions of people.

chief reporter. yes it would. A full litany of efficiencies to be gained and resources to be reallocated from private industry profits and logistical support to the actual provision of health care would be enumerated. On the other hand. Baucus' was instead inclined toward a solution wherein we would eventually subsidize consumers as necessary until we achieved universal health insurance coverage. undoubtedly certain that they could double.0 LO 35 Obama HC Fails – Industry Profit Big Pharma strangehold – health care industry stands to profit from current reform Marshall.Single Payer 2. much of what the consumer has already determined intuitively would be fleshed out in facts and figures. It is an unfortunate political reality that it is these parasites who own so much of Congress in these days of pay-to-play politics. “The case for keeping “single payer health care” off the table.com/talk/blogs/jpieterick/2009/07/the-case-for-keeping-singe-pay. showing the way in which we could achieve universal health care without actually spending more money than is already dedicated to health insurance and health care. if such a proposed solution were to be given serious discussion. George Polk Award winner. You’re A Jerk 35 . And so any potential that the door would be open to arrive at a "throw the bums out" solution to health care reform by honestly considering single payer would never have been allowed to gain traction at all as Obama embarked on this process. And the possibility of the consumers acting upon that realization has the executives in these industries losing sleep. Chair of the Finance Committee and one of the biggest benefactors of health care industry campaign contributions. triple. Stating strong opposition to any public option. Alas. Executives at the major insurance providers were nearly besides themselves in planning the next Congressional fundraisers. nay quadruple their budget for campaign contributions at a mere fraction of the profit to be made from the 42 million new customers they stood to realize out of this proposed "reform" package.talkingpointsmemo. http://tpmcafe. right? Well.” Talking Points Memo.nay. the prime thing the consumer realizes intuitively is that the majority of waste and the inefficiencies under which our health care system suffers is related to the parasitical tagalong that is the insurance/health care/Big Pharma industries. unless you were one of the insurance companies or Big Pharma or the health care industry that has bled our health care system dry. And that would be a good thing.php?ref=reccafe [Mardjuki] And herein lies the reason that a "single payer" health care solution had to remain off the table if we were to proceed with any kind of health care reform in this country. successfully eliminating single payer as an option to be considered allowed the monied interests to reason it was safe . July 15.to proceed with Obama's "health insurance reform. After all. Senator Max Baucus of Montana." These health insurance industry providers calculated that they could improve their take from the health care system if they smartly played the reform game. Joshua. seemed to carry their water quite well for so long as he was able. 2009. potentially highly profitable .

Health Care for America and Democracy for America. you know. This is not single-payer.php?storyId=105442888 Health and Human Services Secretary Kathleen Sebelius says that a single-payer option is not on the table. reporter for the Black Agenda Report.npr. For Obama to "win" his debate. Obama has no principled program or irreducible objectives. She added: "That's not what anyone is talking about — mostly because the president feels strongly. Kay Hagan to endorse the idea of a public health care plan. “Single-Payer Health Care Not In the Plans” http://www. "We shouldn't be focusing resources on each other.even when. Ideally.S. “Obama’s Single Payer Beat Down”." The ads have been embarrassing to rightist Democrats who are Obama's true political soulmates and a bridge to Republicans he seeks to woo. as I do." The objects of his ire are advertisements or fundraisers produced by MoveOn. His reflexive instinct is to lash out to his left when frustrated. which Obama opposes. 7-17-2009. "This is not a trick. hinting darkly that there will be repercussions if unions and activists persist in harassing his fellow center-right Democrats. economy — are exactly why the president says a health care overhaul must be a national priority. since overwhelming majorities of the public support single-payer or a Medicare-for-all program. But those skyrocketing health care costs — and the increasing burden they put on the U.S. framed the issue as "negotiable.Single Payer 2. He cares only that some kind of bill emerges to which he can claim bragging rights. Obama’s healthcare bill excludes single payer which weakens the bill Glen Ford. discouraging more employers from coming into the marketplace. is really the bad. the American people must lose. Obama demands that the Left . although in terms so vague his own chief of staff. 6-16-2009. is a bad direction to go. to demand progressives stand down and await his marching orders . In a pre-Fourth of July teleconference with Democratic congressional leaders.stand down and let Obama do his thing. for the 180 million Americans that have it. Obama's modus operandi is by now well known. Obama would prefer to negotiate the broad outlines of legislation directly with the corporate healthcare profiteers. Obama is in shifting stages of embrace with Healthcare Inc." The president was attempting to shut down paid media messages seeking to pressure corporatist Democrats to support some sort of public healthcare option "" an option that Obama claims to favor. We ought to be focused on winning this debate. In the real world. at best." Remaking the nation's health care system is a massive task: The industry constitutes 18 percent of the U. Obama's own direction is unclear. Debate is permitted only to the Right of his own fuzzy position. by assuring them his administration means their bank accounts no harm . Obama lectured.a courtship that has been Obama's preoccupation ever since his swearing in.org/templates/story/story. gross domestic product.0 LO 36 Obama HC Not Single Payer Single-payer healthcare not in Obama’s bill NPR. No matter. as is the case most of the time. You’re A Jerk 36 . Rahm Emanuel. that dismantling private health coverage As lawmakers on Capitol Hill hammer out legislation to overhaul the nation's health care system this year. "Obama's reflexive instinct is to lash out to his left when frustrated. The president's admonition that progressives focus "on winning this debate" rather than "focusing resources on each other" makes sense only to those operating under the delusion that Obama is in a real fight with corporate healthcare profiteers. MoveOn's advertising plans successfully pressured North Carolina Sen.zmag.org/znet/viewArticle/22033 President Obama has escalated his campaign to suppress single-payer healthcare advocates. whatever that is. http://www. while the Left is shushed and hectored.such as it is ." Sebelius told Steve Inskeep.

Perhaps the most important lesson of American politics for health reform is that partisan majorities do not necessarily pro. vice president @ Economic Policy Institute. is the most powerful lawmaking body in the world. making it difficult or impossible to achieve the necessary level of consensus on a single piece of legislation. substantial overlap exists across committees` iurisdictions. Robert and Roger. The U. Indeed. vice president @ Economic Policy Institute. of course. prof of law @ American University. Consequently. As a consequence. Universal reform impossible even with supermajority – fragmented Congress structure.Single Payer 2. reform will not necessarily follow. and ability to pursue policies that diverge from those sponsored by the executive. Pg 100-101. [Mardjuki] The internal organization of Congress further complicates the road to reform. Congress is organized into a series of commit. clear both the House and Senate to reach the president`s desk. let alone a reform as controversial. system provides no assurance that the president will represent the same party as the congressional majority. does not ensure presidential victory on any given issue—a lesson Clinton learned the hard way. and threatening to powerful interest groups as national health insurance. measured in terms of its independence. Unlike a parliamentary system such as that in Great Britain. legislature. Their first political allegiance is not to their party or president but to their congressional district. prof of law @ American University. 2001. that is no guarantee that the president and Congress will enact any reform legislation. The Next Agenda: Blueprint for a New Progressive Movement. 2001. presidential sponsorship of major legislation. Members of Congress who head committees and subcommittees have their own platforms from which to introduce health care reform bills that differ from the president's or their own parties'. Failure to get a bill through these committees dooms it to defeat. American political parties are weak. administrative capacity. Hickey. divided govemment has become a regular feature of American politics. even with a Congress controlled the president': own party. Robert and Roger. it does not mean there is a majority for any one plan. "The political institutions of American government deliberately fragment power. and the Finance Commit. [Mardjuki] Even if health care recaptures a central spot on the national agenda after the 2000 elections. Borosage. The assumption that attaining a position on the policy agenda and having public majorities as well as presidential support behind reform will guarantee a political victory has misled reformers time and again. a single bill is often considered by a multitude of committees. The Next Agenda: Blueprint for a New Progressive Movement. two key committees—Ways and Means in the House. raise their own funds. However. and run independently from—and sometimes in opposition to—their party's platfom. But the labyrinth that must be navigated be. The inability of congressional majorities to coalesce behind one plan doomed national health legislation during its last two appearances on the national agenda. The lesson is a sobering one for reformers. Hickey. Members of Congress run their own campaigns. Compared to parties elsewhere in the world. lf those conditions were sufficient to enact national health insurance.fore that step is daunting. the U. Even if there is a congressional majority in favor of national health insurance. ln addition. any debate over health reform produces numerous bills sponsored by congressional policymakers seeking to be entrepreneurs. Moreover. ideologically divisive. even if the president’s own party enjoys majority status in both houses of Congress. Legislation must. You’re A Jerk 37 . Pg 100-101. even if there are congressional maiorities in favor of the legislation (as was the case with Medicare legislation in the early l960s).tee in the Senate——have acted in the past as gatekeepers for health insurance legislation. in 1970 to 1974 and in l993 to 1994. 'I'he U.duce policy majorities.0 LO 37 Universal Reform Fails . Borosage. such a law would have been passed five decades ago.S political system creates a number of barriers to the passage of any legislation.S.Congress True national healthcare will fail even with supermajority – American political system structurally flawed.‘° The fragmented structure of Congress and the relative weakness of American political parties combine to create a roadblock to reform.tees and subcommittees that govern various legislative areas.S.

and willing and able to take advantage of fragmented political institutions and of the media.0 LO 38 Universal Reform Fails – Health Politics Too many interest groups – true universal healthcare reform impossible. well handed. These groups—what political scientists call “concentrated interests"—have much at stake both financially and organizationally. Hickey. as well as almost all American health insurers.2' They are generally well organized. and suppliers of medical equipment and technology. Fundamental reform poses a tremendous threat to institutions that are invested in maintaining the medical status quo. pharmaceutical companies. vice president @ Economic Policy Institute.Single Payer 2. 2001. Borosage. You’re A Jerk 38 . prof of law @ American University. Robert and Roger. This includes a large proportion of American hospitals and physicians. Pg 101. and are likely to block any reform that threatens to erode their position. [Mardjuki] A second critical barrier to the adoption of national health insurance is the structure of health politics in the United States. The Next Agenda: Blueprint for a New Progressive Movement.

Single Payer 2.0 LO 39 **ECON – STATES** You’re A Jerk 39 .

who said that figure is "even with the assistance that we receive. a Democrat. 3. says that while the cash infusion from Congress has helped. http://www. causing a 24 percent drop in their revenues nationwide. a quarter of our population is on Medicaid . 7/22/09. a Democrat. "In Vermont. Edward Rendell. economies so we are ready to get along without these federal resources in a couple of years. “Governors bemoan steep slide in state revenues. Demand for Medicaid is ballooning as the recession continues – and Obama’s health care reform transfers unfunded federal mandates to the states – that’s Sack and Pear. the organization's incoming chairman. Wertheimer.. Stimulus was a temporary fix – massive restructuring necessary to avoid increased Medicaid deficits. in the next several years of more than $200 billion. a Republican. As a result.” National Public Radio. even with the federal stimulus.Single Payer 2. Joe Manchin. 2.scpr. the NGA says. Stimulus money only covers half of projected 2009 state budgets – insufficient to stem increased state taxes or program cuts – that’s Lav. staff writer. Meanwhile." You’re A Jerk 40 .0 LO 40 2AC AT: Stimulus Solves State Deficits 1. "We're projecting shortfalls collectively ." says West Virginia Gov. Linda.org/news/2009/07/20/governorsbemoan-steep-slide-state-revenues/ [Mardjuki] The recession has hammered the states. states face a difficult task in figuring out how to close their yawning budget gaps after the stimulus cash runs out in 2011. the states are facing a wholesale fiscal crisis." Douglas said. so (the federal stimulus) was particularly welcome to shore it up over the next couple of years. Jim Douglas. A large chunk of the shortfall comes from the biggest drop in tax revenue on record. Pennsylvania Gov." The urgency of the problem was underscored by the absence of even the NGA's chairman... who appeared at the summit via video link because he was preoccupied with the Keystone State's budget woes. Vermont Gov.. "But we have to restructure our state governments (and) .

competitiveness – that’s Angell. one quick way to do this might be to stop dinking around with alterations to the Medicaid funding formula (as the first stimulus bill did) and simply turn Medicaid into a purely federal program funded entirely with federal dollars. we'd save a little over $10 billion. Federalizing Medicaid would be the ideal second round of stimulus – instantaneous benefits. 7/11/09. but it wouldn’t be congress or the executive branch doing the wasting. rather than being a hodgepodge of 50 different plans. Kevin.motherjones. That kind of thing would work quickly. what form should it take? Matt Yglesias comments: In an ideal world at this point what I’d like to see is more aid to state and local governments. 2. Here in California. I'm not sure Medicaid has really been a great poster child for states as laboratories of democracy anyway.com/kevin-drum/2009/07/let-feds-fund-medicaid [JM] If we need more stimulus. Well. State Medicaid costs are poised to independently devastate state budgets – federal intervention is the only way to stem looming deficits – that’s Olsen. Plan is an instant stimulus that immediately eases state deficits – only a direct injection of federal money into state budgets can prevent procyclical exacerbation of the economic downturn – that’s Mattoon and Lav.S. Drum. 5. “Let the Feds Fund Medicaid?” Mother Jones. This would instantly save states something on the order of $100 billion or so. senior writer. Probably this should just be done in a very crude way — some flat per capita disbursement that could be implemented very rapidly at the federal level and kick specific decisions to someone else. 3. Some of the money would be wasted or used in bad ways. but that's probably OK. You’re A Jerk 41 . so it’d be someone else’s problem. 4. Impact inevitable without reform – Obama’s healthcare bill fails to curb entitlement spending – there’s only a chance that we prevent massive tax increases – that’s Pear. http://www. would be highly stimulative. and would allow structural shifts in the private sector to proceed apace.S.Single Payer 2. senior editor of The Atlantic Monthly. Job loss – Obama’s ineffective healthcare ensures 28 million U.0 LO 41 2AC AT: Kills Econ 1. which would be $10 billion less in demand-destroying budget cuts we'd have to make. Eventually this might lead to Medicaid becoming more standardized throughout the country. Maybe it's time to turn the entire program over to the feds so it's not constantly a procyclical drain on the economy and be done with it. jobs will be lost to offshoring – a single-payer system restores U. Yglesias.

Realization of any one of the five risks could substantially reduce world growth. RADICALLY REVERSE GLOBAL MARKETS Fred Bergsten Institute for International Economics 9-9-04 (The Economist. US vital to world economy – deficit. protectionism. and dollar crash would devastate global markets.Single Payer 2. Deep economic recession damages perception of global economic integration and derails Indian political order. A fourth relates to China. a budget profile that is out of control. were to occur in combination then they would radically reverse the global outlook. a dollar collapse. If two or three. which faces a possible hard landing from its recent overheating. and thus more protectionism and dollar vulnerability. You’re A Jerk 42 . and an outbreak of trade protectionism. China’s volatile economy is completely dependent on ours – the Chinese financial system will implode as debt and loan structures collapse.0 LO 42 2AC AT: US Not Key to Global Econ 1. A further oil shock. “The risks ahead for the World Economy” Lexis) Five major risks threaten the world economy. and a soaring American budget deficit would all generate much higher inflation and interest rates. and much higher with one Most of these risks reinforce each other. leading to widespread unemployment and foreign resentment – that’s Mead. The fifth is that oil prices could rise to $60 to $70 per barrel even without a major political or terrorist disruption. A sharp dollar decline would increase the likelihood of further oil price rises. Three center on the United States: renewed sharp increases in the current account deficit leading to a crash of the dollar. Larger budget deficits will produce larger American trade deficits. 3. 2. opening the door for religious radicalism – that’s Mead. let alone all five.

“Growing Need for Medicaid Strains States. Sack. much of the growth in Medicaid has been among children from low-income families. In most states.nytimes. two-time Pulitzer Prize winner.0 LO 43 Medicaid Costs High Now States swamped by Medicaid expenses because of a prolonged recession and surge in unemployment. “There’s just been a steady increase in the numbers. the waiting area in the office of the county’s Department of Family and Children Services was so packed with applicants that the fire marshal insisted that another room be opened for overflow. New York Times senior journalist.” But Georgia was hardly alone in seeing substantial jumps in enrollment. with 40 states responding. an Atlanta suburb that is home to a growing immigrant population. The program also provides coverage for those with disabilities. which had forecast enrollment growth of about 1 percent for this fiscal year. You’re A Jerk 43 .com/2009/01/22/us/22medicaid. In a nationwide survey. officials there said. Medicaid populations grew by 5 percent to 10 percent in the last 12 months and.” said Glenda G. the underemployed. after declining by 3 percent a year earlier. the growth in 2008 may represent only the leading edge of heightened demand. http://www. according to state officials. Kevin. which is experiencing some of the fastest Medicaid growth in the country (10. state officials now project it will be eight times higher. the current caseload is the highest since the program’s creation in 1965. the regional director over the Gwinnett County office. which had budgeted last year for increases of 1. has averaged more than triple that since June. In Florida.000 new Medicaid enrollees per month. the growth rate was at least double what it had been in the previous year. There’s just an array of need out there. by unprecedented rates in some states. The New York Times found that in some cases the surge in enrollment had overwhelmed social services agencies. pregnant women.html [Mardjuki] Medicaid rolls are surging. Here in Gwinnett County. in many. McMillan. One day last fall. Medicaid enrollment ballooned by 26 percent from July 2007 to July 2008.Single Payer 2.” New York Times. In a number of states. and prompted state fiscal analysts to shred estimates that were often only six months old. 1/21/09. Utah officials expect their state’s Medicaid enrollment to grow by 13 percent this year. In Colorado. Kentucky. nursing home residents. and in some instances parents of covered children and childless adults.4 percent for the 12 months ending in November). State Medicaid officials also say that because enrollment often lags behind job losses by several months. as the recession tightens its grip on the economy and Americans lose their employer-sponsored health coverage along with their jobs. who constitute about half of all recipients. 2009. We’re seeing the newly unemployed. and it has followed the economy. “And there’s no one population.

Medicaid was providing coverage to an average of 50 million people.0 LO 44 Medicaid Drains State Budgets Medicaid spending drains state budgets – state legislators attempting to reduce Medicaid spending. The federal government currently picks up about 57 percent of the tab. the countercyclical program now faces a grim fiscal paradox: by definition. Lawmakers returning to state capitals across the country are preparing to negotiate significant reductions in Medicaid spending by freezing or reducing reimbursements to hospitals and physicians.” New York Times. demand for Medicaid coverage is highest precisely when states are least able to afford it because of shrinking tax revenues. Sack. with Washington roughly matching the spending approved by the states. The cost of the program — $333 billion in 2007 — is shared by state and federal governments.Single Payer 2. New York Times senior journalist. http://www. 1/21/09. eating up 7 percent of the federal budget. and by narrowing eligibility for the program. by eliminating coverage options like dental and vision benefits. You’re A Jerk 44 . and the program is one of the largest drains on every state’s budget.nytimes. But at any one time last year.html [Mardjuki] Eligibility for the income-based program can vary widely by state. or about one of every six in the United States. Kevin. As in any economic downturn. “Growing Need for Medicaid Strains States. 2009.com/2009/01/22/us/22medicaid. two-time Pulitzer Prize winner.

Karen. few people were paying attention to one of the most farreaching proposals being considered as part of overhauling the health-care system: a dramatic expansion and redefinition of the Medicaid program. "These could essentially be unfunded mandates. Phil Bredesen.time. Redefining who is eligible for Medicaid would be one of the major means by which lawmakers hope to achieve universal health coverage — which is one of the reasons that governors. Rendell.) The proposal could hardly come at a worse time for governors. Miss. "Medicaid is a poor vehicle for expanding coverage.00. and would be enormously destructive to state budgets. the outgoing chairman of the NGA. According to the Center for Budget and Policy Priorities.8599. could the governors' rebellion have come at a worse time for President Obama's health-care-reform effort. a Democrat. was unable to attend the Biloxi meeting because he had to stay in Pennsylvania and struggle with the legislature to find a way to plug a $3.1911856. Tumulty. national political correspondent. The recession has drained state coffers of tax receipts. At a luncheon with Health and Human Services Secretary Kathleen Sebelius — who until April had been governor of Kansas — her former colleagues vented their anger at the idea of being handed the bill for yet another Washington initiative.0 LO 45 Obama HC Drains State Budgets Health care reform quietly increases state Medicaid financial commitments – devastates state budgets." says Pennsylvania's Ed Rendell. "It depends on what's being proposed. whose budgets are already straining under the program's growing costs. http://www. it seems.html [JM] Until the nation's governors staged a public revolt last weekend. “Medicaid and the States: Health-Care Reform’s Next Hurdle. even as public need for state safety-net services is growing. are so wary of the idea.2 billion fiscal hole.Single Payer 2. Nor. 7/21/09. at least 48 states are facing shortfalls totaling $166 billion — 24% of their total budgets.com/time/politics/article/0." The issue came to a boil as the National Governors Association (NGA) met in Biloxi. which is being hit from every side by growing doubts.” Time Magazine. Tennessee's Democratic governor." (See the top 10 health-care-reform players. told the New York Times that he regarded the proposed expansion of Medicaid as "the mother of all unfunded mandates" and warned. You’re A Jerk 45 .

particularly the $1 trillion figures being batted around. they said their deep-seated fiscal troubles made it a terrible time to shift costs to the states. With the recession draining states of tax revenues even as their Medicaid rolls are surging. Bredesen was far from alone in his concern. discouraging some doctors and hospitals from accepting beneficiaries. The role of the states in a restructured health care system dominated the summer meeting of the National Governors Association here this weekend — with bipartisan animosity voiced against the plan during a closed-door luncheon on Saturday and in a private meeting on Sunday with the health and human services secretary. And they pointed out that Medicaid already suffered from low payment rates to health care providers. a Democrat. my concern is that if we try to cost-shift to the states we’re not going to be in a position to pick up the tab. http://www. Some of the group’s most notable names — Arnold Schwarzenegger of California.” The governors’ backlash creates yet another health care headache for the Obama administration. If Medicaid is expanded. “I think the governors would all agree that what we don’t want from the federal government is unfunded mandates.nytimes. who was Kansas’ governor before she joined the cabinet in April. any increase in eligibility levels. Christine Gregoire of Washington. a Democrat. “I’m personally very concerned about the cost issue. at least partly because half of them did not attend.” Although many governors said significant change in how the nation handles health care was needed. benefits or payments to doctors would impose new burdens on the states unless Washington absorbs them. which has tried to recruit state leaders to pressure members of Congress to wrap up their fitful negotiations. also a Democrat. Tim Pawlenty of Minnesota and Bobby Jindal of Louisiana — were not here. voiced deep concern Sunday about the shape of the health care plan emerging from Congress.” said Gov. Pear. Pear. Many.” Mr. Kevin and Robert. Kathleen Sebelius. Meanwhile. Sebelius emerged from her hour-long meeting with the governors saying that “there’s a recognition that states don’t have cash right now” and that “it’s difficult to send states the bill if they don’t have the money. But the sentiment among those who were could not have been more consistent. a Republican. New York Times senior journalist. made appearances at the meeting on Sunday. In at least one of several bills circulating in Congress. and the federal Medicaid chief. regardless of political party. Obama also plans to address questions about his health plan at a news conference on Wednesday evening. a former health care executive. Cindy Mann. including the group’s chairman.html [Mardjuki] The nation’s governors. fearing that Washington was about to hand them expensive new Medicaid obligations without money to pay for them.com/2009/07/20/health/policy/20health.0 LO 46 Obama HC Drains State Budgets Medicaid already underwater – Obama’s health care proposals will only drain state budgets further. when stimulus money dries up.com/2009/07/20/health/policy/20health.” added Mr. stayed home to deal with budget crises. two-time Pulitzer Prize winner. Sarah Palin of Alaska.nytimes. They are already anticipating large gaps in Medicaid financing after 2010. Obama. two-time Pulitzer Prize winner. Sack. Gov. the group’s incoming chairman.html [Mardjuki] It was unclear whether the governors would draft a statement expressing their dismay. Sack. Governors consensus – Obama’s healthcare program will exacerbate state funding shortages. Rendell of Pennsylvania. Gov. http://www. “It’s a 45-year-old system originally designed for poor women and their children.” New York Times. 7/19/09. Bill Richardson.” said Gov. Because the states and the federal government share the cost. the state and federal insurance program for the poor. Each of several health care bills coursing through Congress relies on a large increase in eligibility for Medicaid.” New York Times. senior journalist. the National Governors Association projects that states will face aggregate deficits of $200 billion over the next three years . states will almost surely have to increase payments to doctors to encourage more of them to participate. “As a governor. New York Times senior journalist. the New Mexico Democrat who served in the Clinton cabinet and ran for president against Mr. Mr. the states would eventually pick up a share of the new costs. “Governors Fear Medicaid Costs in Health Plan. “We can’t have the Congress impose requirements that we are forced to absorb beyond our capacity to do so. Ms. 7/19/09.” “Medicaid is a poor vehicle for expanding coverage. Sebelius.” said Gov. Both Ms. Edward G. Bredesen. You’re A Jerk 46 .Single Payer 2. It’s not health care reform to dump more money into Medicaid. said he feared Congress was about to bestow “the mother of all unfunded mandates. The governors said in interviews and public sessions that the bills being drafted in Congress would not do enough to curb the growth in health spending. and the governors fear they cannot count on provisions in other bills that they will not bear costs. And they said they were convinced that a major expansion of Medicaid would leave them with heavy costs. “Governors Fear Medicaid Costs in Health Plan. as one means of moving toward universal coverage. Democrats as well as Republicans. Jim Douglas of Vermont. Phil Bredesen of Tennessee. other administration officials spent the day pushing President Obama’s proposal on television talk shows. senior journalist. Kevin and Robert.

The Congressional Budget Office projects that 11 million more people would receive coverage through Medicaid under the House bill. Kevin and Robert. Bill Ritter Jr. trumpeting their opposition in a conference call last week with Senator Max Baucus. The federal government would pay all the costs for those who were newly eligible.html?mod=googlenews_wsj [Mardjuki] Mr. In addition. Medicaid eligibility would be based solely on income. 7/22/09.” said Gov. Rove. two-time Pulitzer Prize winner. Peter R. New Mexico and Washington joined GOP colleagues at the National Governors Association summer meeting to blast the administration for plans to shift millions of families into Medicaid. First. Medicaid would be expanded to cover all nonelderly people with incomes at or below 133 percent of the poverty level. of deficits (38% to 19%). “There’s a concern about whether they have fully figured out a revenue stream that would cover the costs. “There is strong bipartisan opposition to the idea of the states’ issuing bonds to pay for operational expenses. You’re A Jerk 47 . “Governors Fear Medicaid Costs in Health Plan. Those who strongly disapprove now outnumber those who strongly approve of his handling of the economy (35% to 29%). 83. On average. for up to 60 days after birth. In a draft of the bill in the Senate Finance Committee. 7/19/09. Obama’s promise that you can keep your plan is being left on the cutting Another batch of bad news came this week as Democratic governors from Colorado. Gallup showed Mr. Obama is also slipping on the economy. Mr.com/article/SB10001424052970203517304574304161389163586. That could stick states with $440 billion in new costs over the next decade. Obama’s health-care proposals. if they did not have insurance from other sources. ex-presidential senior advisor. Medicaid would also cover newborns. could slightly reduce state spending on Medicaid and the Children’s Health Insurance Program over the next 10 years.Single Payer 2.wsj. Medicaid thus accounts for about 40 percent of the cost and 30 percent of those who gain coverage. New York Times senior journalist. chairman of the Republican Governors Association.0 LO 47 Obama HC Drains State Budgets Increased costs inevitable – various healthcare bills being debated all increase state medical spending. a Democrat. some versions of the legislation. and that if they don’t have all the dollars accounted for it will fall on the states. Haley Barbour of Mississippi. On Tuesday. one of Mr.com/2009/07/20/health/policy/20health. down from more than 60% a few weeks ago and lower than the 56% George W. Obama’s overriding goals was to reduce the rate of growth of health costs. Governors in both parties revolted.” New York Times. Pear. he said. Under the health care proposals before Congress. Many governors expressed frustration that the prolonged negotiations in Washington had made it difficult to gauge the potential impact on their budgets. and of unemployment (31% to 26%).” Only risk that healthcare bill will damage Obama’s cred further – will balloon state deficits. The polls are crumbling because of a flood of bad news about Mr. made two points. One batch of such news came from a July 17 study by the Lewin Group that was commissioned by the Heritage Foundation. http://online. or $29. but states would eventually have to pay their normal share.html [Mardjuki] Asked about the concerns. senior journalist. and that it would increase federal Medicaid spending by $438 billion over 10 years. the federal government pays 57 percent.4 million people—nearly half of those with private coverage—will lose private insurance as employers drop their plans. and that would benefit states by relieving pressure on their budgets. http://www.” Wall Street Journal. Karl. Orszag. of Colorado. including the House bill. he said.” said Gov.nytimes. One of the proposals being considered by the Finance Committee would encourage states to issue bonds to cover the costs of expanding Medicaid. Bush had at this point in his first term. Sack. without regard to factors that have historically been used to decide who qualifies. the federal government would pick up the extra costs for perhaps five years. director of the White House Office of Management and Budget. “ObamaCare in Trouble. Tennessee. the Montana Democrat who leads the committee. “One governor said it would be like taking out a mortgage to pay the grocery bill. Obama’s personal approval was 55%. It projects that if the House bill becomes law.300 for a family of four. deputy chief of staff. In the House bill.

One proposal has called for the federal government to pick up permanently the cost for those newly eligible for the program.com/wpdyn/content/article/2009/07/18/AR2009071801786_pf. according to an estimate by an NGA official. You’re A Jerk 48 . My final point relates to some important things the plan does not do. which is funded by the federal government and the states.com/x-14783-Lawand-Politics-Examiner~y2009m7d21-An-examination-of-the-presidents-health-care-plan-part-2-of-2 [Mardjuki] The plan seeks to expand on Medicare and Medicaid. even as federal funding is eventually reduced. Whatever one thinks about the efficacy and sustainability of these two programs. An NGA official estimated that the cost of that expansion could be around $60 billion a year. I also expect the federal government to place increased mandates on states. so we are ready to get along without these resources in a couple of years. governors may have another looming fiscal burden. States were promised relief after 2019. Balz.” Washington Post. law and politics consultant. not institutionalize it. More troubling proposals have been under discussion. in their current state. according to an analysis prepared by the Center on Budget and Policy Priorities and shared by Rendell's office.Single Payer 2.washingtonpost. A good bill would address this. Locking citizens into a system of third party payer.examiner. The health-care bills moving through Congress include a significant expansion in Medicaid. Employers provide health insurance as a benefit. Governors are already talking about the moves they may have to make once the stimulus money disappears after 2011. But as congressional committees wrestle with projections that show health care turning into a budget buster. "We have to restructure our state governments . especially if the economy is not growing at a substantial pace. they are looking for ways to strip away costs. That proposal. The proposal smelled of an effort to offload some costs of the health-care package during the years that would be included under the Congressional Budget Office's period for "scoring" the budgetary implications of the plan. 7/19/09. http://www. How might states pay for their share? Maybe not at all. The whole concept began during WWII when employers. senatorial aide. governors revolted against a plan under consideration in the Senate Finance Committee. Dan. Budget Problems Are Inescapable. Instead many began offering to take that money and purchase their employees health insurance which until that time was generally purchased privately. senior writer. solidifies private sector insurance. As they do that. 7/21/09.000 tax credit to do so.html [Mardjuki] But even with the stimulus money. hamstrung by wartime wage controls. This would have been augmented by some share of promised Medicaid drug rebates. “At Governors’ Meeting. they themselves are in serious need of reform. It does nothing to address the current employer based system of health insurance. Moore. In fact it solidifies it. http://www. Another proposal floated earlier was for the federal government to pay the entire bill for five years." A state official called it "creative financing. They are in no position. . “An Examination of the President’s Health Care Plan. employee provided insurance drowning under crushing state converge mandates is a major reason for rising medical costs. states face collective deficits of more than $200 billion in the next few years. Last week. at least for the first few years. One congressional source described the measure as "subject to gimmick charge. Christian. I also dislike the idea of being unable to change jobs for fear of losing one’s health insurance coverage. . and get at least a $5." Rendell said it was "absolutely" an attempt by the Finance Committee to make the package look less costly during the years included in the CBO scoring window. Governors have already been warned that 100 percent federal financing is now very unlikely.0 LO 48 Obama HC Drains State Budgets Obama’s healthcare exacerbates states’ Medicare and Medicaid deficits. to handle this type of expansion. Jim Douglas (R).” Manchester Examiner." said Vermont Gov. On the face this will be a serious financial burden to states already facing bankruptcy. who will take over the NGA chairmanship on Monday. would have called on the states to issue 30-year bonds and pay the cost of the Medicaid expansion from the proceeds. could not offer increased salaries as an incentive to recruit talent. Asking the states to issue bonds for the Medicaid expansion would have taken $180 billion off the budget. or fails to keep pace with expanding federal requirements. Congressional gimmicks – hidden state costs in congressional committees’ HC proposals.

at least 48 states are facing shortfalls totaling $166 billion — 24% of their total budgets. even as public need for state safety-net services is growing. http://www.8599." Governors wary of unfunded federal healthcare mandates.” he declared. it will do the opposite. Jr. could the governors' rebellion have come at a worse time for President Obama's health-care-reform effort. Douglas Elmendorf. the outgoing chairman of the NGA. particularly the $1 trillion figures being batted around.0 LO 49 Obama HC Drains State Budgets Obama’s healthcare too costly for states Karen Tumulty. The recession has drained state coffers of tax receipts. (D) summed things up: “There’s a concern about whether they have fully figured out a revenue stream that would cover the costs. it seems. and that if they don’t have all the dollars accounted for it will fall on the states. DuBord. said that “Medicaid is a poor vehicle for expanding coverage. "Medicaid is a poor vehicle for expanding coverage." And even the Mayo Clinic — often cited by Obama as the model of what an efficient. including a meeting with Health and Human Services Secretary Kathleen Sebelius and Cindy Mann." (See the top 10 health-care-reform players. Tennessee's Democratic governor. Steven J.” And Colorado Governor Bill Ritter.) The proposal could hardly come at a worse time for governors. Republicans are calling it a dangerous "experiment. Rendell. “it’s not health care reform to dump more money into Medicaid. the association’s incoming chairman. Tennessee Governor Phil Bredesen. was unable to attend the Biloxi meeting because he had to stay in Pennsylvania and struggle with the legislature to find a way to plug a $3. which is being hit from every side by growing doubts.” Bredesen. National Political Correspondent for Time Magazine.com/index. said. Abortion Stymie Health Reform” http://www. another Democrat. Senators of both parties are trying to put the brakes on the President's drive to have bills passed by the House and Senate by the August recess. high-quality health-care system should look like — is cautioning on its blog that legislation under consideration in the House "misses the opportunity to help create higher quality . Both Democratic and Republican governors voiced animosity toward any reform that would overload states at a time when they are already struggling financially. According to the Center for Budget and Policy Priorities.” You’re A Jerk 49 . At a luncheon with Health and Human Services Secretary Kathleen Sebelius — who until April had been governor of Kansas — her former colleagues vented their anger at the idea of being handed the bill for yet another Washington initiative .com/time/politics/article/0.Single Payer 2. “Governors. has testified that the legislation thus far has too little cost containment. 7-22-2009. “I’m personally very concerned about the cost issue. head of the Congressional Budget Office. “Medicaid and the States: Health-Care Reform’s Next Hurdle”. a Democrat. 7-21-2009.” said Vermont Governor Jim Douglas (R). a former executive in healthcare.1911856. “I think the governors would all agree that what we don’t want from the federal government is unfunded mandates. the federal Medicaid chief. more affordable health care for patients.” Describing it as “a 45-year-old system originally designed for poor women and their children.” Democratic Governor Christine Gregoire of Washington is concerned that “if we try to cost- shift to the states we’re not going to be in a position to pick up the tab. Miss. Nor. Phil Bredesen. staff writer for The New American magazine. “We can’t have the Congress impose requirements that we are forced to absorb beyond our capacity to do so. told the New York Times that he regarded the proposed expansion of Medicaid as "the mother of all unfunded mandates" and warned. In fact.” New Mexico Governor Bill Richardson. worried that Congress was about to bestow “the mother of all unfunded mandates.2 billion fiscal hole.thenewamerican.html The issue came to a boil as the National Governors Association (NGA) met in Biloxi.00.php/usnews/health-care/1492 The National Governors Association met on July 18 and 19. Douglas’ assessment was backed up even by Democratic governors.time.

“There’s a concern about whether they have fully figured out a revenue stream that would cover the costs. the federal government pays 57 percent. Many. The governors said in interviews and public sessions that the bills being drafted in Congress would not do enough to curb the growth in health spending.nytimes. said he feared Congress was about to bestow “the mother of all unfunded mandates. and that it would increase federal Medicaid spending by $438 billion over 10 years. Medicaid would also cover newborns.” said Gov. And they said they were convinced that a major expansion of Medicaid would leave them with heavy costs. discouraging some doctors and hospitals from accepting beneficiaries. or $29. the Montana Democrat who leads the committee. “Governors Fear Medicaid Costs in Healthcare” http://www. stayed home to deal with budget crises.” said Gov. In at least one of several bills circulating in Congress. If Medicaid is expanded. and the governors fear they cannot count on provisions in other bills that they will not bear costs.Single Payer 2. as one means of moving toward universal coverage. The federal government would pay all the costs for those who were newly eligible. Gov.html?hp Although many governors said significant change in how the nation handles health care was needed. “There is strong bipartisan opposition to the idea of the states’ issuing bonds to pay for operational expenses. the National Governors Association projects that states will face aggregate deficits of $200 billion over the next three years. Because the states and the federal government share the cost. Tim Pawlenty of Minnesota and Bobby Jindal of Louisiana — were not here. “One governor said it would be like taking out a mortgage to pay the grocery bill.” Mr. they said their deepseated fiscal troubles made it a terrible time to shift costs to the states. Christine Gregoire of Washington. It’s not health care reform to dump more money into Medicaid. But the sentiment among those who were could not have been more consistent. any increase in eligibility levels. With the recession draining states of tax revenues even as their Medicaid rolls are surging. “Governors Fear Medicaid Costs in Healthcare” http://www. They are already anticipating large gaps in Medicaid financing after 2010. Kevin Sack and Robert Pear. a Democrat. chairman of the Republican Governors Association. a Democrat.html?hp Many governors expressed frustration that the prolonged negotiations in Washington had made it difficult to gauge the potential impact on their budgets. The Congressional Budget Office projects that 11 million more people would receive coverage through Medicaid under the House bill. trumpeting their opposition in a conference call last week with Senator Max Baucus. regardless of political party. Medicaid thus accounts for about 40 percent of the cost and 30 percent of those who gain coverage. “As a governor. Haley Barbour of Mississippi.” said Gov. my concern is that if we try to cost-shift to the states we’re not going to be in a position to pick up the tab. of Colorado. Governors in both parties revolted. Phil Bredesen of Tennessee. On average. It was unclear whether the governors would draft a statement expressing their dismay. when stimulus money dries up. also a Democrat House bill encourages states to issue bonds to fund Medicaid. One of the proposals being considered by the Finance Committee would encourage states to issue bonds to cover the costs of expanding Medicaid. Each of several health care bills coursing through Congress relies on a large increase in eligibility for Medicaid. states will almost surely have to increase payments to doctors to encourage more of them to participate. Medicaid eligibility would be based solely on income. Some of the group’s most notable names — Arnold Schwarzenegger of California. a former health care executive. a Democrat. but states would eventually have to pay their normal share. Rendell of Pennsylvania.com/2009/07/20/health/policy/20health.” You’re A Jerk 50 . the state and federal insurance program for the poor. Sarah Palin of Alaska. the federal government would pick up the extra costs for perhaps five years. Bill Ritter Jr. Edward G. at least partly because half of them did not attend. Under the health care proposals before Congress. Kevin Sack and Robert Pear.0 LO 50 Obama HC Drains State Budgets Governors fear states will pay for Obama’s healthcare. And they pointed out that Medicaid already suffered from low payment rates to health care providers. In a draft of the bill in the Senate Finance Committee. In the House bill. and that if they don’t have all the dollars accounted for it will fall on the states. benefits or payments to doctors would impose new burdens on the states unless Washington absorbs them.nytimes. Medicaid would be expanded to cover all nonelderly people with incomes at or below 133 percent of the poverty level. for up to 60 days after birth.com/2009/07/20/health/policy/20health.” “Medicaid is a poor vehicle for expanding coverage.300 for a family of four. if they did not have insurance from other sources.” added Mr. 7-19-2009 (two-time Pulitzer Prize winner and correspondent for the New York Times). “It’s a 45-year-old system originally designed for poor women and their children. including the group’s chairman. Bredesen was far from alone in his concern. without regard to factors that have historically been used to decide who qualifies. the states would eventually pick up a share of the new costs. 7-19-2009 (two-time Pulitzer Prize winner and correspondent for the New York Times). Gov. Bredesen.

Single Payer 2.0 LO 51 You’re A Jerk 51 .

or significantly increasing the cost of these services. rehabilitative. http://www. Director of BPP State Fiscal Project. Phil. Johnson. as the recession brought sharply weakened revenues. Rhode Island eliminated health coverage for 1.org/cms/index. home care.cfm? fa=view&id=1214.000 low-income parents. Service cuts with particular ramifications for vulnerable populations have occurred in the following areas: Public health programs: At least 21 states have implemented cuts that will restrict low-income children’s or families’ eligibility for health insurance or reduce their access to health care services. The cuts have intensified as the economy has worsened. and Rhode Island is requiring low-income elderly people to pay more for adult daycare. or other services needed by low-income people who are elderly or have disabilities. For example. “An Update on State Budget Cuts.0 LO 52 State Deficits Now – No HC State deficits now – healthcare is the first to go.” Center on Budget and Policy Priorities. Nicholas. Nevada is making it harder for beneficiaries to qualify for nursing home care. You’re A Jerk 52 . Phil. eliminated temporary health insurance for people with serious medical problems. Programs for the elderly and disabled: At least 22 states plus the District of Columbia are cutting medical.500 low-income adults. 6/29/09.cbpp. [Mardjuki] States began cutting their budgets last spring. Arizona has eliminated temporary health insurance for people with disabilities who are coping with serious medical problems. and California and Utah are reducing services covered by their Medicaid programs. Florida has frozen reimbursements to nursing homes and relaxed staffing standards. For example.Single Payer 2. Minnesota is cancelling a health insurance program for 29. At least 39 states to date have reduced services since the recession began. Senior Fellow.

100 disabled individuals. prescription drug assistance. rehabilitative. or substance abuse. the District of Columbia.100 older adults. Maryland. affecting 2. Michigan. Such services help people stay in their own homes and possibly delay or avoid more expensive nursing home care. such as meals and homemaker services. Kansas. This may affect access to prescription drugs for mentally ill or disabled individuals who rely on several medications to manage their conditions. and prescription drug assistance. Ohio plans to close two mental health facilities. It also established a waiting list for vocational rehabilitation services. mental retardation. The state also has cut Medicaid reimbursements to hospitals and community-based services for the elderly. http://www. a program designed to provide time-limited cash assistance to adults with physical or mental disabilities. The state also reduced pass-through grants for various aging programs and funding for local mental health providers. Phil. geriatric mental health services. Alabama has ended homemaker services for approximately 1. low-income elderly people must pay higher rates for subsidized adult day care. including home care. [Mardjuki] At least 22 states and the District of Columbia have cut medical. for people who are elderly or disabled. nursing homes and other providers will not receive scheduled cost-of-living adjustments in their reimbursements and staffing standards will be relaxed for one year. Virginia has decreased reimbursements for special hospitals serving people with needs relating to mental health. elder service centers. Utah. Johnson. Maine. The state also eliminated general assistance.0 LO 53 State Deficits Now – No HC State healthcare being eliminated now – laundry list. These services often allow people to stay in their own homes and avoid nursing home care. In addition. Arizona has eliminated temporary health insurance for people with disabilities who are coping with serious medical problems.cfm? fa=view&id=1214.200 people with incomes below $20. or other services needed by lowincome people who are elderly or have disabilities or significantly increased the amounts that such people must pay for services. Vermont has reduced some home-based services. The state provides these payments to an average of 2.org/cms/index. Tennessee has reduced community-based services for people with intellectual disabilities and cut nursing services for some adults with serious disabilities. In Massachusetts. In Florida. the state has eliminated early intervention services that support young children with special needs for 850 infants and toddlers at risk of developmental delay.000. such as housekeeping and shopping. This is estimated to affect more than 1. “An Update on State Budget Cuts. in the expectation that the freeze will result in staffing cuts. in February 2009 the state eliminated independent living supports for 450 elderly residents and respite-care funding for 130 caregivers.100 disabled individuals each month who cannot work and are not eligible for Temporary Assistance to Needy Families. and Washington.Single Payer 2. and elder support. South Carolina. Director of BPP State Fiscal Project. In Rhode Island. Louisiana will impose a limit on the number of Medicaid prescriptions it will pay for. 6/29/09. Minnesota has capped enrollment at current levels for a program that provides expanded health services and care coordination for people with disabilities.cbpp. Other states that have capped or reduced funding for programs that serve people who have disabilities or are elderly includeCalifornia. Senior Fellow. Nicholas. Georgia has reduced such programs for the elderly as Alzheimer services.” Center on Budget and Policy Priorities. Furthermore. home care. Phil. You’re A Jerk 53 . the governor has ordered cuts in programs for elders. New Mexico will cut cash assistance payments for low-income disabled residents by a third beginning in July. Pennsylvania.

Utah. Rhode Island has frozen state aid for K-12 education at last year’s levels in nominal terms and reduced the number of children who can be served by Head Start and similar services by more than 550. gifted and talented summer centers. professional development for principals and educators. Iowa. Phil. Ohio. health clinics. It also is cutting a variety of other programs. In Nevada. services for disabled students.0 LO 54 State Deficits Now – No Education State K-12 education cut now – laundry list. Senior Fellow. Maryland cut funding for a school breakfast pilot program. Kansas. Arizona enacted mid-year cuts of $96 per pupil in core K-12 funding. The state also cut K-12 funding. South Carolina cut per-pupil funding by $95 this past year. Florida cut aid to local school districts by at least $140 per pupil. California is reducing basic K-12 education aid to local school districts. Connecticut. Hawaii. teacher training. Kentucky. including delaying an all-day kindergarten expansion. and early intervention services to help special-needs children develop appropriately and be ready for school. Maine. Oregon. cutting per pupil expenditures by $400 in a pilot program. young children with developmental delays will lose more than 15. Nicholas. and Virginia. State education grants to school districts have also been cut in Alabama. Washington. such as adult literacy instruction. Mississippi. You’re A Jerk 54 . 6/29/09. and is reducing funding for some grants and programs aimed at helping high-needs students. the governor has ordered various cuts to K-12 education.cbpp. and math and science initiatives.org/cms/index.cfm? fa=view&id=1214. Johnson. http://www. Georgia made a $112 million cut to the equalization component of the state’s education aid formula established to help close the gap in funding between wealthier and poorer school districts.Single Payer 2. Phil. and making across-the-board cuts. Delaware. including spending for mentoring. Additionally. and programs for gifted and talented students. reimbursements for special education residential schools.000 hours of needed services. Idaho. Director of BPP State Fiscal Project. [Mardjuki] At least 24 states have implemented cuts to K-12 education. Massachusetts enacted cuts to Head Start. universal pre-kindergarten programs. “An Update on State Budget Cuts.” Center on Budget and Policy Priorities. eliminating funds for gifted and talented programs and a magnet program for students who are deaf or hard of hearing.

” Center on Budget and Policy Priorities. Rhode Island College.cbpp.300 students for next year. 6/29/09. and limiting enrollment in its nursing school. [Mardjuki] At least 32 states have implemented cuts to public colleges and universities and/or made large increases in college tuition to make up for insufficient state funding. Florida State University plans to lay off up to 200 faculty and staff members.3 percent respectively. and Virginia. Tuition in Arizona this year rose 9. Louisiana. Arizona State University has addressed its loss of state funds by eliminating over 550 staff positions and 200 faculty associate positions. by 6. Oklahoma. The University of Florida has announced it will eliminate 150 positions for the coming year. Pennsylvania. http://www. Johnson. consolidating several schools and almost two dozen academic departments. Utah. Nicholas. Phil. resulting in 49 staff and nine faculty layoffs. and the Community College of Rhode Island all increased tuition for this past academic year. imposing employee furloughs ranging from 10 to 15 days. the California State University system is cutting enrollment by 10.2 percent.cfm? fa=view&id=1214. Mississippi. New Jersey. “An Update on State Budget Cuts. New Mexico. Kentucky. Other states cutting higher education operating funding include Alabama. Hawaii. Tuition at all 11 Florida public universities will rise by 15 percent next year. Minnesota. You’re A Jerk 55 .000 students. Iowa. Maryland.5 percent in response to funding cuts. the University of Rhode Island. Maine. 8. Phil. Tennessee.Single Payer 2. Director of BPP State Fiscal Project.org/cms/index. North Carolina. South Carolina. Idaho. resident undergraduate tuition increased by 14 percent (over $600 per year) between the fall and spring semester of this past academic year. California. Kansas. When Rhode Island cut higher education funding. Vermont. Massachusetts. The budget authorizes the university to increase tuition up to 14 percent to compensate for this funding loss. Budget cuts reduced state funding for the University of Washington by 26 percent for the coming biennium. As a direct result of state budget cuts. Connecticut. The University of California system is reducing California resident freshman enrollment by 2. Nevada .7 percent. At the State University of New York. Colorado. and 4. Each of these institutions went one step further by increasing tuition further mid-year.0 LO 55 State Deficits Now – No Education State higher education budgets cut now – laundry list. Florida has cut university budgets and community college funding. Georgia. Senior Fellow.

Maine.org/cms/index. a number of state colleges and universities in states such as Alabama.500 employees accepted buy-outs for early retirement. Georgia. Overall. Arizona. the District of Columbia. Mississippi. plus the District of Columbia — have laid off or announced plans to lay off state employees. Massachusetts.California. The Tennessee governor has announced elimination of over 2.000 between March 2007 and December 2008. and furloughed remaining employees. South Dakota. Pennsylvania. New Mexico. New Hampshire. Kentucky.0 LO 56 State Deficits Now – Job Loss State employees being fired now – laundry list. Cutting staff — whether on a permanent or temporary basis — also may contribute to increased unemployment.Hawaii. Florida.000 state positions by encouraging early retirement. gave early retirement to 25 employees.cfm? fa=view&id=1214.Minnesota. In Washington. Hiring freezes have also been ordered in Alabama. and Utah. and laying off staff. Maryland. 6/29/09. health care. about 4. New Mexico. Additional states — such as Arizona. North Carolina. Some 1. You’re A Jerk 56 . Phil. New York. Senior Fellow. Iowa. Maine. The Ohio governor has announced plans to eliminate as many as 2.000 state positions. North Carolina. California. To deal with budget cuts in Kentucky. Vermont.000 or more.5 percent of the state workforce. child welfare. Such steps can make it more difficult for residents to obtain state services. As noted above. Michigan. Ohio. the Ohio state workforce declined by 3. Massachusetts. South Carolina. Nevada. child care. Colorado. Michigan. Phil.600 under the cap. Kentucky. andSouth Carolina.Delaware. the state’s workforce is expected to fall by another 2. Hawaii. Michigan. Florida. Arizona. Wisconsin. leaving vacancies unfilled. In the Department of Jobs and Family Services — which oversees disability services. These include Arizona. and Wyoming. Rhode Island plans to reduce the state workforce by 2.Idaho.400. Connecticut. Nicholas. Kansas.Single Payer 2. and delayed a 2 percent salary increase scheduled for November 2008. Johnson. [Mardjuki] At least 40 states plus the District of Columbia are eliminating or not filling various state jobs. Louisiana. A number of states are imposing furloughs and/or pay cuts for some state employees. the Department of Public Advocacy (which defends clients in the criminal justice system) instituted a strict hiring freeze. through a combination of early retirements. Virginia’s governor has eliminated 800 currently unfilled positions.cbpp.” Center on Budget and Policy Priorities. Iowa. or making other cuts affecting their state workforce. laid off 567 state workers. child support.700 positions. and leaving vacancies unfilled. In early January the state replaced the freeze with a cap on the number of budgeted positions at each state agency. and other services — fully 14 percent of positions will be eliminated or left unfilled. and New Jersey are responding to budget cuts by cutting faculty and staff positions. “An Update on State Budget Cuts. imposing mandatory furloughs (time off without pay). Illinois. a hiring freeze imposed by the governor in August caused the state’s workforce to decline by more than 1. Georgia. layoffs. about 5 percent of the state workforce. New Jersey. http://www. The state is encouraging early retirement but has announced that it will lay off workers if needed. Florida. Director of BPP State Fiscal Project. New Jersey has eliminated 2.

Children's services. we were short-sided in the 2010 budget." Neff said. She is expecting anywhere from $300. Georgas said. "We felt like we were unfairly targeted in 2009. “The criminal system will probably grow. The Board of Mental Health treats clients suffering from depression." and again. Georgas said." But now.000 budget hit in 2009. mentoring services throughout the county and youth services. "It's going to impact people who don't have Medicaid. schizophrenia and other mental health issues by contracting out with 18 different agencies as well as psychiatric hospitals to provide service to county residents.0 LO 57 States Deficit Now—Tradeoffs Medicaid tradeoffs with social services in state budgets –Ohio proves. said her department is also preparing to get hit with a financial crunch. "This is going to mean drastic cuts. Elaine Georgas. according to Neff. according to directors of two of the county's service boards. he said.txt Social service agencies in Lorain County are feeling the rippling effects of Ohio's newly passed budget." he said. noting the department already took a $975. but roughly 75 percent of the board's clients are not on Medicaid. "We have heard that our state department (Ohio Department of Alcohol and Drug Addiction Services) has been given a 30 percent budget cut. The Alcohol and Drug Addiction Services Board seeks to minimize substance abuse and work toward prevention by contracting out with agencies who can provide treatment. Services will be slashed and the lines for those in need of assistance will likely be longer. “State Budget Cuts to Affect Social Services”. staff writer.morningjournal." Georgas said. Jordan Cravens. The way Neff has it figured is for every $1 spent on mental health." which will likely work its way down to the county level." Georgas said." Georgas said. "These cuts will definitely be a problem for these clients. Georgas said other clients will likely have to wait longer for services. Georgas explained. http://www.Single Payer 2. executive director of the Lorain County Board of Mental Health. You’re A Jerk 57 . the government could save $11 in keeping citizens out of the court system and prisons. Both Neff and Georgas agreed the impact on the criminal justice system will furthering the ripple effect. families and communities will all bare the burden of the cuts." Georgas said.000 to $400. "Families are going to suffer because people who need treatment need to get treatment as soon as they can." said Charles Neff. He said the board would do its best to maintain its core client services but the cuts would surely impact residential treatment. she said. Neff said the board is expecting between $1 million and $2 million less from the state.com/articles/2009/07/21/news/mj1361976. 7-21-2009. Neff said he foresees the same issue arising — people without Medicaid getting bumped to the back of the line. with preference being given to those with Medicaid. "We got killed in the budget. executive director of the Alcohol and Drug Addiction Services Board of Lorain County.000 in cuts. "They rely on the state funding for services. While the figures are yet to be ironed out. "I know the state's issue is with Medicaid.

Those who work as caregivers in the state’s $4. will probably lose far more as a result of the deal when the state begins dipping into tax streams on which they depend. who control the Legislature and who had worked to prevent what they called a gutting of the state’s social services. You’re A Jerk 58 .7 billion home health care program.0 LO 58 State Deficits Now—Tradeoffs California budget cuts reduce other social services Jennifer Steinhauer. New York Times L. The state’s education budget of nearly $52 billion seemed destined for another large hit. which have already suffered their own losses of tax revenues.com/2009/07/16/us/16calif. Local governments. bureau chief. The deal also required the use of accounting devices used by all states in a time of crisis. “California Approaches a Deal on Budget Cuts”.Single Payer 2. http://www.5 billion. Public colleges and universities across the state have prepared for millions of dollars in cutbacks by furloughing employees. Benefits will also be trimmed in another program the governor eyed for elimination — CalWorks.A. of about $1.html?hp Democrats. Schwarzenegger. like putting off programs or payments until the next fiscal year so the budget gap does not seem as large. leaving them even less able to continue to offer programs like music and physical education. Statewide furloughs of three days a month for government employees are likely to continue through the rest of the fiscal year. Some school districts have already promised raises to teachers. meaning that some children will be on a waiting list for health care. its enrollment will probably be limited. on top of large reductions earlier. officials said. and the agreement in progress calls for the state to repay them over three years. including gasoline taxes. and appeared on the brink of victory in achieving many — if not all — of the reforms he sought for some programs. Medicaid recipients will probably be moved into a managed-care program. held fast to his promise to reject all tax increases. which provides financial assistance to families with children ages 18 and under.nytimes. for example. appeared to be prevailing in some measure by agreeing to cuts to other programs and localities. will most likely face more stringent screening processes intended to curb fraud. a Republican. 7-15-2009. state officials said. as they would put the state in violation of federal standards. Cities can try to borrow the amount they are losing. as the governor once threatened. like fingerprinting and background checks. but many of the financially weaker localities may face the prospect of defaulting on their bonds. While the state’s health care program for poor uninsured children will not end. Mr. Further Medicaid cuts seem unlikely.

u. But that budget depended on a nod from voters on several ballot measures. One of the biggest sticking points was over the $11 billion already cut from public schools. Healthy Families.” Karen Bass. New York Times L.0 LO 59 State Deficits Now –Tradeoffs California budget crisis hurting social services and schools Jennifer Steinhauer. the state was forced to issue millions of dollars in i.com/2009/07/21/us/21calif.’s to vendors and taxpayers in lieu of payment. distributes pain through nearly every aspect of government services. With the deficit continuing to grow.4 billion in new borrowing. among other purposes.9 billion in new revenues and about $2. Local governments will lose millions of dollars that are used to build housing. and the state plans to borrow roughly $2 billion in property taxes from localities. Lawmakers believe that cities and counties could in turn borrow against that borrowing. localities bankrupt or nearly so would be exempt.5 billion in tax increases and $5. While the state’s health insurance program for children. While the governor wanted certain welfare benefits to be reduced from a fiveyear period to two years.1 billion in borrowing. universities and local governments. which would have to be repaid within three years. You’re A Jerk 59 . which is certain to be viewed with trepidation among legislatures across the country also facing huge budget gaps. the speaker of the California Assembly. their state broke and its credit rating shot. $12. Under the new budget. state officials have come up with a compromise that few who receive government services will celebrate. lawmakers signed off on a budget deal with $14. the deal contains $15. 7-20-2009. a Republican. meaning thousands of children will probably be on a waiting list for the program unless a private foundation makes up the balance. Arnold Schwarzenegger’s proposal to eliminate health care programs for children and the state’s generous welfare program. which runs through the 2010 fiscal year. $3. All failed. remains. about $2. It will raid their coffers and repay them over time as the state’s fiscal situation improves. “California Reaches Budget Deal.o.8 billion in spending cuts.Single Payer 2. Schwarzenegger. http://www. localities will basically serve as unwilling lending agents to the state. and Mr. finally sealed the deal with the governor Monday night on a plan to close a $26 billion budget gap.7 billion in accounting maneuvers like shifting a payday into the next fiscal year. In-home services for the elderly and infirm were reduced by several million dollars.6 billion in cuts. along with the creation of a $1 billion reserve fund. the program was instead given an overall cut of $500 million . as the Democraticcontrolled Legislature hopes. which Mr.html?_r=1 California lawmakers. With Billions Cut”. it was cut by $144 million. All told. said in a telephone interview from Sacramento. The budget deal calls for roughly $650 million more in cuts. After weeks of often-cantankerous negotiations. Schwarzenegger had claimed he would not brook. bureau chief. So did public education. “I would characterize this budget as shared pain and shared sacrifice. achieved his goal of having caregivers and the recipients fingerprinted in the future with the goal of preventing fraud. While the Legislature pushed back on Gov.A.nytimes. The plan. Last February. both took large cuts.

often at the expense both of their most vulnerable constituents and of the nation’s economic future. lower-level governments can’t borrow their way through the crisis. of course. for capital. or repairs to decaying roads and bridges than it was one or two years ago? Of course not. The Obama administration will put deficit concerns on hold while it fights the economic crisis. In fact. and the money borrowed to pay for these projects would otherwise sit idle. are refusing to buy anything except federal debt. running temporary deficits would be difficult. Why can’t we keep doing good things? It’s true that the economy is currently shrinking. It makes no sense to add to the problem by cutting public spending. So why are we doing this to ourselves? The answer. especially public investment. “Fifty Herbert Hoovers.com/2008/12/29/opinion/29krugman. Partly that’s because these governments.” New York Times. the nation will be reeling from the actions of 50 Herbert Hoovers — state governors who are slashing spending in a time of recession. to the decision by a committee that manages California state spending to halt all construction outlays for six months. It adds to the sense of insecurity that is one important factor driving the economy down. medical care for families. is that state and local government revenues are plunging along with the economy — and unlike the federal government. state governors aren’t stupid (not all of them. And shredding the social safety net at a moment when many more Americans need help isn’t just cruel. driven by fear. which will force young offenders out of group homes and into prison. 7/22/09. unlike the feds. But that’s the result of a slump in private spending. from a national point of view. are subject to balanced-budget rules. They’re cutting back because they have to — because they’re caught in a fiscal trap.Single Payer 2. You’re A Jerk 60 . When the economy is booming. But even if they weren’t. and those states that can borrow at all are being forced to pay punitive interest rates. But let’s step back for a moment and contemplate just how crazy it is. to be cutting public services and public investment right now. our workers haven’t lost their skills. But right now many of the workers employed on infrastructure projects would otherwise be unemployed. But even as Washington tries to rescue the economy. Now. Think about it: is America — not state governments. Krugman. http://www. Investors.html? _r=1&ref=opinion&pagewanted=print [Mardjuki] No modern American president would repeat the fiscal mistake of 1932. These state-level cutbacks range from small acts of cruelty to giant acts of panic — from cuts in South Carolina’s juvenile justice program. Our capacity hasn’t been diminished. but the nation as a whole — less able to afford help to troubled teens. is much lower now than in more prosperous times. anyway). too. prof of economics and international affairs @ Princeton. in which the federal government tried to balance its budget in the face of a severe recession.0 LO 60 State Deficits Tank Econ Federal economic action ineffective without rectifying state deficit problems. Paul. the true cost of government programs. our technological know-how is intact. public investment competes with the private sector for scarce resources — for skilled construction workers.nytimes.

Phil. risen as the number of families facing economic difficulties increases. Reimburse-ment rates for some health care providers and human services agencies will decline July 1 in Minnesota.cfm? fa=view&id=1214. or soon after. Federal recovery act dollars and funds raised from tax increases are greatly reducing the extent. severity. and other revenue sources used to pay for these services.Single Payer 2. At the same time. These cuts. Senior Fellow. Utah. The cuts enacted in at least 39 states are occurring in all major areas of state services. You’re A Jerk 61 . higher education (32 states). and elsewhere — and school districts will absorb cuts in state aid. sales taxes. 2009. and other areas. the first day of the new fiscal year in most states. In coming months. dental and vision services for many Medicaid recipients in California and Michigan will be eliminated.cbpp. Hundreds of thousands of people with disabilities in those states and in New Mexico will experience cuts in aid. more than three-fourths of states are making spending cuts that hurt families and reduce necessary services. K-12 education (24 states). including Arizona. Nicholas. New Jersey. and Wyoming. public university tuition will rise at double-digit percentage rates in Florida.” Center on Budget and Policy Priorities. 6/29/09. Many cuts — including those hurting vulnerable families — will take effect July 1. [Mardjuki] With tax revenue declining as a result of the recession and budget reserves largely drained. are almost certain to enact further cuts. Phil. Director of BPP State Fiscal Project. For example. http://www. Washington.0 LO 61 State Deficits Tank Econ State deficits have a domino effect – have widespread negative economic impacts. States are making these cuts because the recession has caused declining revenues from income taxes. As of June 25. but only to a point. and economic impact of these cuts. Many of those states.org/cms/index. Illinois. Washington. will make the recession worse because families and businesses have less to spend in their local economies. And these figures do not include the proposed cuts that many states still are discussing. services to the elderly and disabled (22 states). and North Carolina. “An Update on State Budget Cuts. some 18 states had not enacted budgets for the upcoming fiscal year. Massachusetts. in turn. Johnson. the need for these services has not declined and has. including health care (21 states). in fact.

Phil. Combined budget gaps for the next two years are estimated to total more than $350 billion.cfm?fa=view&id=1283 [Mardjuki] The weak economy continues to cause great fiscal distress among states as they begin a new fiscal year (July 1 marked the start of 2010 for most states). Such measures not only can reduce the level or quality of service available to state residents. at least 41 states have reduced overall wages paid to state workers. Johnson. shortfalls are likely to equal $160 to $180 billion. withdrawals from reserves.org/cms/index. Like budget cuts. At least 24 states in 2009 are addressing their budget shortfalls in part by increasing taxes.cfm? fa=view&id=1214. 7/23/09. You’re A Jerk 62 . Like budget cuts. This includes $24 billion in shortfalls that have opened in 12 states in just the few weeks since they passed their 2010 budgets. but also reduce the purchasing power of workers’ families. • At least 33 states have prepared estimates for the 2011 fiscal year. 6/29/09. All of these steps remove demand from the economy. tax increases remove demand from the economy. by reducing the amount of money people have to spend. [Mardjuki] Cuts to state services not only harm vulnerable residents but also worsen the recession by reducing overall economic activity. Director of BPP State Fiscal Project. reduce payments to businesses and nonprofits that provide services. tax increases remove demand from the economy.cbpp. revenue increases.org/cms/index. and several more are considering them. Forty-eight states faced or are facing budget shortfalls. Combined budget gaps for the remainder of this fiscal year and state fiscal years 2010 and 2011 are estimated to total over $350 billion. or similar actions. Cuts to state programs reduce overall economic activity.. Although the recovery package is mitigating states’ fiscal problems. For instance. Many more states will need to consider tax increases or other revenue measures. But tax increases can be less detrimental to state economies than budget cuts because some of the tax increases affect upperincome households so are likely to result in reduced saving rather than reduced consumption. they lay off employees. But tax increases can be better for state economies than budget cuts because some of the tax increases result in reduced saving rather than reduced consumption. as a way to minimize harmful budget cuts. CBPP. Center on Budget and Policy Priorities. All of those states had already taken major steps to balance their budgets and the new gaps will require further action during the year to restore balance. “An Update on State Budget Cuts. which in turn affects local businesses.” Center on Budget and Policy Priorities.cbpp. requiring them to take unpaid leave (furloughs). including some of their most vulnerable families and individuals. • At least 48 states addressed or are facing shortfalls in their budgets for the new fiscal year totaling $163 billion or 24 percent of state budgets. The American Recovery and Reinvestment Act includes roughly $140 billion in fiscal relief for state governments. To date at least 39 states have addressed their shortfalls by reducing services to their residents. by reducing the amount of money people have to spend. http://www. “New Fiscal Year Brings Continued Trouble for States Due to Economic Downturn. Some thirty states have enacted tax increases this year in response to budget shortfalls caused by the recession. States are using these funds to help balance their budgets while minimizing harmful cuts in public services. cancel contracts with vendors. These shortfalls come on top of $111 billion in 2009 gaps that states closed through a combination of spending cuts. When states cut spending. freezing new hires.Single Payer 2. http://www.” Policy Points. States are taking actions to mitigate the extent of these cuts. Senior Fellow. States are using fiscal relief to balance their budgets. Initial estimates of these shortfalls total almost $51 billion. by laying off workers. Cuts to state services not only harm vulnerable residents but also worsen the recession by reducing overall economic activity. enough to close 30 to 40 percent of state shortfalls. or use of federal stimulus dollars. Most states are enacting or considering tax increases. As the full extent of 2011 deficits become known. Phil. as well as such steps as tapping state rainy day funds. states are continuing to cut services like education and health care as they enact 2010 budgets.0 LO 62 State Deficits Tank Econ State deficits prolong recession – hinder increased economic activity. Nicholas. and cut benefit payments to individuals.

Michael. You’re A Jerk 63 . It now stands at 9. “Obama: Health Care Reform Is Essential to Rebuilding Economy.washingtonpost. Fletcher. creating new obstacles for the proposed sweeping health care overhaul. The worsening unemployment picture is expected to slow future economic growth and push projected government budget deficits even higher.html?wprss=44 [Mardjuki] Undercutting Obama's effort also is growing public discontent about his handling of the overall economy. With the nation just beginning to emerge from the most severe economic downturn since the Great Depression. 7/22/09. the administration missed badly when it projected that unemployment would not rise above 8 percent with the measure in place. http://voices. Many economists agree that the employment picture would be much worse had the stimulus plan not been enacted.0 LO 63 More Stimulus Needed .Unemployment Stimulus wasn’t enough – skyrocketing unemployment.Single Payer 2.” Washington Post. staff writer.com/44/2009/07/22/a_news_conference_to_push_hard. despite the $787 billion economic stimulus plan that Obama managed to squeeze through Congress in the early weeks of his administration.5 percent and is projected to surge even higher in the coming months. unemployment is continuing to rise. hurting the credibility of its economic forecasts. Still.

The Fed was both late and slow in lowering its key interest rate from its August 2007 level of 5. but a lot less than advertised. it also was far too small. First round of stimulus insufficient. by consumers. not spent. more coherent policy path back to a strong market economy—not to a European style social-welfare state. some from the increased transfer payments in the stimulus bill. and even larger inflation-adjusted stock market decline of the late 1970s and early ’80s—a new policy path was charted consisting of low tax rates. As early as the summer of 2006. 7/26/09. “Obama Needs a Move to the Middle. permanent government lifelines and stagflation.html [Mardjuki] It is becoming painfully apparent that the Obama administration's stimulus package has failed to halt the deepening recession. It is accepted that. http://www. tragically wasted opportunity. stimulus. all to the inevitable long-term damage of the U. even larger. The current stimulus is not the first but actually the second package. Michael. a majority of politicians probably would agree that it was in the national and.com/x/pittsburghtrib/opinion/s_635198. the administration and the Fed should have predicted the downturn. some private observers predicted the economic recession of 2008. maintaining that the economy was healthy.S. Boskin. it was targeted at tax rebates and. 7/22/09. Infrastructure spending in the pipeline will likely deliver more than this. http://online. quickly disseminated. free trade and less intrusive regulation. sound money.html?mod=googlenews_wsj#printMode [Mardjuki] While strong recoveries sometimes follow deep recessions. Those policies pulled us out of stagflation and led to a quarter-century of growth. slower spending growth. economy. Out of the $320 billion increase in personal disposable income. was more than a year late with its stimulus package. Pressure is building from the left for a second stimulus program.) While President Obama's stimulus package was organized early in his administration. In addition. after more than a year of contraction. What should the government do? As expensive and undesirable as it was to bail out the very "casino" banks which had precipitated a financial meltdown.25 percent. chairman of Council of Economic advisors. near 11% unemployment. economy slipped into recession in December 2007. The specter of massive future tax hikes and inflation is worsening the outlook. Likewise. John. With its privileged access to national statistics and confidential core data. Nor has there been the promised “multiplier” on every stimulus dollar spent. personal consumption outlays have risen only $1 billion. senior fellow @ Hoover Institution. estimated at some $10 trillion. historically recoveries following financial crises have been slow and painful. The last time we had a comparable economic crisis—the double-digit inflation. There is now growing pressure for a second. (To be fair.wsj. professor of econ @ Stanford. less than 10% of the funds have been disbursed and what has been been saved.0 LO 64 More Stimulus Needed .pittsburghlive. therefore.Insufficient January stimulus has failed – limited impact – second round needed.Single Payer 2. arguably. when measured against the aggregate erosion of household wealth.com/article/SB10001424052970203946904574302332578189864. But many Americans fear things are getting out of control. Moving so far in the exact opposite direction invites eventual disaster for American workers and firms.” Wall Street Journal. the Bush administration. 20% interest rates.S. Browne. financial analyst and former British Parliament member. global interest. Half a year and two million lost jobs since the stimulus bill was passed. the U. That’s far short of President Barack Obama’s promised “immediate” help. Score the stimulus a very expensive. We need a better. the first $750 billion package was woefully inadequate. Both the stimulus packages of President Bush and President Obama could be attacked for being too little too late. “What Stimulus?” Pittsburgh Tribune. You’re A Jerk 64 .

nearly every state is raising taxes or fees.000 jobs were lost.0 LO 65 More Stimulus Needed . that means fewer customers and the downward spiral continues. Hidden unemployment is also setting records . And 39 states have cut program outlays on the needy. unemployment will still be in double digits as late as 2011. As the new fiscal year begins. Robert. as well as people whose hours have been involuntarily cut. And there is less than one job opening for every five people seeking jobs. which is expected to total $350 billion by 2011. or laying off workers and reducing programs. founder of The America Report. As EPI observes.com/robert-kuttner/3reasons-we-need-an-econ_b_225962. This is the only recession since the Great Depression in which the job loss wiped out all the job growth of the previous recovery.the worst since 1983 -. Consider: The green-shoots school was expecting that the rising rate of unemployment would continue to slow.Statistics First round of stimulus insufficient – recent unemployment and state deficit statistics prove. A total of 24 other states have enacted tax increases and another 12 all have tax hikes on their agendas. with one of the most liberal governors. The New York Times reports that several states are cutting out summer school. The number of longterm unemployed is at record levels. as in the dance to the death between California Governor Arnold Schwarzenegger and Democrats in the legislature.Single Payer 2. just hiked its sales taxes by 25 percent. their only choice is to cut program spending or raise taxes. and OECD economists project that U. Federal aid under the stimulus covers just 30 to 40 percent of the state shortfall.html [Mardjuki] Several events of the past week should be a wake-up call to the Obama administration.people with part time work who want full time work. senior fellow @ Demo Think Thank. Until strong economic growth returns.5 million more workers. The 9. Stronger stuff is needed. We now have fewer jobs than in May 2000 when the recovery began. The unemployment rate rose to 9. Some of the state budget crisis is self-inflicted. since they only further undercut consumer purchasing power. Deval Patrick.5 percent. http://www. Compounding the problem is inadequate government policy on three crucial fronts: The states. Massachusetts. 7/5/09.huffingtonpost. according to the Center on Budget and Policy Priorities. when tax receipts fall. Kuttner. companies will not resume hiring. But most states are just plain hurting.S. though the economy now has 12. are not permitted to run current budget deficits. as it did in May. At least 48 states face red ink. A total of 467. As our friends at the Economic Policy Institute report. President Obama's economic stimulus simply wasn't designed for a recession this deep. You’re A Jerk 65 .” Huffington Post. And as long as layoffs continue. Bottom line: the medicine isn't working. “Three Reasons We Need an Economic Wake Up Call. So in a deep recession. compounded by a two-thirds supermajority requirement for any kind of tax reform. unlike the Federal government. Both are of course perverse in a recession.5 percent official figure -. But instead the number spiked back up. And I would add that stimulus funds are getting out too slowly.conceals even worse news.

and the speed of getting money into the economy is often a goal of this aid. In this case. senior economist and economic advisor @ Chicago Federal Reserve. The least optimal funding strategy would be for the federal government to reduce its expenditures or raise taxes to fund aid to the states and then for the states to use the money to retire debt. individual state economies are struggling in this recession. You’re A Jerk 66 . California projected a $21 billion deficit after failing to get voter approval for a series of budget balancing fiscal measures. How the federal government finances the aid package must also be considered. For an aid package to be truly stimulative. Recently. for which demand rises during a recession. August 2009.0 LO 66 More Stimulus Needed – States Key Federal aid to states needed to avoid prolonged recession. “Should the Federal Government Bail Out the States? Lessons from Past Recessions. unemployment insurance. It would also be feasible for the federal government to borrow the funds but have the states use the money to retire debt. State governments face significant constraints in raising additional revenues. Richard. such as Medicaid. August 2009. categorical aid increases the accountability for the spending. the federal government hopes to support specific types of state programs. http://www. it would not stimulate growth in the state government sector. and work force training.pdf [Mardjuki] Like the economy in general. “Should the Federal Government Bail Out the States? Lessons from Past Recessions.Single Payer 2. five prominent Democratic governors suggested that the federal government should commit $1 trillion in aid to the states over the next two years. Mattoon. Further. Most effective stimulus is federal funding to balance state budgets.org/publications/fedletter/cflaugust2009_265. As such. such as Medicaid or education.” Chicago Federal Reserve Bank Essay Number 265. Most states are required to balance their budgets regardless of the economic environment. If. unrestricted aid from the federal government that can be used as a state sees fi t is appropriate. This article considers the role of the federal government in helping the states to manage their finances.chicagofed. Mattoon. http://www. the federal government can provide the money on a matching funds basis that requires the state to maintain its contribution to the specific program and not allow it to simply withdraw state funding and replace it with federal dollars. Unrestricted aid can also be spent faster.chicagofed.org/publications/fedletter/cflaugust2009_265.pdf [Mardjuki] Most of the federal government’s aid to counteract the effects of the 1973–75 and 2001 recessions had very few restrictions. this aid might help states avoid enacting spending cuts or tax increases that could deepen or prolong the economic downturn. State government budget woes have been much in the news. the government sector would actually contract. If the goal is to stabilize spending across the state government sector. Whether federal money should be unrestricted or targeted depends largely on the purpose behind the federal relief funds. however.1 In January of this year. it was easy for a state to substitute federal money for own-source revenues. Also. While this would improve the states’ balance sheets.2 The rationale for such financial support is that states (which are generally prohibited from running deficits) need the money to maintain key programs. senior economist and economic advisor @ Chicago Federal Reserve. Richard.” Chicago Federal Reserve Bank Essay Number 265. the federal government needs to borrow the funds and the states need to use the money to either expand spending or avoid tax increases .

state cutbacks have not been as severe as they might have been. state revenues in April and May were down thirty-six per cent from a year earlier. It’s the ordinary way in which state governments go about their business. instead of mitigating them. But the real problem isn’t the fecklessness of local politicians. It’s a push-me. according to a recent study by the Center on Budget and Policy Priorities.org/publications/fedletter/cfljuly2009_264b. You’re A Jerk 67 . has covered thirty to forty per cent of the states’ budget shortfalls.Single Payer 2. http://www. So states have to raise taxes or cut spending. some of the biggest players in the economy—state and local governments together account for about thirteen per cent of G. That aid.0 LO 67 More Stimulus Needed – States Key Stimulus aid unsustainable – increased assistance for state recovery needed. Boyd argued that it may take more than five years for these revenues to fully recover. the opposite is happening.com/talk/financial/2009/07/27/090727ta_talk_surowiecki “Fifty Ways to Kill Recovery” It’s easy enough. Yet there’s no sign that those budget gaps are getting smaller. Think about the $787- billion federal stimulus package.” Chicago Federal Reserve Essay 264b. but it is not sufficient to preclude a combination of spending cuts and tax increases to close the budget gap. http://www.newyorker. to mock state governments nowadays. July 2009.9 billion in 2010.6 billion in 2011. the longer term picture for state (and local) governments looks challenging.s to pay its bills and New York’s statehouse becoming the site of palace coups and senatorial sit-ins. An Illinois perspective was provided by Ginger Ostro. Richard. pull-you approach to fighting the recession. So fiscal policy at the national level is countercyclical: as the economy shrinks. According to Boyd. while significant budget cuts have become routine and are likely to get only deeper in the year ahead.—will be doing precisely the wrong thing. States need more money for budgets even after the stimulus James Surowiecki. investment declines. government expands. At the state level. Receipt of the ARRA money will certainly help. with $250 billion going to state and local governments by specifi c category. is procyclical: it’s amplifying the effects of the downturn. as the federal money runs out. $130 billion will provide immediate fiscal relief. for instance. The act provides $787 billion in total aid. especially for Medicaid and education.O.chicagofed. what with California issuing I. Revenues are expected to fall $2. and $50. Nearly every state government is required to balance its budget. jobs vanish. and tax revenues fall precipitously—in New York. staff writer for The New Yorker. It’s built on the idea that during serious economic downturns the government can use spending increases and tax cuts to counteract the effects of consumers who are cutting back on spending and businesses that are cutting back on investment. while the stimulus money is certainly welcomed. “Asessing the State and Local Sector – Where Will the Money Come From? A Conference Summary.pdf [Mardjuki] Donald Boyd. Now.U. sales plummet. $96.6 billion deficit in FY2010. Even as the federal government is pouring money into the economy. though.5 billion in FY2009 and continue falling in FY2010. Current estimates from the Congressional Budget Office show that the bulk of the stimulus money will be spent in the first three federal fiscal years (FYs) of the program—$47. or both. and.4 billion in 2009. Under differing scenarios based on the behavior of state tax revenues in previous recessions. and that’s precisely what they’re doing: states from New Jersey to Oregon have raised taxes in the past year. The states’ fiscal policy. Money for the states translates directly into jobs not lost and services not cut—which is why you can make a good case that more of the stimulus should have gone to state aid. thanks to the stimulus plan . states as a group would still face potential budget gaps of greater than $100 billion (6%) when the stimulus money is exhausted. 7-26-2009. Ostro noted that with no policy changes Illinois is facing an $11. In one scenario. then. Mattoon.D. senior economist and economic advisor at Chicago Fed. director of the Governor’s Office of Management and Budget. of course. state governments are effectively taking it out. By design. In the midst of this downturn. When times are bad. state tax increases and spending cutbacks are only going to become more common. which includes roughly $140 billion in aid to local governments. outlined the structure of the American Recovery and Reinvestment Act of 2009 (ARRA). Rockefeller Institute of Government.P.

government expands. falling house prices. Nearly every state government is required to balance its budget.s to pay its bills and New York’s statehouse becoming the site of palace coups and senatorial sit-ins. thanks to the stimulus plan. James. overindebted consumers.com/talk/financial/2009/07/27/090727ta_talk_surowiecki [JM] If you came up with a list of obstacles to economic recovery in this country. has covered thirty to forty per cent of the states’ budget shortfalls. state cutbacks have not been as severe as they might have been. then. cautious companies. the opposite is happening. You’re A Jerk 68 . Think about the $787-billion federal stimulus package. investment declines. for instance. http://www. which includes roughly $140 billion in aid to local governments. according to a recent study by the Center on Budget and Policy Priorities. of course. jobs vanish. 7/11/09. In the midst of this downturn. sales plummet. Money for the states translates directly into jobs not lost and services not cut—which is why you can make a good case that more of the stimulus should have gone to state aid. That aid. and perhaps even a payroll tax holiday. So fiscal policy at the national level is countercyclical: as the economy shrinks.Single Payer 2. At the state level. staff writer. often described as one of the great strengths of the American system.O.D. Zandi.com/wpdyn/content/article/2009/07/11/AR2009071100292. then it probably should include more aid to hard-pressed state governments. and. http://www.washingtonpost. what with California issuing I. a delay in legislated increases in marginal personal tax rates in 2011. though. while significant budget cuts have become routine and are likely to get only deeper in the year ahead. it would include all the usual suspects—our still weak banking system. But here are fifty culprits you might not have thought of: the states. It’s a push-me. It’s easy enough. and that’s precisely what they’re doing: states from New Jersey to Oregon have raised taxes in the past year. The states’ fiscal policy. state revenues in April and May were down thirty-six per cent from a year earlier. more aid to stressed households hammered by what will be double-digit unemployment.html [Mardjuki] Planning now for another round of stimulus is prudent. as the federal money runs out. It’s built on the idea that during serious economic downturns the government can use spending increases and tax cuts to counteract the effects of consumers who are cutting back on spending and businesses that are cutting back on investment. States’ procyclical fiscal policy hampering recovery efforts – federal government should go directly to state aid. an expansion of the housing tax credit to stem the ongoing slide in house prices. instead of mitigating them. given that the economy remains in an extraordinarily severe downturn and the risks are decidedly to the downside.— will be doing precisely the wrong thing. But the real problem isn’t the fecklessness of local politicians. Yet there’s no sign that those budget gaps are getting smaller. and tax revenues fall precipitously—in New York. some of the biggest players in the economy—state and local governments together account for about thirteen per cent of G. Suroweicki. to mock state governments nowadays. state governments are effectively taking it out. When times are bad. Federalism.P. Now. or both. It’s the ordinary way in which state governments go about their business. is procyclical: it’s amplifying the effects of the downturn.newyorker. “Do We Need Another Stimulus?” Washington Post. Even as the federal government is pouring money into the economy. So states have to raise taxes or cut spending. Mark. whose budget woes are intensifying. Policymakers could smooth the way for all this if they were able to demonstrate this summer they are serious about addressing the nation's darkening long-term fiscal outlook by credibly paying for health-care reform. though.0 LO 68 More Stimulus Needed – States Key More stimulus needed – aid to states and easing health care deficit key. pull-you approach to fighting the recession. state tax increases and spending cutbacks are only going to become more common.” New Yorker. chief economist @ Moody’s Investor Services and Risk Analysis. If additional stimulus is needed.U. “Fifty Ways To Kill Recovery. has become a serious impediment to reversing the downturn. 7/27/09.

This heightens the potential impact on public services of the shortfalls states now are projecting. general fund spending for fiscal year 2008 — six years into the economic recovery — remained below pre-recession levels as a share of the gross domestic product. Federal assistance can lessen the extent to which states need to take pro-cyclical actions that can further harm the economy.cbpp. and child care remain in effect. State spending fell sharply relative to the economy during the 2001 recession. These important public services were suffering even as states turned to budget cuts to close the new budget gaps. Reserves can be particularly important to help states adjust in the early months of a fiscal crisis. Spending as a share of the economy declined in fiscal year 2008 and is projected to decline further in 2009 and again in 2010. and for all states combined it still remains below the fiscal year 2001 level.” Center on Budget and Policy Priorities. The American Recovery and Reinvestment Act recognizes this fact and includes substantial assistance for states. “State Budget Troubles Worsen.cfm? fa=view&id=711 [Mardjuki] The current situation has been made more difficult because many states never fully recovered from the fiscal crisis of the early part of the decade. In a number of states the reductions made during the downturn in education. http://www. health coverage. higher education. Iris and Elizabeth. You’re A Jerk 69 .0 LO 69 More Stimulus Needed – States Key Federal assistance crucial to stem negative pro-cyclical economic state action. Gold award for contribution to state fiscal policy. Most of this money is in the form of increased Medicaid funding and a “Fiscal Stabilization Fund. Lav. There are also other streams of funding in the economic recovery act flowing through states to local governments or individuals. states have already drawn down much of their available reserves. 6/29/09. but generally are not sufficient to avert the need for substantial budget cuts or tax increases. the available reserves in states with deficits are likely to be depleted in the near future. McNichol. At the end of fiscal year 2006. state reserves — general fund balances and rainy day funds — totaled 11. One way states can avoid making deep reductions in services during a recession is to build up rainy day funds and other reserves. In this recession. The amount in ARRA to help states maintain current activities is about $135 billion to $140 billion — or less than half of projected state shortfalls.5 percent of annual state spending.org/cms/index. In 18 states.Single Payer 2. state budget and tax expert. state budget and tax senior fellow.” This money has reduced to a degree the depth of state spending cuts and moderated state tax and fee increases. Federal assistance Crucial. but this will not address state budget shortfalls.

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A2: ARRA Stimulus Solves Medicaid Deficits
Governor consensus – unfunded federal mandates tank state economies that are surviving on stimulus cash infusions. Trygstad, staff writer. 7/21/09
Kyle. “Governors Warn Congress on Health Care Efforts.” Real Clear Politics. http://www.realclearpolitics.com/politics_nation/2009/07/governors_warn_congress_on_hea.html [Mardjuki] The nation's governors have sent a letter to Congress urging them not to impose "unfunded federal mandates and reforms that simply shift costs to states" as they consider health care reform. A House proposal would provide permanent funding for Medicaid expansions, which the governors support. Writing on behalf of the National Governors Association, chairman Jim Douglas (R) of Vermont says: Any unfunded expansions would be particularly troubling given that states face budget shortfalls of over $200 billion over the next three years. This gap persists even after the Recovery Act's temporary increases in the federal share of Medicaid, which was essential for avoiding dramatic cuts to critical state services and was greatly appreciated by governors. Governors welcome the opportunity to share and expand upon the innovative reforms we have instituted in our states to expand coverage, reduce cost and improve the quality of health care. These reforms should inform congressional efforts and must be preserved and encouraged as part of any national reform. We appreciate your willingness to work with us to pursue financing options that are sustainable at both the federal and state levels. Obama relied on the support of governors, particularly Republicans like Douglas and Florida's Charlie Crist, to sell his stimulus plan. Health and Human Services Secretary Kathleen Sebelius, the former Kansas governor, was dispatched to this weekend's NGA conference to hear the state executives' concerns.

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Trickle Up Stimulus Needed
The economy will not recover without a trickle up policy- unemployment, tax appeals, forclosures Randall Wray, 7-7– Senior Scholar and professor of economics and director of the Center for Full Employment and Price Stability
at the University of Missouri Economic Perspectives from Kansas City, “The Carnage Continues: Time to Ramp Up the Stimulus” July 7, 2009, http://neweconomicperspectives.blogspot.com/2009/07/carnage-continues-time-to-ramp-up.html) Some like to see green shoots everywhere, but that is becoming an increasingly audacious hope. Here are four related stories from the July 5th edition of the New York Times: Tax Bill Appeals Take Rising Toll on Governments By Jack Healy Homeowners across the country are challenging their property tax bills in droves as the value of their homes drop, threatening local governments with another big drain on their budgets…. The tax appeals and reassessments present a new budget nightmare for governments. In a survey conducted by the National Association of Counties, 76 percent of large counties said that falling property tax revenue was significantly affecting their budgets…. Officials in some states say their property tax revenue is falling for the first time since World War II. Safety Net Is Fraying for the Very Poor By Erik Eckholm Government "safety net" programs like Social Security and food stamps have pulled growing numbers of Americans out of poverty since the mid-1990s. But even before the current recession, these programs were providing less help to the most desperately poor, mainly nonworking families with children… The recession is expected to raise poverty rates, economists agree, although the impact is being softened by the federal stimulus package adopted this year…. "It's a good thing we have the stimulus package," Mr. {Arloc} Sherman said. "But what happens to the most vulnerable families in two years, when most of the provisions expire?" Employment Report Sours the Market By Jeff Sommer A grim report on unemployment on Thursday let the air out of the stock market…. In a monthly report, the Labor Department said that 467,000 jobs were lost in June. In surveys, most economists expected 100,000 fewer jobs lost. The unemployment rate edged up to 9.5 percent from 9.4 percent the previous month, to its highest level in 26 years, and virtually all analysts expect joblessness to mount in the coming months. So Many Foreclosures, So Little Logic By Gretchen Morgenson LAST week, the stock market tumbled on news that housing foreclosures and delinquencies rose again in the first quarter . The Office of the Comptroller of the Currency said that among the 34 million loans it tracks, foreclosures in progress rose 22 percent, to 844,389. That figure was 73 percent higher than in the same period last year.... But the most fascinating, and frightening, figures in the data detail how much money is lost when foreclosed homes are sold. In June, the data show almost 32,000 liquidation sales; the average loss on those was 64.7 percent of the original loan balance. What do these reports have in common? They provide powerful evidence that the federal government is not doing enough to help the "real" economy. As Sam Gompers famously responded when asked what workers wanted--"More!"—our nation's state and local governments, households, workers, and poor need more help, now. We have tried the Reagan/Paulson/Rubin/Geithner "trickle down" approach of targeting relief to Wall Street, but the only thing trickling down is misery. The only way to stop the downward spiral is to substitute trickle-up policy—and even if nothing tricklesup, at least we will have helped those most in need.

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Fed Action Key
Interstate issues dealt with more effectively at the federal level. Suroweicki, staff writer. 7/27/09.
James. “Fifty Ways To Kill Recovery.” New Yorker. http://www.newyorker.com/talk/financial/2009/07/27/090727ta_talk_surowiecki [JM] Even more important, federalism is getting in the way of the creation of a “smart” American power grid. This would involve turning the current hodgepodge of regional and state grids into a genuinely national grid, which would detect and respond to problems as they happen, giving users more information about and control over their electricity use, and so on. It could also dramatically reduce our dependence on oil. Wind power could eventually produce as much as twenty per cent of the energy that America consumes. The problem is that the places where most of that wind power can be generated tend to be a long way from the places where most of that power would be consumed. A new grid would enable us to get the power to where it’s needed. But since nobody likes power lines running through his property, building the grid would require overriding or placating the states—and the prospects of that aren’t great. The tension between state and national interests isn’t new: it dates back to clashes in the early Republic over programs for “internal improvements.” Of course, the federal government is far bigger than it once was, and yet in the past two decades we’ve delegated more authority, not less, to the states. The logic of this was clear: people who are closer to a problem often know better how to deal with it. But matters of a truly interstate nature, like the power grid, can’t be dealt with on a state-by-state basis. And fiscal policy is undermined if the federal government is doing one thing and the states are doing another. It’s a global economy. It would be helpful to have a genuinely national government.

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Ezra. chronic under-funding. the fragmentation that contributes so much to the flaws in our health care system would begin to wither away. You’re A Jerk 73 . which would be a huge step forward: One encouraging element of the health care reform bill released today by three House committees is that it would finance expanded eligibility for Medicaid entirely with federal money. Because the program primarily covers adults and individuals with low incomes.0 LO 73 Federalize Medicaid Solves State Budgets Federalization of Medicaid solves dysfunctional state bureaucracies and relieve waterlogged state budgets. along with nursing home residents. good short-term politics. Federally run insurance programs like Social Security and Medicare are vastly more efficient and effective than federal-state counterparts like Medicaid and unemployment insurance. Since its inception in 1965. state budgets are already overwhelmed due to the recession.com/ezra-klein/2009/07/a_win_for_medicaid. The House bill would not require state contributions to pay for expanding Medicaid eligibility to 133 percent of the federal poverty level because. That arrangement has much to do with Medicaid’s huge shortcomings: wide state-to-state variations in eligibility rules and benefit levels. and limited medical options for beneficiaries. Klein. If some new Medicaid beneficiaries have their benefits entirely paid for by the feds. the committees correctly note. it’s conceivable that other categories -. That would create opportunities for the federal government to exert greater control over the largely dysfunctional program. it has never benefited from broad political support. But a potential long-term payoff to this reform would be to open the door to federalizing the program entirely down the road. [JM] http://voices.” Washington Post. One way to do that would be to simply federalize Medicaid funding. a lot of people have been arguing for a third stimulus focused on state budgets and services. editor. and a huge relief for state budgets.washingtonpost. economic and domestic policy expert. It would be good long-term policy. Medicaid’s financing has been shared jointly between the feds and state governments.such as those eligible for both Medicare and Medicaid -. vice president of policy at the Century Foundation. On a related note. Economies of scale. “A Win For Medicaid. and the inability of 50 state governments to each do mischief to the programs have demonstrably led to far superior results for national social insurance. In the process. step by step.could be similarly shifted entirely to federal funding in later reforms. 7/14/09.html Greg Anrig.Single Payer 2. uniform national rules. writes in with a very good point on the House health-care bill: It opens the door to eventually federalizing the Medicaid program. perhaps ultimately folding it into the proposed public health plan.

” state Sen.” Righter said. hospitals and doctors when it comes to changes in state health programs that cover 2. you need to be concerned about Medicaid.” he said. senior reporter. said last week. according to a recent report by Gov. Quinn’s chief health-policy adviser. He is one of four Republican lawmakers who began meeting privately Friday with four of their Democratic counterparts in the General Assembly and a representative of Quinn to discuss ideas for Medicaid reform. Medicaid reforms could save a total of $983 million over the next two years. said Michael Gelder. reform of Illinois’ Medicaid program — or at least firm plans to make changes in the system — appears to be a key component of any resolution to the state budget crisis. says that if costs continue to grow at that rate Medicaid spending will reach $22 billion in 2019 and could represent 50 percent of the state budget.5 million Illinoisans and cost $12 billion a year in state and federal funds.com/taxpayerboard. “It should be obvious to everyone that if you’re concerned about anything in the budget. Republicans say that without changes. http://www. Consensus wasn’t reached on any issues after the two-hour meeting in Chicago. Republican votes may be crucial to reduce the impact of the state’s $9 billion deficit through a potential income tax increase. and more in future years. Howard Peters. Republicans in the Democrat-controlled Illinois Senate and House have all but required that long-term Medicaid reform be part of any budget discussions.” Many Republicans also believe there is too much waste in the system and that some people don’t deserve state-provided health care that was made available to more children and parents under former Gov. The report. senior vice president of the Naperville-based Illinois Hospital Association. Pat Quinn’s Taxpayer Action Board. “We want to make as much positive change as possible. “I’m not sure there is a clear-enough concept of the consequences of these proposals.0 LO 74 Medicaid Reform Solves State Budgets Only massive Medicaid reform solves the state budget crisis Olsen. “It is the 700-pound gorilla quickly turning into the 900-pound gorilla. RMattoon. but the group will meet again Tuesday or Wednesday in Springfield. 6/20/09. According to the most optimistic estimates.Single Payer 2. Dean.” State Journal-Register.sj-r. You’re A Jerk 74 . “Medicaid reform tied to state budget crisis. Dale Righter. which is available online at http://tinyurl. Rod Blagojevich. more than twice the rate of inflation. said Republican fervor for Medicaid reforms appears to be fueled by “the dilemma of raising taxes. But there is disagreement — and outright fear — about the potential ramifications for patients.” Medicaid spending has grown an average of almost 8 percent per year between 2003 and 2008.” “People are almost desperately looking for some kind of ‘silver bullet’ that can get us out of this thing that can be painless. the rising cost of Medicaid will take up more and more state resources and “crowd out” other state services while further delaying payments to Medicaid providers.com/homepage/x488806173/Medicaidreform-tied-to-state-budget-crisis [JM] Regardless of how much money would be saved this year or next.

our essential but flawed state-federal partnership that finances medical care and related services for almost 50 million people. is right on the money. Actuaries predict that state Medicaid expenditures will roughly double by 2017. one basic issue receives less attention than it deserves: The precarious condition of Medicaid.html [JM] Harold Pollack is an associate professor of public health at the University of Chicago. and this piece he sent in. underpaying providers. Figure 1 shows why state policymakers are panicking. states have cut financial corners for decades. the existing framework no longer works. failing to operate these programs with the skill and humanity that patients deserve. You’re A Jerk 75 . (These data are drawn from National Health Expenditure data. we must recognize that the budget challenge is more than a nasty episode brought on by the current downturn. malpractice reform. Rhetoric about soaring Medicaid costs is actually misplaced. I should be more careful here.” Washington Post. States’ Medicaid problems have been building for decades. 6/19/09. Yet painful measures are being taken in many other states. http://voices. He's one of the smartest social policy thinkers I know. Charting a sustainable future for Medicaid is essential for virtually every aspect of health reform. Ezra. links to competing webcasts on value-based insurance design. the tax treatment of employer-provided health plans. economic and domestic policy expert. They are dwarfed by corresponding changes in Medicare. and more. Slapped together 45 years ago as a relatively small program that mainly financed healthcare to welfare recipients and their children. It’s impossible to keep up. My inbox this morning includes a white paper comparing different versions of the public health insurance plan. dozens of states are cutting or constraining services at precisely the moment when these services are most needed to meet human needs and to stabilize local economies.washingtonpost. In truth. arguing that it's time we recognized the centrality of Medicaid and made it a federal program rather than a state partnership. Saddled with balanced-budget requirements and constrained tax bases. barely exceeding 1% of GDP. comparative effectiveness research. past and projected increases in state expenditures are modest.0 LO 75 Medicaid Reform Solves State Budgets Medicaid reform needed to stabilize state budgets and local economies – current system unsustainable. It shows inflation-adjusted medical expenditures by state and local governments between 1960 and 2007. Medicaid has evolved into a huge and diverse program that finances almost half of American nursing home and long-term care.) As state and local medical expenditures cross the $300 billion mark. Amid this health policy tumult. senior editor. and for the fiscal survival of state governments. The cuts seem most dramatic in California. What can be done? First. The worst is yet to come. As a percentage of GDP. Klein. Rising Medicaid expenditures undermine states’ ability to address other pressing needs.Single Payer 2. bears large responsibilities for the care of disabled adults and children. The spreadsheets can be accessed here. delaying payment. and is the major vehicle to cover millions of poor and near-poor Americans who would otherwise be uninsured. adjusted for the CPI and expressed in year-2007 dollars.com/ezraklein/2009/06/guest_graph_the_future_of_medi. “Guest Graph: The Future of Medicaid.

"There is a yearning in this state for single payer. writer for the Boston Globe. yesterday endorsed a bid to pass ballot questions in favor of such a health plan. He said the savings would help provide coverage to the state's estimated 600. to place nonbinding. You’re A Jerk 76 . The candidate backed an effort led by a grass-roots organization called Neighbor to Neighbor. CAMPAIGN 94 ROUNDUP” lexisnexis[LO//AS] Democratic gubernatorial candidate George Bachrach. Bachrach said his state-run single-payer health plan would contain health care costs and yield savings of $ 4 billion currently being allocated to "wasteful administrative costs" and insurance company profits. to be launched tomorrow.Single Payer 2. Bachrach's plan was endorsed by the Massachusetts chapter of Physicians for a National Health Program.000 people who lack health insurance. a supporter of a single-payer health system. “Roosevelt blasted for ties to Bulger.0 LO 76 Single Payer Solves State Deficits Plan would save billions in single states alone Aucoin 94 Don Aucoin." Bachrach said during a news conference outside the State House. single-payer questions on the ballot in seven state senate districts and one state representative district across the state.

Steve Shannon.html [Mardjuki] The state was in the black for the fiscal year that ended June 30. the General Assembly approved a budget-reduction plan that included $45 million in spending that was not in Beshear's original proposal. state agencies have cut more than $600 million as the state repeatedly adjusted its budget to account for falling revenues.Mental Retardation Programs. Yet the number of people eligible for Medicaid will probably remain the same while the state's portion of the bill will increase. Steve Beshear had originally proposed plugging a potential $1 billion shortfall for this fiscal year with $741 million in federal stimulus dollars and a 2. Legislators also approved a tax credit of as much as $25 million for people who buy newly built homes.0 LO 77 Kentucky – Medicaid Chopping Block Kentucky on the brink – Medicaid funding already on the chopping block. It is fully funded for the coming fiscal year. the federal government retroactively increased its share of Medicaid dollars this year to nearly 80 percent of the cost. Lassiter said. Medicaid.7 million short in General Fund dollars and nearly $37 million short in Road Fund money — which pays for transportation projects. said Mary Lassiter. which represents community mental health centers. Gov. stimulus money will sunset by 2010. the state was $55. an insurance program for the poor and the disabled. Over the past 18 months. To balance the General Fund shortfall — which funds the bulk of state government — Kentucky used unspent General Fund money that was allocated to its Medicaid program. there could have been additional cuts in programs.Single Payer 2. Lassiter said. Shannon said. staff writer. "Where do we find money to plug that shortfall?" The shortfall in the state's Road Fund was plugged using savings from restructuring debt and other cost-cutting measures such as restricting travel and cutting other expenses at the Transportation Cabinet. the state picks up about 30 percent of the tab and the federal government pays 70 percent. 7/21/09 Beth.6 percent. Lassiter said. Beshear has said. You’re A Jerk 77 . with a few exceptions." Lassiter said. But in a special legislative session in June. "We're not cutting any projects. The exceptions included the state Medicaid programs and the main funding formula for K-12 education. http://www. However. The state had to balance its books from the last fiscal year before it could determine how how much to cut from this year's budget. Those plans are due this week. Moving money from Medicaid to the General Fund will not affect the Medicaid program. Lassiter said.kentucky.6 percent cut to most state agencies." Lassiter said of saving measures at the Transportation Cabinet. Some of that $45 million included an income-tax credit for active-duty military personnel and an increase in the budgets for public defenders and prosecutors. But some people in the social-services sector questioned whether it was wise to borrow money from a program that is likely to need those dollars in the future. Lassiter said Monday that the state has asked all agencies to show how a 3 percent and a 4 percent cut would effect the delivery of services. For the fiscal year that just ended. which had additional money from the federal stimulus program. director of the Kentucky Association of Regional Mental Health. That means the state had additional state money in that program that could be used to cover the shortfall. Musgrave. is paid with federal and state dollars. “State plugs budget hole with Medicaid money. "Then what are we going to do?" he said. the state budget director. The agency proposals will be reviewed and discussed with Beshear. "This is the fifth budget reduction in 19 months. The additional spending means that the cuts to agencies are likely to be deeper than 2. but only because it received a loan from the Medicaid program. But it probably will be several weeks before agencies are told how much to cut. said the increase in the federal share of the Medicaid program is supposed to sunset in December 2010. If the state had to use money set aside for this year's budget. In general. which began July 1. Now state officials are trying to determine how much money state agencies will have to cut from this year's budget.com/news/state/story/868712.” Lexington Herald-Leader.

Medicaid. Because of the formula used in the calculation of Medicaid support from the federal government.including all payments from all sources. but it is an argument that is going to be heard. the federal reimbursement for Medicaid — the principal medical program for the poor — is in the range of 70 percent of the cost of the care. there are ballooning federal budget deficits — for which Jindal is trying to score political points by criticizing President Barack Obama. but the federal stimulus aid to the state also goes away — a double-whammy. Predicted billion-dollar Medicaid deficit will devastate Louisiana economy. Bobby Jindal and U. Jindall's office says he is trying to work out a solution with federal officials over the looming crisis. The state will start seeing this loss of funding this October.S. We hope Landrieu and the state’s delegation in Congress can plot a way through this thicket. not only does Medicaid reimbursement take another dive. as calculated by the independent Bureau of Economic Analysis. Louisiana's Medicaid funding. We hope that the Obama administration and Congress listen. there is the problem of “Katrina fatigue. members of Congress might be reluctant to make even this one change because the nonpolitical formula should be preserved against future raids. recently met on the problem.” http://www. Finally. but the state’s case for assistance is clouded by political concerns. The drop from 72 to 63 percent will cost the state an estimated $700 million per year. Louisiana's impending dramatic decrease in federal funding is due to what the governor says is a faulty calculation of sources of income in the state. and should not be victimized again by their own government. Louisiana Governor’s Office. Jindal says Louisiana's reimbursement rate will drop from as high as 73 percent to 60 percent . [Mardjuki] http://www. Bobby Jindal says post-storm damage payments from insurance settlements and Louisiana's Road Home program following Hurricanes Katrina and Rita are contributing to a $1 billion Medicaid shortfall for his state.html If this year’s state budget crisis was fun.” Jindal’s top health aide.Single Payer 2.” with the state’s woes after the hurricanes receding in national consciousness. “The people of Louisiana have been devastated by four major storms in just over three years and they’re fighting to get back on their feet.claimsjournal.a dramatic. wait until next year. 7/22/09. 7/22/09. which would normally be 72 percent. Overall. it will decrease to 67 percent. Mary Landrieu. That figure goes far beyond wages and salaries . Because Louisiana is a relatively poor state.a decrease almost twice that of the state with the next largest decrease. Further. Louisiana Gov. and then will decrease to 63 percent in October 2010.0 LO 78 Louisiana – Medicaid Deficit Louisiana set to run into a $1 billion Medicaid shortfall – drop in federal funding and miscalculated budget.com/opinion/51360777. Sen. Louisiana. because of the hugely exceptional circumstances of the 2005 hurricanes.forcing cuts to either public health or higher education. “This formula will put severe pressure on health-care funding. “Insurance. Within the next year.. Gov. Federal Payouts Create Medicaid Problem in Louisiana. calculates payment schedules to the states based on per-capita income.” Jindal said. the state government is going hat-in-hand to the U. Aid to Louisiana on this front will add to the deficit. according to the Bureau of Economic Analysis. has been to Washington to press the state’s case for relief. including insurance and Road Home payments after the 2005 storms. with the full impact starting January 2011. is temporarily enhanced by the federal stimulus. sudden increase which will drop the state's federal Medicaid funding. the governor's office said. North Dakota.” WBRZ News 2.” Louisiana faces a shortfall in the hundreds of millions of dollars per year. The problem? Louisiana’s income was artificially inflated by insurance payments and federal aid in the wake of the hurricanes of 2005. That rate is determined by a formula based on total personal income in the state. “Our Views: Medicaid rate hits Louisiana. in 2011. government for more than $700 million in Medicaid funds. D-La. This coming October.com/news/southcentral/2009/07/22/102426.htm?print=1 [Mardjuki] Associated Press. Louisiana will face the largest decrease of federal Medicaid funding in the nation . And then.2theadvocate. You’re A Jerk 78 . If the reimbursement rate is adjusted for that bogus “income. Louisiana might face significant new budget cuts in the 2011 fiscal year that begins next July 1. From 2005 to 2007. which serves the poor and uninsured.S. Louisiana's per-capita income is reported to have increased by 42 percent . We don’t agree with the latter position. Alan Levine. according to the governor's office. higher-education funding and other key Louisiana priorities. ABC News.

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0 LO 80 **ECON – FEDERAL DEF** You’re A Jerk 80 .Single Payer 2.

This week they could get well get a wakeup call when the unemployment data is released. The weekly number has to begin to improve before the unemployment rate can improve. then the unemployment rate reported for June could approach 10%. while those anticipating fewer jobs increased to 27. As long as credit remains extremely tight the economy has to rely on savings and income.4 percent from 19. Washington has gone on a wait and watch approach to the economy. He earned a Master's Degree in Business Administration from Baylor on June 30. income. When the economy improves employers first slow down their rate of layoffs. The credit markets remain broken. Then employers have their existing workforce work longer hours.3 percent from 25. The news coverage in May and June has been positive. The economy is made up of spending based on access to cash. Prometheus Wealth Management. The weekly claims number released this week will be part of the July unemployment report. The drop is especially significant since people receiving a paycheck had fewer payroll related taxes withheld from their checks. Kamperman runs his own investment advisory firm.com/2009/06/30/falling-consumer-confidence-foreshadows-worsening-jobs- The Consumer Confidence Index fell in June to a reading of 49.8 in May.6 percent.Single Payer 2. They may seek to demean the data for the unemployment rate and call it once again a lagging indicator. The Conference Board stated “the job outlook was also more pessimistic. if one cannot qualify for a mortgage or auto loan one does not spend what savings they have for a downpayment. But with unemployment rising and unemployment benefits starting to run out for those that lost their jobs last summer and fall. Fine. Access to credit remains as tight as ever for both consumers and businesses. Finally employers hire and the unemployment rate begins to go down. or credit. That leaves savings.000 again. Those anticipating more jobs in the months ahead decreased to 17. If that number is above 600.0 LO 81 Consumer Confidence Low Now Consumer confidence is tanking the economy Michael A. Access to cash can come from savings. 2009 (“Falling Consumer Confidence Foreshadows Worsening Jobs Outlook” outlook/ http://www.” If this survey is accurate. The retrenchment in consumer sentiment can only be traced to further deterioration in the real economy.escapethenewgreatdepression. The credit markets and the economy will not heal on their own in the near term. Plus.3 from a reading of 54. but weekly unemployment claims are not a lagging indicator. The green-shoot crowd expected confidence to continue rising. You’re A Jerk 81 . incomes are not in a position to pick up the slack for access to credit.3 percent. then we will know the July unemployment report will also be weak. What I found ominous in the report was the consumer outlook for employment. Based on an increase in the value of the stock markets and the constant press coverage for green-shoots and an improving economic picture. Only meaningful intervention from Washington will fix the credit markets within the next few years. The survey is a measure of attitudes and feelings. The rational response to a deteriorating economy even for those with access to credit is to save more. the decline in confidence in June has come as a cold slapped in the face to those looking for an imminent rebound in the economy.

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Lashout ! Scenario
A) Growth is critical to preventing ineffective forms of intervention that risk nuclear holocaust and wars.
Foster, Ph.D professor @ University of Oregon, 09 (John Bellamy Foster, Ph.D professor @ University of Oregon, March 2009, “A Failed System: The World Crisis of Capitalist Globalization and its Impact,” Monthly Review; 60.10; Wilson Social Sciences Abstracts) As the foregoing indicates, the world is currently facing the threat of a new world deflation-depression, worse than anything seen since the 1930s. The ecological problem has reached a level that the entire planet as we know it is now threatened. Neoliberal capitalism appears to be at an end, along with what some have called "neoliberalism 'with Chinese characteristics.'''54 Declining U.S. hegemony, coupled with current U.S. attempts militarily to restore its global hegemony through the so called War on Terror, threaten wider wars and nuclear holocausts. The one common denominator accounting for all of these crises is the current phase of global monopoly~financed capital. The fault lines are most obvious in terms of the peril to the planet. As Evo Morales, president of Bolivia, has recently stated: "Under capitalism we are not human beings but consumers. Under capitalism mother earth does not exist, instead there are raw materials." In reality, "the earth is much more important than [the] stock exchanges of Wall Street and the world. [yet,] while the United States and the European Union allocate 4,100 billion dollars to save the bankers from a financial crisis that they themselves have caused, programs on climate change get 313 times less, that is to say, only 13 billion dollars.

B) Absent growth, the U.S. will intervene in desperation, triggering lashout and nuclear holocaust.
Burrows, Director of the Analysis and Production Staff in the National Intelligence Council, 09 (Mathew J. Burrows, Director of the Analysis and Production Staff in the National Intelligence Council, 2009, “Revisiting the Future: Geopolitical Effects of the Financial Crisis,” The Washington Quarterly) Types of conflict that the world continues to experience, such as over resources, could reemerge, particularly if protectionism grows and there is a resort to neo-mercantilist practices. Perceptions of renewed energy scarcity will drive countries to take actions to assure their future access to energy supplies. In the worst case, this could result in interstate conflicts if government leaders deem assured access to energy resources, for example, to be essential for maintaining domestic stability and the survival of their regime. Even actions short of war, however, will have important geopolitical implications. Maritime security concerns are providing a rationale for naval buildups and modernization efforts, such as China’s and India’s development of blue water naval capabilities. If the fiscal stimulus focus for these countries indeed turns inward, one of the most obvious funding targets may be military. Buildup of regional naval capabilities could lead to increased tensions, rivalries, and counterbalancing moves, but it also will create opportunities for multinational cooperation in protecting critical sea lanes. With water also becoming scarcer in Asia and the Middle East, cooperation to manage changing water resources is likely to be increasingly difficult both within and between states in a more dog-eat-dog world.

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China ! Scenario (1/2)
A. China will capitalize on the immediate recession and establish itself as the global financial hub.
AFP, Agence France Presse, 08 (AFP, Agence France Presse, November 5, 2008, “'Go East': China Inc. recruiting in gloomy London, New York,” http://afp.google.com/article/ALeqM5gQZZNGoiTxqAkAjWJEnWJwAISZsg) SHANGHAI (AFP) — Spotting an opening in the global fight for talent, China's ambitious financial institutions are planning recruiting trips to London and Wall Street on the wounded financial titans' home turf. Sovereign fund China Investment Corporation has begun a global search, multi-billion dollar Chinese-French fund Fortune SGAM plans interviews on Wall Street and Shanghai's government is headed to London and New York next month with job offers in hand. "There are layoffs on Wall Street since the crisis but China's financial industry is still in its infancy and is hungry for talent," Pei Changjiang, chief executive of the Fortune SGAM Fund, told AFP. It is estimated that the economic turmoil could lead to 165,000 job losses in New York over the next two years, while British think tank Oxford Economics predicts 194,000 job cuts in London over the same period. But from Shanghai the message to the brightest finance minds is unmistakable: China is hiring. Han Zheng, mayor of the China's rapidly growing economic hub, has previously said by 2010 -- when Shanghai hosts the World Expo -- the city will have an infrastructure worthy of an international financial centre. By 2020, he said, it will be one. Since the financial crisis, city officials are saying that could now come even sooner The crisis has presented a rare lesson and opportunity and generally it will help accelerate the establishment of Shanghai as a global financial hub," said the city's deputy mayor in charge of economic affairs, Tu Guangshao. "The US is a fatty and needs to take diet pills but in contrast China is still skinny... It needs to build a strong body," the former vice-chairman of China's securities watchdog wrote in an opinion piece in the official China Business newspaper. More than 600 financial institutions had offices in Shanghai at the beginning of the year but finance jobs account for only 2.4 percent of the 9.1 million-strong workforce, compared to 11 percent in London and 12.7 percent in New York. "More foreign financial institutions will be willing to operate in China, where financial service is in short supply, as their business at home contracts," said Fang Xinghai, director of the city's Financial Services Office.

B. That results in a Sino-American war over Taiwan.
Mearsheimer, professor of Political Science at the University of Chicago, 04 (John Mearsheimer, professor of Political Science at the University of Chicago, September 17, 2004, “Why China’s Rise Will Not Be Peaceful,” http://mearsheimer.uchicago.edu/pdfs/A0034b.pdf) The question at hand is simple and profound: can China rise peacefully? My answer is no. If China continues its impressive economic growth over the next few decades, the United States and China are likely to engage in an intense security competition with considerable potential for war. Most of China’s neighbors, to include India, Japan, Singapore, South Korea, Russia, and Vietnam, will join with the United States to contain China’s power. <<< CONTINUES – 20 PARAGRAPHS LATER – BREAK IN TEXT >>> China is likely to try to dominate Asia the way the United States dominates the Western Hemisphere. Specifically, China will seek to maximize the power gap between itself and its neighbors, especially Japan and Russia. China will want to make sure that it is so powerful that no state in Asia has the wherewithal to threaten it. It is unlikely that China will pursue military superiority so that it can go on a rampage and conquer other Asian countries, although that is always possible. Instead, it is more likely that it will want to dictate the boundaries of acceptable behavior to neighboring countries, much the way the United States makes it clear to other states in the Americas that it is the boss. Gaining regional hegemony, I might add, is probably the only way that China will get Taiwan back. An increasingly powerful China is also likely to try to push the United States out of Asia, much the way the United States pushed the European great powers out of the Western Hemisphere. We should expect China to come up with its own version of the Monroe Doctrine, as Japan did in the 1930s. These policy goals make good strategic sense for China. Beijing should want a militarily weak Japan and Russia as its neighbors, just as the United States prefers a militarily weak Canada and Mexico on its borders. What state in its right mind would want other powerful states located in its region? All Chinese surely remember what happened in the last century when Japan was powerful and China was weak. In the anarchic world of international politcs, it is better to be Godzilla than Bambi. Furthermore, why would a powerful China accept U.S. military forces operating in its backyard? American policymakers, after all, go ballistic when other great powers send military forces into the Western Hemisphere. Those foreign forces are invariably seen as a potential threat to American security. The same logic should apply to China. Why would China feel safe with (continues…no text removed)

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told a gathering at the Woodrow Wilson International Centre for Scholars in Washington that although the government still abided by that principle. the United States can be expected to go to great lengths to contain China and ultimately weaken it to the point where it is no longer capable of ruling the roost in Asia. With the US distracted. there were strong pressures from the military to drop it. And the conflagration may not end there as opportunistic powers elsewhere may try to overturn the existing world order. forces deployed on its doorstep? Following the logic of the Monroe Doctrine. Italy. the US had at the time thought of using nuclear weapons against China to save the US from military defeat. The balance of power in the Middle East may be similarly upset by the likes of Iraq. it is determined to remain the world’s only regional hegemon. would not China’s security be better served by pushing the American military out of Asia? Why should we expect China to act any differently than the United States did? Are they more principled than we are? More ethical? Less nationalistic? Less concerned about their survival? They are none of these things. Taiwan is likely to be an important player in the antiChina balancing coalition. Singapore. of course. Japan. Japan. which is sure to infuriate China and fuel the security competition between Beijing and Washington. allowing China to control that large island. China’s neighbors are certain to fear its rise as well. then a full-scale war becomes unavoidable. C. While the prospect of a nuclear Armaggedon over Taiwan might seem inconceivable. to a lesser extent. The United States does not tolerate peer competitors. for China puts sovereignty above everything else. There would be no victors in such a war. South Korea. Major-General Pan Zhangqiang. president of the military-funded Institute for Strategic Studies. He said military leaders considered the use of nuclear weapons mandatory if the country risked dismemberment as a result of foreign intervention. and Vietnam. and even China.” Lexis) THE high-intensity scenario postulates a cross-strait war escalating into a full-scale war between the US and China. the Philippines and.truce or a broadened war. In south Asia. are worried about China’s ascendancy and are looking for ways to contain it.S. it cannot be ruled out entirely. Beijing also seems prepared to go for the nuclear option. Russia may seek to redefine Europe's political landscape. the United States is likely to behave towards China much the way it behaved towards the Soviet Union during the Cold War. Gen Ridgeway said that should that come to pass. which could have led to the use of nuclear weapons. Extinction. they will join an American-led balancing coalition to check China’s rise. In his book The Korean War.Single Payer 2. In essence. short of using nuclear weapons. as well as Japan. as well as smaller powers like Singapore. each armed with its own nuclear arsenal. a personal account of the military and political aspects of the conflict and its implications on future US foreign policy. In the end. Germany. France. it is hard to imagine the United States . The US estimates that China possesses about 20 nuclear warheads that can destroy major American cities. “Regional Fallout: No one gains in war over Taiwan. and they too will do whatever they can to prevent it from achieving regional hegemony. A Chinese military officer disclosed recently that Beijing was considering a review of its "non first use" principle regarding nuclear weapons. In the region. Gen Ridgeway said that US was confronted with two choices in Korea -. Japan. If Washington were to conclude that splitting China would better serve its national interests.0 LO 85 China ! Scenario (2/2) (Continues…no text removed) U. Straits Times 2k (Straits Times. Finally. Beijing has already told the US and Japan privately that it considers any country providing bases and logistics support to any US forces attacking China as belligerent parties open to its retaliation. commander of the US Eighth Army which fought against the Chinese in the Korean War. June 25.horror of horrors -. As it demonstrated in the twentieth century. If China were to retaliate. If the US had to resort to nuclear weaponry to defeat China long before the latter acquired a similar capability. east Asia will be set on fire. You’re A Jerk 85 . Indeed. much the way Britain. Therefore. 2000. there is little hope of winning a war against China 50 years later. Conflict on such a scale would embroil other countries far and near and -. we would see the destruction of civilisation. there is already substantial evidence that countries like India. this means South Korea. joined forces with the United States to contain the Soviet Union during the Cold War. which is why China is likely to imitate the United States and attempt to become a regional hegemon. In fact. and Russia. Will a full-scale Sino-US war lead to a nuclear war? According to General Matthew Ridgeway. THE AMERICAN RESPONSE It is clear from the historical record how American policymakers will react if China attempts to dominate Asia.raise the possibility of a nuclear war. given Taiwan’s strategic importance for controlling the sea lanes in East Asia. hostilities between India and Pakistan. could enter a new and dangerous phase.

massively increasing the number of casualties and potentially triggering a full-scale nuclear conflict. J. A terrorist attack with a nuclear weapon would be devastating in terms of immediate human and economic losses . Speice. the report stressed the likelihood that terrorism and nonproliferation will remain priorities even as resource issues move up on the international agenda. Burrows. 47 Wm and Mary L.C.Single Payer 2.D.D. Director of the Analysis and Production Staff in the National Intelligence Council. Dunn & Crutcher's Washington. 1427. For those terrorist groups that remain active in 2025. Burrows. D. 52 as well as increase the likelihood that regional conflicts will draw in the United States and escalate to the use of nuclear weapons. 06 (Patrick Speice. Terrorist groups in 2025 will likely be a combination of descendants of long established groups— Inheriting organizational structures. J.” The Washington Quarterly) In surveying those risks. Extinction. Rev. Terrorism’s appeal will decline if economic growth continues in the Middle East and youth unemployment is reduced. leakage of nuclear knowledge and material from Russia will reduce the barriers that states with nuclear ambitions face and may trigger widespread proliferation of nuclear weapons. command and control processes. Director of the Analysis and Production Staff in the National Intelligence Council.C. associate in Gibson. “Revisiting the Future: Geopolitical Effects of the Financial Crisis. and training procedures necessary to conduct sophisticated attacks—and newly emergent collections of the angry and disenfranchised that become selfradicalized. Dunn & Crutcher's Washington. 49 Moreover. 2009.0 LO 86 Terror ! Scenario A. 51 This proliferation will increase the risk of nuclear attacks against the United States [*1440] or its allies by hostile states. Lexis) The potential consequences of the unchecked spread of nuclear knowledge and material to terrorist groups that seek to cause mass destruction in the United States are truly horrifying. D. the diffusion of technologies and scientific knowledge will place some of the world’s most dangerous capabilities within their reach. B. 50 In addition to the threat posed by terrorists. particularly in the absence of economic outlets that would become narrower in an economic downturn. there would be immense political pressure in the United States to discover the perpetrators and retaliate with nuclear weapons.. associate in Gibson. office. You’re A Jerk 86 . Economic growth is critical to preventing WMD terrorism. office.. however. February 2006. 09 (Mathew J.

Single Payer 2.0 LO 87 **COMPETITIVENESS** You’re A Jerk 87 .

Today.Single Payer 2. “Is America Losing Its Edge?” November / December 2004. For the last five decades. however. aerospace. Although the United States' technical dominance remains solid.S. Indian companies are quickly becoming the second-largest producers of application services in the world. Singapore. as the United States is learning.org/20041101facomment83601/adam-segal/is-america-losing-its-edge. South Korea. the personal computer. and managing database and other types of software for clients around the world. to keep its privileged position in the world. supplying. South Korea has rapidly eaten away at the U. and preferential policies for science and technology (S&T) personnel. biotechnology. and Taiwan is rising. U.S.S. and many other types of manufacturing. globalization cuts both ways: it is both a potent catalyst of U. The percentage of patents issued to and science journal articles published by scientists in China. the globalization of research and development is exerting considerable pressures on the American system. You’re A Jerk 88 . increased investment in research and development (R&D). developing. It was Americans who invented and commercialized the semiconductor. other countries merely followed the U. the United States must get better at fostering technological entrepreneurship at home. Asian governments are improving the quality of their science and ensuring the exploitation of future innovations. and the Internet.foreignaffairs. Indeed. Foreign Affairs. this technological edge-so long taken for granted-may be slipping. Through competitive tax policies. http://www. and the most serious challenge is coming from Asia. The United States will never be able to prevent rivals from developing new technologies.0 LO 88 Competitiveness K2 Heg Competitiveness is key to US hegemony and economy Segal 04 – Senior Fellow in China Studies at the Council on Foreign Relations [Adam.S. technological innovation and a significant threat to it. But this won't be easy. lead. advantage in the manufacture of computer chips and telecommunications software. it can remain dominant only by continuing to innovate faster than everyone else. scientific innovation and technological entrepreneurship have ensured the country's economic prosperity and military power.html] The United States' global primacy depends in large part on its ability to develop new technologies and industries faster than anyone else. and advanced materials used in semiconductors. And even China has made impressive gains in advanced technologies such as lasers.

government does not tolerate or condone torture are necessary in order to separate the new administration from that costly legacy. A few early actions that lie wholly within his authority can make an immediate impact. as Bush administration apologists (and many lawyers) say. Rome. including the five neighboring countries at the center of the arc of crisis that directly threatens the United States' national security -. Venice. Presidential directives making clear that the U. Iraq. Well. France. the rise and fall of great nations is driven primarily by their economic strength. “The Next President: Mastering a Daunting Agenda” To restore the United States to its proper world leadership role.not because it is nice to be popular but because respect is a precondition for legitimate leadership and enduring influence. two areas of weakness must be repaired: the domestic economy and the United States' reputation in the world. Although the economy is usually treated as a domestic issue. U. But there is one pattern that comes very close to being a law of history: in the long run. a lot of things in life are complicated. And restoring respect for American values and leadership is essential -.S. a new national policy on energy and climate change will be essential.the gift that keeps on giving to the United States' enemies. closing it. The most compelling such actions would be issuing a clear official ban on torture and closing the detention facility at Guantánamo Bay. Ambassador to the United Nations from 1999 to 2001. A NEW FACTOR History is not immutable.S. Portugal. to repair the economy in the long term.all had their day.Single Payer 2. and their international decline followed inexorably from their economic decline. closing it is complicated.S. You’re A Jerk 89 . Foreign Affairs September/October 08. This will require more than a cyclical upturn. and Pakistan. the United Kingdom -. Because the Bush administration limited itself to punishing only those at the very bottom of the chain of command at Abu Ghraib. which now holds only 260 prisoners. reviving it is as important to the nation's long-term security as is keeping U. Current Chair of Asia Society. no matter how difficult. Richard Holbrooke. imperial China. the damage to the United States' image has been immense and continuing -. is not just desirable but imperative.Turkey. too. Iran. The president should address both issues as early as possible in order to strengthen his hand as he tackles pressing strategic issues. military strength unchallengeable.0 LO 89 Econ K2 Heg A strong economy is key to military strength and sustainable hegemony. As for Guantánamo. the Netherlands. Guantánamo must not become the next president's albatross. Cuba. Afghanistan.

The economy will do better in the current quarter than in the last one. The flapping of a butterfly's wings may trigger a hurricane in the Home Counties. today it has three. By 1907. the United States had seven of the top 20 banks. alongside Fareed Zakaria's prophetic The Post-American World.84 trillion .0 LO 90 Econ Decline Killing Heg Now Economic decline is killing US hegemony now. measured by market capitalisation. China has not been wholly unscathed by the astonishing collapse of exports that struck Asian economies in late 2008 and early 2009. In April. China did not have a single bank among the world's top 20.3 per cent a year between now and 2013.8 per cent this year . China is imbued with a remarkable sense of patriotism that is not just a product of Communist Party propaganda. lexis) In February. People whose grandparents survived the Great Leap Forward and whose parents endured the Cultural Revolution can surely cope with a decline in the growth rate from 11 to 6 per cent. Even before its economy becomes the world's biggest. and imports of oil by just under 14 per cent. Three years ago.but Beijing is clearly getting more bangs for its bucks. a Wall Street crash could send a shockwave across the entire British Empire. Financial crises often accelerate the gradual shifting of the geopolitical tectonic plates.worth $787 billion . It was inflation that undermined the foundations of Habsburg power and opened the way for the Dutch Republic. In March alone. they believe China is on the way back. The spouse with the money generally wins the argument. Just visit the nearest bookshop if you don't believe me. the Congressional Budget Office anticipates that total debt will nearly double in the decade ahead. “The Trillion Dollar Question. 6/2/09. China's holdings of US Treasuries rose $23. According to Bank Credit Analyst research.has had rather a muted impact. for household debt to return to a more sustainable level. the Obama administration will have to junk its predictions of 3 per cent growth next year and 4 per cent the year after that. You’re A Jerk 90 .has an almost imperial character to it. who predicted just a few years ago that China's gross domestic product could equal that of the United States by 2027. It's a measure of China's new economic influence that commodity traders attribute much of the recent upward pressure on oil. it may be time to start believing the projections made by Jim O'Neill and his colleagues at Goldman Sachs. and the biggest. in much the same way. Not since the Second World War has the gap between income and spending been so huge. Especially when the argument is about the other spouse's debts. but warned of an impending "period of chillness''.7 billion.while China's is forecast to grow by more than 6 per cent.which saw both bonds and the dollar drop sharply . In short. JP Morgan Chase. the US economy will contract by 2.roughly half of total expenditure and nearly 13 per cent of GDP. China's growing presence in commodity markets in sub-Saharan Africa and South America . Ferguson.$585 billion . To be sure. There. But house prices are still falling at close to 20 per cent year on year. compared with $418 billion last year.84 trillion deficit. the Chinese are understandably alarmed by this tsunami of red ink. financial crises in the United States had only marginal effects on the City of London. but also as an investor . Like other rising powers in past centuries. including the top two. fixed investment surged by nearly 34 per cent.will have caused palpitations in Beijing.Single Payer 2. 9 (Niall. copper and other raw material prices to Chinese purchases. Could this be one of those great turning points in history. while Britain survived the contemporaneous South Sea Bubble with its fiscal system intact. Indeed. Moreover. however. And a crisis in commercial real estate could blow a new hole in the balance sheets of US banks. is rated fifth. Last week's financial market action .not just as a buyer. Of course. China can play a much more assertive role in its relations with the United States.” The Daily Telegraph. real consumer spending would need to grow at no more than 1. With the lion's share (around 70 per cent) of their $2 trillion of international reserves held in the form of US bonds. And what debts! The US federal government's deficit this year will be $1. If that calculation is correct. China's stimulus is worth less in dollar terms . they are to history what earthquakes are to geology. The rate of foreclosures per month is still rising. China is still piling up those dollar-denominated bonds. It was the disastrous Mississippi Bubble of 1718-19 that fatally weakened ancien régime France. when the balance of power tilts decisively away from an established power and towards a rising challenger? It is possible. after all. You don't need a Nobel prize in economics to know that $100 billion won't finance much of a $1. The US stimulus package . But Deutsche Bank recently predicted that Chinese reserves will rise by only $100 billion this year. Yet I do not believe (as some Sino-pessimists do) that the regime in Beijing faces a serious threat of social unrest. People are proud of their country's economic miracle over the past 30 years. Just consider the impact of this crisis on the United States and China. Today the top three are all Chinese. Net imports of iron ore leapt by a third. you'll soon find Martin Jacques's darkly visionary When China Rules the World. For most of the nineteenth century. After two wretched centuries. no amount of stimulus can swiftly reduce the debt burden weighing down America's over-leveraged consumers. According to the International Monetary Fund. Many more Chinese than American workers have lost their jobs since this crisis began. Moreover. a harbinger of a new era of American power. the People's Daily acknowledged the "global importance and influence'' of Chimerica. In 2006. Something similar may be happening as a consequence of the American financial crisis that began nearly two years ago. a crisis in the market for subprime mortgages could signal the waning of US hegemony and the advent of a Chinese century.

The new numbers will come as part of a semiannual review that. 58 percent said the president and Congress should focus on keeping deficits down. managing editor. you’ve undermined the basis for the rest of your policies. is the kind of earnest-but-dull document that causes many Washington eyes to glaze over. White House officials rebuff such suggestions.” he added. even if that delays an economic recovery.shtml [Mardjuki] President Barack Obama’s economic forecasts for long-term growth are too optimistic.of respondents approved of Obama’s handling of the economy. it is now just shy of 10 percent. if Obama clings to current optimistic forecasts for long-term growth. Jeanne. saying the midyear correction is precisely intended to keep their economic program reality based.did not fully anticipate the severity and pace of this recession. She said the White House will be updating its official forecasts. a bare majority . he risks accusations that he is basing his fiscal plans on fictitious assumptions . In addition. 4. And the general public is paying attention. 4 percent growth in 2011.6 percent growth in 2012 and 4. the new forecasts . where even the administration’s current debt projections already are prompting deep concerns on political and substantive grounds. upbeat predictions and the mainstream consensus about how the economy is likely to perform in a new budget forecast to be unveiled next month. But a series of POLITICO interviews in recent days with independent economists of varied political stripes found widespread disdain for Obama’s first round of assumptions. too. http://www. Christina Romer.precisely the sort of charge he once leveled against the Bush administration.” said Robert Shapiro.Single Payer 2. But they matter greatly to policymakers and the financial markets as a measure of whether the country can afford Obama’s big agenda. The administration is already under intense pressure over its economic calculations on the most politically sensitive statistic: employment. said in a POLITICO interview that the administration . The White House will be forced to confront the disconnect between its original. Alternately. Higher deficit figures also would arrive at a critical moment in the health care debate.2 percent growth next year. This time.51 percent . In a June NBC/Wall Street Journal poll. chairwoman of the White House’s Council of Economic Advisers. 7/14/09. You’re A Jerk 91 .could send a jolt through Capitol Hill.” Obama’s current forecasts envision 3.” CBS News/Politico. many economists warn. with some experts invoking such phrases as “rosy” and “fantasy.2 percent growth in 2013.cbsnews.com/stories/2009/07/14/politics/politico/main5157452. “But it’s also dangerous and risky because if the forecast doesn’t come true. as lawmakers are already struggling to find a way to pay for the president’s nearly $1 trillion reform package. a former Clinton economic adviser. down from 56 percent in February. a miscalculation that would mean budget deficits will be much higher than the administration is now acknowledging. “Experts: Obama Too Optimistic on Economy.0 LO 91 Econ K2 Obama Agenda Econ key to Obama’s agenda – must follow through on high expectations and promises. under ordinary circumstances. It creates the basis for the revenues you need for health care and climate change. and that’s understandable because a quick recovery makes the rest of the agenda possible. however. the poll found. “They used a rosy forecast. Cummings.if they are anything like what many outside economists expect . Deficit figures do not pack the same emotional punch as unemployment lines do. The administration once vowed to use stimulus policies to keep the jobless rate below 8 percent.like many independent economists .

and Steffie Woolhandler. Fee schedules are negotiated annually between provincial medical associations and governments. and Woolhandler. administrative overhead in Canada’s health system. disinterested civil servants and .pnhp. is about half the US level. much as a fire department is funded in the United States. nearly twice the average in Canada. Canadian physicians. Health care’s enormous bureaucratic burden is a peculiarly American phenomenon. which are mostly private. which resembles that of the United States in its emphasis on private. No nation with NHI spends even half as much administering care nor tolerates the bureaucratic intrusions in clinical care that have become routine in the United States. All patients have the same coverage. Proponents of NHI. MD + MPH. nonprofit institutions. Unfortunately. are paid a global annual budget to cover all costs. The key to administrative simplicity in Canada and other nations is single-source payment. MD. 15% of current health spending Himmelstein. American physicians spend nearly 8 hours per week on paperwork and employ 1. fee-for-service–based practice. The Department of Medicine at Cambridge Health Alliance/Harvard Medical School. Reducing our bureaucratic apparatus to Canadian levels would save about 15% of current health spending. obviating the need for administratively complex per-patient billing. and even skeptics all agree on this point. 11/07. $300 billion annually. bill by checking a box on a simple insurance form. Our biggest HMOs keep 20%—even 25%—of premiums for their overhead and profit. enough to fully cover the uninsured and to upgrade coverage for those now underinsured. You’re A Jerk 92 . Indeed.66 clerical workers per doctor.Single Payer 2. MD.0 LO 92 HC Reform Key to Econ National Health Insurance would cut annual costs by $300 billion.php) [LO//JW] In contrast to CDH. And HMOs inflict mountains of paperwork on doctors and hospitals. dept Medicine Harvard. Canadian hospitals. ‘07 (David U. The average US hospital spends one-quarter of its budget on billing and administration. far more than in Canada. Physicians for a National Health Program of Chicago. “Our Health Care System at a Crossroads: Single Payer or Market Reform?” www.org/news/2008/may/our_health_care_syst. Himmelstein. a properly structured NHI program could expand coverage without increasing costs by reducing the huge health administrative apparatus that now consumes 31% of total health spending. Canada’s NHI has 1% overhead and even US Medicare takes less than 4%. most of whom are in private practice. neither piecemeal tinkering nor wholesale computerization can achieve significant bureaucratic savings.

"It's not the start of a new bull market. it's going to lead to a depression. As in his 2002 book "Conquer the Crash." Experts believe that deflation and depression will come soon Parry. SEVEN MORE YEARS? Riskier assets such as commodities. The benchmark U. 7/23 Chris Isidore. leading to job loss and decreased production Isidore. while corporate bond prices will plunge precipitously by next year as broad economy. While gold may have already topped at above $1. "It's a very rare event.reuters. In July. S&P 500 stock index's rebound by nearly 40 percent since it sagged to a 12-year closing low of 676 points on March 9 is not sustainable. debt bubble and deflationary depression. are likely to have short lived intense rallies.000 an ounce in March 2008. chief executive at research company Elliott Wave International in Gainesville. he said. And while lower prices might sound like a positive to consumers with budgets stretched to the breaking point. "Our models are (showing) right now that it is a much bigger bear market than most people realize. Businesses unable to make a profit in an environment of declining prices will likely cut production and lay off more workers. Treasury bond prices are likely to fall in a long term bear market. “The inflation vs.S. Prechter said in an interview with Reuters.com/2009/06/23/news/economy/inflation_deflation_debate/index. As banks continue to accumulate losses and corporate earnings fall. and stocks which are currently anticipating that the severe global economic downturn may be bottoming." he told Reuters in a wide ranging interview. The Consumer Price Index. You’re A Jerk 93 ." Prechter also painted a bleak picture for commodities like silver and is largely unenthusiastic about gold. " I think the next leg down will be at least as severe if not more severe than what we just experienced. Georgia. reporters for Reuters “Stocks still face deflationary collapse: Prechter” http://www.0 LO 93 Deflation Coming Deflation is a pertinent threat in the short-term and could lead to a deflationary spiral. the government's key inflation measure.S. "I think we are going to have bouts of deflation separated by recoveries." he said.cnn. believing the precious metal made a major peak when it rose above $1. "I think the predominant risk in the next 6 to 12 months is deflation." said Prechter. with huge government debt issuance being the main catalyst." which warned of the dangers of a U. equities may plunge to half their lows hit in March as a deflationary depression bites. which moves inversely to its price. he said." Oil may rally further from current levels just below $60 per barrel but the upside will be capped at about $80 per barrel as the commodity is locked in a long-term bear market." he said. and Mnyandu 5/14 John Parry.000 last year.htm?postversion=2009062313 But others argue the economy is still so weak that deflation." he added.com/article/wtUSInvestingNews/idUSTRE54D4IL20090514?pageNumber=2&virtualBrandChannel=0 NEW YORK (Reuters) . banking system and company earnings sustain more damage from a financial crisis that's akin to the Great Depression." said Mark Zandi.S. There's vacant real estate across all property types. That could cause a deflationary spiral. crude oil hit a record peak above $147 per barrel and was just above $57 per barrel around noon on Thursday. but within an inexorable long-term decline that may last another seven years. senior writer for CNN Money. could be signs that prices are likely to keep falling. deflation debate” http://money. coupled with rising unemployment and low factory utilization. Unemployment continues to rise. "There's excess capacity everywhere. who forecast the 1987 stock market crash. corporate bonds.S.Longtime technical analyst Robert Prechter.Single Payer 2. "the difficulties will probably last through about 2016. something along the lines of 1929-1932. Oil and U." Prechter said. Treasury bonds are also locked in long term bear markets. We're not at the bottom yet. This year-over-year decline in prices. I don't see how businesses can raise prices in this environment. Haddadin. senior writer for CNNMoney. posted its largest 12-month drop since 1950 in May. chief economist at Moody's Economy. economists are in general agreement that deflation is far more destructive to the economy than inflation. he said. "There will be plenty of rallies along the way. 10-year Treasury note yield. U. is the more serious threat.S. " Deflation is coming. Prechter continues to advocate safer cash proxies such as Treasury bills. hit a five-decade low of 2. Hathaim Haddadin.04 percent in mid-December. The U. predicted this week that U. and Ellis Mnyandu . So you want to stay on the side of safety. The Great Depression and Japan's so-called Lost Decade of economic stagnation are both well-documented examples of the damage that deflation can cause.S.com. or a drop in prices.

Yet the feeling persists that falling prices must be beneficial. Every month. A widespread drop in prices is known as deflation. but ultimately their salaries are paid from the taxes levied on earnings and.uk/news/article.0 LO 94 Deflation Coming Economists agree that deflation is a major possibility and could culminate in a depression Isidore. your pound goes further. Home prices. Put simply.that is. in the worst case scenario. you become better off. Warnings? Why would any kind of killjoy warn against this latter-day consumer paradise? The short answer is deflation is a disaster in the making. That results in growing job losses. It eats into earnings.thisismoney. Deflation is a general fall in the overall level of prices. With the world sliding into recession. While high levels of inflation are a menace. assuming that prices will be even higher next week. and they should know . And several economists say they are far more worried about the threat of deflation now than they have been in the past.Lower prices are probably at the bottom of the list of most Americans' current economic worries. worsening the squeeze. senior writer for CNNMoney.com/2008/12/17/news/economy/deflation/?postversion=2008121810 NEW YORK (CNNMoney.the prospect of falling prices must sound like heaven. even cause a depression. prices. The biggest problem with deflation is that when businesses need to continually cut prices to spur sales. Deflation destroys incomes but not debts. Anyone in the private sector relies on prices of some sort . Earnings may shrink. You’re A Jerk 94 . a viral attack on the economy. prices fall further. writer for ThisisMoney “Deflation: Who wins when prices fall?” http://www.be it the cost of a cup of tea for a cafe owner or fees for an architect . But for a growing number of economists. It is called deflation and there have been new warnings about it from the Bank of England. This inevitably bears down on economic activity. It is little use a greengrocer rejoicing over a shrinking fuel bill if the prices he can charge for his produce are also dwindling. It makes no sense to buy now what will be cheaper next week or next month. More specifically. As people hold off. The Federal Reserve may also be more concerned about deflation as well. deflation causes chaos on a number of fronts. Deflation throws that process into reverse. but borrowings remain stubbornly of the same size.for their income. the adult equivalent of being given the run of a sweet shop. almost everyone .html?in_article_id=468029&in_page_id=2 For anyone living on a budget .cnn.Single Payer 2. thus. it's not just the price of consumer goods that fall. Public-sector workers are better protected for a while. So we're all in the same boat. Falling wages and constant debts mean that deflation is destructive to the economy Atkinson 09 Dan Atkinson. stock prices and even people's salaries often head lower as well. 08 Chris Isidore. This becomes a self fulfilling prophecy. where does your pay come from if not from prices? Unless you are very lucky and your line of work somehow escapes the crumbling of prices. And typically.co. “The growing threat of deflation” http://money. senior writer for CNN Money. and could. But ingrained deflation is bad for the same underlying reason that high inflation is bad: it destroys money values and confidence in the price system. That is why the Bank of England's job is to hold inflation not at zero but at two per cent a year. deflation in Britain has become a real possibility. When inflation is high. they eventually respond by cutting production. Moderate inflation is useful. a moderate level helps oil the wheels of the economy. then your income will be sucked into the downward spiral.Japan was plagued by deflation in the Nineties and it caused havoc with its economy. it's their biggest fear.com) -. people buy now. Without lifting a finger. In Japan they call it 'price destruction'.

0 LO 95 Increases Competitiveness Single Payer healthcare benefits spillover.3% healthcare tax on payroll. Any Canadian can go to any doctor or hospital in the country. and we'd make so businesses more competitive with their foreign competitors and keep more jobs in the United States. Further savings occur because there is no longer a need for a health insurance component of automobile or home insurance.html[LO//AS] The Canadian system is a publicly funded insurance program where costs are controlled and both hospitals and doctors are private. such as private health insurance. Canadians are healthier and live longer than Americans. But this would be more than offset by the 10-15% of wages they'd no longer have to pay for health benefits. though under the current proposal they would pay an additional 3. to defend it vociferously.Single Payer 2. The benefits to competitiveness are obvious. and the costs for prescription drugs. competition has led to great redundancies in expensive equipment such as for CAT scans. The bankruptcy attorneys might not like it because over 50% of bankruptcies are due to health care costs.000 Americans who die prematurely because they have no health care at all. long-term care. there is no alternative program. This together with cost controls insures that everyone including the poor. employees changing jobs would no longer suffer delays and costs for COBRA. there are agreements among all provinces that provide for treatment of any Canadian citizen regardless of where the need occurs. Single payer healthcare decreases the cost of employees.htm Businesses would no longer provide health care. Wakeforest Law School Graduate and Lawyer. vision and dental.co. which often is picked up by the new employer. so will the 18. retired business owner and member of the Business Coalition for Single Payer Healthcare “Why should businesses support single-payer healthcare?” http://www. increasing business competitiveness and stopping outsourcing Lohman No Date Given Jack Loman. mental health. Estimates show that Canadians produce American cars for $700 less than Americans do because of the difference in the costs of providing health care to employees. but this would be offset by the elimination of co-pays. Effective planning eliminates duplication of facilities and expensive technology. Since there is a "single payer". And we'd improve the economy as families would have more money to spend on products and services.businesscoalition. Workers would also be taxed an additional 3.net/why_should_businesses.. We'd have a Cadillac system for the same 16% of GDP we are spending today. And it would be portable. The great success of their system causes almost all Canadian politicians. You’re A Jerk 95 . who use the same system. Preventive care to an entire population minimizes expensive care associated with undetected. The economic advantages of the Canadian system are multi-faceted. Canadian doctors make about one third less that American doctors and yet their satisfaction level is high because they have more time to practice medicine because paper work is minimized. Each province has its own system and its own unique way of funding it. There is less loss of productive labor due to absence and sickness and health care is much more practical and less expensive for companies to provide to employees. receives the same high quality care. untreated health problems. It is called single payer because there is only one "payer". doctor groups buy high technology equipment and then compete for selling these services. they are already covered. increasing competitiveness and decreasing the cost to make goods Robinson No Date Given Bruce Robinson. Canada has a much higher percentage of general practitioners and fewer specialists. they make sure it is funded adequately. More importantly.S.3%. but they'll survive. to which Canadians can turn for basic health care.boulder. In spite of this decentralized approach. In the U. “Canada's Single Payer Health Care System It's Worth a Look” http://bcn. There is very little litigation because there is no need for awards to cover future health care costs.us/health/healthwatch/canada. even conservatives. Since the wealthy as well as the middle income people have no alternative. it is easier to set up and adhere to budgetary limits. deductibles.

Single Payer 2.S. U. Economic Growth. Under Secretary for Technology. according to leading economists. of Commerce. Gary Bachula. NIST Director Ray Kammer will discuss the Institute's budget request. You’re A Jerk 96 . focusing primarily on the Office of the Under Secretary and the Office of Technology Policy (US/OTP). and the competitiveness of American companies. Technology is the single most important driver of economic growth. Dept. as we approach the new millennium. Prepared Testimony before the House Appropriations Committee. technology is playing an ever increasing role at home and around the world--in securing improvements in our standard of living.S. I Technological Leadership is Vital to U.0 LO 96 Competitiveness K2 Growth Competitiveness is key to economic growth. 3-11-1998. the economic security of our country. [Federal News Service. our quality of life. lexis] My testimony this morning will address the initiatives of the Technology Administration. Now. p. Jobs & Competitiveness Technology is the engine of economic growth. accounting for as much as 50 percent of the Nation's long-term growth.

Single Payer 2.0 LO 97 **Medicaid Reform** You’re A Jerk 97 .

You’re A Jerk 98 .thinkprogress. the large state role in Medicaid is extremely ill-advised.Single Payer 2. http://yglesias. acts as a macroeconomic stabilizer.0 LO 98 Federalize Medicaid Good Federalization of Medicaid increases quality of care.” Think Progress. gubernatorial concerns that Medicaid expansion will wreak devastation on state budgets. mandated increases in state-level Medicaid expenditures are pretty questionable policy. You’d also almost certainly get better health care coverage for poor people in most of the country. 7/20/09.” increasing burdens on state government just when the states can’t afford to spend money. So that’s obviously off the table for now. you’d see a much larger federal role in Medicaid and this would reduce the severity of recessions and in general reduce the need for contentious debates about stimulus bills. In general in the United States you get better “quality of government” at the federal than at the state level. associate editor @ Atlantic Monthly and TPM Media. but that the Senate legislation is less clear. it would “look like” a big increase in taxes and spending. But even though switching the financial responsibility from the state to the federal level wouldn’t involve any net change in the tax burden or the size of the public sector.php [JM] Kevin Sack and Robert Pear reporting for the New York Times raise a non-crazy worry about the health reform legislation before the congress. And in macroeconomic terms.org/archives/2009/07/medicaid-and-healthreform. Yglesias. Matt. and reduces severity of recessions. And certainly when you become very concerned with slightly arbitrary metrics like CBO scores across a 10-year window rather than with overall fiscal responsibility. But something to keep an eye on during the health reform debate is that while Medicaid expansion is good. “Medicaid and Health Reform. state Medicaid responsibilities tend to work as “automatic destabilizers. it creates incentives to craft legislation that shunts costs onto the states thus “hiding” them from the prying eyes of the scorekeepers. To the best of my knowledge. Better to have the federal government pick up the bulk of the tab for expansions. My go-to guy on Medicaid issues says the House bill handles this concern fairly well. In an ideal world.

bipartisan mismanagement of public employee health and retiree benefits. the existing framework no longer works.html As state and local medical expenditures cross the $300 billion mark. As my colleague Colleen Grogan suggests.0 LO 99 Medicaid Reform Needed Medicaid costs is the cause of state budget crisis’s Ezra Klein. delaying payment. underpaying providers. It’s all too plausible to devise scenarios in which state Medicaid programs end up bearing large unanticipated costs. The recent stimulus package suggests another useful path. Saddled with balanced-budget requirements and constrained tax bases. associate editor at The American Prospect. Suppose. we should recognize and embrace the fact that Medicaid has become a central pillar of the American welfare state. 7-19-2009.html Looking at these figures.com/ezra-klein/2009/06/guest_graph_the_future_of_medi. “Guest Graph: The Future of Medicaid” http://voices. In truth. that medical improvements gradually raise average lifespan of Alzheimer’s patients in long-term care. the federal government must carry an increasing share of the Medicaid burden . 7-19-2009. states have cut financial corners for decades. These fixes will help. but for millions of others. Yet painful measures are being taken in many other states. not only for poor people. Rising Medicaid expenditures undermine states’ ability to address other pressing needs. They face legal and institutional constraints on deficit financing and new taxes. The program has outgrown the financial and administrative capacity of state governments. health reform can also help by providing new forms of public or private coverage for low-income Americans who might otherwise require Medicaid. Properly designed.washingtonpost. too. States’ Medicaid problems have been building for decades. Until December 31. Federalized Medicaid solve long-term budget for states Ezra Klein. The impact of competing proposals for state finances has received less attention than it should. the federal government agreed to pay a higher matching rate to states that agreed to maintain Medicaid eligibility and benefits at roughly pre-recession levels. but they will not be enough. for example. dozens of states are cutting or constraining services at precisely the moment when these services are most needed to meet human needs and to stabilize local economies. we must recognize that the budget challenge is more than a nasty episode brought on by the current downturn. “Guest Graph: The Future of Medicaid” http://voices. associate editor at The American Prospect. The cuts seem most dramatic in California. 2010. Actuaries predict that state Medicaid expenditures will roughly double by 2017. They bear the consequences of their severe. One way or another. you might reasonably ask: Why are states complaining? The answer is: They lack the fiscal capacity to bear the load. The worst is yet to come.washingtonpost.Single Payer 2. States also bear readily-overlooked systemic risks. These subsidies should be enlarged and made permanent. You’re A Jerk 99 .com/ezra-klein/2009/06/guest_graph_the_future_of_medi. Yet another challenge of health reform. Or suppose that the firms which offer private long-term care policies run into trouble. in return for greater federal oversight over matters such as quality assurance and reimbursement. What can be done? First. failing to operate these programs with the skill and humanity that patients deserve.

But even though switching the financial responsibility from the state to the federal level wouldn’t involve any net change in the tax burden or the size of the public sector. Federal only Medicaid more effective than state and lessens state’s burdens Matthew Yglesias. mandated increases in state-level Medicaid expenditures are pretty questionable policy. But something to keep an eye on during the health reform debate is that while Medicaid expansion is good. “Let the States Fund Medicaid?”. gubernatorial concerns that Medicaid expansion will wreak devastation on state budgets. it creates incentives to craft legislation that shunts costs onto the states thus “hiding” them from the prying eyes of the scorekeepers. “Medicaid and Health Reform”. My go-to guy on Medicaid issues says the House bill handles this concern fairly well. You’re A Jerk 100 . So that’s obviously off the table for now. but it wouldn’t be congress or the executive branch doing the wasting.php Kevin Sack and Robert Pear reporting for the New York Times raise a non-crazy worry about the health reform legislation before the congress. which would be $10 billion less in demanddestroying budget cuts we'd have to make. Well. what form should it take? Matt Yglesias comments: In an ideal world at this point what I’d like to see is more aid to state and local governments.org/archives/2009/07/medicaid-and-health-reform. but that's probably OK. http://www. one quick way to do this might be to stop dinking around with alterations to the Medicaid funding formula (as the first stimulus bill did) and simply turn Medicaid into a purely federal program funded entirely with federal dollars.thinkprogress. it would “look like” a big increase in taxes and spending. state Medicaid responsibilities tend to work as “automatic destabilizers. and would allow structural shifts in the private sector to proceed apace.0 LO 100 Medicaid Reform Needed Medicaid should be funded solely by the federal government Kevin Drum. And in macroeconomic terms. you’d see a much larger federal role in Medicaid and this would reduce the severity of recessions and in general reduce the need for contentious debates about stimulus bills. Probably this should just be done in a very crude way — some flat per capita disbursement that could be implemented very rapidly at the federal level and kick specific decisions to someone else. You’d also almost certainly get better health care coverage for poor people in most of the country.” increasing burdens on state government just when the states can’t afford to spend money. rather than being a hodgepodge of 50 different plans. In general in the United States you get better “quality of government” at the federal than at the state level. 7-11-2009. That kind of thing would work quickly. 7-20-2009. the large state role in Medicaid is extremely ill-advised . so it’d be someone else’s problem. Some of the money would be wasted or used in bad ways. This would instantly save states something on the order of $100 billion or so. And certainly when you become very concerned with slightly arbitrary metrics like CBO scores across a 10-year window rather than with overall fiscal responsibility. Eventually this might lead to Medicaid becoming more standardized throughout the country. Maybe it's time to turn the entire program over to the feds so it's not constantly a procyclical drain on the economy and be done with it.Single Payer 2. we'd save a little over $10 billion. To the best of my knowledge. associate editor of The Atlantic Monthly. I'm not sure Medicaid has really been a great poster child for states as laboratories of democracy anyway.com/kevindrum/2009/07/let-feds-fund-medicaid If we need more stimulus. Here in California. but that the Senate legislation is less clear. staff writer for Mother Jones.motherjones. Better to have the federal government pick up the bulk of the tab for expansions. In an ideal world. http://yglesias. would be highly stimulative.

Despite these expenditures.Olin and Letsch. 1975). bureaucratic interference and the low status of the recipients (Holahan.5 billion. 1978). which can compensate for the low fees by generating enormous volumes of claims (Cromwell and Mitchell. 1981). more likely to have graduated from foreign medical schools and have fewer hospital accreditations (Yett. We argue that Medicaid can only be successfully restructured as part of a major reform of the entire American health care system. Volume 11. 1992. Medicaid eligibles have difficulty accessing care. are usually far lower than those allowed by private insurers and the Medicare program (Cromwell and Burstein. Held. total health care expenditures will rise from about 12 percent of GNP in 1990 to about 18 percent of GNP by the year 2000 (Burner.Single Payer 2.0 LO 101 Medicaid Reform Needed Medicaid reform sorely needed – failure to achieve its goals..The current program for providing the poor with health care coverage is part of the problem. “Medicaid’s Role in Moves Toward Universal Health Care. [Mardjuki] It is widely recognized that the United States spends far more on health care than any other nation but nevertheless fails to provide health coverage for many millions of its citizens. Associate at MHA. Access to physicians is also limited by the fact that many mainstream providers are reluctant to treat Medicaid recipients for a whole host of nonmonetary reasons: excessive paperwork. Volume 11. Others recognize the economic advantages of very large Medicaid practices. 1985).S. Ernst and Hay. 1980).” Policy Studies Review. Since its inception in 1966. De Alteriis. The Medical Assistance program (Medicaid) provides health services for around 20 million poor Americans. Despite the program's costs. 1984). Finally. as well as a number of other possibilities and permutations. Those physicians who do treat large Medicaid caseloads tend to be older. Cromwell and Mitchell. You’re A Jerk 101 . total costs for 1992 are projected to reach $129 billion (Burner et al. Many recipients have difficulty accessing care. 1992). between 30 and 40 million Americans do not have health coverage (Levit. [Mardjuki] Medicaid is very costly. it has been much criticized and its costs have soared. what they can obtain is often of poor quality. Kletke and Ncckerrnan. by 1990 total costs had reached $75 billion. Associate at MHA. the quality of care they receive is often poor. reported delays in payment. Preliminary data for 1991 suggest that total costs rose by more than 30 percent to $98 billion. While other OECD nations have successfully curbed health care inflation. Remedial measures that have already been tested are examined. 1992). When the program was initiated in 1966. 1987. costs are expected to rise still further in the U. There are geographic and demographic inequities in service provision. This paper considers the problems faced by the Medicaid program in the context of the problems faced by the American health care system. Waldo and McKusick. 1983). Most importantly. Martin. De Alteriis. 1992. we contend that the existing research tells us what should be done.” Policy Studies Review. According to the latest estimates. Holahan and Carlson. Martin. “Medicaid’s Role in Moves Toward Universal Health Care. Medicaid does not cover all poor individuals. Winter 1992. Medicaid expensive and ineffective – limited access to proper care. One study even found that a large proportion of private physicians refused to treat Medicaid recipients because of their ideological opposition to government involvement in health care provision (Sloan. Low fees have led to low physician participation rates (Perloff. One reason is that Medicaid fees for private physicians." They provide shorter visits and fewer physical examinations than mainstream medical practices (Mitchell and Cromwell. Even if Medicaid recipients are seen by private providers. even in the most generous states. Winter 1992. These large Medicaid practices are also known as "Medicaid mills. what we need now is the political will to act. total annual federal and state costs were $1. 1992). Some of these physicians attract scarcely any private patients. Der.

California and Wisconsin. Idaho and South Dakota..3 percent of Medicaid costs. over 80 percent of the poor received Medicaid coverage in Hawaii. Associate at MHA. Medicaid's funding levels for prenatal services until recently were very inadequate. In 1981. and the quality assurance mechanisms are poor (Alan Guttmacher Institute. [Mardjuki] There are major inequities in the way the states confer benefits and eligibility. while under 25 percent of the poor received Medicaid coverage in Wyoming. Private providers are unwilling to treat pregnant beneficiaries. 1988). Volume 11. All Medicaid programs must cover individuals receiving Supplementary Security Income (SS!) and Aid to Families with Dependent Children (AFDC>. 1985). You’re A Jerk 102 . “Medicaid’s Role in Moves Toward Universal Health Care. The infants of women without adequate prenatal care are twice as likely to need intensive care as the infants of women who do receive adequate prenatal care (Munninger. Michigan.Single Payer 2.S. Some recipients fare exceptionally badly. in the words of the United States General Accounting Office. whose numbers have risen steeply in recent years (from 2. 1987). 1988). The largest expenditures are for disabled 551 recipients. Another group that suffers greatly are individuals with developmental disabilities. Hurdle and Schurman. 1988). De Alteriis. There were also considerable differences in the number of services provided by the states. while AFDC children under the ages of 21 were responsible for only 12.” Policy Studies Review. Butler and Howard. "pervasive horizontal inequity-similar people in similar circumstances but in different states . some provided almost all the 32 services permitted by federal legislation while others provided little more than the minimum six mandated by federal legislation (Cromwell. treated unequally in terms of both Medicaid eligibility and generosity of benefits" (U. In 1987. 551 recipients' total costs soared from $3 billion to $17 billion (Howell. Infants born to Medicaid recipients have been very poorly served (Rosenbaum. 1989). 1987). Andrews and Gornick. 551 recipients were responsible for 73 percent of Medicaid costs.0 LO 102 Medicaid Reform Needed Patchwork state Medicaid programs must be rectified to correct inequal treatment of the impoverished. While AFDC recipients' per capita costs actually fell. Martin. Hughes. not all necessary services are covered by state programs. the total number of Medicaid eligibles has risen only moderately (by 6 percent).. Winter 1992. The result of all this is. 1992.4 million in 1975 to 3. General Accounting Office.3 million in 1987). Over the same period. Many are inappropriately institutionalized and denied access to appropriate care in their home communities (Smull.

” Policy Studies Review.0 LO 103 Medicaid Bad Public perception of Medicaid destroyed by years of fraud and criminal activity. criminal activity plagues the program. Finally. 1988).g. Rice and Labelle (1989) found that states' efforts to reduce Medicaid physician fees merely led to an increase in these sorts of practices by the physicians who remained in the program (but see Feldman and Sloan. such as pharmacies. Evans. de Alteri is. “Medicaid’s Role in Moves Toward Universal Health Care..Single Payer 2. Volume 11. 1988). some physicians perform tests or prescribe drugs that are not required. refer recipients to networks of specialists even though specialist care is not required and direct recipients to particular ancillary providers. In the worst scenarios. Many of the providers who do see Medicaid recipients appear to have target incomes (e. 1986). "phantom" providers. created by skillful con artists. increasing the stigma which deters both providers and eligibles. Major scandals inNew York state have involved pharmacists that supplied controlled substances to eligibles for "kickbacks.g. [Mardjuki] Medicaid is tainted by extensive fraud and abuse. You’re A Jerk 103 . in which they have an interest (U.S. De Alteriis. The bad publicity from a succession of scandals across the nation has damaged the Medicaid program. 1974) which they achieve-despite the low fees-through a variety of questionable practices." and podiatrists who colluded with shoe stores to prescribe ordinary sneakers as "prescription footwear" (c. Winter 1992. Associate at MHA. Congress. 1992. 1977). For example.. Martin. bilked Medicaid for millions of dollars of utterly nonexistent services (Cryta.

If health care is a basic right. more physicians will see private patients and fewer will see Medicaid eligibles. Martin. we also need to recognize the political realities of the day. most notably Medicaid. if it accepted that basic health care is a right. On the other hand. The health care industry is extremely powerful. The rhetoric in the 1992 presidential campaign focused primarily on cost containment so that middle Americans could be ensured adequate coverage and the budget deficit could be reduced. at their discretion. Volume 11. health care reform should focus on values and priorities. One package designed to increase Medicaid eligibility and control costs would make poverty the sole criterion for eligibility and rely on managed care to contain costs (Oberg and Polich. If we take this approach. block grant long-term care and change the federal funding formulas for acute-term care (Holahan and Cohen. Expanding health care coverage sometimes seemed to be a secondary concern.” Policy Studies Review. This is a mistake. You’re A Jerk 104 . director of Medical Health Administration. Volume 11. Winter 1992. Martin. then the federal government would be obliged to guarantee it. then the poor will always have limited access and an inferior quality of care. its reform will not threaten the private health care industry. we can also draw on research into the Medicare program and into other nations' public health care systems. such as increased or equalized coverage. even if they are discontent with the system as a whole. Government intervention is looked upon far less favorably in the United States than in Europe and Canada. The Medical Assistance program is greatly affected by the actions of other health care programs. major problems would remain unsolved. However.Single Payer 2. If health care is considered a benefit. Most privately insured Americans are content with their own health plan. Winter 1992. If a change in the Medicare program's reimbursement ra tes lowers hospital profit margins. [Mardjuki] Ultimately. the hospital will probably try to increase the number of Medicaid recipients they admit (or their lengths of stay in the hospital) to recoup the lost Medicare revenue. “Medicaid’s Role in Moves Toward Universal Health Care. there is a logic to starting with the reform of the Medicaid program. 1987). In the process. 1988). De Alteriis. As it is a government program. If the Medicaid inpatient rates are relatively high. Furthermore. we should include the following elements in our reforms. akin to life. director of Medical Health Administration. These reforms always have several desirable goals. Least politically contentious way of restructuring healthcare is by reforming Medicaid. If Medicaid inpatient rates are relatively low. While the proposals could lead to some improvements in Medicaid. Medicaid is a welfare benefit -not a right-to be granted by the states. “Medicaid’s Role in Moves Toward Universal Health Care. Medicaid must compete in a health care system run by market forces. make poverty the criterion for eligibility. so proposals to reform the nation's health care that do not fully consider Medicaid will have a less positive impact than they otherwise might.” Policy Studies Review. Bearing all that in mind. which would be nice to extend to every citizen but which we cannot afford to do. If health care is to be distributed by market principles. liberty and the pursuit of happiness. and take that route toward achieving our objectives. but they do not consider Medicaid reform in the context of radical reform of the American health care system. 1992. then widespread change is required. this will likely affect Medicaid recipients.0 LO 104 Reform Must Start With Medicaid Medicaid reform must be considered in the context of massive healthcare restructuring – Medicaid is the starting point of effective reform. If private insurers raise physicians' fees in a state. Consequently. 1992. horizontal inequities are not surprising. Only by changing these principles and combining Medicaid reforms with major structural reforms of American health care system can Medicaid's problems be solved. then reform of the American health care system might not benefit current Medicaid recipients and might not reach all of those now uninsured. A more radical package would divide the acute care and long-term care components of Medicaid. the nation's health care system could be transformed. we should start by reforming existing government programs. offering the lowest reimburse must be expected. We need to stress the moral and legal imperatives rather than the need to control costs if we are to implement policies that would involve a high degree of redistribution. [Mardjuki] Proposals for reform are usually combined into packages. For just as surely as Medicaid reform proposals that ignore the nation's health care system as whole will have limited success. Medicaid already covers a large proportion of the poor and uninsurable. We have a solid body of research specifically about Medicaid to guide us. hospitals will probably try to decrease the number of Medicaid recipients they admit (or their lengths of stay in the hospital) and attract more privately insured patients to compensate for the lost Medicare revenue. If affordable universal coverage is our goal. Most of Medicaid's problems can be traced to the principles which characterize the program. De Alteriis. As the payer of the last resort.

html 6-13-2003.org/about/Crossroads/06_13_03. given the perverse incentives that frequently drive behavior in health care. http://www. n117 That. in part. n115 The original hope was that Medicare would grow into universal health insurance. Other than that. Its universal coverage nature creates the ability to redistribute benefits to those who are neediest. has not been accomplished and for a variety of reasons . n114 Nor can it be the case that the public is satisfied because the major objectives of Medicare's designers' have all been achieved.do? docLinkInd=true&risb=21_T7030952640&format=GNBFI&sort=BOOLEAN&startDocNo=1&resultsUrlKey=29_T7030952644&cis b=22_T7030952643&treeMax=true&treeWidth=0&csi=7405&docNo=3 The claim that Medicare's "popularity" is not only "overwhelming" but "well deserved because the program has achieved all its designers' major objectives" n111 is [*240] clearly contestable.bring Medicare more in line with the structure of health care financing and delivery that is evolving to serve the non-Medicare population. that support mostly reflects relatively superficial understanding of Medicare's role in helping America's elderly with large medical expenses." n119 You’re A Jerk 105 . n116 Moreover. while the sick must remain in their existing plan in order to retain their physicians. n118 Since the claims are factually false. if the factual claims about politically relevant factors are questionable. my take-home lesson is that there are examples in the success of Medicare we can apply to other sectors of our population. not coverage only for the elderly. as Marilyn Moon and others have amply demonstrated. 3. Medicare was designed as a basic model for eventual spillover Theodore R. http://www. However.Single Payer 2. the government protects the rights of all beneficiaries to essential health care.and should . In a marketdriven economy. 2. The authors cite no evidence to support their claims about the breadth and depth of the public's views. 13th President of Johns Hopkins. the disabled. Moon argues somewhat convincingly that Medicare has been a success.com/us/lnacademic/results/docview/docview. private-sector health plans.0 LO 105 Medicare Spill Up A Medicare structure can be modeled on a larger scale Dr. Consider one claim where the grounds for objection are quite obvious: the assertion that "congressional reforms will . n113 To the extent Medicare is broadly popular.hopkinsmedicine. of course. is one of the major conclusions of the program's history we have sketched: the key objective of expansion has not been achieved. 2K. That. It has been argued that. Marmor and Gary J. the reformers anticipated that Medicare would largely remove financial fearfulness from the lives of older Americans facing sickness. Brody. McKissick. “Is Medicare Cost Effective?”. Medicare's cost effectiveness arises from the fact that it does not need to expend funds on marketing and sales-functions that are obligatory for the success of competitive. and those suffering from renal failure. “Medicare's Future: Fact. Professor of Public Policy and Management at Yale and Professor of Political Science at Yale.lexisnexis. some argue that the competitive model for health insurance has not been successful. It pools risk in order to share the burdens of health care among the healthy and the sick. the healthy can and will change health plans for savings of only a few dollars a month. injury and other medical burdens. that same work undercuts the easy connection between knowledge of the program (especially the extent to which objectives are understood to have been satisfied) and the support for the program. she stresses the importance of preserving three essential tenets of the program: 1. None of them are "straightforward" in the sense that reasonable analysts could not find grounds for questioning their normative plausibility or predictive accuracy. William R. Moreover. Such behaviors lead to asymmetric risk pools and cost inequities. the public is largely uninformed. so are the causal connections. Through Medicare. n112 While the work of Larry Jacobs and other public opinion scholars establishes that Medicare is broadly approved. While not necessarily denying that certain reforms might be needed. the "implications" drawn are equally suspect. Moreover. Fiction and Folly”. This was all sobering news to a market-driven entrepreneur such as yours truly.

'' says John Deeble. over the long haul it may prove the most rewarding. From the time the idea was first conceived. ''If you phased in the Australian system over eight years. health services fellow at Australian National University in Canberra.5 percent levy on gross income over A$ 10. and are expected to rise to 19 percent within five years. he says.000 (US$ 7. ''We had very tough political obstacles to get around. Medicare’s political sponsors accepted incremental steps that they believed would not detract from their ultimate goal. it would be foolish to focus on short-term strategies to the point of abandoning long-term aims. a conservative government scrapped the program and another liberal leadership started over with a new one. it took fifteen years of political struggle before federal health insurance for the elderly was adopted. the Australian health insurance system is only concerned with the monitoring of costs and ensuring that payments are made promptly. Hickey. and to begin a long-term political campaign to secure eventual enactment.'' says Peter Botsman. ''It's kept costs under pretty tight control. Botsman.'' he says. tends to prompt short-term visions and encourage impatience. You’re A Jerk 106 . in the US they were $ 95. Yet one clear option for reformers is to reject these pressures by agreeing on a single programmatic model and legislative goal. Australia went through a similar experience in the 1970s.'' Australia's 12-year-old universal health insurance system is funded by a flat 1. Costs have been consistently held to 8 percent of GDP. As with Medicare.'' And. who helped design the 1973 and 1984 programs. ''My message for the US is that you can have a single-payer system with choice. who has written a national health-insurance strategy for the US. The debate over Medicare is instructive. vice president @ Economic Policy Institute. with its individualistic focus and shifting coalitions. Hospital care is free. and the commitment to absorb defeat. says Lesley Russell. Australia's reform process took years. American politics. she notes. prof of law @ American University. not with the actual delivery of services. it might want to take a look down under. Pg 116-117. starting in 1972. ''And you can have a private hospital system and a private health insurance system coexisting alongside a dominant single payer. Robert and Roger. Phasing in means the plan saves hundreds of billions of dollars Foster 94 Catherine Foster.Single Payer 2. In the short run this may be a painful route. as are most physician visits. but it does not limit what doctors can charge. travels frequently to Washington to clarify misconceptions about the Australian system.0 LO 106 Slow Phase In Key – Medicare & Australia Prove Medicare creation proves – selection of single model and slow phase-in is only viable option. They closed down one state's [New South Wales] hospital system for seven months and refused to work.100) for singles. Costs are set by the government. 2001. Safety nets ensure that out-of-pocket spending is capped.'' Dr. manager of public affairs for the drug company Merck. It had a system similar to the present American system. That raises some conflict with doctors and with private hospitals. and cost containment that satisfies all consumers' needs about health care. The Next Agenda: Blueprint for a New Progressive Movement. Borosage. diversity. ''the US would save between US$ 891 billion and $ US3 trillion. pharmaceuticals are subsidized. executive director of The Evatt Foundation. time to build and maintain a coalition. but they never abandoned the campaign for Medicare. Staff writer of The Christian Science Monitor “Australians Offer US Tips on Health Care” lexis-nexis [LO//AS] AS the United States Congress wades deeper into the difficult debate over reforming the nation's health care. Medicare customers can choose their own physicians on a daily basis. as well as through general revenue. allaying US fears about a bloated and intrusive bureaucracy. Health care costs in the US account for 14 percent of GDP. Botsman says the cost comparisons alone are dramatic: Administrative costs in Australia in 1987 were US$ 19 per capita. Along the way. and faced the same difficult issues of reform. a liberal think tank here. this will require patience.'' Botsman says. Sharpe & Dohme. [Mardjuki] A related lesson is that although it may be necessary to respond to short-term political and economic constraints. Low-income earners and pensioners hold a health card that entitles them to additional services. ''The doctors managed to change the Constitution so they couldn't get conscripted into a national health service.

1992. the federal government should administer the public health plan. director of Medical Health Administration. It should improve the average public health care recipient's access to quality care and help control overall costs. state and local government be covered by the public plan. [Mardjuki] The starting point for our plan would be the merger of Medicaid and Medicare. If the uninsured were added to this program. De Alteriis. we might insist that all public servants (and their families) in federal. Private individuals and employers could buy into the program at any time.” Policy Studies Review. Volume 11. To set a good example. Winter 1992.0 LO 107 Medicare Subsume Medicaid? Successful healthcare reform requires Medicare to subsume Medicaid to slash costs through economics of scale. You’re A Jerk 107 . Federal control would also help ensure that the new program fully utilized the advantages of its large market share.Single Payer 2. the proportion of the total health care market covered by the new program would rise still further. The volume of business that could be granted to approved or preferred providers would increase the program's ability to negotiate with the health care industry. This would create a very large program that could use its market share to control costs and ensure access. To ensure that horizontal inequities are removed. “Medicaid’s Role in Moves Toward Universal Health Care. Martin.

Kaiser Family Foundation. Kaiser Commission on Medicaid and the Uninsured. • Most Medicaid enrollees receive care through private managed care plans that are designed to promote access to care. Extensive research shows that coverage is key to securing access to needed health care services. Health reform will not address all the gaps in the health care system that Medicaid now helps to fill such as providing long-term care and helping to sustain the health care safety-net and covering many of the supportive services that the chronically ill and disabled need. thus covering Medicaid enrollees in private coverage would be more costly. Washington. and provide stable financing by establishing a countercyclical financing mechanism during economic downturns. • Bolster Medicaid with broader efforts to contain costs across the health system (public and private) to help ensure long term sustainability. Henry J. This strong foundation will help to assure the success of larger health reform efforts.Single Payer 2. • Many low-income individuals do not have access to employer coverage and cannot afford or access private coverage through the individual market. You’re A Jerk 108 . As we move forward. Accounting for the health needs of its beneficiaries. Why build on Medicaid? Medicaid already serves 60 million Americans and provides a base of affordable and comprehensive coverage that is well suited for low-income and high-need populations. and Rudowitz ’09 (Diane Rowland. Medicaid also helps support community health centers and other safety-net providers in medically underserved areas. Washington. Rowland. develop strategies to expand the primary care workforce to provide better access to primary and preventive care. control costs and improve quality with shared responsibilities across employees. Medicaid plays an important role for some disadvantaged populations and the program has broad public support. DC. Kaiser Commission on Medicaid and the Uninsured. the Kaiser Commission on Medicaid and the Uninsured. • Medicaid has a well developed administrative structure in every state that has enabled it to be a cornerstone in federal and state efforts to expand coverage. Vice President. Kaiser Family Foundation. ScD. and promote better access by addressing payment rates to help boost provider participation. Deputy Director. “Medicaid As A Platform For a Broader Health Reform: Supporting High-Need and Low-Income Populations”) As debate on national health reform moves forward. government.0 LO 108 Medicaid Expansion Key Building upon Medicaid would be a great way to expand healthcare. and Robin Rudowitz Principal Policy Analyst. and many have significant health needs. Leading health reform proposals rely on a combination of public and private approaches to expand coverage. consumers and insurance markets. expanding coverage to the uninsured as well as addressing health care cost and quality issues have emerged as the dominant drivers for system reform. How can Medicaid be a stronger platform for health reform? • Expand Medicaid’s reach to more low income individuals by basing eligibility on income alone with federal minimum standards and making additional progress to increase participation rates. Medicaid offers a strong foundation on which broader health reforms can be built by providing coverage for the high-need and low-income populations and providing a vehicle to reach more low-income uninsured with affordable coverage. Executive Director. Barbara Lyons MPA. Lyons. and establish system-wide quality standards along with the implementation of health information technology to promote an efficient health care system based on positive outcomes. PhD. • Medicaid enrollees fare as well as the privately insured populations on important measures of access to primary care even though they are sicker and more disabled. 5-09. Kaiser Commission on Medicaid and the Uninsured. DC. • Provide adequate Medicaid financing by having the federal government assume the costs of expanding Medicaid coverage or by shifting some current Medicaid costs to the federal government. Washington. Medicaid is a low-cost program with lower per capita spending than private insurance. The costs of private health care and Medicare premiums are lessened by having Medicaid insure these highneed populations and provide key services not covered by private plans or Medicare. enhance quality and control costs. • Ensure that current and new enrollees receive Medicaid’s benefit and cost-sharing protections.620 for a family of three in 2009). employers. DC Co Chair. Executive Vice President. What problems do low-income individuals face in today’s health care system? • Two-thirds of the 45 million uninsured are low-income individuals (below 200% of the poverty level or $36.

Single Payer 2.0 LO 109 **SOLVENCY** You’re A Jerk 109 .

or $33. has testified that the legislation thus far has too little cost containment. Karen. with it." Medicaid has become the latest sticking-point issue in health reform because of the daunting challenge of how to cover those most likely to find themselves without health coverage. high-quality health-care system should look like — is cautioning on its blog that legislation under consideration in the House "misses the opportunity to help create higher quality.” Time Magazine. But a draft proposal by the Senate Finance Committee would have the feds paying the additional cost for only five years. 7/21/09. "Medicaid coverage for low-income adults could help establish a strong floor of coverage for the low-income population.1911856.Single Payer 2.00.html [JM] Douglas Elmendorf.com/time/politics/article/0.") What Congress is now considering is whether to make income alone the determinant of Medicaid coverage. Not Coverage.) The argument in favor of expanding Medicaid is largely one of efficiency." And even the Mayo Clinic — often cited by Obama as the model of what an efficient. after which the states would have to pick up their typical share of existing Medicaid costs. more affordable health care for patients. (Read "Cost. the disabled and those in need of nursing-home care. In fact. it will do the opposite. http://www.400 for an individual and $29.0 LO 110 Low-Income Uninsured Coverage Needed Low-income families form a disproportionate amount of the uninsured – successful health care reform provide them with coverage. “Medicaid and the States: Health-Care Reform’s Next Hurdle. Republicans are calling it a dangerous "experiment.200 for a family of four — account for about half the uninsured in this country. upon which additional expansion efforts could build. financing and administrative structure. The existing program "is designed to meet the needs of low-income individuals and those with complex health needs and has an existing delivery. which averages over 40%. which was established alongside Social Security in 1965 to cover low-income children." You’re A Jerk 110 . Low-income adults — those who earn under 200% of poverty. Under the current rules. many of them are not eligible for Medicaid. Tumulty. head of the Congressional Budget Office. it is difficult in some areas to find health-care providers who are willing to accept Medicaid patients.300 for a family of four — would be eligible. Already. all non-elderly people earning at or below 133% of poverty — about $14. national political correspondent. The Congressional Budget Office predicts that the House proposal would add 11 million to the Medicaid rolls. accounting for about a third of the estimated 40 million uninsured Americans who would gain health insurance under the proposal. the poor elderly.8599. (Watch a video on uninsured Americans. But there are real questions as to whether the program could handle the strain of that many new clients. Governors warn that unless they increase the amount that Medicaid reimburses doctors and hospitals — and. Drive Health-Care Debate. Under the health-reform bill now being considered by the House." says the nonpartisan Kaiser Family Foundation. Senators of both parties are trying to put the brakes on the President's drive to have bills passed by the House and Senate by the August recess. the cost of the program — the supply of providers will not come close to meeting the demand for medical services. their parents. The House bill would have the Federal Government pick up the entire cost for those newly covered under Medicaid — $438 billion over 10 years.time.

extends coverage. such as all children under 18. Children are relatively inexpensive to insure. [Mardjuki] A new single-payer system could be designed for the entire population. Expand Medicare and replace Medicaid. Expand Medicare to everyone. copayments and deductibles would be reduced for low-income persons. has fairly effective cost control mechanisms. this approach would not include the millions of uninsured who are noneligible for either Medicaid or Medicare. Rather than continuing two publicly funded health insurance programs. thus eliminating Medicaid. increase administrative efficiency. some states that provide more generous benefits might have difficulty reducing benefit levels and/or restricting eligibility.0 LO 111 Solvency – Medicare Based System Solves A healthcare system structured off of Medicare solves – relieves state budgets.Single Payer 2. Public universal coverage for children also would reduce employers' costs for family coverage and help expand employer-based insurance. which would decrease costly overutilization of emergency rooms by guaranteeing access to primary care. and low-income persons above the poverty line could buy into the program on an income-related sliding scale. This incremental approach would build on recent Medicaid expansions. especially states with historically narrow Medicaid eligibility and low serviceprovision levels. mandated Medicaid expansion could also be very costly for the states. 199-211. and public perception is one of a second-class system. Everyone living in families at or below 100% or 150% of the federal poverty level could automatically be included. RN and MSN @ Ball State University. Miller. “Health Care Reform: Clarifying the Concepts. Rather than including everyone. or persons of all ages with disabilities. Anna. Private insurance systems could insure for services not covered by this single public plan. special groups that now lack health insurance could be added to Medicare. and expand access to vulnerable populations. A Medicaid expansion could include mandatory enrollment in managed care through health maintenance organizations (HMOs) or Preferred Provider Organizations (PPOs). Expansion of existing public programs might be more politically acceptable than establishing completely new programs (Harrington. existing governmental health insurance programs could be modified and expanded to provide insurance coverage for specific population groups. Expand Medicaid.” Journal of Community Health Nursing. Changing Medicaid from a combined state-federal program to a federal program like Medicare would provide uniform eligibility and benefits across all states. Because states pay up to one half the Medicaid expenditures. The existing single-payer Medicare system could be expanded to include everyone. is highly popular with constituents. and well child care. Volume 4. low-income uninsured persons might not be able to afford to buy into the Medicaid program. Expand Medicare to special populations. Pgs. another incremental approach is to expand the present single-payer Medicare program to include low-income and uninsured persons. such as home-care waivers and expanded coverage for low-income pregnant women and children. This approach would relieve states of escalating Medicaid costs and allow states to focus on funding long-term care. by contrast. perinatal. Politically. and there would be no charge for most preventive services. adding preventive. 1990). Medicare. 1993. single adults. 1991). It also has the negative potential of increasing federal budget deficits. Adding children to Medicare would provide coverage for the 43010 of all children who now are uninsured (Friedman. Federalize Medicaid. Everyone would have a medical identification card (like a Medicare card). You’re A Jerk 111 . Low-income persons could be added to the existing federal-state Medicaid program. and cuts costs. and reports low administrative costs. benefits and eligibility vary greatly and contribute to high administrative costs. Medicaid expenditures have escalated more rapidly than other health care sectors. Alternatively. and their improved health brings societal benefits over many years. On the negative side. On the negative side. Adding low-income persons could provide work incentives for welfare recipients because becoming employed would no longer mean losing Medicaid benefits.

is a whole lot less than "next best?" The House plan is not set to go "live" until January of 2013. where the focus should have been from the start.com/node/29667). http://www. like the fact that we will have a presidential election in November of 2012. Why are we writing 1. So.1114455. how much more dire will things be in four years? What will the insurance companies be doing between now and 2013? How will they be positioning themselves to accommodate the changes that are coming? What will we see from them in the next 3 1/2 years that will signal they have even the slightest interest in improving our access to and delivery of actual health care? What this is really all about. by most accepted measures. Global Sourcing Finance Chief at GE Healthcare.0 LO 112 Squo Reform Fails – Need Single-Payer Only a single-payer system mitigates costs – Medicare proves. that we know works well and could be expanded or duplicated with relative ease and in a much shorter period of time? You’re A Jerk 112 . what will the millions of currently uninsured people do between now and 2013? And. “Why not singlepayer?” Baltimore Sun. Medicare.le. 7/20/09 Anne. you wondered if there's a political reason why the plan won't be fully operational until 2013. and millions of older Americans had been enrolled and were getting health care with hardly a hiccup. maybe." The question that her response prompts from me is. House Speaker Nancy Pelosi responded to one of the questions by saying. healthier than we are.baltimoresun.letters200jul20. creating a Rube Goldberg-ian system whose biggest benefit will be to insurance companies that have done nothing in the last several decades to improve the current system .0. with an economy in decline.com/news/opinion/readersrespond/baled. All of the major developed nations have some form of single-payer health care. wouldn't you wonder why it's going to take so long to get essential elements of this version of reform in place? Wouldn't you wonder why the elements that are designed to help the millions of uninsured are the ones that are going to take the longest to implement? Or. but our next best choice is to support an exchange and a public option. No. and their people are. not insurance. If I told you that in less than a year after the historic Medicare legislation was signed into law. "For 30 years I have supported a single-payer plan. thousands of people losing their jobs every month and losing their coverage. from all appearances. why are we giving up on the best solution and settling for something that. the program was up and running. Having a shiny new insurance policy will not help if the out-of-pocket costs are such that people still cannot afford to see the doctor or get the medications they need. or dropping coverage altogether.when we have a single-payer model. and it might not be good for the fortunes of the current president or the senators and representatives up for re-election if a new health care system is not going well or is not all it was advertised to be. Schoonmaker. Their spending per-person on health care is less than half what we spend here. that is not a typo.but a lot to assist the political careers of more than a few members of Congress who are crafting this "reform" (and making those who need accessible and affordable care the most wait the longest to get it) .Single Payer 2.story [Mardjuki] In a Q-and-A recently posted on the Web site Crooks & Liars (http://crooksandliars. is health care.000-plus-page bills. with more employers changing to plans that cover less and cost the individual more.

Firms like General Motors (GM) and Ford are crippled by the growing burden of health costs. and continue to grow rapidly . 11/07. Meanwhile. which add $1500 to the price of a GM car versus $419 for a German Mercedes and $97 for a Japanese Toyota [2]. Forty-five million Americans have no health insurance. Health care costs will reach $7498 per capita this year. But now. MD + MPH + Physicians for a National Health Program of Chicago. and Steffie Woolhandler.org/news/2008/may/our_health_care_syst. and Woolhandler.pnhp. MD. 50% higher than in any other nation. Governments face a double whammy: ever-expanding benefit costs for their employees (eg. Market pressures threaten medicine’s best traditions. The Department of Medicine at Cambridge Health Alliance/Harvard Medical School. resulting in more than 18. Opinion on solutions is more divided. low-wage employers like Wal-Mart gain competitive advantage by purchasing goods made overseas (where health benefit costs are low) and offering only the skimpiest of health coverage to their US workers. MD + MPH.Single Payer 2. Himmelstein. firemen. Tens of millions more have inadequate coverage. dept Medicine Harvard. You’re A Jerk 113 . “Our Health Care System at a Crossroads: Single Payer or Market Reform?” www.000 unnecessary deaths annually according to the Institute of Medicine [1]. the accelerating collapse of employment-based coverage under the pressure of globalization is reopening debate. and police) as well as sharply escalating costs for public programs such as Medicaid and Medicare. Discussion of health reform was muted in the 1990s after the defeat of President Clinton’s Byzantine scheme for universal coverage.0 LO 113 Squo HC Fails The Current Health Care System Sucks Himmelstein. ‘07 (David U. teachers. And bureaucracy overwhelms both doctors and patients.php) [LO//JW] Almost all agree that our health care system is dysfunctional.

Quickly doing the math.com/talk/blogs/jpieterick/2009/07/the-case-for-keeping-singe-pay. George Polk Award winner. as is the number of people needed to simply keep up with the myriad of different bookkeeping and other paper trails that are created. Eliminating all such highly paid executives could be expected to result in enormous savings without compromising so much as the availability of a single visit to a Doctor. Duplication of services is understood to be extensive and extremely wasteful. Joshua. almost without regard for how large that family might be.. there is an intuitive sense that a single administration overseeing a universal plan is surely far more efficient than a multitude of private corporations establishing their own bureaucracies to manage their own little corner of the comprehensive system that is required.talkingpointsmemo.to oversee a singular bureaucracy in charge of providing universal health care to all. To begin with.a government Administrator. yes. July 15. It was recently reported. the consumer reasons that simply removing this one executive from the equation for one year provides enough financial resources to provide lifetime health care coverage for themselves and their extended family. This CEO will be expected to earn in the neighborhood of $197. You’re A Jerk 114 . Multiples of $197k? Well. probably at the level of a Cabinet Secretary . chief reporter.Waste Single-payer reform more efficient . per provider. that Bill McGuire. These same consumers understand that it will take one CEO .6 billion during 2005. Marshall.” Talking Points Memo. American health care consumers have looked around at other industrialized nations and see single payer systems that are serving all their constituents at less cost per person than our present system. accumulated total compensation of $1. for example. Without even getting into the specific details of how these other programs work.000 (Highest rate now paid to any Cabinet Secretary) and will replace an untold number of private executives. generally as one whole system of paperwork and policies.Single Payer 2. http://tpmcafe.. “The case for keeping “single payer health care” off the table. the American health care consumer is able to determine intuitively that there are a number of ways in which a single payer plan can introduce efficiencies that result in real savings over present costs. former CEO of UnitedHealth Group. etc.S.eliminates duplicative bureaucracy.0 LO 114 Single Payer Solves . 2009.php?ref=reccafe [Mardjuki] Having first identified health care reform as a critical issue confronting the U. each making multiples of this salary.

more than $350 billion per year.org/facts/single_payer_resources. Health facilities and expensive equipment purchases would be managed by regional health planning boards.0 LO 115 Single Payer Solves – Waste & Patchwork Single Payer solves – eliminates patchwork systems of administrative waste.Single Payer 2. reproductive health care. prescription drug and medical supply costs. Combined. Costs would be controlled through negotiated fees. mental health. Physicians would be paid fee-for-service according to a negotiated formulary or receive salary from a hospital or nonprofit HMO / group practice. including: doctor. The potential savings on paperwork.pnhp. hospital. Doctors and hospitals must maintain costly administrative staffs to deal with the bureaucracy.” http://www. dental. You’re A Jerk 115 . vision. Patients would regain free choice of doctor and hospital. preventive. Single-payer financing is the only way to recapture this wasted money. this needless administration consumes one-third (31 percent) of Americans’ health dollars. global budgeting and bulk purchasing. and doctors would regain autonomy over patient care. long-term care. all Americans would be covered for all medically necessary services. Under a single-payer system. PNHP 2009. underwriting. Hospitals would receive a global budget for operating expenses. Private insurers necessarily waste health dollars on things that have nothing to do with care: overhead. [Mardjuki] “Single Payer Resources. are enough to provide comprehensive coverage to everyone without paying any more than we already do. A single-payer system would be financed by eliminating private insurers and recapturing their administrative waste. Modest new taxes would replace premiums and out-of-pocket payments currently paid by individuals and business.php The reason we spend more and get less than the rest of the world is because we have a patchwork system of for-profit payers. sales and marketing departments as well as huge profits and exorbitant executive pay. Physicians For A National Health Program. billing.

A few frills -. But taxes would probably have to be even higher. this freedom is increasingly being constrained. It would grant every legal U. 82 lexis-nexis [LO//AS] LESS OVERHEAD. mental-health treatment. the government would pick up the entire tab for covered procedures.Single Payer 2.such as private hospital rooms -.S. Thanks to the paperwork and complexity of private insurance. "Single-payer provides the best assurances that patients would be able to seek care from any doctor of their choice. Even so. You’re A Jerk 116 . the savings would amount to about $ 1. But single-payer will do the most to eliminate much of the bureaucracy that has become the plague of American medicine. But most managed-care plans also limit doctors' income. chairman of the American College of Surgeons. McDermott would finance all this with stiff federal tax increases.enough to provide coverage for 40 million uninsured Americans. while many of the alternatives would continue to leave millions uninsured. In addition. McDermott would increase the federal cigarette tax to $ 2 a pack from 24 and impose a new 50% excise tax on handguns and ammunition. the U. ranks below many of these nations in life expectancy and infant mortality. some 24% of the nation's health-care spending now goes to administration.S. Under the leading single-payer proposal. sponsored by Representative Jim McDermott (D-Wash. business.S. the U. Businesses with more than 75 workers and wages averaging more than $ 24. As in Canada. Japan. Smaller businesses would pay 4%. effectively capping their income. while individuals would pay 2. single-payer offers equally compelling advantages. and long-term nursing-home care. since under single-payer the states would negotiate fee schedules with physicians. Symonds director of the Forgotten Half Project education program at Harvard “WHITHER A HEALTH-CARE SOLUTION? OH. By combining huge administrative savings with caps on national health spending. or the European Community. Pg.S.would not be covered. which would be offset by a steep decline in insurance premiums.) and 92 other House Democrats. For U. the government would become responsible for virtually all medical bills. Yet the CBO estimates that the single-payer system would trim overhead by up to $ 100 billion a year -. CANADA” Business Week SOCIAL ISSUES. Critics challenge some of McDermott's projections.000 per employee would face an 8." says Dr.1%. compared with only 11% in Canada. David Murray. The difference is that under single-payer. 75% of Americans would pay less than they do now for coverage. Number 3363. will devote 14% of gross national product to health care: at least 40% more than Canada. the single-payer approach has the potential in the long run to cut spending more than any other plan.4% payroll tax. No other plan is as generous. That group's stand shocks many observers. physicians would have more freedom to order necessary medical services without the constant second-guessing and micromanagement of managed care. Single-payer would also allow consumers to choose a doctor without paying higher premiums or extra charges for this fundamental privilege. McDermott estimates. This year.0 LO 116 Single Payer Solves – Bureaucracy Less overhead costs and decreased bureaucratic costs of $100 billion a year mean that the plan makes single-payer cheaper and more effective Symonds 94 William C.000 a year per family. By 2003. resident full coverage starting in 1997. For consumers. the predominant concern should be controlling runaway spending on health care. including prescription drugs. Ultimately. Thanks to the proliferation of managed-care plans.

Editor of New England Journal of Medicine. receiving a budget from the NHI to cover all operating costs. A National Health Insurance Program is the only affordable option for universal. Quentin Young.often rules designed to avoid payment. A National Health Insurance Program would save at least $150 billion annually by eliminating the high overhead and profits of the private. investor-owned insurance industry and reducing spending for marketing and other satellite services.org/single_payer_resources/proposal_of_the_physicians_working_group_for_singlepayer_national_health_insurance .the creation of a comprehensive National Health Insurance (NHI) Program. Ron Anderson. “Proposal of the Physicians’ Working Group for single-Payer National Health Insurance. Christine Cassell. Doctors and hospitals would be freed from the concomitant burdens and expenses of paperwork created by having to deal with multiple insurers with different rules . NHI would make it possible to set and enforce overall spending limits for the health care system. Commissioner of Baltimore City Health. Senior Lecturer @ Harvard Medical School. Such a program . American Academy of Pediatrics. Investor-owned facilities would be converted to notfor-profit status. and reducing costs inevitably means limiting access. and their former owners compensated for past investments. President of American College of Physicians. It would squeeze out bureaucratic waste and eliminate the perverse incentives that threaten the quality of care and the ethical foundations of medicine. Most hospitals and clinics would remain privately owned and operated. Angell. CEO Parkland Health System. You’re A Jerk 117 . Under the current system. During the transition to an NHI. expanding access to health care inevitably means increasing costs.would cover every American for all necessary medical care. http://www. 2009. MD.” Physicians For A National Health Program.php [Mardjuki] We endorse a fundamental change in America’s health care .which in essence would be an expanded and improved version of Medicare . Physicians could continue to practice on a feefor-service basis. slowing cost growth over the long run. Joel Alpert.pnhp. Peter Beilenson. But an NHI could both expand access and reduce costs. Marcia. American Public Health Association. the savings on administration and profits would fully offset the costs of expanded and improved coverage.0 LO 117 Single Payer Solves – Medical Consensus Medical community consensus – only single payer system solves. hospitals or clinics. or receive salaries from group practices. comprehensive coverage.Single Payer 2.

ous. Borosage. lt has brought a decent level of medical care to the country’s citizens and consumes 40 percent less of the an. however. Universal health insurance has been for most Canadians the coun. system. Robert and Roger.“ The appeal of such an approach is obvi. coverage that protects Canadians whether they are in their home province or not). for whom. public administration (for accountability). ln fact.mented and hence less accountable decisionmaking process in the United States. featuring constant claims Canada's doctors and other medical occupations that "crises' are imminent or in full bloom. There is continuous discussion about how much to spend. The trouble with the term.S. on what. and under what nnles of fairness of access or financing. no deductibles or co. accessible terms (that is. Hickey.try`s postwar public triumph. You’re A Jerk 118 . The necessary consequence of Canada’s methods of financing and cost-control-paying for medical care from each provincial budget. and portability (that is.ally want. There. The Next Agenda: Blueprint for a New Progressive Movement. comprehensive pub. setting budgets for hospitals.insurance payments). Canada°s Medicare system is more cost·efficient and more easily un-derstood than other altematives. Medicare itself is a single-payer plan in the sense that the insurance funds that pay for Medicare’s benefits are in a single program. Pg 114.lic health insurance program is Canada’s Medicare.0 LO 118 Single Payer Solves – Dem Accountability Canada proves – single payer system ensures democratic accountability. is that it inadequately describes what most people who call for a single·payer plan re. There is also a democratic accountability that is truly astonishing when compared to the enormously frag. prof of law @ American University. vice president @ Economic Policy Institute. 2001. A necessary corollary is constant media attention to Canada’s "sing]e-payer" program. [Mardjuki] The final option we want to discuss is what are conventionally referred to as “single·payer" plans—the model of choice for many reformers since the early 1980s. the governing legislation prescribes broad physician and hospital coverage (“comprehensive care").nual national income than is consumed by medical care in the United States. and it places far fewer constraints on professional autonomy and patient choice than is the case within the current U.Single Payer 2. and limiting what doctors and drug firms can charge—is ongoing controversy. The dominant model of a single-payer.

g. You’re A Jerk 119 . school-based smoking prevention programs) whose costs are difficult to attribute (and bill) to individual patients. or via computer. Selective enrollment policies would be prohibited and patients would be permitted to disenroll with appropriate notice. a feature essential for minimizing entrepreneurial incentives. Regulation of payment for capital and profits would be similar to that for hospitals. Continuity of care would no longer be disrupted as patients’ insurance coverage changes due to retirement or job change. Physician payment would cover only the work of physicians and their support staff. Ron Anderson.pnhp. American Public Health Association. and financial incentives based on the utilization or expense of care would be prohibited. for cosmetic surgery). The proposed pluralistic approach to delivery would avoid unnecessary disruption of current practice arrangements. Canada. expenditures for program administration and reimbursement bureaucracy might be restricted to three percent of total costs. 3.0 LO 119 Single Payer Solves – Fair Wages Single payer structure allows for fair practitioner compensation. while providing a predictable and stable financial support. containing costs and facilitating health planning. and several European nations have developed successful mechanisms for reconciling the inflationary potential of fee-for-service practice with cost containment. and salaried positions within group practices or HMOs receiving capitation payments. and would receive extra payment for any bill not paid within 30 days.Salaries within institutions receiving global budgets: Institutions such as hospitals.eg. group practices. Physicians accepting payment from the NHI could bill patients directly only for uncovered services (e.” Physicians For A National Health Program. All three proposed options would uncouple capital purchases and institutional profits from physician payment and other operating costs. The fee-for-service option would greatly reduce physicians’ office overhead by simplifying billing.S. physician. The capitation premium would not cover inpatient services (except physician care) which would be included in hospital global budgets. “Proposal of the Physicians’ Working Group for single-Payer National Health Insurance. MD. These regulatory options are not difficult (and have not required extensive bureaucracy) when all payment comes from a single source. Such funding could also stimulate the development of community prevention (eg. CEO Parkland Health System. 1. monitoring for extreme practice patterns. and medical home care. migrant clinics. and other institutions could elect to be paid capitation premiums to cover all outpatient. Angell. Physicians employed in such institutions would be salaried. excluding most current HMOs and some practice management firms that contract for services but don’t own or operate any clinical facilities. health centers. salaried positions in institutions receiving global budgets. Similar measures might be needed in the U. The negotiation process and regulations regarding capital payment and profits would be similar to those for inpatient hospital services. Editor of New England Journal of Medicine. Incentives for capitated providers to skimp on care would be minimized since unused operating funds could not be diverted to profits or capital investments. binding fee schedule.Salaries within capitated groups: HMOs. Christine Cassell. Commissioner of Baltimore City Health. group practices. and would exclude reimbursement for costly office-based capital expenditures for such items as MRI scanners. These include: limiting the supply of physicians. and even capping individual physicians’ reimbursement. Global budgets for institutional providers would eliminate billing. There might also be a concomitant cap on spending for the regulatory apparatus .org/single_payer_resources/proposal_of_the_physicians_working_group_for_singlepayer_national_health_insurance . Joel Alpert.php [Mardjuki] The NHI would include three payment options for physicians and other practitioners: fee-for-service. American Academy of Pediatrics. and home care agencies could elect to be paid a global budget for the delivery of care as well as for education and prevention programs. Investor-owned HMOs and group practices would be converted to not-for-profit status. setting overall limits on regional spending for physicians’ services (thus relying on the profession to “police” itself).Single Payer 2. Peter Beilenson.Fee-for-service: The NHI and representatives of the fee-forservice practitioners (perhaps state medical societies) would negotiate a simplified. Only institutions that actually deliver care could receive NHI payments. 2. HMOs would pay physicians a salary. Quentin Young. http://www. 2009. Marcia. Physicians would submit bills to the NHI on a simple form. Senior Lecturer @ Harvard Medical School. President of American College of Physicians.

“Proposal of the Physicians’ Working Group for single-Payer National Health Insurance. and ameliorate financial pressures that skew drug development. assure that the fruits of publicly funded drug research are not appropriated for private profit. Quentin Young. Angell. minimize medication errors. Australia) have resulted in substantial savings. Joel Alpert. Similar programs in the U. Editor of New England Journal of Medicine. based on a national formulary.0 LO 120 Single Payer Solves – Drug Costs Single payer system lowers drug costs – pressure on big pharma. the formulary would specify use of the lowest cost medication. President of American College of Physicians.S.Single Payer 2.” Physicians For A National Health Program. American Academy of Pediatrics. based on their costs (excluding marketing or lobbying). Senior Lecturer @ Harvard Medical School.org/single_payer_resources/proposal_of_the_physicians_working_group_for_singlepayer_national_health_insurance . curtail pharmaceutical marketing. The NHI would negotiate drug and equipment prices with manufacturers. Where therapeutically equivalent drugs are available. NHI could simultaneously address two pressing needs: (1) providing all Americans with full coverage for necessary drugs and supplies. upgrade monitoring of drug safety. the NHI could exert substantial pressure on pharmaceutical companies to lower prices. and (2) containing drug costs. Marcia. American Public Health Association. Ron Anderson.php [Mardjuki] NHI would pay for all medically necessary prescription drugs and medical supplies. You’re A Jerk 120 . http://www. Commissioner of Baltimore City Health. 2009. Peter Beilenson. and in other nations (e. Additional reforms are urgently needed to: improve prescribing practices. Christine Cassell.g. An expert panel would establish and regularly update the formulary. CEO Parkland Health System.pnhp. Suppliers would bill the NHI directly (for the negotiated wholesale price plus a reasonable dispensing fee) for any item in the formulary that is prescribed by a licensed practitioner. As a monopsony purchaser. with exceptions available in case of medical necessity. MD.

Physicians could concentrate on medicine. but physicians could increase their incomes only by working harder. and sending the slip (or electronic equivalent) to the physician payment board. nor by bureaucratic dictum. 2009. Billing would involve imprinting the patient’s NHI card onto a slip. every patient would be fully insured. Nurses and other personnel would enjoy a more humane and efficient clinical milieu. Angell. Salaried practitioners would be insulated from the financial consequences of clinical decisions. American Academy of Pediatrics. Marcia. Since savings on patient care could no longer be used for institutional expansion or profits.would be limited.php [Mardjuki] Physicians would have a free choice of practice settings. Christine Cassell.0 LO 121 Single Payer Solves . You’re A Jerk 121 . MD. http://www. obviating the need for the kind of detailed administrative oversight characteristic of current practice. American Public Health Association. Commissioner of Baltimore City Health. The entrepreneurial aspects of medicine . Treatment would no longer be constrained by the patient’s insurance status. Ron Anderson.the problems as well as the possibilities . “Proposal of the Physicians’ Working Group for single-Payer National Health Insurance. This simplification of billing would save each practitioner thousands of dollars annually in office expense. Fee-for-service practitioners would be paid promptly. CEO Parkland Health System.” Physicians For A National Health Program. Costs would be contained by controlling overall spending and limiting entrepreneurial incentives. The burdens of paperwork associated with billing would be lightened. Bureaucratic interference in clinical decision making would sharply diminish.org/single_payer_resources/proposal_of_the_physicians_working_group_for_singlepayer_national_health_insurance . Quentin Young. President of American College of Physicians. checking a box indicating the complexity of the encounter. Peter Beilenson.Physicians No discentive for physicians – decreased bureaucratic hoops and paperwork. Senior Lecturer @ Harvard Medical School. pressure to skimp on care would be minimized.pnhp.Single Payer 2. Joel Alpert. Editor of New England Journal of Medicine.

campusprogress. Our futures deserve better. This is paramount because patients need the best healthcare. You’re A Jerk 122 . The most significant omission in the leaked health care reform legislation from the Senate Finance Committee is the absence of the public option . Nothing could be further from the truth. bloated by advertising. “A Market for Compassion: Single-Payer Health Insurance”. 9-5-2008. However. if single-payer health care were on the table it would be the more progressive plan to fight for. Co-ops are a weak alternative to the public plan and have been tried before.” This is unacceptable. but private providers will continue to deliver care. and executive compensation.pubmedcentral. not the best middlemen to pay for it. and all we can say is “well it’s better than nothing. A single-payer system will harness the market's strengths while addressing its limitations. and seemed to quickly latch onto the co-op idea as means to having it both ways. is a scheme for health care “co-ops” that would pool individuals and businesses together into consumer co-operatives to purchase health insurance and services. affordable health care for all.[2] But they worry that it lacks the spirit of the American market. The private health insurance market is inefficient.gov/articlerender. providers are insulated from competition because private insurers often restrict coverage to select physicians. Healthcare bill alternative plans weak compared to single payer Campus Progress.) Baucus [Chairman of the Senate Finance Committee] has been talking out of both sides of his mouth on the public plan for some time. In its place is the co-op proposal.0 LO 122 Single Payer Solves –Efficient Single payer most efficient option for federal plan Prajwal Ciryamv. the government will fund health insurance. http://www. concede that single-payer insurance is probably our most efficient option. A single-payer system will give all consumers the power of choice and open all healthcare providers to the effects of consumer decisions. consumers can create competition among healthcare providers. part of the Center for American Progress for college students. However. Many Americans. but are instead releasing watered-down bills. http://fundingourfuture. why not single-payer health care? Yes. Currently. Single-payer works because of the efficiency of specialization .Dakota). (Kaiser Health News has profiled one existing co-op in Seattle. In addition.fcgi?artid=2580082 In a single-payer system. along with many other health care reform supporters. duplicated bureaucracies. after the Great Depression.N. “A ‘Better than Nothing’ Future”. the 47 million uninsured Americans[3] have little impact on the market.org/tag/single-payer-health-care/ Nothing is what some of these proposals seem to offer. and slated for further discussion.Single Payer 2. drenched in industry money and influence. Economies of scale will save the money to make this possible. 7-19-2009. We can’t afford weak alternatives. and failed. What's worse. Campus Progress. dividends. Mother Jones does a good job of summing up the ugly compromise: What is in the Finance Committee’s draft. MD/PhD from Northwestern University. insurance policies are so complex and individuals' future needs so unpredictable that consumers cannot make the informed selections that induce competition between insurers. The government will manage the paperwork and private entities will provide the care. including Democratic presidential nominee Barack Obama. For example. introduced by Senator Conrad (D. has been advocating for the public health insurance option that will provide quality. Adam Smith would be proud. Congress should be writing the strongest proposals possible.nih.

June 10. You’re A Jerk 123 . As long as health care is a priority for our nation. but that is because they spend 60% and 33% less than we do on health care. 6-10-09 (John Conyers. we can afford to provide true universal health care with the $2. US Representative on the Subcommittee on Health. Labor. Steffie Woolhandler of Harvard Medical School.Single Payer 2. woman. Employment. The facts show otherwise. It is true that Canada and the United Kingdom have had waits for elective procedures. implementing a single-payer system with non-profit delivery would save approximately $300 billion dollars per year and contain long. Waiting lines do not exist in countries that adequately fund national health care. US rep. this problem will never materialize.term costs. 2009. Another argument utilized by those skeptical of single-payer reform is that we cannot afford a single-payer system where we insure every man.5 trillion we already spend each year. Lexis Nexis) [LO//JW] Opponents of single-payer argue that scarcity of care and long waiting lines will inevitably occur in universal singlepayer systems. Congressional Testimony. according Dr. If we deliberately hold down costs with a cohesive and efficient public-private partnership.0 LO 123 Single Payer Solves –Efficient Despite concerns. Waiting lines exist when government invests too little in the medical professionals and equipment that make up our health care infrastructure. Jr.. and Pensions. In fact. single-payer health care assures coverage and timely access to care Conyers. and child in the United States.

Additionally. Yet. Taiwan proves Conyers. Only a single payer health care system for all solves. Lexis Nexis) [LO//JW] I would like to caution the committee about the dangers of enacting partial reforms that leave some individuals uninsured. Governor Deval Patrick has been forced to cut money from safety-net providers such as public hospitals and community clinics. Congressional Testimony. This argument was initially raised when Medicare was debated in The the Congress in the 1960s. In fiscal year 2009. Until 1995. 6-10-09 (John Conyers. 2009. 2009. has minimal financial barriers to care. Employment. Jr.3 billion dollars. Over the course of the next six years.sanctioned monopoly for an industry that has left thousands of state residents without health insurance due to escalating premiums. without the cost-containment measures that are integral parts of any public insurance plan. Medicare was enacted in 1965 and fully implemented in 1966. and Pensions. health care spending has exploded in Massachusetts. Massachusetts proves Conyers. Congressional Testimony. We have heard this argument before. and deductibles. As a result. US rep. The Massachusetts reform effort has failed to contain costs and provide universal coverage because it is built around our broken for-profit private insurance system. You’re A Jerk 124 .. The best example of such a legislative failure is the Massachusetts Health Reform Act. while only spending 2 percent on administrative costs. Labor. the country seamlessly transitioned to a single-payer national health insurance system. June 10. Jr. and do little to contain the out of control growth of health expenditures. US Representative on the Subcommittee on Health. Lexis Nexis) [LO//JW] naysayers will also argue that dismantling our employer-based health care system is politically and economically untenable. If the goal of reform is to limit costs and improve access to care. Taiwan had a private health insurance market remarkably similar to our own. and maximizes value for patients . Labor. functions without a profit motive. co-pays. private insurance giveaway pursued in Massachusetts. Employment. the reform cost taxpayers $1.. Today. Instead of pursuing a reform strategy that has been successful in developed nations around the world namely. the experience of the nation of Taiwan shows that such a transition is feasible. has low administrative costs. their system boasts a 70 percent approval rating from doctors and patients. enacted by that state's legislature in 2006. 6-10-09 (John Conyers.0 LO 124 Single Payer Solves –Empirics A shift to single-payer from privatized health care is possible. and Pensions. improving access to health insurance that emphasizes prevention. June 10.lawmakers in Massachusetts instead created a government. Not surprisingly. US rep. grow the ranks of the underinsured.Single Payer 2. I would respectfully submit that single-payer offers a far better model for reform than the incremental. US Representative on the Subcommittee on Health.

The majority of the uninsured (52%) say the main reason they don’t have health insurance is because it is too expensive and the next most common reason they give is not being eligible for their job’s health benefits (11%). parents of dependent children. then parents of dependent children last (though this varies by state). even at the very lowest income levels. regardless of how young they are. * receive an offer of insurance.amsa. Medicaid eligibility is based on a combination of income and population “category. Department of Health and Human Services 05 U. with one-in-ten (11%) uninsured above 500% FPL. While the income distribution of the uninsured is skewed toward those with lower incomes. and * be able to afford an offer of coverage.8 million uninsured are more likely to be poor and low income than higher income.org%2Fuhc %2FMythsAboutUninsured.(3) That the uninsured are concentrated among lower-income individuals is not surprising. and the elderly. with coverage of children and pregnant women being available at higher income levels.google.hhs. Data from employers shows that average single coverage premiums for employer sponsored insurance represent 2. the disabled.S.0 LO 125 Uninsured Impoverished Most people are uninsured because of low income Kaiser Communication on Medicaid and the Uninsured No Date Given Kaiser Communication on Medicaid and the Uninsured “Myths about the Uninsured” http://docs. The income levels at which these groups qualify differs from state to state. Not all low-income individuals are eligible for Medicaid. Childless adults who are not disabled or elderly rarely qualify for Medicaid .pdf+uninsured+americans+income&hl=en&gl=us&pli=1 The majority of uninsured.gov/health/reports/05/uninsuredcps/index. You’re A Jerk 125 .0% of income at 300% FPL. pregnant women. Figure 2 shows that over half of the uninsured are below 200% of poverty. Those with incomes above 300% of poverty should generally find employer insurance affordable. not because they don’t need it. say they forgo coverage because they cannot afford it.” The population groups that qualify for Medicaid are generally children. and group to group.Single Payer 2. given that low-income individuals are less likely to: * be working.(4) That the uninsured comprise non-trivial percentages of middle and upper income individuals is surprising.7% of income for a family of four at 300% FPL (with a higher percentage for smaller families). followed by the disabled and elderly. with 25% below the poverty line and 28% between 100% and 199% of poverty. Uninsured people are more likely to have low incomes U. Only 7% of the uninsured report the main reason they lack insurance is because they don’t think they need it. Figure 2 shows 27% of the uninsured have incomes above 300% of poverty.htm#income The 45. and average family coverage premiums represent 4. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation “Overview of the Uninsured in the United States: An analysis of the 2005 Current Population Survey” http://aspe.S.com/gview?a=v&q=cache %3AUSbyK8FNL18J%3Awww. and if they do work they are less likely to be working full time.

Poverty's impact is felt most by the nation's children. Poor Health. Uninsured children are at greater risk of experiencing health problems such as obesity.health/index.html) [LO//JW] As financially strapped families struggle to cover basic needs such as food. the CDC said.Single Payer 2. The prevailing thought is that the problem needs to be addressed. and generally lead less-healthy lifestyles. Woolf said.S. The prevalence of these illnesses does not bode well for future generations. associate producer with the CNN Medical Unit. CNN. individuals tend to be more stressed.as salaries drop. More than half remained uninsured specifically because they simply couldn't afford it. 9/4/06. the economic consequence to everybody. Centers for Disease Control and Prevention found more than 40 million people of all ages went without insurance at some point in 2005. health insurance often takes a back seat on the list of priorities. "These people are going to develop diseases at a higher rate and the health care system is going to feel the brunt of it.0 LO 126 Uninsured are Poor Poverty. heart disease and asthma that continue to affect them later in adulthood. A National Health Survey conducted by the U. and quickly. he said.cnn. Research consistently highlights the negative link between reduced income and worsening health -. to all Americans and all taxpayers. researchers say they hope policies can be put into place that will keep Americans from living under such difficult conditions in the wealthiest country in the world." Woolf said. shelter and the increasing cost of energy.com. “Poverty and Poor Health are Intertwined. By making the public more aware of the direction the economy is taking. and Lack of Health Care Are Intertwined CNN ‘06 (Sabriya Rice." Woolf said. Experts Say” http://www. "If we amplify the scale by the results of poverty left to run loose.com/2006/HEALTH/08/29/poverty. Children under the age of 5 are more likely to live in extreme poverty. will be substantial. You’re A Jerk 126 .

http://www. Marcia.pnhp. Editor of New England Journal of Medicine.” Physicians For A National Health Program. Senior Lecturer @ Harvard Medical School. since it would eliminate excess administrative costs.php [Mardjuki] Myth #1 is that we can’t afford a national health care system. It makes more sense to pay just once. profits. we will have to ration care. cost-shifting and unnecessary duplication. and if we try it. taxes at all levels of government. A single-payer system would be far more efficient. Furthermore. it would permit the establishment of an overall budget and the fair and rational distribution of resources. MD.Single Payer 2.0 LO 127 A2: High Cost Single payer more cost effective Angell. We should remember that we now pay for health care in multiple ways — through our paychecks. “Statement of Dr. My answer is that we can’t afford not to have a national health care system. and out-of-pocket. the prices of goods and services. 2009.org/facts/statement_of_dr_marcia_angell_introducing_the_us_national_health_insurance_act. Marcia Angell introducing the US National Health Insurance Act. You’re A Jerk 127 .

For us. and Canada. the problem is not the system. You’re A Jerk 128 . spends about a third of what we do per person.” Physicians For A National Health Program. 2009. K. such as the U. http://www. “Statement of Dr. it’s the system.Single Payer 2.) If they were to put the same amount of money as we do into their systems.0 LO 128 A2: No Innovation/Wait Single payer system efficient and innovative Angell. For them. there would be no waits and all their citizens would have immediate access to all the care they need. medical care would be threadbare and less available. Marcia.org/facts/statement_of_dr_marcia_angell_introducing_the_us_national_health_insurance_act.pnhp. MD. But that’s because they spend far less on health care than we do. (The U. innovative technologies would be scarce under a single-payer system. K. Senior Lecturer @ Harvard Medical School. and in general. Marcia Angell introducing the US National Health Insurance Act. Editor of New England Journal of Medicine.php [Mardjuki] According to Myth #2. it’s the money. we would have long waiting lists for operations and procedures. This misconception is based on the fact that there are indeed waits for elective procedures in some countries with national health systems. it’s not the money.

Angell. Marcia Angell introducing the US National Health Insurance Act.pnhp. nothing could be more onerous both to patients and providers than the multiple.0 LO 129 A2: Bureaucracy Single payer comparatively streamlined bureaucracy compared to private industry. bureaucratic regulations. but privately delivered.Single Payer 2. Indeed. http://www.” Physicians For A National Health Program. Marcia. That’s currently the case with Medicare. which is publicly funded. many doctors who once opposed a single-payer system are now coming to see it as a far preferable option. MD. 2009. Editor of New England Journal of Medicine. intrusive regulations imposed on them by the private insurance industry. But in fact. “Statement of Dr. although a national program would be publicly funded. Senior Lecturer @ Harvard Medical School. As for onerous regulations. which would subject doctors and other providers to onerous. You’re A Jerk 129 .org/facts/statement_of_dr_marcia_angell_introducing_the_us_national_health_insurance_act.php [Mardjuki] Myth #3 is that a single-payer system amounts to socialized medicine. providers would not work for the government.

Single Payer 2. Some Americans like to say that. the NIH.org/facts/statement_of_dr_marcia_angell_introducing_the_us_national_health_insurance_act. or the IRS privatized.” Physicians For A National Health Program. Others are education.php [Mardjuki] Myth #4 says that the government can’t do anything right. An investor-owned insurance company reports to its owners. Editor of New England Journal of Medicine. It says that when it comes to vital needs. clean water and air. not 280 million individuals competing with one another. http://www. such as Representative Conyers is providing. We live in a country that tolerates enormous disparities in income. Some people say that a single-payer system is a good idea. and the support of the medical profession and public. I would not want to see. I want to mention one final and very important reason for enacting a national health program. \ You’re A Jerk 130 . we are one community. all of which we already acknowledge are public responsibilities. 2009. and without considering the alternatives. In seeking to ensure adequate health care for all our citizens. but with courageous leadership. without thinking of all the ways in which government functions very well indeed. but politically unrealistic. the medical profession and the public would be enthusiastic about a single-payer system if the facts were known and the myths dispelled. Angell. That may be an inevitable consequence of a free market economy. equal justice.0 LO 130 A2: Utopian? Single payer viable – necessary but needs support. Marcia. We should remember that the government is elected by the public and we are responsible for it. But those disparities should not extend to denying some of our citizens certain essential services because of their income or social status. “Statement of Dr. and protection from crime. for example. and social privilege. there would be powerful special interests opposing it and I don’t underestimate them. not to the public.pnhp. I believe there is nothing unrealistic about a National Health Insurance Program. material possessions. Yes. we have an opportunity today to reassert that we are indeed a single nation. One of those services is health care. Marcia Angell introducing the US National Health Insurance Act. In my opinion. That is a self-fulfilling prophecy. regardless of who they are. We need to acknowledge the same thing for health care. the National Park Service. helps ensure that we remain a cohesive and optimistic country. Senior Lecturer @ Harvard Medical School. Providing these essential services to all Americans. MD.

Since much of the program we envision would be regionalized. Marcia.scaling it up 7 or 8 fold should not prove difficult. There is no reason whatsoever that would make it hard to scale up. Senior Lecturer @ Harvard Medical School. or the Veterans Administration. You’re A Jerk 131 . 2009. The Ontario Health Insurance Program. MD. with regions similar in size to Ontario. http://www. Joel Alpert. health care is administered at the provincial level. Ron Anderson. Indeed. In Canada. that program seems a sound indication that scale should not be problematic. CEO Parkland Health System.pnhp. Angell.org/facts/singlepayer_faq. but it wouldn’t work when scaled up to meet the needs of a large country like the US A: Medicare is a national program that works reasonably well. which includes the city of Toronto as well as rural areas.0 LO 131 A2: Scale Up Not Possible National modeling off Medicare feasible – Canada proves. “Single-Payer FAQ. Canada. Commissioner of Baltimore City Health. Medicare was initiated (and administered for tens of millions of enrollees) before computers became available . Peter Beilenson. American Academy of Pediatrics. is a good example.Single Payer 2.php#socialized [Mardjuki] Q: Universal healthcare is okay for a small country or organization like Switzerland. American Public Health Association. Christine Cassell. President of American College of Physicians.” Physicians For A National Health Program. Editor of New England Journal of Medicine. Quentin Young.

Pgs. The single government payer could be the state. a health care trust fund similar to Social Security or Medicare would receive designated tax revenues. [Mardjuki] In a single-payer system. Medicare and Medicaid funds. 1989). excise or consumption taxes.S.0 LO 132 A2: National Health Program Bad Single-payer system streamlined and efficient. "sin taxes" on alcohol and tobacco. Most single-payer systems allow private insurance coverage for additional benefits not included in the public program. as in Japan (Sokolovsky & Kline. 1991).” Journal of Community Health Nursing. Single-payer systems are not to be confused with a national health program. eliminate exclusions for preexisting medical conditions. as exists in Great Britain. Volume 4. with consumer choice of provider. Miller. co-payments. Service delivery would remain in the private sector. surtaxes on upper income individuals. insurance premiums. 1993. and make health insurance portable between jobs. 199-211. Anna. not national health program. value-added taxes (VAT). You’re A Jerk 132 . such as Canada's provincial system (U. Increased consumer taxes would be balanced by consumer savings from lower deductibles. General Accounting Office [GAO].Single Payer 2. Revenue sources could include individual and corporate income taxes. which are then paid to providers by a single governmental entity. payroll taxes. RN and MSN @ Ball State University. Single-payer systems would incorporate various cost containment mechanisms and insurance reforms. and supplemental insurance costs. and employer and employee premiums. where health care providers are salaried government employees working in government-owned and operated facilities. or the federal government. “Health Care Reform: Clarifying the Concepts.

David.S.Single Payer 2. A system structured like Canada's but with double the funding could provide high-quality care without the waits or shortages that Canadians have experienced. bill by checking a box on a simple insurance form. MD. MD & MPH. Woolhander. Canada and numerous other nations use this solution and it works. Conservative Spending. nonprofit institutions. but today Canada spends barely half what we do per capita.0 LO 133 A2: Canada Empirically Fails US single payer solves – even with financial failure Canadian health higher than US. http://www.org/PDF_files/LiberalBenefitsConservativeSpending. Canada’s health care funding was starved by governments responsive to pressure from the healthy and wealthy who did not want to subsidize care for the sick and poor. or patients with cancer and others who need expensive or long-term care need never fear exceeding their benefits. Himmelstein. do not bill for individual patients.S.” Counterpoint. They are paid a global annual budget to cover all costs. Canada's health outcomes remain better than ours: their life expectancy is two years longer and most quality comparisons indicate that Canadians enjoy care equivalent to that received by insured Americans.pdf [Mardjuki] The key to achieving significant health care savings is single. Fee schedules are negotiated annually between provincial medical associations and governments but all patients have the same coverages. hightechnology care have resulted.source payment. Canadian and U. 2002. for both cardiovascular disease and cancer. Canadian death rates are lower than those in the U. Canadian hospitals. “Liberal Benefits. much as a fire department is funded in the U. You’re A Jerk 133 . Stephanie. December. Unfortunately.S. Even though shortages of expensive. which are mostly private.. Physicians. health care spending was once comparable.pnhp. m ost of whom are in private practice. during the 1990s. For instance. especially among younger individuals with potentially curable malignancies.

gives much of the power to his arguments: He straddles the divide between those who write health policy and those who live it. He is. "People don't look at what's going on in this system right now. they get sent home the same day they have the baby. fear of vast new taxes. less artful in political positioning than Mr. Women have a baby." Mr. is particularly powerful.from a private practice to the Seattle/King County Jail to the Foreign Service in Zaire. he says. plan wouldn’t affect it Toner 94 Robert Toner. in terms of rationing. "If you have a hernia operation. He was a psychiatrist for two decades in a variety of settings -. He was appointed to the Ways and Means Subcommittee on Health in 1992. McDermott says. he asserts. You’re A Jerk 134 . writer for the New York Times “Competing Plan Is Stuck Offstage In Debate Over Better Health Care” lexisnexis[LO//AS] Mr. and. and there is some grumbling in the House that Mr. you don't get to stay in the hospital overnight. he served 15 years in the Washington State Legislature. where he worked with American personnel in sub-Saharan Africa. where he worked on legislation to provide low-cost insurance to low-income and unemployed people. This. right now in this country." Mr. in fact. McDermott says he has heard all the objections to a single-payer system: fear of government.0 LO 134 A2: Rationing Status quo already faces rationing. it's happening all the time. The single-payer movement is often faulted for its political naivete.Single Payer 2. They hand you a bottle of pills and send you home after your surgery. Before coming to Congress in 1988. fear of rationing. The rationing issue. Cooper. in fact. McDermott has the physician's full measure of disdain for insurance companies. particularly unjustified. McDermott could be more aggressive and more strategic in pressing his case. "That's rationing done by insurance companies.

Medicare is an example of a mostly single-payer system. conveniently for those opposing it. Little wonder.S. And the Congressional Budget Office estimates that it would require a breathtaking $ 556 billion increase in federal spending by 1998. You’re A Jerk 135 . single-payer health care is NOT socialized medicine. tossed into the same boat too frequently: Socialized medicine is a system in which the government owns the means of providing medicine. But let’s get one thing straight. Single-payer health care is not socialized medicine. Admittedly. Number 3363. it's time to give the single-payer plan a hard second look. singlepayer is radical. economy to the federal government seems about as politically palatable as eliminating the tax breaks for homemortgage interest. 82 lexis-nexis [LO//AS] For months. as is France. Pg. CANADA” Business Week SOCIAL ISSUES. Conservatives are painting this option as “socialized medicine” or “government take-over”.org/tag/single-payer-health-care/ So why isn’t single-payer health care on the table? Well to start. nonstarter. But the payer does not own the doctors or the hospitals or the nurses or the MRI scanners. But this radicalism would serve some profoundly conservative purposes. Freedom to choose doctors and physician autonomy make single-payer health care uniquely non-socialist Symonds 94 William C. Symonds director of the Forgotten Half Project education program at Harvard “WHITHER A HEALTH-CARE SOLUTION? OH. of the care .Single Payer 2. It would decimate the health-insurance industry in one swift stroke. or Canadian-style.0 LO 135 A2: Socialized Medicine Single payer is not socialized medicine Campus Progress. I liked the Daily Kos explanation of the major differences between the two terms that are getting. the single-payer. For this reason. 7-19-2009. or in reality. the American College of Surgeons recently backed fundamental aspects of a single-payer plan. It’s a system in which one institution purchases all. “A ‘Better than Nothing’ Future”.campusprogress. At first blush. And the insurance industry strongly opposes the plan because it would mean the end of their glory days. No other plan would do more to preserve the two traditional bedrocks of American medicine: the freedom to choose your own doctor and the autonomy of physicians to order care as they see fit. part of the Center for American Progress for college students. most. Both these principles are seriously compromised by more "conservative" proposals that would force most Americans into managed-care plans. But now that the flaws of President Clinton's and other reform plans have become painfully evident and the debate has veered toward gridlock. http://fundingourfuture. the idea solution to health-care reform has been dismissed as a of turning over one-seventh of the U.

Even so.0 LO 136 A2: Socialized Medicine American single-payer could handle increased demand – not socialized. vs. Few believe there's any chance Congress will approve a single-payer plan this year. president of New Directions for Policy. "Americans get quite antsy -. based upon how much you or your insurer can afford to pay. Meyer. a Washington-based think tank. But at what cost? The CBO predicts that single-payer's liberal provisions would jack up demand for physician services by 30%. By 2003. You’re A Jerk 136 .S..Single Payer 2. 9. or as much as 8. CANADA” Business Week SOCIAL ISSUES. Canada and many other nations have already proven such budgets work.S. better than the U." Rather. thus sharply slowing the medical arms race that has burdened the U. The fear is that the states would then have to ration care by imposing waiting lines and limiting spending on new technology." says Jack A. system. "the Canadian system has served society. Number 3363. "They're not going to wait weeks or months for surgery.5% in Canada. single-payer would establish a national health budget indexed to economic growth. and the average citizen. to $ 175 billion. Symonds 94 William C. McDermott's plan. Proponents contend that this would force better planning. and triple demand for drug-abuse treatment. To control spending. de facto rationing already exists." argues Vickery Stoughton. Pg. sometimes called Canada Deluxe." But Canada's 30 years of experience with single-payer suggests care would not be compromised anywhere near as much as opponents predict. Opponents foresee a nightmare. Opponents have raised some legitimate concerns. with underutilized facilities. an American who has worked as CEO of both Toronto Hospital and Duke University Medical Center. But if Congress approves a bill that allows states to opt for single-payer.about waiting 45 minutes to fill up their gas tanks. Canadians do face waiting lines for some nonemergency procedures and have far less high-tech equipment. it's by far the best way to control costs while preserving the freedom of choice and physician autonomy that made American medicine great. as Clinton's plan would. home health care by 50%.6% below what it would be without any changes. the CBO estimates. 82 lexis-nexis [LO//AS] LIBERAL PROVISIONS. In the U.if not furious -. and give the government unbridled power to make life-and-death decisions. many observers expect it to be adopted by one or more states. would minimize constraints by continuing to allocate about 14% of GNP to health care. Symonds director of the Forgotten Half Project education program at Harvard “WHITHER A HEALTH-CARE SOLUTION? OH. Such laboratories would soon demonstrate that single-payer is not "socialized medicine.S. Many fear that single-payer would lead to runaway demand for services and then rationing. health-care spending would be cut by $ 114 billion.

Since only healthy individuals would be attracted to the MSAs/HSAs. Angell. By placing everyone in the same pool.000 more than men’s annually. but little to families with average incomes. Hence. hence they would tend to select plans with more comprehensive coverage. Currently.org/facts/singlepayer_faq.000 more out-of-pocket than her male counterpart. HSAs/MSAs discriminate against women. Quentin Young. keeping health insurance costs affordable for everyone. CEO Parkland Health System. on average. Christine Cassell.php#socialized [Mardjuki] Medical savings accounts (MSAs) and similar options such as health savings accounts (HSAs) are individual accounts from which medical expenses are paid. http://www. $1.Single Payer 2. which generally would be paid out-of-pocket. on the MSA/HAS plan. whose care costs. Senior Lecturer @ Harvard Medical School. Ron Anderson. Commissioner of Baltimore City Health.0 LO 137 A2: MSA/HSA Medical saving accounts don’t solve – decreases overall affordability and discourages preventative care. “Why not MSAs/HSAs?” Physicians For A National Health Program.pnhp. American Academy of Pediatrics. Joel Alpert. Once the account is depleted and a deductible is met. President of American College of Physicians. Moreover. You’re A Jerk 137 . and thus serve as a covert tax cut for the wealthy. Individuals with significant health care needs would rapidly deplete their accounts and then be exposed to large out-of-pocket expenses. Marcia. American Public Health Association. driving up premiums and threatening affordability. Finally. usually a managed care plan. medical expenses are covered by a catastrophic plan. the cost of high-risk individuals is diluted by the larger sector of relatively healthy individuals. Editor of New England Journal of Medicine. Peter Beilenson. which accounts for most health costs. HSAs offer substantial tax savings to people in highincome brackets. the average woman pays $1. MD. higher-cost individuals would be concentrated in the more comprehensive plans. 2009. and do nothing to restrain spending for catastrophic care. MSA/HSA plans discourage preventive care.

providers sometimes use "creative billing" to sidestep existing cost control mechanisms. An insurance firm that engages in these practices may reduce its own outlays. “Health Care Reform: Clarifying the Concepts. Market competition relies on an informed consumer. Senior Lecturer @ Harvard Medical School. health care choices often are made during crises when fear. however. Goldberg. Miller. consumers might not have enough information to make informed choices for themselves and for other family members. benefits would vary with the insurance carrier or the employer's choice of insurance plan. “Won’t Competition Be Impeded By a Universal Health Care System?” Physicians For A National Health Program. however. Competition among insurers (the payers) is not effective in containing costs either. Anna. increased demand usually generates greater supply (more products). In addition. Compared to HMO physicians. it results in competitive practices such as avoiding the sick. You’re A Jerk 138 . pain.0 LO 138 A2: Free Market More Efficient Free market approach increases costs – duplicative equipment and competitive treatments.org/facts/singlepayer_faq. feefor-service physicians tend to provide more hospital-intensive. etc. Within a fee-for-service reimbursement system. and are the major cause of rising costs. and even an expanded market system would leave an estimated 4. uninformed consumers. cherry-picking. In addition. increased availability of hospital beds. Rogers. For example. Editor of New England Journal of Medicine. Marcia. President of American College of Physicians. MD. American Academy of Pediatrics. Volume 4. The preferred scenario has hospitals coordinating services and cooperating to meet the needs of their communities. There are two main areas where competition exists in health care: among the providers and among the payers.9 million persons uninsured (White House. CEO Parkland Health System. RN and MSN @ Ball State University.php#socialized [Mardjuki] Advocates of the “free market” approach to health care claim that competition will streamline the costs of health care and make it more efficient. In a market economy. Christine Cassell. but at the expense of other payers and patients. Rather. [Mardjuki] Arguments Against Market Competition: The present market-oriented system has left millions uninsured. There are inherent difficulties in relying on market competition to provide universal access and control costs. denial of payment for expensive procedures. When. providers have incentives to create demands for the services they provide using self-determined fees. 2009. In the health care system. Angell. What is overlooked is that past competitive activities in health care under a free market system have been wasteful and expensive. 199-211. American Public Health Association. They also waste money on advertising and marketing. It is unknown whether voluntary participation would achieve significantly increased insurance coverage or whether tax credits and vouchers would provide a sufficient incentive to purchase adequate health insurance. http://www. medical technology. Pgs. 1993. and worry can cloud decision making. Peter Beilenson. Leibowitz. 1984). 1992). Ron Anderson. Free market-based healthcare invariably fails – emotional decisionmaking. & Newhouse. for example. hospitals compete they often duplicate expensive equipment in order to corner more of the market for lucrative procedure-oriented care. As in our current system. and demand generated by supply. Quentin Young. Joel Alpert. This drives up overall medical costs to pay for the equipment and encourages overtreatment. Commissioner of Baltimore City Health. demand is generated by supply.” Journal of Community Health Nursing.Single Payer 2. or outpatient services results in increased use of those services.pnhp. and therefore more expensive medical care (Manning.

http://www. they ignore a large body of research and statistics that conflicts with their portrayal. CEO Parkland Health System.S. 2009. Quentin Young. highly selective and overtly biased reinterpretations of previously published data — mostly from the Joint Canada/U. Joel Alpert. “Recent Attacks on Single Payer Health Reform: Ideology Masquerading as Scholarship” Physicians For A National Health Program. While they extensively cite the few pieces of published data that supports their grim view of Canada’s health system. Survey of Health (JCUSH). Their analysis rests on idiosyncratic. Editor of New England Journal of Medicine.php#socialized [Mardjuki] The O’Neills collected no new data. Ron Anderson.S. Angell. Peter Beilenson.org/facts/singlepayer_faq.Single Payer 2. American Academy of Pediatrics. Commissioner of Baltimore City Health. Senior Lecturer @ Harvard Medical School. a population-based survey conducted jointly by the U. MD. and Canadian government statistical agencies. Christine Cassell.0 LO 139 A2: O’Neill Free market approach increases costs – duplicative equipment and competitive treatments. American Public Health Association.pnhp. Marcia. President of American College of Physicians. You’re A Jerk 139 .

small business (fewer than 100 employees) provided 51% of all jobs (Edwards et al.S.0 LO 140 A2: Employer-Based HC Employer-based insurance fails – doesn’t cut costs. Miller. You’re A Jerk 140 . “Health Care Reform: Clarifying the Concepts.. [Mardjuki] : Opponents of the play or pay approach point out that employers do not really pay for employee benefits. health care costs (Polzer. Small businesses might be unable to afford the added expense of providing health care insurance. RN and MSN @ Ball State University. Volume 4. 199-211. In 1990. 1990). American business already underwrites approximately 30% of U. with a lower quality and less adequate public plan.” Journal of Community Health Nursing. Some fear that employer-mandated insurance establishes a two-tier system. they simply pass added costs on to consumers through higher prices. 1992).Single Payer 2. Pgs. A play or pay approach also does not inherently improve quality or efficiency of services or reduce administrative costs. 1993. Anna.

and suggest it may be a slippery slope to a government-based system (Griffin. and they do not have to provide statemandated insurance benefits or participate in state high-risk pools (National Health Policy Forum. (Note that selfinsured is not to be confused with individual insurance for those not part of group plans. 1992). 1993. Moran. more than one half of all Americans live in areas with a population density too low for more than one HIPC to operate. and past experience does not indicate that HMOs are necessarily more cost-effective than other models (Polzer. controlling costs. For example. RN and MSN @ Ball State University. 1986). only Hawaii has received such a waiver because the Hawaii plan was in place before ERISA was enacted (National Health Policy Forum. ever more companies will try to escape government mandates by becoming self-insured. 1990). Without an ERISA waiver. Himmelstein. 1991). and the problems involved in educating consumers to make cost-efficient choices. The federal ERISA law exempts self-insured businesses from state insurance mandates (Rublee. [Mardjuki] Managed competition continues the present employer-paid insurance with its inherent difficulties. however.Single Payer 2. Many large businesses selfinsure and assume their own health care costs rather than buying health insurance (Dobson. 1990). Some question the feasibility of mandating nationwide managed competition. Anna. 1992). Therefore. Large-scale use is untried. thus making competition impossible in those areas (Clancy. self-insured companies can choose to provide fewer benefits or require higher co-payments.) Opponents of managed competition also point out the difficulty in using outcomes to evaluate physicians. Employee Retirement Income Security Act (ERISA) waivers. technically they do not sell insurance and thus are exempt from state regulations. Before mandating managed care across the country. & Young. 1992). they have no authority over self-insured companies. This would require Medicaid and Medicare waivers. inner city areas may have difficulty attracting competing health plans. & Woolhandler. minimal knowledge about consumer health care decision-making processes.0 LO 141 A2: Managed Competition Managed competition fails – lack of quality control and structure not nationally viable. In addition. Volume 4. Although these self-insured businesses often contract with an insurance company to manage their insurance claims processes.” Journal of Community Health Nursing. some suggest that states first be given freedom to try various methods of providing universal coverage. are more important and more difficult to obtain. You’re A Jerk 141 . Pgs. Unless states receive an ERISA waiver. and improving quality. “Health Care Reform: Clarifying the Concepts. which may be possible. question whether managed competition would provide sufficient incentives for quality medical care. 199-211. Miller. Inherent difficulties include lack of accurate and understandable quality outcome data from health care providers. To date.

Single Payer 2. Hickey. Given doctors’ unhappiness with their growing lack of clinical authority and with the corporatization of American insurance that incorporates large segments of the medical community. A similar thing happened some months back to the American Medical Association. they may prove a key catalyst to its enactment. "We felt as a board that the single-payer system would probably provide the best assurances that patients would be able to seek care from any doctor of their choice. Historically. Murray said the College of Surgeons's policy making board has not backed down from its consensus in favor of a Medicare-style." You’re A Jerk 142 . The Next Agenda: Blueprint for a New Progressive Movement. "Because physician groups have historically been so opposed to single-payer. “Surgeons' uproar shows reform rift” Lexis-Nexis [LO//AS] When the Board of Regents was first discussing this about eight to 10 months ago. physicians have been a strong obstacle to large-scale reform. I think almost to a person our reaction was: 'Single-payer system? You've gotta be kidding!' " Murray said in an interview. Physicians may be increasingly persuaded that they will fare better under a public system that would reinstate their clinical autonomy than under the corporate control of private health plans. In the future. vice president @ Economic Policy Institute. AMA leaders scrambled to fashion a compromise that put the group on record as neither favoring nor opposing such a policy. we began to take a little different approach. prof of law @ American University. Knox. That alliance could reasonably be taken a step further. it suddenly sounds like a radical statement. Despite all the damage control and spin. executive director of the American Academy of Family Physicians. Robert Graham. The transformation of the medical system through various managed care practices has created deep discontent among physicians with current arrangements. Robert and Roger. Pg 118-119. consumer groups and physicians’ associations have subdued their traditional enmity and are working together to pass both state and federal laws regulating HMOs and other managed care plans. 2001." said Dr. Single Payer has gained backing. got input from all over the country.0 LO 142 A2: Physician Backlash Growing physician discontent with current regime – can be catalyst for large-scale reform. Already. "Then as we learned more of what was going on. when anyone says anything moderate about it. [Mardjuki] The events of the past decade have provided new opportunities to expand the coalition for health reform. single-payer approach to health reform. writer for the Boston Globe. The AMA previously favored an "employer mandate" that would force employers to help pay for their workers' coverage. But to placate conservative physicians opposed to the Clinton plan with its employer mandate. Borosage. and learned how the Clinton plan would partially be financed by cutting back on Medicaid and Medicare. including physician associations Knox 3/20 Richard A." Murray and leaders of other physician groups say the College of Surgeons did not anticipate the reaction they got from members.

Single Payer 2.0 LO 143 **Add-ons** You’re A Jerk 143 .

and a nationally syndicated columnist He won the 1995 Warren Brookes Award for Excellence in Journalism “LAMBRO: Obama's budget to raise small-business taxes” February 27. too. Obama ran for president saying he will raise taxes on wealthy Americans by boosting the present 35 percent top income tax rate to the nearly 40 percent rate under President Clinton in the 1990s. Small businesses and the entrepreneurs who lead them have been the primary drivers of job growth over the past decade." saying that "small businesses. middle-class families. Lambro 2/27 Donald Lambro is the chief political correspondent of The Washington Times. 2009 (http://www. everyone with a 401(k). saying that this was not the time to raise taxes on higher income people because it would further weaken the economy. and fewer jobs .com/news/2009/feb/27/obamasbudget-to-raise-small-business-taxes/)[LO//AS] Business advocates charged that multiple tax increases on Americans earning more than $250. resulting in less government revenue.not more. "You don't build a house by blowing up its foundations.and his budget calls for letting President George W. as the recession deepened last year. chief lobbyist at the U. too. <insert econ impact> You’re A Jerk 144 .0 LO 144 Small Business Add-on Health care taxes would destroy small businesses – key to the economy. less economic growth.000 a year would whack small businesses who pay the individual income tax. but many economists. less economic growth. Business advocates charged that multiple tax increases on Americans earning more than $250. House Minority Leader John A. the author of five books on the government and the economy. Then. This plan would punish them with higher taxes. he changed his mind. "You don't build a house by blowing up its foundations. Bush's two top tax rates expire at the end of 2010 . and produce as much as 60 percent of all jobs. retirees." Mr. and produce as much as 60 percent of all jobs." said Bruce Josten. and fewer jobs . Chamber of Commerce.which will cost an estimated $1 trillion over 10 years . chief lobbyist at the U." said Bruce Josten. resulting in less government revenue.S. say it could still be in a recession or in a weakened condition well into 2011. The White House expects the economy to be in a recovery at that time.000 a year would whack small businesses who pay the individual income tax. and anyone who flips on a light switch is going to pay higher taxes under this plan.washingtontimes. On Capitol Hill. family farms. charities.Single Payer 2. But Mr. Small businesses and the entrepreneurs who lead them have been the primary drivers of job growth over the past decade.not more. including members of the Federal Reserve Board.S. Boehner of Ohio called the budget plan a "job killer. This plan would punish them with higher taxes. Obama needs increased revenue to launch his national health care plan .

editors for Yes! Magazine. longer wait times for treatment. as a business owner. which sells customer relationship. There's little argument that the system is broken.Single Payer 2. What's not well known is that the dialogue about fixing the health care system is just as broken. those critics are probably right—socialized medicine will probably lead to higher individual taxes.com/smallbiz/content/jul2009/sb20090721_906996.0 LO 145 Small Business Add-on Ext Businesses are suffering from privatized HC Pibel and Gelder 06 Doug Pibel and Sarah Van Gelder. Written in Business Week “National Health Care: How Small Business Will Fare” http://www. But take a look at these numbers from a client of mine—a 50-person manufacturer in Pennsylvania. That works out to 18% of its payroll cost. (This included the owners. And a national health insurance system would be a good thing for small business owners. Insurance premiums increased 73 percent between 2000 and 2005. National Health Insurance helps small businesses Marks. But one thing I know for sure: British food is terrible. and per capita costs are expected to keep rising.) And this is for a pretty basic Blue Cross plan. The shocking facts about health care in the United States are well known.000 net health insurance on a payroll totaling $2. For one. Yes. national health care spending will double over the next 10 years. Way cheaper. In 2008 it paid $375. The National Coalition on Health Care (NCHC) estimates that. and it counts General Electric and Verizon among its members. lower-quality health care. But Americans in increasing numbers know what their leaders seem not to—that the United States is the only industrialized nation where such stories as Joel's and Kiki's can happen. Marks is the author of four best-selling small business books. author of best-selling small business books. service. 7/21 owner of the Marks Group. Among politicians and pundits. without reform. Not a bad thing. a national insurance plan would be cheaper for me. Employers who want to offer employee health care benefits can't compete with low-road employers who offer none. Rogers (D-FL). and a strong urge to have tea and biscuits at 4 o'clock. Ray (R-IA) and Paul G. and financial management tools to small and midsize businesses. If we opt for Kennedy's proposal. it would save $337. Nor can they compete with companies located in countries that offer national health insurance .yesmagazine. The NCHC is not some fringe advocacy group—its co-chairs are Congressmen Robert D. publicly funded system is off the table. an award-winning publication “ Health Care: It's What Ails Us” http://www.org/issues/health-care-for-all/1498[LO//AS] Businesses are suffering too.businessweek. the company would save about $208.086 million.500 per year! You’re A Jerk 145 . a universal. Now before my fellow conservatives handcuff me to a TV and force me to watch 20 hours of The Franken & Davis Show.000. let me explain. If we go with the President's 8% plan.htm [LO//AS] Will national health care benefit us as a country? I'm not really sure.

site of residence. and the pursuit of happiness. between ethnic and racial groups. the underinsured. The current canon of medical ethics reasons acceptable behavior from four basic principles one of which is justice . and psychological health or the opportunity to be as fully as possible restored to such a state. In order to meet the constitutional test of equal protection. of acquiring. The Declaration of Rights of the Pennsylvania Constitution speaks of universal inherent and indefeasible rights. the uninsurable. Our current system denies care to many and violates that ethical precept in the care of countless more. and protecting property and reputation. ethnicity. or age. those housed and those homeless. those who can access the system only after a minimal problem has progressed through neglect and want of access to crisis proportions. and of pursuing their own happiness. Chief of Radiation Therapy for the Pittsburg Health System. You’re A Jerk 146 . emotional. or the profit needs of third parties much less the generally regarded criteria of race. I respond that in the absence of optimal physical. One need ask whether there are conditions under which in the daily life of a Pennsylvania resident these rights are compromised or denied. “Establishing a Right to Health Care. Barry Tepperman. property and reputation are meaningless. current or prior infirmity. according to what they will pay for and what employers have contracted for.Single Payer 2. This creates the medically ethically untenable situation where. in a fashion which does not discriminate according to factors such as financial resources or potential. these rights cannot be achieved. http://www. Chief for Pittsburg Health System. in the same physicians' practice treating comparable patients different insurers will demand different standards of care a distinction based on the insurers' need for profit and not on any scientific evidence or medical logic. Only a system that guarantees equal access for all and a single standard of care based on scientific evidence will pass the test of equal protection for all Pennsylvania residents and I would submit to you that only through a single-payer universal health care system can that be achieved.simple fairness and equity in the use and application of resources. to create castes of medical untouchables. liberty. life and liberty are devalued.org/page/community/group/AdvocatesforSinglePayerHealthCare) [LO//JW] The Declaration of Independence speaks to unalienable rights including life. I maintain that by implication of these sweeping but generally accepted statements this nation grants a fundamental and irrefutable right to health and to health care. current employment or future prospects. religion.democrats. possessing. If an individual's quality of life is compromised for want of health care. physical ability.” Speech to PA’s House of Representatives. ‘06 (Dr. which include enjoying and defending life and liberty. society differentiates in access to health care between the rural and the urban. 9/21/06.is unachievable. such care needs to be of equal quality and equally accessible to all residents of the state. the uninsured. Even those who are as Pennsylvania fully insured as this system allows are distinguished according to their private insurer and the quality of their insurance.0 LO 146 Equal Protection Universal Health Care Solves Equal Protection Rights Tepperman. happiness for him and for those who care for him . Department of Radiation Oncology at Allegheny General Hospital. graduated from the University of Toronto with an MBA in Health Administration.

0 LO 147 **2AC** You’re A Jerk 147 .Single Payer 2.

” http://www.php? page=3733 [Mardjuki] CNN senior medical correspondent Elizabeth Cohen has herself adopted this terminology in discussing healthcare reform. You’re A Jerk 148 .g. Private insurance systems could insure for services not covered by this single public plan. 676. perinatal. and there would be no charge for most preventive services. ABC News/Washington Post. such rhetoric confuses rather than informs. Anna. blurring the differences between the Canadian model of government-administered national health insurance coupled with private healthcare delivery that single-payer proponents advocate. Obama has not expressed support for singlepayer. that's all the more reason media should include it in the public debate about the future of healthcare. 1993. The views of CNN's senior medical correspondent notwithstanding. 1990). Expand Medicare to everyone. Expansion of Medicare system popular – less contentious than new healthcare reform. opinion polling (e. copayments and deductibles would be reduced for low-income persons. RN and MSN @ Ball State University. Americans start to think what President Obama is proposing is some kind of government-run health system--a la Canada. 199-211.fair.0 LO 148 Plan Pop Plan popular – public and Congress. The existing single-payer Medicare system could be expanded to include everyone.Single Payer 2.” Journal of Community Health Nursing. Though more than 60 lawmakers have co-sponsored H. Expansion of existing public programs might be more politically acceptable than establishing completely new programs (Harrington. existing governmental health insurance programs could be modified and expanded to provide insurance coverage for specific population groups. adding preventive.. Pgs.org/index. both the idea and its advocates were marginalized in yesterday's healthcare forum. and healthcare systems such as Britain's. FAIR March 6. [Mardjuki] A new single-payer system could be designed for the entire population. Everyone would have a medical identification card (like a Medicare card). “FAIR Study: Media Blackout on Single-Payer Healthcare. Alternatively. and well child care. the single-payer bill in Congress. in which healthcare (and not just healthcare insurance) is administered by the government. Miller. 10/9-19/03) suggests that the public would actually favor single-payer." Particularly in the absence of actual coverage of single-payer. 2009. Fairness and Accuracy in Reporting. But given the high level of popular support the policy enjoys. “Health Care Reform: Clarifying the Concepts. Volume 4. stating (CNN Newsroom. 2/26/09) that "if in time.R. a la England--he will get resistance in the same way that Hillary Clinton got resistance when she tried to do tried to do this in the '90s.

2001. Pg 115. and the managed care trade association have treated the Canadian model as the problem rather than the solution. At the same time.lic legislation. the United States has the most intrusive regulation of medical care practice of any OECD nation.`° Forty groups sponsored this campaign. Robert and Roger. prof of law @ American University. but the intensity of opposition to it by financially interested and ideologically opposed par. Borosage. Hickey. lt is no sur. and the pharmaceutical trade association.prise that the HIAA. the National Association of Manufacturers. however.Single Payer 2. In short. ln spring 2000 a newly formed group disingenuously describing itself as "Citizens for a Better Medicare" launched a multimedia campaign "urging American seniors to reject the Canadian model of health insurance and coverage of prescription drugs." You’re A Jerk 149 . The Next Agenda: Blueprint for a New Progressive Movement. the trade association of the drug industry. including such traditional opponents of government health insurance as the Chamber of Commerce. this model has awakened the intense opposition of groups whose incomes would be harmed by such a reform. although the bulk of that intrusiveness arises from private regulation rather than pub. vice president @ Economic Policy Institute. the problem with the Canadian model is not an absence of substantive merit. the AMA.ties. [Mardjuki] Indeed.0 LO 149 Plan Unpop Single payer healthcare controversial – plethora of interest groups. Perhaps that is why Canada's model has held such appeal for American reformers during the past quarter century.

yet Truman used that defeat as an element in his presidential campaign against the infamous “do-nothing" Congress. In 1948. In contrast. You’re A Jerk 150 . President Truman’s national health insurance plan went down to defeat. it is equally critical to influence the terms on which one loses. even unsuccessful legislative efforts may keep health reform on the agenda and in some circumstances may help expand support for it. As our overview of the politics of national health insurance makes clear. Robert and Roger. after the Clinton health plan politically irnploded in I994. prof of law @ American University. [Mardjuki] If You Lose. Reformers must confront the reality that political setbacks and legislative defeats are not only possible but probable. Pg 116. vice president @ Economic Policy Institute. Borosage. In that respect. The Next Agenda: Blueprint for a New Progressive Movement.Single Payer 2. the obstacles to enactment of substantial reform are formidable. there still may be political benefit to extract if responsibility for blocking expanded health insurance coverage can be clearly pinned on the opposition. As important as it is to shape the terms of victory. therefore the blame for the failure of health reform lay as much on President Clinton as it did on his congressional opponents. The administration had no end-game strategy when legislative support for health refom failed to materialize. Lose the Right Way. The lesson for reformers is this: If legislation cannot pass.0 LO 150 Losers Win? Placing blame on opposition expands support for failed healthcare reform. Hickey. even the administration abandoned its plan. 2001.

The existing single-payer Medicare system could be expanded to include everyone. "I think the American people want to take a closer look at this legislation . But 52 fiscally conservative Democrats . They want to feel more comfortable with it.known as Blue Dogs . his health-care overhaul isn't likely to be ready this week despite his fondest hopes. copayments and deductibles would be reduced for low-income persons.Single Payer 2." Jim Cooper. A new single-payer system could be designed for the entire population. said over the weekend. and hoped for the same success on health care. 199-211. adding preventive. and Congressional opposition. the Obama administration was delighted it had managed to push through a major climate-change bill in the House of Representatives. The president's poll numbers are. a Blue Dog from Tennessee. Pgs. "If we're able to stop Obama on this. so that Americans would have a new health-care system by October. which begins at the end of the week. On Monday. Obama had wanted the bill passed before the August recess. Private insurance systems could insure for services not covered by this single public plan. and there is lingering fallout from the president's remarks last week about the arrest of a friend. Miller. Pelosi has pledged to bring unruly Democrats to heel and pass the bill in the days to come.have emerged as a major thorn in the side of the Obama administration and party leaders. Everyone would have a medical identification card (like a Medicare card). existing governmental health insurance programs could be modified and expanded to provide insurance coverage for specific population groups. Expansion of existing public programs might be more politically acceptable than establishing completely new programs (Harrington. Anna. Democrats also headed into a lengthy meeting on Monday afternoon to review the bill section by section in an attempt to better understand the concerns of the Blue Dogs while they hold up the bill. Austin. RN and MSN @ Ball State University. but it seemed unlikely with the Blue Dogs still standing firm. the White House was hopeful it could get much of its agenda through Congress in 2009. [Mardjuki] 3. It will break him. and have grown bolder in openly defying Obama and his powerful allies.brandonsun. it will be his Waterloo. His poll numbers have slipped. staff reporter. but deficit spending and rising unemployment. taking a hit as Americans worry not just about health-care reform. A month ago. It's all made for a tense atmosphere in Washington that has Republicans gleeful at the idea of using health-care reform to cause permanent damage to Obama. Expand Medicare to everyone. indeed. Expansion of Medicare system popular – less contentious than new healthcare reform. and well child care. 2. The dog days of summer are not being kind to President Barack Obama. You’re A Jerk 151 . including House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid. “Obama’s first White House summer one of http://www.” Brandon Sun. and are resisting admonishments from those top Democrats not to jeopardize Obama's most cherished and ambitious legislative effort. 7/27/09 Jillian. Alternatively. perinatal.com/story. 1990)." Republican Senator Jim De Mint recently proclaimed.0 LO 151 2AC Healthcare Politics (1/3) 1. Won’t pass – slowed momentum.php?story_id=150210 [Mardjuki] controversy. The Blue Dogs take issue with crucial elements of their party's health-care reform bill. and there would be no charge for most preventive services. Cooper said a vote in the House on the bill likely wouldn't be held until after Labour Day. Indeed. “Health Care Reform: Clarifying the Concepts. Democratic leaders pointed to a new congressional report to refute Republican claims that their health-care reform plan would amount to a government takeover of the health insurance industry. Obama’s decreasing popularity. No spillover – politicians evaluate bills on a case by case basis – make them read evidence this affects other bills. Volume 4.” Journal of Community Health Nursing. 1993. The Blue Dogs are apparently fearful that Republicans will have the upper hand in the 2010 mid-term elections. health-care headaches. The report from the Congressional Budget Office suggested a government plan could co-exist with private insurers without driving them out of business.

injecting vast sums of money into the economy. Bush. That’s Woodhead 9. Intrinsicness allows the aff to test the relevance of the link. and other areas of national life. energy policy. according to Democratic pollster Geoff Garin. b.0 LO 152 2AC Healthcare Politics (2/3) 4. Uniqueness overwhelms the link – some semblance of health care is guaranteed by Obama’s political clout – it’s too big to fail. The DA isn’t intrinsic – a. His healthcare plans have stalled on Capitol Hill. charismatic Obama presented such a contrast to George W. the estimate for another plan was even larger—$1.healthcare. "Regardless of how it is initially structured.html President Obama is heading into stormy waters. which will in turn cause delays in considering the massive bills this summer and could jeopardize passage in the fall. This was because the supremely articulate.Single Payer 2. Iran election.6 trillion. Over the past couple of weeks. reversing his momentum. But the ground may be shifting. his job-approval ratings are dropping. Federal policymakers could control both impacts – they can pass the plan and healthcare reform 5. It’s fair – we’ll only make one intrinsicness argument per debate. It’s reciprocal – negative can counterplan out of advantages to test their germaneness to the plan. This sent legislators scurrying to reduce the price tags. America's Health insurance Plans and the Blue Cross Blue Shield Association wrote. "The public [government] plan.com/articles/news/obama/2009/07/01/strategists-worry-obamas-popularity-is-dropping. Obama has endured a surge of bad news. Obama’s political capital is down. Until now. bailing out the financial industry. which initially boosted his ratings. The Congressional Budget Office estimated that one of the major Democratic healthcare proposals being circulated in the Senate would cost an astounding $1 trillion. Another setback came when two powerful insurers' associations announced their opposition to an Obama-backed government health plan that would be in competition with private. No link – do the plan and pass universal healthcare. President Obama has enjoyed a honeymoon with the country and the media (although not with opposition Republicans). a government plan would use its built-in advantages to take over the health insurance market. he is being faulted for a shaky response to the post-election violence in Iran. auto industry. and confidence in his handling of the economy is ebbing. In a letter to senators released this week. Obama is very appealing as an individual. is an important tool to discipline insurance companies. In addition. not healthcare – healthcare doesn’t send the financial signal of solvency international investors are looking for You’re A Jerk 152 . “Strategists worry Obama’s popularity is dropping” http://www. Impact inevitable – Boston Globe 9 is in context of Social Security reform. 7/1/2009. and Obama delivered. In fact. News. he has moved the federal government into a more activist role than it has had under any other president in years. voters wanted action from their president in tough times. The warning signs are enough to worry Democratic strategists that Obama may be sinking into a trough that will sap his influence just when he needs it most. Finally. employer-sponsored plans. I think.usnews. 7. economy U.S.S. This solves back any infinite regression claims. b. and proposing huge changes in healthcare. taking over much of the U." 6." But Obama told a news conference Tuesday. who remains unpopular.

but the country does not. Obama’s rise to power has fulfilled a nation’s egalitarian promise and remedied racial injustice. http://www. 10. Winners win . either increasing the deficit or raising taxes 8 percent – that’s Pear 9. but rather as the president. At no other point in his presidency will Obama have four years to mitigate the impact of his tough choices.0 LO 153 2AC Healthcare Politics (3/3) 8. It would only be natural for the first black president to harbor a sense of responsibility to avoid alienating parts of the country. Given the fluctuations of the polls leading up to Obama’s victory in November. 9. and move on—as he said he has done. And given the state of the country he inherited. Obama seems to be taking pains to prevent divisiveness at a time when he should be taking clear policy directions and expending political capital. Obama should begin stepping on some toes. most Americans judged the presidential contender based on his positions and their read on the current condition of the country. the public is probably prepared to countenance some far-reaching and consistent policy making. Some Americans may have surmounted preconceptions of race in voting for Obama. Obama should consider that promise now fulfilled and the symbolic gain made. he faces nothing but tough choices. To some Americans. @ National Interest. seem to perceive Obama as a black president. <CASE OUTWEIGHS> You’re A Jerk 153 . but not as the overriding priority. 3/26/’9 [Barack the Timid. Obama still has four years for those policy decisions to yield results.org/Article. by and large. rather than on preoccupations with his race. Americans regard the symbolic salve on racial wounds as a welcomed development. Indeed. Can’t solve the economy – Obama’s healthcare proposals cause entitlement spending to skyrocket.aspx?id=21156] But an appreciation for those headlines of history could unduly influence the president. but he has to steer that ocean liner in the right direction—and be persistent.Single Payer 2. And given the state of the country and its foreign endeavors. to the benefit of those eponymous ordinary Americans—and those not so ordinary.a Fight Is Critical For Obama to Assert Strength Ximena Ortiz.

Single Payer 2. RealClearPolitics. would "immediately and aggressively" pursue ratification of the comprehensive ban on the testing of nuclear weapons .S. especially in light of our testing moratorium. tighter global export controls.wsj. Arms control negotiations with the Russians will be challenging enough. the Obama administration must now follow through on its pledges. 6/30/09 (Jon and Richard. accessed 8/14/02 Relinquishing the right to conduct tests — thereby gambling the U. it will become impossible to keep extending the life of our arsenal. militarily effective. Senate to forgo forever a test program that could in the future be of critical importance for our defense and the defense of our allies . it is not clear that future adversaries will be convinced that the American nuclear arsenal is. Earlier in the week. but the Obama administration must also successfully negotiate with Capitol Hill. warned in a speech last October that in the absence of a nuclear modernization program. 3. nuclear deterrent on the technologically risky SSP — poses an unacceptable security risk.com/sections/world/TakingSides/takingsides1.html) Obama's speech on Sunday should begin the process of clearing the air. which won't be easy. “Danger or Deterrent?” 1999. in his Prague speech. http://www.com/articles/2009/04/nuclear_arms_in_the_developing. There is no evidence indicating that political capitol would spillover onto CTBT 5. mostly out of concerns about verification -. and a new framework for civilian nuclear energy development that precludes development of national uranium enrichment facilities. Mr. "[a]t a certain point. CTBT won’t be ratified – it’s not verifiable Kyl and Perle. even the most modest of which Congress has repeatedly declined to fund. It also failed because of an understandable reluctance on the part of the U. Staff Writer. “Our Decaying Nuclear Deterrent. Votes aren’t there from the GOP Grotto. He announced support for Senate ratification of the CTBT and a verifiable FMCT. They want to build nuclear weapons.S. no reason that’s key to prolif 3. without evidence. American Enterprise Institute. But the Obama administration also hopes that by addressing developing country concerns about disarmament. http://abcnews. CTBT only stops testing. even if the SSP functions as it is supposed to. who is now Mr.go. When it comes to deterrence. 2.html) Thus. the perception of a potential adversary is critical.realclearpolitics. ’09 (Andrew. meaning it would be unstrategic You’re A Jerk 154 . The right to test is essential to credible deterrence Barbara Conry.S. Moreover. indeed. Arizona. that ratification of the test-ban treaty will discourage other countries from developing nuclear weapons. which means that the majority Democrats will still need to attract the support of more than a half-dozen Republicans for CTBT and FMCT ratification. Countries like Iran and North Korea would not sign CTBT a. The administration believes. associate policy analyst at Cato. The Senate has a responsibility to ensure that no future Saddam Hussein or Slobodan Milosevic has any reason to doubt the effectiveness of the American nuclear arsenal.or stimulate it? 4. These steps toward nuclear disarmament are worthwhile in their own right. Which countries does it have in mind? Iran? North Korea? Syria? Countries alarmed by the nuclear ambitions of their enemies? Allies who may one day lose confidence in our nuclear umbrella? There are good reasons why the test-ban treaty has not been ratified. “Nuclear Arms in the developing world. The Wall Street Journal.” April 8.it simply is not verifiable. Treaties require a two-thirds majority in the Senate.” http://online.html." Suppose future problems in our nuclear arsenal emerge that cannot be solved without testing? Would our predicament discourage nuclear proliferation -. The attempt to do so in 1999 failed in the Senate.com/article/SB124623202363966157.0 LO 154 2AC CTBT Politics (1/3) 1. these countries will be much more inclined to support an ambitious nonproliferation agenda that includes a more intrusive International Atomic Energy Agency Inspections regime. Obama's own secretary of defense. he laid out an ambitious arms control agenda with Russia for achieving substantial nuclear reductions. Obama announced that the U. Senator and Fellow. Robert Gates. Of course.

can’t fall into terrorist hands. doesn't like the phrase ''nuclear proliferation. ''And that makes for internal stability. ''The gradual spread of nuclear weapons is more to be welcomed than feared. a war between nuclear powers cannot be decisively won without the risk of total destruction. the time period just after a country goes nuclear-in the case of North Korea. adjunct professor of political science at Columbia University. ''If states can score only small gains because large ones risk retaliation. ''they have little incentive to fight. After all. WALTZ. . But we've had nuclear military capabilities extant in the world for 50 years and now. although heads of state. he adds. even to so-called ''states of concern'' like Iran and North Korea. Bennett 05 Drake Bennett. that makes for peace. North Korea has just declared itself a nuclear power. In recent weeks. As the Nuclear Nonproliferation Treaty. so it brings it home. And North Korea in the past has sold nuclear technology to Libya and Pakistan.'' Waltz writes. he argues. .'' Strictly speaking. the disagreement between Waltz and his critics is over the meaning and value of nuclear deterrence in a post-Cold War world. we only have nine nuclear countries. The US signing it would not incentivize them to sign it if they dislike the US 6. a school that sees world politics as an unending. “Give nukes a chance Can the spread of nuclear weapons make us safer?” http://www. including the leader and his family.'' When fighting does break out. You have a positive effect.'' was published last August-dismisses Waltz's larger linkage between proliferation and security as ''perverse. In part. amoral contest between states driven by the will to power. As he sees it.'' remains one of the most influential 20th-century works on international relations. ''most countries don't need them. but nonetheless interesting.'' co-written with the Stanford political scientist Scott D. the scholars who spend their time thinking about the issue are in fact deeply divided over the consequences of the spread of nuclear weapons. Updated and republished two years ago to take into account the nuclearization of India and Pakistan. ''It refers to things that spread like wildfire. a Soviet invasion of Western Europe. Each could kick off a regional arms race. while Iran sponsors Hezbollah and Hamas.'' But the eventual acquisition of nuclear weapons by those few countries that see fit to pursue them. however. Iran is in negotiations with the United States and Europe over what is widely suspected to be a secret weapons program of its own. ''Man. the backbone of nonproliferation efforts for the past 35 years.boston. Few among Waltz's colleagues share his unwavering confidence in the pacifying power of nuclear weapons. there's an increasing sense that it is failing. legislators. writer for The Boston Globe.com/news/globe/ideas/articles/2005/03/20/give_nukes_a_chance/?page=3 KENNETH N. Waltz's argument may seem a Panglossian rationalization of the inevitable. Nuclear proliferation creates an increase in international stability – even anti-prolif experts agree that nuclear weapons are deterrents.'' Waltz is not a crank. nuclear states grow cautious. Even Graham Allison. comes up for review this May. ''With a nuclear war. the widely noted ''Nuclear Terrorism: The Ultimate Preventable Catastrophe. that he's for. even counting North Korea. nuclear weapons prevent wars. and that makes for cautious behavior. Yet Allison-whose latest book. Put simply. As a result. the present moment-is the most dangerous. Allison argues. But it's also an argument over the motives that drive some countries to pursue nuclear weapons and others to want to keep the nuclear genie to themselves. Waltz spells out his theory most thoroughly in the 1995 book ''The Spread of Nuclear Weapons. and you can certainly see that in the India-Pakistan relationship'' since both countries acquired their nuclear arsenals.'' ''The term proliferation' is a great misnomer. and would only decrease the chance of great power wars. concedes some of Waltz's argument. In such a context. He is not a member of an apocalyptic death cult. But plenty among them see at least some merit in the picture he paints.'' he said in a recent interview. The international community already holds disdain for them. This is partly because nascent nuclear nations don't have the best command and control systems for their weapons. ''There's something known in the literature as a crystal ball effect. it is likely to be a localized proxy conflict like the Korean War instead of.'' In particular.0 LO 155 2AC CTBT Politics (2/3) b. Since the risk of escalation in any conflict is so high.''' Allison says. intelligence officials. Sagan in the form of an extended debate. in You’re A Jerk 155 . More troubling is that historically. His 1959 book. Still. and War. argues Waltz. the State. He is perhaps the leading living theorist of the foreign policy realists. the possession of nuclear deterrents by smaller nations can check the disruptive ambitions of a reckless superpower. . then. ''The only thing a country can do with nuclear weapons is use them for a deterrent. the spread of nuclear weapons has taken on what might appear to be a wildfire-like quality.'' Especially in a unipolar world. even blunt the urge for territorial expansion. since they contribute far more to a country's security than any geographical buffer could. Waltz is as against the proliferation of nuclear weapons as the next sane human being. say. and opinion columnists are nearly united in their deep concern over the world's nuclearization. Nuclear weapons. in words Waltz wrote 10 years ago and has been reiterating ever since. not signing CTBT would not uniquely increase it c.Single Payer 2. probably most of the people living in the capital are going to be killed. a dean and professor at Harvard's Kennedy School of Government and one of the country's most visible nonproliferation crusaders. it contains the same arguments Waltz makes today in interviews.'' Waltz told me.

Goldfischer charges.'' are unlikely to give their weapons to terrorists. that nuclear states. Russia's inability in the years since the Cold War to keep track of all its nuclear materials-shows that even a country's strong interest in maintaining control of its nuclear weapons is no guarantee that some won't fall into the wrong hands. a political scientist at the University of Chicago and another preeminent realist thinker.Single Payer 2. that are twice as high as those in Russian Roulette. or is there something more strategic at work? In Waltz's formulation. Mearsheimer argues. Utgoff is terrible a. The problem of ''loose nukes''-in particular.) Waltz.'' Mearsheimer adds. given American capability and American policy?'' 7. ''Any country that gave [nuclear weapons] to terrorists who would use them against the US.0 LO 156 2AC CTBT Politics (3/3) every so-called nuclear ''conflict dyad''-US/USSR. Kennedy himself put the chance of nuclear war during the Cuban Missile Crisis at one in three-odds. Disad is an intrinsic policy option – permutation solves You’re A Jerk 156 . John F. To share Waltz's faith in the pacifying effects of proliferation. thinkers like Waltz and Mearsheimer. ''If you were making decisions for North Korea or Iran. Nevertheless. raise a question that tends to get lost in much of the news coverage of proliferation: Do nuclear states like the United States oppose proliferation simply out of concern for their citizens' safety. . nations acquire nuclear weapons not to menace their neighbors but to protect themselves. which will act somehow at the critical moment. Allison points out. . no matter how ''rogue. Mearsheimer. ''is utterly convinced that there's a rational core in every brain similar to his own. John J.'' . old c.'' And that doesn't begin to account for the possibility of an accidental launch or an attack by an Al Qaeda operative whose effective statelessness and hunger for martyrdom make him undeterrable. No link – Fiat is a magic wand that eliminates the political process 9. and that no one will be able to reach a leadership position in any society who will make the potentially suicidal decision to launch when a massive retaliation is a certainty.'' (Goldfischer is himself a proponent of what he calls Mutual Defense Emphasis-a proposed treaty regime in which nuclear arsenals would be sharply reduced and mutually acceptable missile defenses installed by opposing nuclear powers. Mearsheimer agrees with Waltz. USSR/China.'' Waltz asks. doesn’t actually indicate a chance of extinction 8. is to subscribe to a sort of ''nuclear theology. ''wouldn't you be deadly determined to get nuclear weapons. Even today's long-established nuclear powers. describes himself as closer to Waltz than to Allison on the issue. no warrants b. for example. Whatever its sympathies. with their dogged focus on the calculus of national advantage and interest. the primary threat is the United States. And to the governments of North Korea and Iran. ''Iran is highly unlikely to give nuclear weapons to terrorists. says David Goldfischer of Denver University's Graduate School of International affairs. Allison notes. in large part because they would be putting weapons into the hands of people who they ultimately did not control. raising the threat of nuclear terrorism. ''would disappear from the face of the earth. may owe their continued survival as much to luck as logic. And the precarious hold on power of the government in a nuclear nation like Pakistan only adds to the volatile mix. India/Pakistan-the first of the two to go nuclear came close to launching a preemptive attack to profit from its nuclear advantage. and there's a reasonably good chance that they would get Iran incinerated'' if the weapon was traced back to the regime in Tehran.

When it comes to reducing the federal deficit.4 trillion in federal spending.dll/article? AID=/20090721/REG/907219990) Hedge fund managers and corporate boards received low marks with regard to ethical behavior in a recent survey of financial-industry professionals. which believed deficits really didn’t matter. respondents generally consider corporate boards and corporate executives to be most responsible for the current financial crisis. More than 2. You’re A Jerk 157 . or the next generation.com/articles/2009/05/25/opinion/our_opinion/opinion2. 3. markets.is a necessary but temporary evil to jump-start the country out of recession. market systems.5 percent of next year’s projected $3..txt] The Daily Independent. The CFA Institute yesterday released the Financial Market Integrity Index illustrating “soured sentiment and shaken faith” among financial professionals regarding the ability of current U. the deficits will not dip below $500 billion a year for the next decade. President Obama recently sent to Congress a proposal to either eliminate or reduce spending for 121 programs for a savings of $17 billion.Single Payer 2. and $1. even assuming a fully recovered economy. What additional revenues there are in his budget are earmarked to offset the cost of his health-care reforms..000 investment professionals participated in the research by taking the survey either online or via telephone interview in February and March. Nevertheless. .8 trillion this year.-based respondents were likely to recommend investing in U. However.the Wall Street bailout. Ashland. the stimulus package .. The Financial Market Integrity Index is designed to gauge chartered financial analysts’ perceptions of the state of ethics and integrity in different markets around the world. despite all of his assuring words.. Deficits growing now – no fix coming THE DAILY INDEPENDENT 5 – 25 .S. The White House forecasts show that. We can no longer afford to leave the hard choices for the next budget. expect President Obama to boast in future years about cutting the deficit.S. only 49% (versus 68% a year ago) of U. that would be a tactic lifted from his predecessor.S. Those outside the United States also appear to have lost faith in the U.” Those words come after eight years of irresponsible spending during the administration of President George W.3 trillion next. but there’s nothing in his budgets or his economic policy speeches to indicate a serious assault on the deficit once the current crisis passes. the perception of hedge fund managers was lowest overall. In short. Bush. not deficit reduction.investmentnews.com/apps/pbcs. And his proposal immediately ran into a storm of opposition on Capitol Hill. Maybe deficits really do matter to Obama. The federal government now borrows a whopping 46 cents of every $1 it spends. In the ethical-behavior category. the next administration. President Obama plans on passing the problem of the deficit to the next president. Based on their perception of market ethics and integrity alone. Investor confidence low – comprehensive study proves Jeff Benjamin. If so. According to the report that accompanied the survey findings. far short of matching his words. Failure to rectify ballooning state Medicaid deficits makes economic decline inevitable. but his proposals sure don’t indicate that. Maybe so.09 [President’s policies don’t match his words. Investment News. President Barack Obama’s actions fall far. .S. New White House forecasts show a deficit of $1. The new president recently told his Cabinet: “We can no longer afford to spend as if deficits do not matter. 2. 7/21/2009 (http://www. 4. We control the internal link to the impact – only federal action to stem states’ negative procyclical actions ends the recession – that’s Mattoon and Lav. it represents 0. Obama’s words were most welcome. For those who us who believe that bringing spending in line with revenue does matter. Obama’s actions tell a different story. Some form of healthcare reform is inevitable by the end of the year – Obama is banking his entire agenda on successful passage and is expending all the political clout he has to push it through –– that’s Woodhead. according to the finding. investor protections to ensure an orderly functioning of the equity markets. If that sounds like a lot. To be fair. The White House contends big spending . http://bgdailynews. almost four times the previous record set by President Bush.0 LO 157 2AC Econ DA (1/3) 1. mostly from his own Democrats trying to protect their pet projects. with pension fund managers earning the top-rated spot.

000 a year would whack small businesses who pay the individual income tax. which resembles that of the United States in its emphasis on private. chief lobbyist at the U. a properly structured NHI program could expand coverage without increasing costs by reducing the huge health administrative apparatus that now consumes 31% of total health spending. fee-for-service– based practice. Canadian hospitals. resulting in less government revenue. Chamber of Commerce.php) [LO//JW] In contrast to CDH.health care taxes would destroy small businesses – key to the economy. obviating the need for administratively complex per-patient billing. neither piecemeal tinkering nor wholesale computerization can achieve significant bureaucratic savings. everyone with a 401(k). MD. resulting in less government revenue. retirees. too. Indeed. less economic growth. Proponents of NHI. and fewer jobs . Turn . The average US hospital spends one-quarter of its budget on billing and administration. which are mostly private. Small businesses and the entrepreneurs who lead them have been the primary drivers of job growth over the past decade.washingtontimes. Then. Turn – plan slashes healthcare costs by $300 billion Himmelstein. most of whom are in private practice. less economic growth.pnhp. Health care’s enormous bureaucratic burden is a peculiarly American phenomenon. The Department of Medicine at Cambridge Health Alliance/Harvard Medical School. But Mr. nearly twice the average in Canada. No nation with NHI spends even half as much administering care nor tolerates the bureaucratic intrusions in clinical care that have become routine in the United States." Mr. Physicians for a National Health Program of Chicago. MD + MPH. chief lobbyist at the U. as the recession deepened last year. MD.not more. Fee schedules are You’re A Jerk 158 . "You don't build a house by blowing up its foundations. family farms. too. and produce as much as 60 percent of all jobs. On Capitol Hill. Unfortunately. 6. enough to fully cover the uninsured and to upgrade coverage for those now underinsured. administrative overhead in Canada’s health system. saying that this was not the time to raise taxes on higher income people because it would further weaken the economy. is about half the US level." saying that "small businesses. and anyone who flips on a light switch is going to pay higher taxes under this plan. Bush's two top tax rates expire at the end of 2010.which will cost an estimated $1 trillion over 10 years . House Minority Leader John A. charities.S. he changed his mind. “Our Health Care System at a Crossroads: Single Payer or Market Reform?” www. "You don't build a house by blowing up its foundations. disinterested civil servants and . nonprofit institutions. say it could still be in a recession or in a weakened condition well into 2011.66 clerical workers per doctor. including members of the Federal Reserve Board. and Woolhandler. and fewer jobs .com/news/2009/feb/27/obamasbudget-to-raise-small-business-taxes/)[LO//AS] Business advocates charged that multiple tax increases on Americans earning more than $250. Obama needs increased revenue to launch his national health care plan .not more. but many economists. $300 billion annually.000 a year would whack small businesses who pay the individual income tax. Canada’s NHI has 1% overhead and even US Medicare takes less than 4%. Small businesses and the entrepreneurs who lead them have been the primary drivers of job growth over the past decade. Lambro 2/27 Donald Lambro is the chief political correspondent of The Washington Times. American physicians spend nearly 8 hours per week on paperwork and employ 1. Our biggest HMOs keep 20%—even 25%—of premiums for their overhead and profit." said Bruce Josten. much as a fire department is funded in the United States.and his budget calls for letting President George W. and Steffie Woolhandler. are paid a global annual budget to cover all costs. 2009 (http://www.org/news/2008/may/our_health_care_syst.S. ‘07 (David U. Canadian physicians. bill by checking a box on a simple insurance form. Business advocates charged that multiple tax increases on Americans earning more than $250.0 LO 158 2AC Econ DA (2/3) 5. And HMOs inflict mountains of paperwork on doctors and hospitals. dept Medicine Harvard. and even skeptics all agree on this point. and a nationally syndicated columnist He won the 1995 Warren Brookes Award for Excellence in Journalism “LAMBRO: Obama's budget to raise small-business taxes” February 27. 11/07. far more than in Canada. the author of five books on the government and the economy. middle-class families. This plan would punish them with higher taxes. This plan would punish them with higher taxes. and produce as much as 60 percent of all jobs. Himmelstein. Obama ran for president saying he will raise taxes on wealthy Americans by boosting the present 35 percent top income tax rate to the nearly 40 percent rate under President Clinton in the 1990s. The key to administrative simplicity in Canada and other nations is single-source payment.Single Payer 2. Boehner of Ohio called the budget plan a "job killer." said Bruce Josten. The White House expects the economy to be in a recovery at that time. Reducing our bureaucratic apparatus to Canadian levels would save about 15% of current health spending.

and those states that can borrow at all are being forced to pay punitive interest rates. It makes no sense to add to the problem by cutting public spending. 7/22/09. anyway). is that state and local government revenues are plunging along with the economy — and unlike the federal government. the nation will be reeling from the actions of 50 Herbert Hoovers — state governors who are slashing spending in a time of recession. But that’s the result of a slump in private spending.” New York Times.0 LO 159 negotiated annually between provincial medical associations and governments. are subject to balanced-budget rules. to be cutting public services and public investment right now. And shredding the social safety net at a moment when many more Americans need help isn’t just cruel.federal economic action ineffective without rectifying state deficit problems. You’re A Jerk 159 . often at the expense both of their most vulnerable constituents and of the nation’s economic future. state governors aren’t stupid (not all of them. especially public investment. our workers haven’t lost their skills. Our capacity hasn’t been diminished. public investment competes with the private sector for scarce resources — for skilled construction workers.com/2008/12/29/opinion/29krugman. But right now many of the workers employed on infrastructure projects would otherwise be unemployed. Now. http://www. They’re cutting back because they have to — because they’re caught in a fiscal trap. to the decision by a committee that manages California state spending to halt all construction outlays for six months. Investors. Krugman. from a national point of view. are refusing to buy anything except federal debt. unlike the feds. It adds to the sense of insecurity that is one important factor driving the economy down. and the money borrowed to pay for these projects would otherwise sit idle. 7. our technological know-how is intact. medical care for families. Partly that’s because these governments. But even as Washington tries to rescue the economy. But even if they weren’t. or repairs to decaying roads and bridges than it was one or two years ago? Of course not. “Fifty Herbert Hoovers.html? _r=1&ref=opinion&pagewanted=print [Mardjuki] No modern American president would repeat the fiscal mistake of 1932. which will force young offenders out of group homes and into prison. So why are we doing this to ourselves? The answer. running temporary deficits would be difficult. in which the federal government tried to balance its budget in the face of a severe recession. of course. driven by fear. All patients have the same coverage. These state-level cutbacks range from small acts of cruelty to giant acts of panic — from cuts in South Carolina’s juvenile justice program. lower-level governments can’t borrow their way through the crisis. too. When the economy is booming. prof of economics and international affairs @ Princeton. In fact. but the nation as a whole — less able to afford help to troubled teens. the true cost of government programs. for capital. But let’s step back for a moment and contemplate just how crazy it is. is much lower now than in more prosperous times.nytimes. Why can’t we keep doing good things? It’s true that the economy is currently shrinking. Paul. 2AC Econ DA (3/3) Plan solves impact .Single Payer 2. Think about it: is America — not state governments. The Obama administration will put deficit concerns on hold while it fights the economic crisis.

" said Chris Whatley. That comes as good news for the Pentagon and nation. As a result." The reality of how the vast majority of the stimulus money will be spent is quite different.Single Payer 2. The public face of the stimulus package has been the worker in a hard hat. but it also calls for caution to avoid falling behind on future manpower needs. http://www. education.0 LO 160 2AC Military DA (1/2) 1. Budget Cuts mean recruiting will decrease Watertown Daily Times ’09 (Watertown Daily Times 5-12-09 http://www.com/article/20090512/OPINION01/305129958) The Defense Department has benefited from the recession which has boosted enlistments and helped meet the nation's manpower needs. Arnold Schwarzenegger appeared before the cameras at a job site along a freeway east of San Francisco. 2009. California Gov. "We all talked about 'shovel-ready' since September and assumed it was a whole lot of paving and building when. the Washington director of the Council of State Governments. He estimates states will get three times more money for education than for transportation. 3. Earlier this spring.msn. Technological dominance means that each one of our soldiers can do more damage than one of the enemy’s. is hitting pay dirt in the huge federal effort to turn the economy around. so much so that they can again be more selective in choosing their recruits. He declared that the stimulus-financed project would provide paychecks for 235 construction workers who otherwise would have to "stand in the unemployment line.com/id/31110642// Remember the "shovel-ready" projects lined up for all that stimulus money? It turns out social spending. eliminating the use of a military 2. part of the administration's desire to provide immediate fiscal You’re A Jerk 160 . Economic decline means that the US withdraws.watertowndailytimes. more than construction. then other countries would perceive that the US is no longer a threat c. highways and rail projects. for example. a service of the National Governors Association and the National Conference of State Legislatures.7 billion budget for recruiting and retention by almost $800 million. two-thirds of the stimulus program will go toward tax cuts. the Army has been issuing waivers to those with criminal records or health problems who would have been unacceptable before. so we need less soldiers b. and that raises questions about how much help the Recovery Act backed by President Barack Obama will be to the economy in the long run. including airports. By comparison. a trade group for state governments. relief for state budgets and direct payments to the unemployed and others hurt by the recession. The recession has made the armed services a more appealing alternative to job seekers at a time that the Pentagon is also increasing manpower levels to meet security needs. June 4. food stamps and other social services. unemployment benefits. That is no longer necessary. Overall. Economic power is perceived more than military readiness . according to Federal Funds Information for States. getting back on the job to rebuild the nation's infrastructure. about 15 percent of the money is for transportation. Stimulus spent over 300 billion dollars on expanding social services AP Associated Press.if every single state’s economy collapsed. Impoverished already have healthcare from Medicaid so they wouldn’t join the military – their link ev assumes welfare-style programs which the plan doesn’t do 4. Most of the roughly $300 billion coming directly to the states is being funneled through existing government programs for health care. that's not the case. the Pentagon plans to cut its $7. The armed services have met or exceeded their recruitment goals in the past few months. In order to meets its goals. in fact. Case internals outweigh the disad’s a.msnbc. Government programs benefit Two-thirds of recovery money that flows directly to states will go toward health care.

Ebsco) Attacking U. Foreign Affairs. In addition. Walt. http://www.0 LO 161 relief. Soft power is key to hegemony. Democrats who crafted the package say they directed most of it to existing government programs such as Medicaid and education to prevent state economies from slipping even more. Academic Dean and Robert and Renee Belfer Prof of International Affairs at Harvard’s Kennedy School of Government). Jones has told Secretary of Defense Robert M. troops for Afghanistan 7. Obama’s health care reform bill will pass before the end of the year – impact is inevitable – that’s Woodhead 9. leaving its opposition isolated and ineffective.com/content/2009-07-20/ed-mcphee-attackeconomy) With U. Troops unnecessary. completing the review and getting more Afghan forces involved in the fight before requesting additional U. b. armed forces sometimes seem like the United Nation’s police force. keeping teachers and others employed while strengthening the social safety net. the chairman of the Joint Chiefs of Staff. The wide spread of troops reeks of imperialism. and that its dominance harms them. July/1/09 (Bob Woodward.S. Accordingly. primacy advances broader global interests.hurts soft power The Michigan Daily.com/wp dyn/content/article/2009/06/30/AR2009063002811. The Washington Post. the new overall commander in Afghanistan. Vol. Increase in U. supremacy. July 23. immoral. hypocritical. and unsuited for world leadership. McChrystal. Walt. and it continually damages the nation’s economy.S.S.S. The U. Sep/Oct 2005. said keeping teachers and police officers employed should help prevent the recession from getting worse. Michael Mullen. 05 (Stephen M. a Southern California economist. 2AC Military DA (2/2) John Husing. but it encourages other people to resent and resist U.S. Only a country with imperial intentions would spread their troops that widely. One goal was to help fill state budget gaps. Academic Dean and at Harvard’s Kennedy School of Government. McChrystal has undertaken a 60-day review designed to address all the issues in the war. While billions of dollars eventually will flow to infrastructure projects. Washington finds it easier to rally international support for its policies. But he said the stimulus package would have improved communities' ability to grow over the long haul if it had dedicated more money to public works. U. that they should focus on implementing the current strategy. affordable housing and other projects designed to create jobs.html?sid=ST2009063002822) The day before in Kabul. Gates and Adm. Jones delivered the same message to Gen. Examples range from the expansion of the USSR to Alexander the Great’s Macedonian conquest.S. legitimacy is also a favorite way to erode Washington's international clout.S.michigandaily.S. 84. You’re A Jerk 161 . Much smaller pieces of the pie will be allocated for weatherization. This assault on U. 2009.S. Washington Post staff writer. legitimacy does not directly challenge U.different approach key Woodward.washingtonpost. the United States' opponents are currently seeking to convince others that Washington is selfish. Ed Mcphee. troop’s results in imperialism. July 1. 6. When people around the world believe that U.’s imperialism has dramatically damaged the way the rest of the world looks at our nation.Single Payer 2. Issue 5. Soft Power Turn a.S. troops stationed in more than 150 countries according to statistics for the Department of Defense on the Census Bureau's 2009 statistical abstract. power. the United States has much to gain from the perception that its power is legitimate. 5. As the world's dominant power. http://www. 7/23/09 (The Michigan Daily. Stanley A. Washington Post Staff Writer. 2009.

Despite this. supplying. writer for the Dallas Morning News “Senator says health insurance plan won't cover illegal immigrants” http://www. the chairman of the Senate Finance Committee said Thursday. a study for the NATIONAL BUREAU OF ECONOMIC RESEARCH http://www.0 LO 162 2AC Immigration DA (1/4) 1. said at a meeting with reporters.nber. Max Baucus.25377b8. U. and many other types of manufacturing." Universal health insurance is a key aim of health reform proposals backed by President Barack Obama and key Democrats in Congress. natives benefit more from innovation and commercialization in the United States than abroad. Cheaper labor is wanted during bad economic times b. D-Mont. Indeed. Indian companies are quickly becoming the second-largest producers of application services in the world.S. assuming the immigrants would have been less innovative or less able to commercialize their innovation elsewhere or that U. developing. "That's too politically explosive. Professor of Economics at McGill University.html Health care reforms aiming for universal coverage won't provide insurance for illegal immigrants and may not address the cost to state and local governments for providing medical care to this large group of the uninsured. the globalization of research and development is exerting considerable pressures on the American system. lead.. "We're not going to cover undocumented aliens. writer for the Dallas Morning News. the fact that immigrants increase patenting per capita without reducing native patenting shows that their presence in the United States provides a previously undocumented benefit to natives. “HOW MUCH DOES IMMIGRATION BOOST INNOVATION?”. and the most serious challenge is coming from Asia. It was Americans who invented and commercialized the semiconductor. and advanced materials used in semiconductors. and managing database and other types of software for clients around the world. 5/22 Jim Landers.html The United States' global primacy depends in large part on its ability to develop new technologies and industries faster than anyone else. increased investment in research and development (R&D).dallasnews. Recession means businesses are more likely to hire illegal immigrant a. And technological competitiveness is key to hegemony Segal 04 Writer for Foreign Affairs "Is America Losing its Edge?" http://www.S. aerospace. 08 Jennifer Hunt. b." Sen. Asian governments are improving the quality of their science and ensuring the exploitation of future innovations. meaning businesses want cheaper labor 3. and Taiwan is rising. and preferential policies for science and technology (S&T) personnel. Today. advantage in the manufacture of computer chips and telecommunications software. The percentage of patents issued to and science journal articles published by scientists in China. Innovation turn a. the personal computer. undocumented workers. and bills being assembled in House and Senate committees are aiming to reach that goal through a mix of incentives and mandates. scientific innovation and technological entrepreneurship have ensured the country's economic prosperity and military power. however. 2. And even China has made impressive gains in advanced technologies such as lasers. Immigration key to innovation Hunt et al. The difference is fully explained by the greater share of immigrants with science and engineering education. as the United States is You’re A Jerk 162 . Although the United States' technical dominance remains solid.org/20041101facomment83601/adam-segal/is-america-losing-its-edge. For the last five decades. biotechnology. Through competitive tax policies.Single Payer 2. Indeed.pdf page 24 We find that a college graduate immigrant contributes at least twice as much to patenting as his or her native counterpart. this technological edge-so long taken for granted-may be slipping.com/sharedcontent/dws/dn/latestnews/stories/0522DNBUShealthcare. South Korea. Normal means is that the plan doesn’t affect illegal immigrants – mitigates the link Landers. implying immigrants are not innately more able than natives.S. Singapore. and the Internet. minimum wage just rose. other countries merely followed the U.foreignaffairs. immigrants are less likely to have patented recently than observably similar native scientists and engineers.org/papers/w14312.S. South Korea has rapidly eaten away at the U.

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globalization cuts both ways: it is both a potent catalyst of U.S. technological innovation and a significant threat to it. The United States will never be able to prevent rivals from developing new technologies; it can remain dominant only by continuing to innovate faster than everyone else. But this won't be easy; to keep its
privileged position in the world, the United States must get better at fostering technological entrepreneurship at home.

4. Immigration will increase
(Carl Haub, senior demographer at the Population Reference Bureau, 02 08, “U.S. Population Could Reach 438 Million by 2050, and Immigration Is Key,” http://www.prb.org/Articles/2008/pewprojections.aspx <http://www.prb.org/Articles/2008/pewprojections.aspx> ) It is no surprise that immigrants and their descendants will play a large role in future U.S. population growth, as they do now and have for much of the country's history. But the projections detailed in the new report, authored by demographer Jeffrey S. Passel and writer D'Vera Cohn, differ from previous projections from the U.S. Census Bureau by assuming that the rate of immigration will hold steady—sending the net number of immigrants from 1.4 million per year in 2005 to 2.1 million per year by 2050 as the population total rises. This assumed increase in immigrants is, as the Pew report puts it, "in line with, but somewhat slower than, the growth trend of the last several decades."The Pew projections also offer a unique analysis of immigrants' role by taking into account the different birth rates of first-, second-, and third-generation immigrants. The authors estimate that immigrants arriving after 2005, and their children and grandchildren, will account for 82 percent of the population growth between 2005 and 2050.

5. Highest immigration rate in history of America now Scott, staff writer, 2009
(Jenny, 2-10-09, “Immigration High” http://www.nytimes.com/2002/02/10/weekinreview/february-3-9-national-immigrationhigh.html?scp=4&sq=immigration%20high&st=cse) [Charlie Stephens]

The number of foreign-born residents and children of immigrants in the U.S. has climbed to its highest level in history, the Census Bureau announced. More than a quarter are from Mexico; that is the largest share
held by any country since 1890, when Germany accounted for 30 percent. On average, they are more urban, less educated and less affluent than other Americans, but as likely to be in the labor force. They make up 20 percent of the population -- less than the 1910 peak of 35 percent.

6. Immigration is good for the economy – they contribute at least $10 billion each year Melissa Marietta 06. [“Undocumented immigrants should receive social services”] http://findarticles.com/p/articles/mi_m0IMR/is_1-2_81/ai_n16599310/pg_4/?tag=content;col1 The National Research Council has found that "immigration benefits the U.S. economy overall, and has little negative effect on the income and job opportunities of most native-born Americans." (17) It asserts that "immigrants add as much as $ 10 billion to the economy each year and they will pay more in taxes than they use in government services over their lifetimes." (18) Jeffery Passel, the author of several studies on immigration, adds "that all immigrants arriving after 1970 pay a total of $70 billion in taxes to all levels of government, thereby generating $25-$30 billion more than they use in public services." (19) 7. Recession doesn’t matter - Mexico was also hit, meaning there is a minimal risk that they are comparatively better off than us

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8. Mexican Stability turn a. Immigration is key to Mexican stability Weintraub 07
Sidney Weintraub, holder of the William E. Simon Chair in Political Economy and professor emeritus at the Lyndon B. Johnson School of Public Affairs of the University of Texas at Austin, “The Immigration Debate and U.S.-Mexican Relations” http://docs.google.com/gview?a=v&q=cache%3ASQ6z89XAYQUJ%3Acsis.org%2Ffiles%2Fmedia %2Fcsis%2Fpubs%2F070625_weintraub_commentary.pdf+immigration+us-mexican+relations&hl=en&gl=us&pli=1 This polarized depiction has been changing slowly, especially since NAFTA came into effect in 1994. NAFTA itself was a significant departure in trade policy in that Mexico until then tried to limit trade and investment relations with the United States only to embrace the salience of the United States as a market and as a source of foreign investment. In the years before NAFTA, Mexico had a conscious policy of not having any policy toward U.S. immigration practices, but then lobbied hard for regularization of undocumented Mexican immigrants and a large temporary worker program – Mexico sought what former foreign minister Jorge Castañeda called “the whole enchilada.”

Mexican President Felipe Calderón publicly criticized the U.S. intention to build fences along the border during a joint press conference with President Bush when the latter was on an official visit in Yucatán. If the United
States is effective in cutting off undocumented immigration from Mexico, and if there is not a substantial temporary worker program to offset Mexico’s safety valve, this may introduce a severe problem in Mexico to create enough good jobs at home to reduce the emigration push force. Destabilization in Mexico, which could ensue, is mainly a Mexican problem, but one that will have repercussions next door in the United States. The United States would then have to devise policies to deal with Mexican instability.

b. Mexican stability key to US security and prosperity Roberts and Walser 2/12
James Roberts, Research Fellow For Economic Freedom and Growth at the Center for International Trade and Economics (CITE), and Ray Walser Senior Policy Analyst for Latin America at the Douglas and Sarah Allison Center for Foreign Policy Studies “Growing Instability in Mexico Threatens U.S. Economy and Border Security” http://www.heritage.org/research/latinamerica/wm2290.cfm

Mexico's ongoing political stability and economic health are critical to the prosperity and national security of the United States. The Obama Administration must make confronting the many challenges facing our southern neighbor both a foreign and a domestic policy priority. In order to realize this vital American interest,
the current Administration should do the following:

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9. Healthcare is not a magnet for immigration King, writer for Center for American Progress, 07
(Meredith L. King, Writer for Center for American Progress; a program dedicated to improving American lives through thoughts and actions 6/7/07 http://www.americanprogress.org/issues/2007/06/pdf/immigrant_health_report.pdf

Job opportunities across the country are the “magnet” that draws immigrants to the country; not federal incentives such as health care coverage and services. Immigrants are most likely to be employed in indus-tries that do not offer health insurance coverage, such as agriculture, construction, food processing, restau- rants, and hotel services.31 Immigrants are nearly four times more likely to work in the agricultural industry and two times more likely to work in the construction industry.32 Uninsured rates in these industries are over 30 percent for all workers compared to 19 percent for workers across all industries.33 Work opportunities through guest-worker programs also drive immigration. Yet the guest-worker pro-grams for temporary, unskilled labor (the H-2A pro- gram for agriculture workers and the H-2B program for non-agriculture workers) provide limited, if any, health care benefits to the documented
immigrants in the programs.34 Immigrants in the H-2A program do have limited legal protections, including employer compensation benefits for medical costs and payment for lost time due to temporary or permanent work injury. But ag-ricultural employers in this program are not required to provide health insurance or other needed servic-es.35 And existing protections are rarely enforced. Immigrants in the H-2B programs do not even have those limited benefits. Their employers are obligated to offer full-time work and pay the prevailing wage rate, but there is no regulation requiring any of the benefits afforded H-2A workers.36 And while it may seem that H-2A workers have limited access to the health care system on paper, in practice they often find that they do not. These laborers often toil in two of the most dangerous industries, agriculture and forestry. Fatality rates in these two industries are nearly 10 times the national average.37 Yet both H-2A and H-2B workers often do not have health insurance to cover appropriate care. Even worse, if an injury or illness is severe, immigrant workers in these two programs lose their jobs and therefore their legal status to stay in the United States.38 Immigrant day workers experience a similar fate. A 2003–2004 national survey of predominantly undocumented day workers found a high level of occupational injuries. One-fifth of the day laborers had suffered a work-related injury, but less than half received medical care for their injuries.39 Purchasing health insurance through the private market is an unlikely option for mmigrants as well. The unskilled work of many immigrants is often low-wage;40 day workers were unlikely to have annual earnings that exceeded $15,000 and full-time immi- grant workers average $23,000 in annual income in 2003.41 Yet the average annual premiums cost paid by a worker for individual employer coverage was $508 and for family coverage was $2412 that same year.42

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According to the Rockefeller Institute of Government. As both Clinton and Bradley learned. Not researchable. Pg 112. it recognizes the variation in state health care systems and reform preferences.and moderate income families and is jointly funded by Washington and the states. which provides health coverage to low. 2. it is politically difficult to build legislative and public constituencies around ideas that have no prior history of support from legislators or consumer groups active in health care policy. the federalist strategy is not problem-free. b.cbpp. Continued job losses will depress revenues further. Federalist healthcare politically controversial – lacks single-payer’s prior history of support Borosage. However.cfm?fa=view&id=1283 [Mardjuki] The state revenue situation is rapidly worsening. 50 State fiat bad – a. shifting the focus of debate from the details of a particular plan to the fundamental question of whether legislators support universal coverage. 2001.form debate—and one that lacks the familiarity of. We can’t research specific solvency answers to a mechanism that isn’t predictable. Center on Budget and Policy Priorities. Substantively. 4.6 percent in the first quarter of 2009 compared with last year.payer insurance. Hickey. You’re A Jerk 166 . it taps into the rhetoric of devolution. [Mardjuki] The federalist option thus solves the puzzle of how to translate a majority favoring health reform into legislation when that majority cannot agree on the precise shape of reform.org/cms/index. http://www. states' rights. single. • Sales taxes are the largest source of state tax revenue. state revenues must grow.” Policy Points. Politically. Kills decisionmaker education – no cost benefit analysis is involved because senators don’t consider the possibility of other actors enacting their policy – it’s not real world. Counterplan doesn’t end states’ procyclic economic action – only a federal system solves – that’s Lav and McNichol. 7/23/09. Income taxes and other taxes are also falling as wages and investment income decline. But overall revenues last year were essentially flat and have weakened dramatically this year. States can’t solve – increased taxes exacerbate the recession. Entire econ advantage is a complete solvency takeout to this counterplan – state legislatures are already struggling to pay for current Medicaid programs – counterplan plunges states further into the red and exacerbates the recession – that’s Sack and Mattoon. 3. vice president @ Economic Policy Institute. The fifty states have never uniformly passed a single policy. The Rockefeller Institute of Government reports state tax collections fell 12. As a result. The first and largest barrier it has to surrnount is that it represents a new alternative in the American health re. “New Fiscal Year Brings Continued Trouble for States Due to Economic Downturn. lt also puts opponents of reform on the defensive. and they are declining due to the fall in both personal consumption and business purchases. more families are turning to programs like Medicaid. They can have their CP if they have solvency evidence for the states uniformly doing every single plank of the CP – CP’s grounded in the literature are the only ones we can predict and research. The Next Agenda: Blueprint for a New Progressive Movement. • Employers are reducing jobs and cutting back on employer-provided health coverage. c.0 LO 166 2AC States CP (1/2) 1. 6. 5. Perm do both – perm accesses double coverage of dual single-payer healthcare systems. • To keep pace with the cost of services. income tax collections during the first four months of this year fell by 26 percent compared to the same period last year.Single Payer 2. BPP. States face other problems from the weakening economy. Robert and Roger. prof of law @ American University. for example. and choice.

Another objection might be that the federalist strategy would circumvent natural gridlock only to allow reform to fall victim to political deadlock at the state level. prof of law @ American University. Borosage. Pg 112. because citizens’ access to medical care services would be a function the health system chosen by the state in which they reside. Robert and Roger. vice president @ Economic Policy Institute. Some legislatures might replicate congressional failure to enact reform. in critics’ view. 8. inefficient. Hickey. States fail – inequitable. even though the federalist plan mandates a state plan for cost control. <INSERT STATE SPECIFIC ECON DA/STATE POLITICS DA> You’re A Jerk 167 . 2001.Single Payer 2. and vulnerable to state politics deadlock. The Next Agenda: Blueprint for a New Progressive Movement. or some states might resist the imposition of a federal mandate for health reform that they do not welcome for ideological or financial reasons.0 LO 167 2AC States CP (2/2) 7. Such a system would be unfair. in the absence of a national budget for health care the state’s control over medical care spending could be even less certain than under the single-payer model. In addition. [Mardjuki] The objection most likely to be raised is that the state-by-state variation permitted by a federalist health system would be inequitable.

The latter depends a lot on per capita income—that is.5 billion for health services in 2006. States then vary greatly in the extent to which public programs cover those who remain without coverage. more than half of the cost of Medicaid and the State Children’s Health Insurance Program (SCHIP) is borne by the federal government.5 billion by states You’re A Jerk 168 . The evidence shows that although federal matching rates are inversely related to income with the intent of encouraging states to spend more—that is. Pgs 667-669. http://healthaff. coverage and spending variation. This insurance varies among states because of industry and firm size. 6. Some variation is inevitable and exists in Medicare and private coverage as well.4 That is. the federal and state spending on Medicaid services is much higher in high-income states than in low-income states. the marginal cost of additional spending is lower for lower-income states—the fact is that most states don’t take advantage of the federal offer of higher matching funds.0 LO 168 A2: States CP States can’t solve – can’t cover uninsured. “State Variation in Medicaid Spending: Hard to Justify. states are left with very different shares of the population without employer-sponsored insurance. education. a great deal of federal money supports these programs. For example. people with low incomes are a higher share of the population in some states than others.5 Thus. states’ ability to pay—but it also depends on the general philosophy toward income transfers to lower-income populations. We have shown elsewhere that states with lower levels of spending have lower levels of access and worse health outcomes. Moreover. higher-income states tend to spend far more per capita from their own resources. Director of Health Policy Research Center @ The Urban Institute. In the end. Between the variation in spending per enrollee and the share of low-income populations that are covered.org/cgi/content/full/26/6/w667 [Mardjuki] Martin and colleagues’ paper does not address another major source of variation in Medicaid spending: that states cover very different shares of their low-income populations.6 Of this.2 As a result. state spending is determined by federal matching rates that vary inversely with state per capita income and with states’ willingness to spend from their own resources.0 billion was spent by the federal government and $135. such that even with the lower federal matching contributions. income. uninsurance rates differ greatly among states.3 This is in part because states have very different problems to address. Although the nation has chosen to have a decentralized system to provide coverage to low-income Americans. the variations in Medic-aid spending are quite extensive. As a result. and a number of other factors. $179. Volume 26 No.Single Payer 2. 2007. States face very different problems in covering their low-income populations because of the variation in employer-sponsored insurance. But whether the variation that we observe in Medicaid is acceptable is another matter. September 18. the spending variations have consequences that are felt at the national level. The incentives in Medicaid to have low-income states spend more by having federal payments offset lower state per capita incomes have simply not been successful. John.highwire. Medicaid programs spent $314. Holahan. composition.” Health Affairs: Policy Journal of the Health Sphere.

Moreover.org/cgi/content/full/26/6/w667 [Mardjuki] States must provide a minimum amount of coverage and benefits. The large federal contribution to Medicaid and SCHIP and the fact that state matching rates vary inversely with state per capita income seems to recognize a national interest in extending coverage to low-income groups. political agreement on an approach to extending coverage to all will be difficult to achieve.0 LO 169 A2: States CP Federal action key to increase coverage and eliminate state treatment variation. Moreover. Ironically. This not only will have consequences for the states in which they reside. September 18. You’re A Jerk 169 . then wide state variations are problematic. If there is a strong national interest. A national solution will be needed to eliminate the extensive variations that the current system has brought. But such a solution would have huge costs to the federal government. The result of a stalemate will be that low-income people will continue to be treated very differently depending on where they live.highwire. Connecticut. Holahan. but because poor access to health care will affect health outcomes. Other relatively progressive states including New York. Vermont. but they have considerable flexibility in extending coverage and structuring benefit packages. Massachusetts has enacted a plan to achieve (close to) universal coverage. http://healthaff. the recent interest in extending subsidies to low-income people through federal tax credits suggests that even those who oppose expanding government insurance programs in general accept the need to extend health insurance coverage to low-income Americans. “State Variation in Medicaid Spending: Hard to Justify. Coverage of individuals and spending on health services will be subject to state officials’ willingness to pay. 6. Other states will be left with the current mix of programs. John. it is likely that only these more progressive states can achieve the political consensus necessary to substantially extend coverage.” Health Affairs: Policy Journal of the Health Sphere. 2007.Single Payer 2. Volume 26 No. regardless of where they live. regardless of where they live. Director of Health Policy Research Center @ The Urban Institute. Pgs 667-669. the recent interest in state health reform is likely to make current inequities worse. But it can be argued that there is a national interest in how these programs work. In American politics today. There would actually be more national uniformity in the Bush administration tax proposals than exists in the current Medicaid and SCHIP structure. it will have implications for the nation as well. and Illinois have enacted or are seriously considering major proposals to extend coverage to all. including the degree in which they cover long-term care services. regardless of the generosity of federal matching payments available to them. Pennsylvania.

You’re A Jerk 170 . Until December 31. Or suppose that the firms which offer private long-term care policies run into trouble. The recent stimulus package suggests another useful path. Looking at these figures.0 LO 170 A2: States CP States ineffective – can’t fund. not only for poor people. but they will not be enough. It’s all too plausible to devise scenarios in which state Medicaid programs end up bearing large unanticipated costs. These fixes will help. They face legal and institutional constraints on deficit financing and new taxes. you might reasonably ask: Why are states complaining? The answer is: They lack the fiscal capacity to bear the load. As you can see. “Guest Graph: The Future of Medicaid.html [JM] Figure 2 is identical to Figure 1—except that it includes federal expenditures on the same graph. One way or another. too. bipartisan mismanagement of public employee health and retiree benefits. the federal government must carry an increasing share of the Medicaid burden. Yet another challenge of health reform. Projections of future expenditures show the same pattern. http://voices. These subsidies should be enlarged and made permanent. 2010. Klein. for example. but for millions of others. that medical improvements gradually raise average lifespan of Alzheimer’s patients in long-term care. 6/19/09. Properly designed. Ezra.washingtonpost.com/ezraklein/2009/06/guest_graph_the_future_of_medi. Suppose.” Washington Post. As my colleague Colleen Grogan suggests. in both relative and absolute terms. The program has outgrown the financial and administrative capacity of state governments. health reform can also help by providing new forms of public or private coverage for low-income Americans who might otherwise require Medicaid. federal expenditures have increased much faster. economic and domestic policy expert.Single Payer 2. we should recognize and embrace the fact that Medicaid has become a central pillar of the American welfare state. unanticipated costs. They bear the consequences of their severe. stimulus insufficient. States also bear readily-overlooked systemic risks. senior editor. The impact of competing proposals for state finances has received less attention than it should. the federal government agreed to pay a higher matching rate to states that agreed to maintain Medicaid eligibility and benefits at roughly pre-recession levels. in return for greater federal oversight over matters such as quality assurance and reimbursement.

to be the Grinch. Complexity does not contribute value and is expensive. Our so-called employer-based health care pays only 20 percent of the cost. and have been a source of frustration and expense. The big one is that states don’t have the fiscal stability to run universal health care. or. the Department of Veterans Affairs and insurance premiums for government employees at the federal. The universal programs currently discussed in Congress involve multiple tax exemptions and credits to pay for insurance premiums to multiple companies at multiple levels of poverty for multiple plans. Who should pay for health care? The simple answer is. We might be able to achieve universal coverage without adding any more tax money to the system. And the states don’t have the regulatory authority. you don’t really want this being a state-run solution. and their average overhead is 31 percent. They contribute nothing of value. We pay a social worker to spend 3-1/2 hours per family to enroll them in Medicaid. He was formerly an associate editor for The American Prospect political magazine “Bridging the Gaps” http://www. where the Democratic governor. 49 of 50 states cant deficit spend. Lifting their health care burden and throwing in workers’ compensation premiums. when they tried it. which would be redundant in a single-payer program. village. and then moved out of the state in order to kill the model. Medicaid. and to make sure that no one gets services who is not properly poor. Business and industry should not pay for health care. all of us! The more critical question is how we pay. The best of them operate at an overhead of 15 percent. which is more than the single-payer countries pay per capita to cover their entire population. but they’re not going to work. "I say to you with a clear heart that I've tried everything. It didn’t work in Hawaii. This process is expensive. the size to do that. increasing coverage through state plans is worthwhile. The simplest and therefore the most economical way to pay is single payer. Government already pays more than 60 percent of health care cost through Medicare. they have been contemptuous of patients and the medical profession. We should not pay through special programs for the poor. and one big one. It’s happened time and time again -. the people.org/csnc/blogs/ezraklein_archive?month=10&year=2007&base_name=bridging_the_gaps I’m here. The insurance industry is complex and expensive. This is money wasted by complexity that will not buy a single MRI or colonoscopy. well. which saw an economic downturn move more people onto their subsidies exactly as the state’s revenues dropped. Medicare — 65 and you’re in — operates at 3 percent. told his state that. Indeed. We have lived with HMOs for nearly two generations and they have failed to deliver affordable care. and cost will determine our achievement of quality universal coverage. which are. The plans fall for a few small reasons. the states have been unable to solve Klein 07 Ezra Klein. they are not sustainable without government subsidy. These useless middlemen cost us $400 billion every year. at the end of the day. like Oregon. We should not spend resources on anything that does not contribute value. There is no big lump of federal money that will make the problem go away. We should not pay through insurance.prospect. save in a few cases. As a stopgap. We’ve got all these great universal bills passing at the state level. demeaning. Phil Bredesen.600 per capita for health care. and the insurers first jacked up the premiums. It didn’t work in Washington State. Simplicity is frugal and effective.000 people uninsured. upon killing off Tenncare and leaving 300. I simply don’t trust them to fundamentally reform the system. city. they are pretty great.0 LO 171 A2: States CP Empirically. By their own admission. I think. might assuage their resistance to a modest increase in corporate tax. and I’m here to tell you that. It didn’t work in Tennessee. Moreover. and many other states. empty our pockets for the last 20 percent in the form of deductibles and co-pays. state. because it affects cost in a big way. repetitive and perpetuates disparities. Medical professionals have made tremendous progress but at a cost that puts care out of reach for a third of our people. Government already pays more than $3. and we. blogger for the Washington Post. more than once. How we pay matters. That means that when the state goes into recession and more people need subsidies and the revenues to give them don’t exist the state can’t borrow the money. the biggest problem in the system. town and school district levels. but health care reform is more than access – it’s actual reform to bring down costs.in some states.Single Payer 2. You’re A Jerk 171 . and they are in enough trouble already. It would certainly improve their competitiveness in the global economy and create a few more jobs at home. So they dismantle the program." Similar plans failed in Oregon. They have no moral or legal obligation. the money. in Massachusetts.

these are well documented: administrative inefficiency. Hickey. has its downside: The pincer strategy simplifies administrative concerns by building on existing programs. vice president @ Economic Policy Institute.Single Payer 2. imposing penalties on the laggards. the pincer strategy. one might reasonably question the effectiveness of Medicaid and CHIP as building blocks toward universal coverage. the addition of new populations to Medicaid would improve recipients’ medical care experience or merely exacerbate existing problems. such as raising the level of federal matching funds allocated to states. and perpetual underfunding. unfortunately. You’re A Jerk 172 . Pg 113-114. limitations of access. Enrollment in CHIP so far has been disappointing. however. Lastly. and millions who are eligible for Medicaid have never applied for coverage.0 LO 172 A2: Pincer CP/Medicaid Expansion CP Pincer strategy can’t control costs. Remedies for the latter problem have been proposed. The Next Agenda: Blueprint for a New Progressive Movement. Robert and Roger. But the key question is whether. In addition. In the case of Medicaid. would do little to control costs. or alternatively. [Mardjuki] Each of these advantages. Borosage. 2001. prof of law @ American University. some state government have deliberately tried to keep enrollments down by limiting outreach campaigns. this is due to the daunting bureaucratic and administrative hurdles that must be cleared in order to enroll. To some extent. however. even with the appropriate policy reforms.

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