Rookie Policy Evidence Set - Neg

Pharmaceutical Innovation Disadvantage 1NC Shell

A. US markets subsidize medical research for the rest of the world – we’re key to pharmaceutical innovation

Grossman 3/9 (Nicholas Grossman, Lecturer in International Relations at the University of Iowa, “What Everyone’s Forgetting About Healthcare”, Arcdigital Media, https://arcdigital.media/what-everyones-forgetting-about-healthcare-d5106db21c2e)

Every other economically advanced country has a form of universal healthcare. And, though the systems vary, they all spend less while achieving better outcomes. Compared to every country on that list, the United States has lower life expectancy at birth, higher infant mortality, and higher obesity. And more American seniors have two or more chronic conditions (68%). Canada (56%) and Australia (54%) are the only others above 50%. The comparison isn’t as simple as advocates make it out to be. With other advanced economies clamping down on the profit motive, the United States effectively subsidizes research and development of drugs and medical devices for the rest of the world. However, it’s fair to say a single-payer system with private health providers (like Canada), a publicly run system (like the UK), or strict price controls and required insurance (like Japan) could plausibly give the United States better care for less money. But it’s politically impossible. That’s obviously true now, with Republicans in charge, but it’s probably true for the foreseeable future.

B. Single payer lowers prices and suppresses innovation

Pitts, 16-- Leonard Pitts Jr., president of the Center for Medicine in the Public Interest and a former Food and Drug Administration associate commissioner, “Op-ed: Single-payer health care unworkable, too costly,” The Philadelphia Inquirer March 8, 2016, Lexis, NCC Packet Draft

The real problem with a single-payer system, however, is much simpler: The approach has failed everywhere it has been tried - from Europe to Canada to Sanders' own state of Vermont. In almost every instance, government-run health care has suppressed medical innovation and made it harder for patients to get the treatment they need at a price they can afford. Both candidates ought to be discussing practical ways to fix our health system's most serious flaw - too much government intervention. Instead, they're quibbling over the many faults of a single-payer program that would dramatically lower the quality of care for all Americans. While he has yet to provide many serious details, Sanders' proposal creates a single-payer health program that would "cover the entire continuum of health care," from inpatient care to hearing, vision, and oral health. Sanders tends to frame his plan as a way to "join every other major industrialized nation on Earth and guarantee health care to all citizens." But one need only look at these other nations to understand why Sanders' vision is a step in the wrong direction. As anyone who has ever stood in line at the Department of Motor Vehicles can understand, government-run systems are invariably wracked by inefficiencies. When it comes to health care, one size doesn't fit all. For instance, Canadian patients hoping to see a specialist physician can expect to wait more than 18 weeks. An MRI scan in that country takes more than 10 weeks. Waiting times have grown so long in Sweden's single-payer system that one in 10 citizens has opted for private coverage. In order to contain health costs, Sanders promises to "stand up to drug companies and negotiate fair prices for the American people." But again, the disastrous effects of drug price controls have been clearly demonstrated throughout Europe. To take one example, the United Kingdom's National Health Service (NHS) consistently denies patients access to the most up-to-date treatments if they are deemed too expensive by regulators. These decisions often lead to avoidable suffering for those in need of care. Last summer, in fact, British health administrators refused to pay for a breakthrough ovarian cancer drug until patients had undergone three rounds of chemotherapy. Drug price controls also come at the expense of medical innovation, as they weaken the incentive for pharmaceutical firms to invest in research and development. In the 1970s, four European countries invented 55 percent of the world's new drugs. Decades of increasing price controls in Europe pushed drug development efforts - representing hundreds of billions of dollars of investment and economic activity - to the United States. Between 2000 and 2010, those four countries accounted for a third of pharmaceutical innovation, while the U.S. share rose to 57 percent. The nonpartisan National Bureau of Economic Research cautions that "cutting [drug] prices by 40 to 50 percent in the U.S. will lead to between 30 to 60 percent fewer R&D projects being undertaken." Less research means fewer new medicines and fewer lives saved.

C. Only pharma innovation solves global pandemics that risk extinction

Sachs 14 (Jeffrey, Professor of Sustainable Development, Health Policy and Management @ Columbia University, Director of the Earth Institute @ Columbia University and Special adviser to the United Nations Secretary-General on the Millennium Development Goals) “Important lessons from Ebola outbreak,” Business World Online, August 17, 2014, http://tinyurl.com/kjgvyro)

Ebola is the latest of many recent epidemics, also including AIDS, SARS, H1N1 flu, H7N9 flu, and others. AIDS is the deadliest of these killers, claiming nearly 36 million lives since 1981. Of course, even larger and more sudden epidemics are possible, such as the 1918 influenza during World War I, which claimed 50-100 million lives (far more than the war itself). And, though the 2003 SARS outbreak was contained, causing fewer than 1,000 deaths, the disease was on the verge of deeply disrupting several East Asian economies including China’s. There are four crucial facts to understand about Ebola and the other epidemics. First, most emerging infectious diseases are zoonoses, meaning that they start in animal populations, sometimes with a genetic mutation that enables the jump to humans. Ebola may have been transmitted from bats; HIV/AIDS emerged from chimpanzees; SARS most likely came from civets traded in animal markets in southern China; and influenza strains such as H1N1 and H7N9 arose from genetic re-combinations of viruses among wild and farm animals. New zoonotic diseases are inevitable as humanity pushes into new ecosystems (such as formerly remote forest regions); the food industry creates more conditions for genetic recombination; and climate change scrambles natural habitats and species interactions. Second, once a new infectious disease appears, its spread through airlines, ships, megacities, and trade in animal products is likely to be extremely rapid. These epidemic diseases are new markers of globalization, revealing through their chain of death how vulnerable the world has become from the pervasive movement of people and goods. Third, the poor are the first to suffer and the worst affected. The rural poor live closest to the infected animals that first transmit the disease. They often hunt and eat bushmeat, leaving them vulnerable to infection. Poor, often illiterate, individuals are generally unaware of how infectious diseases -- especially unfamiliar diseases -- are transmitted, making them much more likely to become infected and to infect others. Moreover, given poor nutrition and lack of access to basic health services, their weakened immune systems are easily overcome by infections that better nourished and treated individuals can survive. And “de-medicalized” conditions -- with few if any professional health workers to ensure an appropriate public-health response to an epidemic (such as isolation of infected individuals, tracing of contacts, surveillance, and so forth) -- make initial outbreaks more severe. Finally, the required medical responses, including diagnostic tools and effective medications and vaccines, inevitably lag behind the emerging diseases. In any event, such tools must be continually replenished. This requires cutting-edge biotechnology, immunology, and ultimately bioengineering to create large-scale industrial responses (such as millions of doses of vaccines or medicines in the case of large epidemics). The AIDS crisis, for example, called forth tens of billions of dollars for research and development -- and similarly substantial commitments by the pharmaceutical industry -- to produce lifesaving antiretroviral drugs at global scale. Yet each breakthrough inevitably leads to the pathogen’s mutation, rendering previous treatments less effective. There is no ultimate victory, only a constant arms race between humanity and disease-causing agents.

Answer To: Big Pharma is Evil

Pharmaceutical profits are key to innovation against emerging disease threats – that solves extinction

Engelhardt 8 – PhD, MD, Professor of Philosophy @ Rice (Hugo, “Innovation and the Pharmaceutical Industry: Critical Reflections on the Virtues of Profit,” Ebrary)

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

Economy Disadvantage 1NC Shell

A.Economic Growth is stable and steady, but needs to stay that way

Schoen 5/31 (John W., Cnbc economic reporter, “A region-by-region breakdown of where the Fed sees the economy now,” 5/31/17, http://www.cnbc.com/2017/05/31/economy-is-slow-and-steady-growth-with-little-sign-of-inflation.html, DOA 6/20/17) NCC

The U.S. economy continued to grow at a steady, if sluggish, pace from early April through late May, according to the Federal Reserve's latest survey of regional economic conditions. That slow pace also helped keep inflation in check, according to comments from the businesses polled by the central bank's 12 regional districts. "On balance, pricing pressures were little changed from the prior report," the central bank said in its Beige Book report on the economy. The Fed has begun to tighten interest rates as the economy continues improving. The central bank held rates near zero for nearly a decade in the aftermath of the financial crisis. The majority of the Fed's 12 districts reported that local businesses had a positive outlook over the near term, despite a recent softening in consumer spending. Two districts — Boston and Chicago — said growth had slowed, while New York said business activity had "flattened out." More regions cited worker shortages across a widening range of occupations. Employment and wages grew at a modest to moderate pace. The U.S. unemployment rate — currently 4.4 percent — is at a near 10-year low. Despite tighter labor markets, there's little sign that inflation is heating up.

B. Single Payer would require massive tax increases – your assumptions of cost savings are politically absurd and empirically denied

Pollack, Professor at the University of Chicago School of Social Service Administration, 2015, (Harold, “Medicare for All — If It Were Politically Possible — Would Necessarily Replicate the Defects of Our Current System” Journal of Health Politics, Policy and Law 2015 Volume 40, Number 4: 923-931, published online before print June 29, 2015, doi: 10.1215/03616878-3150172, p925-926 TOG, *NDCC WAVE ONE*)

Then there is the minor matter of raising taxes by perhaps 8 percent of gross domestic product (GDP) as we move health care spending more fully onto public budgets. To Seidman’s credit, he acknowledges the need for a large tax increase to bring health care onto the public budget. This is a subject that often attracts embarrassed hand-waving among single-payer advocates. Seidman identifies important elements that should be in the mix: a payroll tax, a valued-added tax, an income tax surcharge. That is a heavy lift.

It may be an even heavier lift. Seidman’s essay claims that we might reduce health care spending from 18 percent to 15 percent of GDP. I find this politically implausible. We’re not going to wring nearly one-fifth out of our health care economy while we simultaneously impose radical changes to health care financing. Such contraction is the precise opposite of what we did in establishing Medicare. It will be a miracle if we hold medical spending steady at 18 percent given our aging population. In one 2013 analysis, Michael E. Chernew (2013: 861) calculates that “if the gap between inflation-adjusted per beneficiary Medicare spending and GDP growth per capita drops to zero—a level never sustained for a significant period—Medicare spending will rise from 3.7 percent of GDP to 5.1 percent in 2035.” Under any financing system, we will probably require substantially greater revenue to prevent health care from deeply damaging the federal budget. Neither political party has acknowledged this reality.

Although the electorate and its congressional representatives like to believe that they support fiscal discipline, the evidence to back up these protestations is thin. The ACA’s most unpopular elements are those concerned with cost control or deficit reduction: the Independent Payment Advisory Board, the Cadillac tax,the employer mandate, reduced subsidies to Medicare Advantage plans, the medical device tax, reduced Medicare reimbursement rates to hospitals, the individual mandate. At least the first five of these items are unlikely, politically, to survive in current form.

C. High tax rates hurt the economy.

Carroll, Research Fellow at Tax Foundation, 2009 (Robert, “The Economic Cost of High Tax Rates”, https://taxfoundation.org/economic-cost-high-tax-rates/, DoA 8/19/2017, DVOG, *NDCC WAVE ONE*)

Economic Effects of High Tax Rates
High tax rates discourage work, saving and entrepreneurship. They also encourage taxpayers to rearrange their tax affairs to receive more of their compensation in less heavily taxed forms and to take greater advantage of the myriad tax preferences in today’s tax code. For example, taxpayers can reduce their tax bill by financing more of a home purchase, receiving more of their compensation as tax-free fringe benefits, or rebalancing their investment portfolios towards tax-exempt state and local government bonds.

It’s important to remember that every time a taxpayer makes a decision based on tax considerations rather than economic merit, we all lose. It wastes resources by redirecting them to less productive uses. The cost of high tax rates is not trivial. Research on the major changes in tax rates over the last several decades—the lower tax rates enacted in 1981, 1986 and 2001 or the higher tax rates enacted in 1993—finds that the behavioral responses can be large. This research generally finds that for every 1 percent decrease in the after-tax reward from earning income, taxpayers reduce their reported income by about 0.4 percent.

This does not mean that tax cuts pay for themselves. Rather, tax rate changes can have a profound effect on the size of the tax base, with lower tax rates increasing the size of the tax base and higher tax rates, such as those proposed by President Obama, shrinking the tax base. A shrinking tax base is not only suggestive of the economic costs of high tax rates, but also means that the government will take in less revenue than the casual observer might assume.

High Tax Rates Will Shrink the Federal Income Tax Base
Consider the combined effect of President Obama’s proposal to raise the top tax rate from 35 percent to 39.6 percent and the new surtax. This means high-income households will receive 54 cents rather than 65 cents from every dollar they earn; that is, the after-tax reward from earning income falls by 17 percent. Based on the research mentioned above, with such large increases in tax rates, we can expect taxpayers facing the top tax rates to reduce their reported incomes by nearly 7 percent.

What is critically important from the government’s perspective is that while it collects an extra 10 cents for every dollar subject to the higher rates, it loses over 45 cents for every dollar by which reported income falls due to taxpayers working less or otherwise reporting less income.

Overall, simulating the effect of the higher tax rates in 2011 shows that the federal government can expect to raise at most only 60 cents on the dollar. While “large” is always in the eye of the beholder, losing 40 cents on a dollar should cause us all to question this policy. Moreover, this is a cautious estimate. It is based on the behavioral response estimated for the overall taxpaying population, even though high-income households are likely to be much more responsive. Thus, we might expect an even faster shrinkage of the federal tax base from these tax increases.

Effect of High Tax Rates on the Entrepreneurial Sector
The impact of the higher tax rates on the entrepreneurial sector is also particularly troubling. An often underappreciated feature of our tax system is that roughly one-third of all business taxes are paid by owners of flow-through businesses—the sole proprietorships, partnerships, and S corporations that are often small in size and entrepreneurial—when they file their individual tax returns. These businesses are an important source of innovation and risk taking. The relatively large size of this sector also distinguishes the U.S. from other developed nations and adds to the flexibility and dynamism of the U.S. economy as these businesses are highly capable of bringing new ideas and products to market.

Despite the importance of these businesses to the U.S. economy, they will bear a substantial portion of the higher tax rates. About one-quarter of taxpayers who derive at least 50 percent of their income from a flow-through business will be subject to the higher tax rates (see below table). Moreover, a substantial share of the new revenue—40 percent for the increase in the top two tax rates and 29 percent for the high-income surtax—can be attributed directly to the income reported for flow-through businesses by their owners.

D. Recessions cause health crises

Buysse 10 (I.M., Universiteit Utrecht, Wrtiting for the WHO collaborating centre for pharmacoepidemiology & pharmaceutical policy analysis, “Impact of the economic recession on the pharmaceutical sector,” Feb. 2010, http://apps.who.int/medicinedocs/documents/s17419e/s17419e.pdf, DOA 6/18/17 NCC)

With the collapse of the housing market in the USA and parts of Europe in 2007 the world entered a financial crisis which lasted at least through the years 2008 and 2009. Depending on the country governments adjusted their budgets, which had considerable impact on the available funding to pay for health services.(1-3) In the Organisation for Economic Cooperation and Development (OECD) countries the average amount spend on healthcare before the recession was about 9% of the gross domestic product (GDP), ranging from 6% in Korea, Mexico and Poland to 15,3% in the USA (numbers of 2005).(4) In a recession governments may choose to lower their health care budgets. Since medicines or pharmaceuticals are a substantial part of the health care budget world wide (around 17% in OECD countries) it is likely that governments may take measures to reduce these costs. As a consequence patients may find themselves unable to pay for their health services. It is hard to gauge the implications of the recession on people's health. Experience from past recessions has shown that the impact can be severe. (5) Stukler et al. showed that suicides and homicides rose among working-age men and women when unemployment rose rapidly during times of recession in Europe. A one percent increase in unemployment caused an increase in suicides of 0,79%. (6) An increase in underweight rates among primary school children and low birth weight were observed during the crisis in Thailand.(7) In Mexico mortality among elderly and children was 5-7% higher during the crisis of 1995-1996 when compared to non-crisis years. According to the authors this increase is most likely related to the magnitude of economic crisis and a reduction in public sector medical services. (8) These are some examples of the possible impact of an economic crisis on public health.

Counter-Plan: Reform the ACA

The United States federal government should:

-Fully fund payments due to insurers through the ACA
-Extend the time the individual marketplace is open and fully fund enrollment efforts for the marketplace
-Fully enforce the individual mandate
-Provide $100 billion over the next decade to stabilize state markets and reinsurance programs
-Provide tax credits to those enrolling in the individual marketplace
-Repeal the Cadillac tax on health plans
-Repeal the ACA tax on insurance coverage, and,
-Repeal the employer mandate

The counterplan stabilizes the ACA and expands coverage

Jost 2017 - Emeritus prof at the Washington & Lee U School of Law
Timothy Stoltzfus, "Why Democrats Should Help Trump Fix Obamacare," Mar 27, www.politico.com/magazine/story/2017/03/why-democrats-should-help-trump-fix-obamacare-214957

In any event, the individual market was stabilizing, not collapsing, heading into 2017, as the Congressional Budget Office affirmed. In the complicated world of health insurance, the term “death spiral” has a specific meaning, and we are not there yet—the ACA’s premium tax credits ensure that health insurance will be affordable for most exchange enrollees even if markets tend toward older, less healthy people. But Trump must take action now to ensure that insurers do not flee the individual market for 2018, particularly given the confusion the administration has created over the past two months.

It would be prudent to take no chances. More than 20 million Americans with individual insurance will lose coverage if the market collapses, and their financial security and, in many cases, their lives are at stake. These include not just those covered by the ACA’s exchanges, but also millions of farmers, ranchers and self-employed people who get coverage through the off-exchange market. They must not be abandoned.

The administration should take steps immediately that it can take administratively without legislation to protect the market, including:

Continued funding the cost-sharing reduction payments at issue in House v. Price, making full payment to insurers for the money still owed them for 2016 under the ACA’s program for reinsuring high cost-claims, and settling the insurer lawsuits challenging the failure of the government to make risk corridor payments due insurers who lost money insuring consumers through the exchanges for 2014 and 2015. These are technical issues, but they involve billions of dollars in commitments that were made by Congress to insurers through the ACA. If the administration drops the defense of House v. Price, for example, insurers will lose $9 billion owed them for 2017 for reducing deductibles and out-of-pocket limits for 6 million low-income consumers covered by the exchanges. Insurers are very unlikely to return to the market for 2018 if these commitments are broken; some may even try to leave for 2017.

Pursuing initiatives to ensure market stability. The administration has proposed revisions of current rules to this end, but some of these are ill-advised. Pending proposals to reduce the length of time consumers will have to enroll in the individual market for 2018 or to increase the paperwork burden consumers face in enrolling mid-year when they lose other coverage would discourage healthy people from enrolling and do more harm than good. Supporting state efforts, like Alaska’s, to reinsure individual market insurers for high-cost cases, can make a real difference for reducing premiums, while fully funding the enrollment efforts of HealthCare.gov can help maintain a vital individual insurance market.

Enforcing the individual mandate. Like it or not, the mandate remains our primary means for encouraging healthy as well as unhealthy people to enroll in coverage. The CBO report on the Republican repeal plans projected that repealing the mandate would have increased the number of the uninsured by 14 million in one year. The administration has communicated mixed messages as to whether the mandate will be enforced or not. It now must say clearly that the mandate remains the law of the land, and will be enforced.

The demise of the Republican plan also could open the door for bipartisan efforts to rescue the individual market. Don’t laugh; it’s possible. Few noticed the almost unanimous bipartisan approval by the House last week of a bill partially repealing the McCarran-Ferguson Act, which has long exempted certain anticompetitive actions of health insurers from the antitrust laws. Not enough was attention given, either, to aspects of the Republican American Health Care Act that Democrats should support. These include:

$100 billion over the next decade for funding for state market stabilization efforts, particularly reinsurance programs;

Tax credits to help middle-income Americans who must purchase health insurance in the individual market afford coverage. As the conservative health-care analyst Avik Roy has proposed, these should be combined with means-tested tax credits to make insurance affordable for both lower- and middle-income Americans. Democrats could also consider more generous treatment of health savings accounts for middle- and upper-income Americans coupled with continued protection of cost-sharing reduction payments for lower-income Americans.

Repeal or delay of the widely disliked tax on employer-sponsored “Cadillac” health plans;

Repeal or delay of the ACA tax on insurance coverage, coupled with assurances that the cost-savings insurers receive would be passed on to consumers; and

Repeal of the employer mandate, which has created a tremendous amount of paperwork for employers but offers largely illusory protection for employees.

Answer To: Single Payer is Good for the Economy

Medicare historically exceeds cost predictions

Sue Blevins, 03 4-11-03 (Blevins: president of the Institute for Health Freedom. “Universal Health Care Won’t Work – Witness Medicare.” Cato Institute. Accessed 7-19-17 https://www.cato.org/publications/commentary/universal-health-care-wont-work-witness-medicare JSD.

However, before we accept such a drastic shift in national health policy, we should examine how single-payer health insurance could affect all individuals’ health care costs, choices and privacy. If history is any indication, any single-payer initiative will end up costing much more than advocates claim. That, in turn, will lead to higher taxes and/or rationing under which the government will determine which medical treatments will and will not be covered. How do we know this will happen? Because single-payer health care has already been empirically tested on seniors in the United States. Many people may not realize it, but the Medicare program is one of the largest single payers of health care in the U.S. and in the world. An examination of Medicare’s 38-year-old track record provides evidence of what happens when the government controls the financing of health services for millions of U.S. citizens. Consider the following facts. When Medicare was debated in 1965 (the year it was signed into law), business and taxpayer groups were concerned that program expenditures might grow out of control. However, single-payer advocates assured them that all seniors could easily be covered under Medicare with only a small increase in workers’ payroll taxes. The federal government’s lead actuary in 1965 projected that the hospital program (Medicare Part A) would grow to only $9 billion by 1990. The program ended up costing more than $66 billion that year. Just three years after Medicare was passed, a 1968 Tax Foundation study found that public spending on medical care had nearly doubled in the first few years of Medicare. In subsequent decades, Medicare payroll taxes and general taxes have continued to rise to pay for skyrocketing health care costs.

Single-payer would destroy the economy through tax hikes and revenue disruption

Pipes 16 (Sally, CEO of the Pacific Research Institute and contributor @ CNBC, “The Ugly Reality of Single-Payer,” 1/31/16, https://www.usnews.com/debate-club/is-single-payer-health-care-a-good-idea/the-ugly-reality-of-single-payer, DOA 6/20/17 NCC)

This is complete nonsense. Every other single-payer system around the world delivers subpar care at astronomical cost. Worse still, the multitrillion-dollar tax hikes – that's "trillion," with a "t" – that Sanders has proposed to finance his single-payer monstrosity would decimate the American economy. Voters in need of a definitive reason to dismiss Vermont's "democratic socialist" as a legitimate candidate now have one. Sanders's "Medicare-for-All" proposal would require $14 trillion in new public spending over the next decade and would expand the size of the federal government by over 50 percent. He plans to cover those costs by ratcheting up taxes on virtually everyone. He wants to hike income tax rates by 2.2 percentage points and levy a new 6.2 percent payroll tax on employers. He'd also dramatically crank up income tax rates for families making over $250,000 year. And he'd set the estate tax at 65 percent. These new taxes would slow our economy to a halt. They'd rob businesses of capital to invest in expansion and job creation. The returns on entrepreneurship would dwindle. Corporations would direct investments to friendlier environs abroad. Sanders ought to be intimately familiar with the eye-popping costs of single-payer. They just prevented leaders in his home state from implementing a single-payer scheme within their borders. Four years ago, the Vermont legislature approved a plan to create a state-level single-payer system with basically all the features of Sanders's "Medicare-for-All." But last month, Gov. Peter Shumlin announced that he'd be killing the project, specifically because the requisite tax increases on individual earners and businesses "might hurt our economy." The Sanders "Medicare-for-All" plan is specific about how much lucre it'll extract from the American public, but short on the details about how it would actually be administered. How will physicians' compensation be determined? Who will they work for? For those that refuse to leave private employment, what will the punishment be? Who will own hospitals? The list of unanswered questions goes on and on. Sanders and his ilk are pushing for single-payer in the United States in large part because they admire socialized health care systems in other countries like the United Kingdom and Canada. In their romanticized view, single-payer is more efficient, more egalitarian, more humane and less costly. But the facts don't fit that portrayal. Single-payer systems typically use price controls to control the cost of health care goods and services. Those price controls cause the purveyors of health care goods and services to limit the supply that they'll deliver. Limited supply meets unlimited patient demand – after all, health care appears "free" – and shortages result.

Solvency Take-Outs

Can’t Solve -- Demand for Doctors, especially with increased coverage, outstrips supply

IHS report for the Association of American Medical College, 2015, (“The Complexities of Physician Supply and Demand: Projections from 2013 to 2025,” prepared for the Association of American Medical Colleges by IHS Inc., Washington, DC: Association of American Medical Colleges, available at https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=AAMC-_-ScientificAffairs-_-PDF-_-ihsreport, accessed 6.17.2017 TOG p.vi-vii, *NDCC WAVE ONE*)

Study results suggest the demand for physician services is growing faster than supply. While growth in the supply of APRNs and other health occupations may help to alleviate projected shortfalls to an extent, even taking into consideration potential changes in staffing, the nation will likely face a growing shortage in many physician specialties—especially surgery-related specialties. A multi-pronged strategy will be needed to help ensure that patients have access to high-quality care.

All supply and demand projections are reported as full time equivalent (FTE) physicians, where an FTE is defined for each specialty as the average weekly patient care hours for that specialty. 2 Key findings include:

·         Demand for physicians continues to grow faster than supply, leading to a projected shortfall of between 46,100 and 90,400 physicians by 2025. Although physician supply is projected to increase modestly between 2013 and 2025, demand will grow more steeply (Exhibit ES-1). Across scenarios modeled, total physician demand is projected to grow by 86,700 to 133,200 (11-17%), with population growth and aging accounting for 112,100 (14%) in growth. By comparison, physician supply will likely increase by 66,700 (9%) if labor force participation patterns remain unchanged, with a range of 33,700 to 94,600 (4-12%), reflecting uncertainty regarding future retirement and hours-worked patterns.

·         Projected shortfalls in primary care will range between 12,500 and 31,100 physicians by 2025, while demand for non-primary care physicians will exceed supply by 28,200 to 63,700 physicians. The shortfall range reflects comparisons of all the supply scenarios to all the demand scenarios, and uses the 25th to 75th percentiles of projected shortages across the comparisons. These percentiles reflect that the extreme shortage/surplus projections are least likely to occur as the extreme shortage/surplus projections compare the highest/lowest demand projections to the lowest/highest supply projections.

·         Expanded medical coverage achieved under ACA once fully implemented will likely increase demand by about 16,000 to 17,000 physicians (2.0%) over the increased demand resulting from changing demographics. The Congressional Budget Office estimates that 26 million people who otherwise would be uninsured in the absence of ACA eventually will have medical insurance. Taking into consideration the health and risk factors of the population likely to gain insurance and estimated changes in care utilization patterns associated with gaining medical insurance, the projected increase in demand for physician services is about 2.0%. The increase is highest (in percentage terms) for surgical specialties (3.2%), followed by primary care (2.0%), medical specialties (1.7%), and “all other” specialties (1.5%). Within these broad categories there are differences in the impact of ACA for individual specialties.

·         The lower ranges of the projected shortfalls reflect the rapid growth in supply of advanced practice clinicians and the increased role these clinicians are playing in patient care delivery; even in these scenarios, physician shortages are projected to persist. New payment methodologies, including bundled payments and risk-sharing arrangements, and innovations in technology, suggest that the work of health professionals may be restructured in the coming years. Given the number of nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists graduating each year, if labor force participation patterns remain unchanged then the supply of advanced practice nurses (APRNs) will grow more rapidly than is needed to keep pace with growth in demand for services at current APRN staffing levels. These trends suggest that an additional 114,900 APRNs could be available to absorb into the health care system to both expand the level of care currently provided to patients and help offset shortages of physicians. Similarly, the supply of physician assistants (PAs) is projected to increase substantially between 2013 and 2025, though additional research is needed to quantify the expected impact. While this rapid growth in supply of APRNs and PAs could help reduce the projected magnitude of the physician shortage, the extent to which some specialties (e.g., surgery specialties) can continue to absorb more APRNs and PAs given limited physician supply growth is unclear.

·         Due to new data and the dynamic nature of projected assumptions, the projected shortfalls of physicians in 2025 are smaller than shortfalls projected in the earlier study. We project that demand for physicians in 2025 will exceed supply by 46,100 to 90,400. This compares with a 130,600 shortfall projected in the 2010 study. Current projections suggest primary care physician demand in 2025 will exceed supply by 12,500 to 31,100 physicians (the 2010 study projected a 65,800 shortfall, about half the overall shortage). The projected shortfall for non-primary care is 28,200 to 63,700 (versus a projected shortfall of 64,800 in the 2010 study). Factors explaining differences between the 2015 and 2010 projections include:

o   The U.S. Census Bureau revised downward its 2025 population projections by about 10.2 million people (from 357.5 million to 347.3 million). This downward revision equates to approximately 24,000 lower FTE demand for physicians.

o   The number of physicians completing their graduate medical education has risen from about 27,000 to about 29,000 annually.

o   The new projections more closely reflect implementation of ACA, growth in supply of advanced practice clinicians, and trends in use of health care services.

o   The 2010 study assumed that supply and demand were in equilibrium in 2008 for all specialties except primary care, whereas this update assumes supply and demand were in equilibrium in 2013 for all specialties except primary care and psychiatry. Hence, the new demand projections extrapolate a “2013” level of care delivery compared with the “2008” level of care delivery extrapolated by the earlier 2010 projections.

Single Payer won’t be any better than status quo – your solvency authors are imagining a perfect system that won’t survive contact with our actual politics; fiat can’t solve this its not plan text that is the problem – it’s the millions of small implementation details that will gum everything up

Pollack, rofessor at the University of Chicago School of Social Service Administration2015, (Harold, “Medicare for All — If It Were Politically Possible — Would Necessarily Replicate the Defects of Our Current System” Journal of Health Politics, Policy and Law 2015 Volume 40, Number 4: 923-931, published online before print June 29, 2015, doi: 10.1215/03616878-3150172, p926-928, TOG, *NDCC WAVE ONE*)

The initial sales pitch would be admirably simple: we will mail a Medicare card to every American. Yet because single payer upends so many things the ACA seeks to leave intact, Medicare for All would raise intricate and divisive transitional issues. The ACA’s major sales pitch to the healthy and insured was, “If you like your insurance, you can keep it.” This pledge proved politically damaging when it could not be fully kept for a very small proportion of Americans who do not receive marketplace subsidies and who had previously purchased rather minimal or risk selected plans.

Medicare for All would be fundamentally more disruptive for tens of millions of people. As a matter of basic accounting, a huge reform that creates millions of winners creates millions of losers, too: affluent workers receiving generous tax expenditures, too many constituencies to count across the supply side of the medical economy who are likely to be squeezed in a new system, individuals subject to small or large tax increases, to name a few. This list includes some of the most powerful and organized constituencies in American politics. They would have to be accommodated in complex, sometimes unappetizing, ways.

It is in the writing of detailed legislation that one confronts the specific issues that must be addressed. To my knowledge, no fully articulated single-payer proposal was ever drafted. This is telling. Medicare for All would require a serious rewrite of state-federal relations, radical surgery to the Employee Retirement Income Security Act (ERISA), the digestion of various Medicaid functions now performed by state governments, and a myriad of other granular details.

Then there are the legal and constitutional challenges. Some would argue that Medicare for All avoids the ACA’s constitutional minefields exemplified by the individual mandate. It doesn’t. The basic issues in National Federation of Independent Business v. Sebelius, 132 S. Ct. 2566 (2012), went beyond whether a mandate is a tax or other niceties. The real fight concerned the constitutional propriety of a post–New Deal expansive federal government that seeks to regulate and humanize our national health care market.

Medicare for All would stake an even greater claim to contested views of federalism and the reach of national government. At this writing, one awkward sentence of the ACA has produced a specious but dangerous Supreme Court challenge in King v. Burwell (759 F.3d 358 (4th Cir. 2014), cert. granted, 135 S.Ct. 475 (2014)). I’m confident that constitutional conservative advocates and judges would identify more plausible concerns and glitches in any single-payer plan.

Many of the most sensitive challenges that now bedevil the ACA would be sensitive challenges to a Medicare for All system, as indeed they long have been within Medicare and Medicaid. Within any financing system, we would require new care models for complex patients. We would face the economic, organizational, and human challenges of end-of-life care. We would make difficult decisions about network adequacy and patient cost sharing and face difficult questions in designing essential health benefit provisions for autism, substance use disorders, and cancer. We would face difficult questions regarding safety net reimbursement rates. We would face our society’s tenuous commitment to the well-being of our most disadvantaged citizens. Federalizing care for dual-eligible Medicare-Medicaid recipients might be done in a way that resembles states with the most expansive Medicaid programs. Just as plausibly, national policies could resemble the policies of far less generous states.

In all of these matters, Medicare for All cannot offer itself as the replacement of our depressing health politics. It would have to arise as another product of that very same process, passing through the very same legislative choke points, constrained by the very same path dependencies that bedevil the ACA. Any politically feasible single-payer plan would include a dense thicket of provisions for the myriad of protected publics ranging from veterans to public employees to retirees to affluent professors whose health coverage is more generous than a national plan can uniformly provide.

Such realities would render Medicare for All an inferior, more convolu