OFF

The aff’s technical care intervention depoliticizes health and masks broader structural violence
imposed by neoliberalism.
Clare Bambra 5, professor of public health in the Institute of Health and Society at Newcastle University,
2-18-2005, "Towards a politics of health," Health Promotion International, Volume 20, Issue 2, 1 June
2005, Pages 187–193

WHY HAS HEALTH BEEN APOLITICAL? It is perhaps puzzling that despite its evident political nature, the
politics of health has been underdeveloped and marginalized: it has not been widely considered or
discussed as a political entity within academic debates or, more importantly, broader societal ones . There is
no simple explanation for this omission; the treatment of health as apolitical is almost certainly the result of a complex interaction of issues. We describe some of

these below, though we would not claim that our list is exhaustive. Health = health care Health is often reduced and misrepresented as
health care (or in the UK, as the National Health Service). Consequently, the politics of health becomes significantly
misconstructed as the politics of health care —see for example Freeman (Freeman, 2000). As an illustration, the majority of
popular UK political discussions about health concern issues such as the ‘State or the market ?’ debate about
National Health Service (NHS) funding, organization and delivery, or the demographic pressures on the future provision of

healthcare facilities (Rhodes, 1997). The same applies in most other—especially ‘developed’—countries. The limited, one-dimensional
(Carpenter, 1980) nature of this political discourse surrounding health can be traced back to two
ideological issues: the definition of health and the definition of politics. The definition of health that has
conventionally been operationalized under Western capitalism has two interrelated aspects to it: health
is both considered as the absence of disease (biomedical definition) and as a commodity (economic definition). These
both focus on individuals, as opposed to society, as the basis of health: health is seen as a product of
individual factors such as genetic heritage or lifestyle choices, and as a commodity that individuals can
access either via the market or the health system (Scott-Samuel, 1979). This remains the case despite our sophisticated understanding
of health promotion—as is evident if one ignores the rhetoric of the governments of ‘developed’ nations and looks instead at their health policies. Health in

this sense is an individualized commodity that is produced and delivered by the market or the health
service. Inequalities in the distribution of health are therefore either a result of the failings of individuals
through, for example, their lifestyle choices; or of the way in which health care products are produced, distributed and
delivered. In order to tackle these inequalities, political attention is directed towards the variable that
is most amenable to manipulation—the healthcare system. It is important to note that this limiting,
one-dimensional view of health is common across the ideological spectrum , with left-wing versus
right-wing health debates usually consisting of a more versus less state intervention dichotomy . Orthodox
UK left-wing politics is guilty of placing health care and the NHS at the centre of its discussions and struggles about health. This ‘NHS illusion’ has resulted in the
naive perspective amongst health activists that societal ill-health can be cured by more and better NHS services. At best, this perspective is slowly changing, as is
shown by the enthusiasm of some in the UK for New Labour's emphasis on tackling health inequalities through the NHS—while it simultaneously widens them
through its neo-liberal macroeconomic, trade and foreign policies (Bambra et al., 2003). Health and politics Figure
2 outlines four broad
definitions of politics. The first concept, which is the most prevalent definition within mainstream
political discourse, places very restrictive boundaries around what politics is—the activities of
governments, elites and state agencies—and therefore also restricts who is political and who can engage
in politics (i.e. the members of governments, state agencies and other elite organizations). It is a ‘top-down’ approach that
essentially separates politics from the community. This should be contrasted with the last definition,
which offers a much more encompassing view of politics: politics is everything; it is a term that can be
used to describe any ‘power-structured relationship’ (Millett, 1969). This is a ‘bottom-up’ approach as any and every issue is political
and likewise anyone and everyone can engage in a political act. The dominance of the first conceptualization of politics, as the
art of government and the activities of the state, influences which aspects of health are considered to be
political. Health care, especially in countries like the UK where the state's role is significant, is an
immediate subject for political discussion. Other aspects of health, such as health inequalities or health
and citizenship, are excluded from this narrow popular definition of politics and are thereby seen as
non-political . In order to increase which aspects of health are regarded as political, our understanding of politics needs to be contested and redefined.
Health and political science Health has not been seriously studied within political science—nor for that matter, with a handful of exceptions (Signal, 1998; McGinnis
et al., 2002; Navarro, 2002), has politics within health promotion. This has compounded its exclusion from the political realm. Health to a political scientist, in
common with more widely held views, most often means only one thing: health care; and usually, only one minor aspect of health care: the health care system.
Some political scientists will argue that they do study health as a political entity; however, what is actually under analysis is the politics of health care. The roots of
this focus on health care derive from the dominance of certain schools of thought within political science and of their corresponding definitions of the political.
Figure 2 outlined the different schools of thought in political science and their respective conceptualizations of politics. These schools are not of equal weight within
political science and the discipline is dominated, especially in the USA, by the behavouralist, institutionalist and rational choice strands. To adherents of these schools
politics—and therefore political science—is concerned with the processes, conditions and institutions of mainstream politics and government. The politics of health
care is therefore the politics of institutions, systems, funding and elite interactions. Health, in its broader sense, is therefore apolitical and should only be the concern
of disciplines such as sociology, public health or medicine. In this way specified aspects of health, namely health care issues, are politically defined as political while
all other aspects are not. Responsibility and authority The
conceptualization of health as non-political is also in part due to
medicalization—the transfer of power over and responsibility for health from individuals, the public and
therefore political life, to powerful elites, namely the medical and health professions and the multinational
pharmaceutical companies. When we conceive of ill-health as episodes of disease manageable by the delivery of

healthcare, we are … transferring the responsibility for health from society as a whole to an elite
possessing what we define as the necessary professional and technical expertise for the management
of disease (Scott-Samuel, 1979). However, unlike the impression given in the above quote, this transfer of
responsibility is not always voluntary. Drug companies and the medical profession have taken the power
and responsibility for health for themselves (Illich, 1977). They have thus been able to determine what
health is and therefore, how political it is (or, more usually, is not). Their historic power over the
definition and management of health has contributed substantially to its depoliticization: health is
something that doctors are responsible for, they are the providers, and we are the recipients . Their
authority and responsibility over health has further emphasized its commodity status—when ill, an
individual visits a doctor and/or purchases drugs (commodity) to regain health (another, albeit less
obvious commodity). Ill-health is a transient state caused by the presence of disease. It can be ended by the appropriate application of medical
technology. This depoliticization of health, via the transfer of power and responsibility to these

professional and/or commercial groups, means that we do not acknowledge our power over our own
health or our autonomy over our own bodies. Health policy Health policy, as currently popularly
conceptualized, is usually synonymous with policy content. Certainly, it is relatively unusual to find
discussions of health policy that are not focused on the pros and cons of particular courses of action in
relation to particular political parties. In reality, however, health policy is part of a broader public policy
agenda, whose practical aspects are inextricably linked with power and politics . Given this, the
reduction of ‘health policy’ to ‘the content of health policies’ diverts attention from , and renders
invisible the political nature of the policy process . Policy is formulated within certain preset political
parameters, which define what is, and what is not, possible or acceptable . For example, the
fundamental requirement within Western neo-liberal economies for inequality (between those who
labour and those who profit) makes the meaning of UK government policies to ‘tackle inequalities’ at
best highly questionable— no modern government will support a policy process that permits the full
implementation of radical equity policy. Government policy in this area therefore consists of (loudly
trumpeted) minor reform; no policy connections are ever made with the macro-political causes of the
major economic, social and health inequalities , such as macroeconomic policy, trade policy, defence policy, foreign policy and international
development. For example, none of these featured in the UK Treasury's Cross Cutting Spending Review on

Health Inequalities (HM Treasury and Department of Health, 2002), which was intended to examine the
impact on health inequalities of the expenditure programmes of all government departments. Nor are
the actions of the World Trade Organization, of trans-national corporations, or of the World Bank usually
taken into account. One conclusion regarding this failure to see the wood for the trees is that there is
an important need for awareness of how the political context limits how health policy is formulated.
Another is that this failure does not occur by chance: both the masking of the political nature of
health, and the forms of the social structures and processes that create , maintain and undermine
health, are determined by the individuals and groups that wield the greatest political power. TOWARDS A
POLITICS OF HEALTH What this all adds up to is nothing less than a challenge to a wide range of actors—health

promotion and public health specialists, policy makers, politicians, health and political scientists—to
emerge from the closet and to begin the long overdue task of elaborating the practice, policy and theory
of a newly identified discipline—health politics, the political science of health. We believe that we have
more than adequately justified the need for health politics to emerge as a discipline and field of practice
no less important than medical sociology or health economics on the one hand, or than political
sociology or political psychology on the other. We are confident that the practice of health promotion
and public health will gain immeasurably from the explicit recognition of this key determinant of
health and its incorporation into evidence-based strategies, policies and interventions.

This securitizes the provision of medical care which creates biopolitical hierarchies of insurential
sovereignty. This is the greatest historical cause of imperial wars.
Luis Lobo-Guerrero 12, PhD in International Relations @ Lancaster University Professor of History and
Theory of International Relations at the University of Groningen, Senior Lecturer in International
Relations at Keele University and has been Visiting Research Fellow at the Department of War Studies,
King’s College London, “Insuring War: Sovereignty, Security and Risk,” 2012, Routledge

Insurantial sovereignty is an expression of what has been analysed in the wider governmentality and risk
society literatures as the political management of risk (e.g. Beck 1992; Daston 1988b; Hacking 1990; Knight 1921; Luhmann
1993; Moss 2002; O’Malley 2004; Dean 1999; Dillon and Lobo-Guerrero 2008a; Rose 1999; De Goede 2008b; Ericson and Haggerty 1997; Baker
and Simon 2002; Dillon 2008). It constitutes a vast phenomenon with multiple manifestations in different
historico-political experiences. The most prominent have so far been the forms of welfarism that
emerged in late nineteenth century Europe . This form of insurantial sovereignty refers to the need to sustain social and political
peace in an age of revolution. The biopolitics of the welfare state , evident for example in the Bismarckian project, were

related to a rationality of government concerned with the governance of populations experiencing

dramatic economic and social change as a result of industrialising processes . As suggested by Wagner for the case
of late nineteenth century Austria, interventions at the biological–medical level contributed to counter the

political-historical dimension of dialectical accounts of revolution based on class struggle (Wagner 2009: 21).
Defert, writing on the development of accident insurance schemes in the same period in France, commented that these schemes aimed
at ‘providing bourgeois solutions to proletarian problems’ (1991: 212). Ewald noted for the same case that
actuarial strategies for socialising risk lied at the core of the idea of government (Ewald 1986). The formulation
and development of those schemes, which are quite particular to the specific development of western societies, evidence the productive
interaction between the political and the insurantial through a rationality of government of risk management of which not much is yet known. A
second manifestation of insurantial sovereignty, although widely related to the first, is that of the insurability of lives. In the last three centuries
of the Western political experience life insurance has been a central vehicle for the transformation of the vital economic and productive
potential of individuals and populations into investment capital. Life as investment capital has been required to advance many of the individual
and collective ventures that have characterised capitalist systems (e.g. mortgages to acquire property, shipping ventures, construction projects
and state funding in the form of annuities). This is so, as will be analysed in detail in the third volume of this trilogy, because as a form of
security life insurance enables the credit required for capitalist economic growth. Capitalism is here understood not as a single economic or
political system but as noted by Nigel Thrift, as ‘a set of networks which, though they may link in many ways, form not a total system but rather
a project that is permanently under construction’ (2005: 3). By investing in lives, a practice that has been subject to the regulation and moral
control of states in varied ways, life insurance became a site of sovereign intervention and regulation of vital capacity which was to become a
definitive feature of western liberal economies. A third site for the production of insurantial sovereignty , the subject
matter of this book, is that of insurance and war . It constitutes a space from which to study the ways in which forms of insurance,
and moreover, imaginaries of insurance (Ewald 1991), have been complicit in making possible expressions of
sovereignty such as the waging of war . Although relationships between insurance and war have attracted relatively little
academic attention (with the exception of Clark 2004a, b; Kingsley 1911; Royce 1914), evidence of them abound. For example, insurance
has been used in modern warfare as an intelligence instrument and also as a source for the funding of
war efforts . A prominent case in point is that of Germany during the Nazi period . Gerald Feldman’s historical
study of the collaboration of the insurance company Allianz with the Third Reich between 1933 and 1945 demonstrated how life insurance
records were used to expropriate the capital invested in the lives the regime had decided to destroy
(2003: e.g. 236–277). Feldman narrates how actuarial records were use to locate and expropriate assets of
‘the enemies of the people and the State’ such as Jews and communists at home and in the conquered
territories (2001: 391–395). The history of Allianz during that period closely illustrates the ways in which the insurance industry
was employed as a means to further the interests of the regime . The relationship between insurance and war for the
Third Reich was even more complex and has the potential to contribute to a different political understanding of the war effort, as recently
declassified documents in the United States National Archives seem to indicate (US National Archives 2011). According
to Fritz,
German companies at the beginning of the war controlled close to forty five per cent of the worldwide
reinsurance industry, an element which provided the regime with a valuable source of information on
the lives, property and assets of many enemy, as well as friendly countries (2001b). Although a private business, the
influence of the Nazi regime transformed the informational resources of the industry into intelligence
material with which to dominate the economic spheres of the conquered territories . Insurance
practices also proved useful in the Allies’ counter-intelligence efforts . For example, the American X2, part of the
Office of Strategic Services (OSS) created to coordinate espionage activities behind enemy lines, established in 1943 a small
Insurance Intelligence Section which proved its value in acquiring the blueprints of several industrial
facilities, some even within concentration camps, for which reinsurance was being sought in the market
(Fritz 2001b). Based on neutral countries, intelligence agents with an insurance background sought to underwrite

enemy assets as a way of identifying targets of strategic relevance to the enemy (see Naftali 1993; Fritz 2001a:
A1, Section National/Foreign). The use of insurance for intelligence purposes was not restricted to Germany and
to the Allies. Through declassified documents in the United States it is now known, for example, that in 1941 ‘the San Francisco office of a
British insurer resold coverage of the Panama Canal... to two Japanese firms’. A report of the OSS mentions that ‘[i]n connection with this
insurance, there was forwarded to Tokyo a detailed description of the locks, all machinery in connection therewith, exact location, etc.’ (as cited
by Fritz 2001a: A1, Section National/Foreign). These experiences in employing insurance as an instrument of war are
but an example of an intimate relationship that has developed between practices of statehood and the
use of actuarial resources as instruments for government . Those relationships, as will be shown later, have their origins
in late seventeenth and early eighteenth century efforts to encompass developments derived from the Probabilistic Revolution into strategies
aimed at balancing moral economic orders with the political economies of states. In
the process, the primordial governmental
concern of achieving security within and outside the state gave rise to the wider phenomena detailed
here as insurantial sovereignty. Rather than seeking to analyse this form of sovereignty in the abstract and the general, this book
concentrates on exploring insurance and war relations in the specificities of the British experience of employing maritime insurance as an
instrument of war beginning with the Napoleonic Wars and ending with the twenty-first century.

The alt comes first – only a reorientation away from market-driven care can lead to improvements in
outcomes – the aff just props up the unsustainable, for-profit hospital industrial complex
Fran Baum 09, Flinders discipline of public health, November, “Changes Not for the Fainthearted:
Reorienting Health Care Systems Toward Health Equity Through Action on the Social Determinants of
Health,” American Journal of Public Health; Washington99.11 (Nov 2009): 1967-74.

There is now a considerable body of evidence pointing to the vital importance of social and economic
factors at a collective, societal level in directly determining population health and health equity. Many of
the social and economic advances of the past were made without any explicit attention to improving
health but, in many cases, resulted in improvements in health nonetheless . A conclusion to draw from such outcomes is that
although major social, economic, and political processes and policies may not be intended to affect health or health equity (for better or worse), in all likelihood they will. Historical

case studies16 and contemporary analyses of political systems17,18 indicate that governments are most
successful in promoting health when they invest in social protection and create health promoting
environments. Evidence also indicates that life expectancy has been linked more to improved living conditions than to improved health care services.16,19,20 Equally, the capacity
of the health care sector to improve population health and health equity is strongly influenced by other sectors.21,22 Yet, despite this evidence, countries'

investments in and through the health care sector are overwhelmingly confined to the provision of
curative health services, especially hospital services, rather than being channeled to prevention and
health promotion . Moreover, when health promotion is incorporated at all, it is generally aimed at
changing the behavior of individuals rather than creating wider physical, social, and economic
environments supportive of healthy behavior .23,24 In any case, an investment emphasis on new medical
interventions tends to increase health inequities because interventions reach more advantaged groups
before, if ever, trickling down.25 Simply continuing to chase new biomedical and technical interventions will clearly not be enough. In addition, although it is
widely recognized that access to health care is a crucial social determinant of health, an inverse care law26 operates whereby those with the worst health status receive less health care, and
this pattern is evident both within countries (poor and excluded groups are in poorer health than are their richer counterparts but are less able to access or benefit from care) and between
them (poor countries have the highest burdens of disease but the lowest levels of financial, technical, and institutional resources to address them). In low- and middle-income countries in
particular, socioeconomic inequalities translate into huge inequities in health care use.27 As a simple example, approximately 150 million residents of countries with limited public sector health
care have suffered financial catastrophe- a large proportion of them pushed further down or backward into poverty as a result of paying for their health care-owing to the introduction over

recent decades of much wider application of user fees and the increasingly large role of private health care providers.28 A BIOMEDICAL IMAGINATION OF HEALTH AND CARE The
health care sector is clearly dominated by a biomedical imagination . In the sections to follow, we discuss
the implications of this situation in terms of the bias toward individualism that drives the choice of care
and prevention strategies and tends to result in health care being viewed as a commodity that can be
readily privatized . In such a worldview, curative medicine is privileged over strategies that emphasize
disease prevention and health promotion . Health care sectors need to focus much more on understanding the dynamics of health in populations and the
ways in which the factors that promote population health differ from those that affect individuals. Biomedicine and Individualism The health care models favored

by most advanced industrial countries and health care sectoral development in many poorer countries
under current aid and trade arrangements reflect the influence of a long-standing Western biomedical
and individualistic concept of health. Biomedical individualism is discernible at the heart of much health policy in rich and poor countries alike (with some notable
exceptions). 29 Lukes'30 analysis of power in public policy suggests that powerful actors (e.g., medical

personnel) are able to shape understanding and perceptions so that only policies and interpretations
that fit with the dominant discourse are considered. The persistence and extent of medical dominance have been noted consistently since the
rise of modern medicine, most famously by Virchow in the 19th century and more recently by Doyal31 and Navarro and Shi32 in relation to advanced economies, and by Sanders and Richard33

The dominance of a medical imagination in health care over the long term can
in relation to low- and middleincome countries.

be seen in the context of wider social and class relations in which medical conservatism reflects wider
forces of social and political conservatism and resistance to heterodox knowledge .3 4 But the
biomedical model also fits neatly with the dominant contemporary political discourse of market
individualism, with its culture of opportunity over entitlement and its disavowal of the distributive role of the state.35,36 It is not surprising, under these
international conditions, that health care sectors promote the provision of clinical care and focus on
exhorting individuals to change their behavior at the expense of a focus on features of the
environmental, political, or economic systems that produce ill health and inequity.37-39 Downstream
responses to health problems appear seductively easy and attract more short-term political support
than responses that focus upstream on structural causes of ill health.40 Growing Privatization Commodification
of social resources under the dominance of the market has resulted in a large and growing private health
care sector-dramatically so in low-income countries-that profits from the growth and expansion of
clinical care and pharmaceutical treatments. I n this environment, health budgets are devoted
overwhelmingly to hospitals, medical and pharmaceutical services, and biomedical research , and budget incentives
encourage patient throughput rather than health outcomes. Although medical education and research are overwhelmingly clinical

in focus, it is important to note that the medical imagination and the biomedical model of health care
cannot be portrayed as simply a matter of one influential class group subordinating the views of the
mass majority. The medical imagination is supported by a strong public demand for curative services.
That demand is, itself, fueled by a popular imagination of medicine as the key to quick physical fixes and
ever-extending longevity.41 The preference in media reportage for cures for cancer and other diseases contributes to the tenacity of this popular imagination while the
greater population health effects of more fundamental but less dramatic public health and social policy reforms go unheralded.42 Bias Toward Curative Medicine The compact of

medical, political, commercial, and popular dedication to curative medicine is reflected in health care
spending trends in the member countries of the Organisation for Economic Co-operation and
Development (OECD). In 2006, the vast majority of these countries spent between 8% and 10.5% of their
gross domestic product on health care (excluding the United States, which spent 15.3% of its gross
domestic product on health care ). Thirty years ago, the same OECD countries were spending between 5% and 7%.43 The extent of these spending increases and the
often relatively small health gains spread unevenly across groups (witness, for instance, the extremely poor health status of Aboriginal people in Canada and Australia)44-compounded by the

Leaving
recognition of escalating health care costs to come with the growing burden of chronic disease in poor countries-raise the question of the sustainability of the biomedical model.

aside the fact that health care sectors as currently constituted appear to exacerbate health inequities,
the logic of increasing longevity, increasingly prevalent chronic conditions, and increasingly sophisticated
(and expensive) pharmaceutical and medical products and interventions points to the possibility of
health care systemic overload and bankruptcy . Such considerations may make more urgent the
argument in favor of balancing the medical imagination with a sociological one, recognizing the limits
to medicine, and contributing to a political climate in which medical and pharmaceutical spending are
reset in a more rational proportion to investment in action on social determinants of health.
 OFF

The fifty states and relevant subnational territories of the United States should provide funding and
technical assistance to tribal nations in the United States to fully fund Indian Health Services through
mandatory spending at least including Urban Indian Health facilities, comprehensive sexual and
reproductive health care coverage, including the expansion of tribe-operated health insurance and
service provision.
The fifty states and relevant subnational territories should amend their constitutions to allow deficit
spending, and funds should be allocated based on the same tribal qualification criteria as the federal
government.
Cooperation between the states and tribes solves
Erich Steinman 4, Assistant Professor of Sociology at Pitzer College, “American Federalism and
Intergovernmental Innovation in State-Tribal Relations,” Publius: The Journal of Federalism, Volume 34,
Number 2, Spring 2004, pp. 95-114

However, unlike
previous periods in which legal trends similarly gave states little encouragement to work
respectfully with tribes as sovereign governments, an intergovernmental policy framework now informs state-
tribal relations. Many states and tribes have explicitly intergovernmental mechanisms for communication and
cooperation in place. Thus, even while states and tribes might be engaged in controversial disputes over
some specific policy domains , they are more likely to sustain simultaneously less problematic and fairly
normalized relations in other domains . For example, even while several California governors have fought with tribes over
gaming, intergovernmental cooperation in the realm of law enforcement has been actively promoted by the California Department of Justice.86
Although legal ambiguity and uncertainty still are tremendous factors in state-tribal relations, and there remains a great deal of conflict, states
and tribes are not paralyzed by these factors. Even
if the Supreme Court weakens some tribal rights or powers,
deepening intergovernmental interactions, much of it taking place far from the spotlight directed at more controversial issues,
have greatly advanced local relations in many states. In the past, tribal officials promoting coexistence faced the task of
introducing to state officials the unfamiliar concept of tribes as legitimate governments, and of promoting to wary or resistant tribal officials
cooperative interaction with state governments. Today, the challenge is frequently that of passing on the new approach by educating new state
officials about the status of tribes and identifying the logic and benefits of continued or expanded cooperation to officials from both sets of
governments.

Such efforts are supported by the overall continuity of presidential support for working with tribes as sovereign governments in a government-
to-government manner. Policy principles first formally issued by President Ronald Reagan and further amplified by the William J. Clinton
administration were subsequently reaffirmed by President George W. Bush and agencies that work extensively with tribal governments, such as
the Environmental Protection Agency.87 Although as a candidate, George W. Bush signaled his clear support for states' rights vis-ä-vis tribes,
since taking office his administration has not formally renounced any fundamental policy principles supportive of tribal governments. However,
the evolving federal policy climate under the Bush administration, as constituted by administrative rulings and practices, budget allocations, and
the absence of new initiatives supporting tribal governments, has bolstered the position of states. For these reasons, tribal leaders have
criticized the administration and pronounced its actions a continuing threat to tribal sovereignty. Nonetheless, there are reasons to doubt that
the federal policy climate will definitively shift in a way that further emboldens and assists state resistance to tribal status and claims.

Even though the Republican-controlled Congress has displayed little enthusiasm for tribal governments since 2000, it is unlikely to take strong
action expressly undercutting tribal status and rights. In the self- determination era, Congress has moved cautiously on tribal issues, wary of the
political heat of any drastic action explicitly changing the status quo of a symbolically loaded and poorly understood—and hence manipulable—
issue domain. Now that gaming revenue has allowed some tribes to become significant political actors, any congressional action that directly
threatens gaming-related sovereign protections and principles would undoubtedly be challenged vociferously by politically savvy and financially
well-endowed tribal opponents. Aware of these factors and the moderate legislative history, it
is unlikely that either states or
tribes expect any action in the near future clearly defining tribal rights and state-tribal relations . If these
conditions hold, cooperation and collaboration will remain viable and frequently attractive options.
CONCLUSION

Indian tribes remain outside the United States constitutional structure, even though Indian reservations are geographically incorporated within
the national boundaries. Although there are numerous treaties establishing formal relations between Indian nations and the United States
government, federal policy has historically vacillated in its treatment of tribal groups. Correspondingly, American
political philosophy has generated mixed accounts of tribal status. Because of these factors, tribes have long been anomalies within American
governance. Given this context, the pro-tribal federal policy of self-determination and tribes' subsequent claims to be sovereign governments
elicited renewed conflict between states and tribes. Neither federal law nor policy clarified tribal status or definitively structured state-tribal
relations, providing significant leeway for these sets of actors to experiment and innovate. However, lacking positive models for interaction and
driven by both material and symbolic factors, states and tribes engaged in extensive and frequent litigation amidst overall adversarial relations.

An identifiable set of tribal actors and their allies, along with cooperative state officials, proposed new relations in the 1980s. These actors
emphasized non-litigious strategies, practical solutions, and coexistence under conditions of legal ambiguity. Importantly, they cast state-tribal
relations as another variant of intergovernmental relations that unsurprisingly contain elements of both conflict and cooperation. They
implemented these approaches in both informal and formal ways, and aggressively promoted them to other actors around the country. Over
time, a widening number of states and tribes adopted these approaches.

These outcomes are significant for a number of reasons. They mitigate more polarizing dynamics and events that are likely to
continue to occur. Although gaming and shifting legal trends are notable current factors complicating state-tribal relations, other factors are sure
to appear in the future. The use of intergovernmental frameworks and functional state-tribal relationships
increases the motivation of state and tribal officials to sustain their relationship even in challenging
periods . They equip these officials with potential tools for responding creatively to challenges. A strength of the intergovernmental
framework is its flexibility, as the emphasis is on a dynamic relationship rather than on a fixed distribution of rights and powers. While
the use of intergovernmental approaches is dependent on a political and legal climate that provides some affirmation of tribal status and rights,
it is salient under a wide range of conditions rather than only when there is robust and coherent federal support for tribes as sovereign
governments.

The intergovernmental relationship framework is also more efficient, and is more likely to generate sound
public policy , than exclusively litigious approaches. Furthermore, the events described here have increased the degree to which tribes are
functionally included in the diverse intergovernmental matrix of American governance, even as sovereign tribal nations remain outside the U.S.
federalist structure. Although other actions by the federal government contributed to this process, state-tribal relations have been
independently consequential in creating this new outcome. None of these developments constitute formal changes to American
federalism. However, they have reconfigured the landscape of American governance. Enjoying distinct powers, tribal governments are now
visible and active as a category of government within the boundaries of the United States.
 OFF
NHI means any system of socialized health benefits to all or nearly all citizens
Slee 91, MD/MPH, President @ Commission on Professional and Hospital Activities

(Vergil, Slee's Health Care Terms, n. pag., Accessed July 29, 2017

National Health Insurance--Any system of socialized health insurance benefits , covering all or nearly
all citizens , established by federal law, administered by the federal government and supported or
subsidized by taxation.

Vote Negative – Subsets allow a proliferation of affirmatives dealing with specific groups. It wrecks
predictable negative strategy and undermines core debates over big stick health care reform.
Incremental versus comprehensive reform is the key pivot point for dividing ground
 OFF
Interpretation---national health insurance can be provided through an individual mandate, employer
mandate, or public insurance program
Thomas Bodenheimer 16, MD, MPH, Founding Director of the Center for Excellence in Primary Care,
University of California-San Francisco; and Kevin Grumbach, MD, Founding Director of the Center for
Excellence in Primary Care, University of California-San Francisco, 2016, Understanding Health Policy: A
Clinical Approach, Seventh Edition, p. 185-196

The controversies that erupt over universal health care coverage become simpler to understand if one returns to the four basic modes
of health care financing outlined in Chapter 2: out-of-pocket payment, individual private insurance,
employment-based private insurance, and government financing. There is general agreement that out-of-
pocket payment does not work as a sole financing method for costly contemporary health care. N ational h ealth
i nsurance involves the replacement of out-of-pocket payments by one, or a mixture, of the other three
financing modes .¶ Under government-financed national health insurance plans, funds are collected by a
government or quasigovernmental fund, which in turn pays hospitals, physicians, health maintenance organizations (HMOs), and other
health care providers. Under private individual or employment-based n ational h ealth i nsurance, funds are collected
by private insurance companies, which then pay providers of care.¶ Historically, health care financing in the United States
began with out-of-pocket payment and progressed through individual private insurance, then employment-based insurance, and finally
government financing for Medicare and Medicaid (see Chapter 2). In the history of US national health insurance, the chronologic sequence is
reversed. Early attempts at national health insurance legislation proposed government programs; private employment-based national health
insurance was not seriously entertained until 1971, and individually purchased universal coverage was not suggested until the 1980s (Table 15-
1). Following this historical progression, we shall first discuss government-financed national health insurance, followed by private employment-
based and then individually purchased coverage. The
ACA represents a pluralistic approach that draws on all three of these
financing models: government financing, employment-based private insurance, and individually purchased
private insurance.¶ GOVERNMENT-FINANCED NATIONAL HEALTH INSURANCE ¶ The American Association for Labor
Legislation Plan¶ In the early 1900s, 25 to 40% of people who became sick did not receive any medical care. In 1915, the American Association
for Labor Legislation (AALL) published a national health insurance proposal to provide medical care, sick pay, and funeral expenses to lower-paid
workers—those earning less than $1,200 a year—and to their dependents. The program would be run by states rather than the federal
government and would be financed by a payroll tax–like contribution from employers and employees, perhaps with an additional contribution
from state governments. Government-controlled regional funds would pay physicians and hospitals. Thus, the first national health insurance
proposal in the United States was a government-financed program (Starr, 1982).¶ In 1910, Edgar Peoples worked as a clerk for Standard Oil, earning $800 a year. He lived with his wife and three sons. Under the
AALL proposal, Standard Oil and Mr. Peoples would each pay $13 per year into the regional fund, with the state government contributing $6. The total of $32 (4% of wages) would cover the Peoples family.¶ The AALL’s road to national health insurance followed the example of European
nations, which often began their programs with lower-paid workers and gradually extended coverage to other groups in the population. Key to the financing of national health insurance was its compulsory nature; mandatory payments were to be made on behalf of every eligible person,
ensuring sufficient funds to pay for people who fell sick.¶ The AALL proposal initially had the support of the American Medical Association (AMA) leadership. However, the AMA reversed its position and the conservative branch of labor, the American Federation of Labor, along with
business interests, opposed the plan (Starr, 1982). The first attempt at national health insurance failed.¶ The Wagner–Murray–Dingell Bill¶ In 1943, Democratic Senators Robert Wagner of New York and James Murray of Montana, and Representative John Dingell of Michigan introduced a
health insurance plan based on the social security system enacted in 1935. Employer and employee contributions to cover physician and hospital care would be paid to the federal social insurance trust fund, which would in turn pay health providers. The Wagner–Murray–Dingell bill had its
lineage in the New Deal reforms enacted during the administration of President Franklin Delano Roosevelt.¶ In the 1940s, Edgar Peoples’ daughter Elena worked in a General Motors plant manufacturing trucks to be used in World War II. Elena earned $3,500 per year. Under the 1943
Wagner–Murray–Dingell bill, General Motors would pay 6% of her wages up to $3,000 into the social insurance trust fund for retirement, disability, unemployment, and health insurance. An identical 6% would be taken out of Elena’s check for the same purpose. One-fourth of this total
amount ($90) would be dedicated to the health insurance portion of social security. If Elena or her children became sick, the social insurance trust fund would reimburse their physician and hospital.¶ Edgar Peoples, in his seventies, would also receive health insurance under the Wagner–
Murray–Dingell bill, because he was a social security beneficiary.¶ Elena’s younger brother Marvin was permanently disabled and unable to work. Under the Wagner–Murray–Dingell bill he would not have received government health insurance unless his state added unemployed people
to the program.¶ As discussed in Chapter 2, government-financed health insurance can be divided into two categories. Under the social insurance model, only those who pay into the program, usually through social security contributions, are eligible for the program’s benefits. Under the
public assistance (welfare) model, eligibility is based on a means test; those below a certain income may receive assistance. In the welfare model, those who benefit may not contribute, and those who contribute (usually through taxes) may not benefit (Bodenheimer & Grumbach, 1992).
The Wagner–Murray–Dingell bill, like the AALL proposal, was a social insurance proposal. Working people and their dependents were eligible because they made social security contributions, and retired people receiving social security benefits were eligible because they paid into social
security prior to their retirement. The permanently unemployed were not eligible.¶ In 1945, President Truman, embracing the general principles of the Wagner–Murray–Dingell legislation, became the first US president to strongly champion national health insurance. After Truman’s
surprise election in 1948, the AMA succeeded in a massive campaign to defeat the Wagner–Murray–Dingell bill. In 1950, national health insurance returned to obscurity (Starr, 1982).¶ Medicare and Medicaid¶ In the late 1950s, less than 15% of the elderly had health insurance (see
Chapter 2) and a strong social movement clamored for the federal government to come up with a solution. The Medicare law of 1965 took the Wagner–Murray–Dingell approach to national health insurance, narrowing it to people 65 years and older. Medicare was financed through social
security contributions, federal income taxes, and individual premiums. Congress also enacted the Medicaid program in 1965, a public assistance or “welfare” model of government insurance that covered a portion of the low-income population. Medicaid was paid for by federal and state
taxes.¶ In 1966, at age 66, Elena Peoples was automatically enrolled in the federal government’s Medicare Part A hospital insurance plan, and she chose to sign up for the Medicare Part B physician insurance plan by paying a $3 monthly premium to the Social Security Administration.
Elena’s son, Tom, and Tom’s employer helped to finance Medicare Part A; each paid 0.5% of wages (up to a wage level of $6,600 per year) into a Medicare trust fund within the social security system. Elena’s Part B coverage was financed in part by federal income taxes and in part by Elena’s
monthly premiums. In case of illness, Medicare would pay for most of Elena’s hospital and physician bills.¶ Elena’s disabled younger brother, Marvin, age 60, was too young to qualify for Medicare in 1966. Marvin instead became a recipient of Medicaid, the federal–state program for
certain groups of low-income people. When Marvin required medical care, the state Medicaid program paid the hospital, physician, and pharmacy, and a substantial portion of the state’s costs were picked up by the federal government.¶ Medicare is a social insurance program, requiring
individuals or families to have made social security contributions to gain eligibility to the plan. Medicaid, in contrast, is a public assistance program that does not require recipients to make contributions but instead is financed from general tax revenues. Because of the rapid increase in
Medicare costs, the social security contribution has risen substantially. In 1966, Medicare took 1% of wages, up to a $6,600 wage level (0.5% each from employer and employee); in 2015, the payments had risen to 2.9% of all wages, higher for wealthy people. The Part B premium has
jumped from $3 per month in 1966 to $104.90 per month in 2015, higher for wealthy people.¶ The 1970 Kennedy Bill and the Single-Payer Plan of the 1990s¶ Many people believed that Medicare and Medicaid were a first step toward universal health insurance. European nations started
their national health insurance programs by covering a portion of the population and later extending coverage to more people. Medicare and Medicaid seemed to fit that tradition. Shortly after Medicare and Medicaid became law, the labor movement, Senator Edward Kennedy of
Massachusetts, and Representative Martha Griffiths of Michigan drafted legislation to cover the entire population through a national health insurance program. The 1970 Kennedy–Griffiths Health Security Act followed in the footsteps of the Wagner–Murray–Dingell bill, calling for a single
federally operated health insurance system that would replace all public and private health insurance plans.¶ Under the Kennedy–Griffiths 1970 Health Security Program, Tom Peoples, who worked for Great Books, a small book publisher, would continue to see his family physician as
before. Rather than receiving payment from Tom’s private insurance company, his physician would be paid by the federal government. Tom’s employer would no longer make a social security contribution to Medicare (which would be folded into the Health Security Program) and would
instead make a larger contribution of 3% of wages up to a wage level of $15,000 for each employee. Tom’s employee contribution was set at 1% up to a wage level of $15,000. These social insurance contributions would pay for approximately 60% of the program; federal income taxes
would pay for the other 40%.¶ Tom’s Uncle Marvin, on Medicaid since 1966, would be included in the Health Security Program, as would all residents of the United States. Medicaid would be phased out as a separate public assistance program.¶ The Health Security Act went one step
further than the AALL and Wagner–Murray–Dingell proposals: It combined the social insurance and public assistance approaches into one unified program. In part because of the staunch opposition of the AMA and the private insurance industry, the legislation went the way of its
predecessors: political defeat.¶ In 1989, Physicians for a National Health Program offered a new government-financed national health insurance proposal. The plan came to be known as the “single-payer” program, because it would establish a single government fund within each state to
pay hospitals, physicians, and other health care providers, replacing the multipayer system of private insurance companies (Himmelstein & Woolhandler, 1989). Several versions of the single-payer plan were introduced into Congress in the 1990s, each bringing the entire population
together into one health care financing system, merging the social insurance and public assistance approaches (Table 15-2). The California Legislature, with the backing of the California Nurses Association, passed a single-payer plan in 2006 and 2008, but the proposals were vetoed by the

Governor.¶ THE EMPLOYER-MANDATE MODEL OF NATIONAL HEALTH INSURANCE ¶ In response to Democratic Senator
Kennedy’s introduction of the 1970 Health Security Act, President Nixon, a Republican, countered with a plan of his own, the nation’s first
employment-based, privately administered national health insurance proposal. For 3 years, the Nixon and Kennedy approaches competed in the
congressional battleground; however, because most of the population was covered under private insurance, Medicare, or Medicaid, there was
relatively little public pressure on Congress. In 1974, the momentum for national health insurance collapsed, not to be seriously revived until the
1990s. Theessence of the Nixon proposal was the employer mandate, under which the federal government
requires (or mandates) employers to purchase private health insurance for their employees .¶ Tom Peoples’ cousin
Blanche was a receptionist in a physician’s office in 1971. The physician did not provide health insurance to his employees. Under Nixon’s 1971
plan, Blanche’s employer would be required to pay 75% of the private health insurance premium for his employees; the employees would pay
the other 25%.¶ Blanche’s boyfriend, Al, had been laid off from his job in 1970 and was receiving unemployment benefits. He had no health
insurance. Under Nixon’s proposal, the federal government would pay a portion of Al’s health insurance premium. ¶ No
longer was
national health insurance equated with government financing . Employer mandate plans preserve and
enlarge the role of the private health insurance industry rather than replacing it with tax-financed
government-administered plans. The Nixon proposal changed the entire political landscape of national health insurance, moving it
toward the private sector.¶ During the 1980s and 1990s, the number of people in the United States without any health insurance rose from 25
million to more than 40 million (see Chapter 3). Approximately three-quarters of the uninsured were employed or dependents of employed
persons. In response to this crisis in health care access, President Clinton
submitted legislation to Congress in 1993 calling for
universal health insurance through an employer mandate . Like the Nixon proposal, the essence of the Clinton plan
was the requirement that employers pay for most of their employees’ private insurance premiums . The
proposal failed.¶ A variation on the employer mandate type of n ational h ealth i nsurance is the voluntary approach. Rather
than requiring employers to purchase health insurance for employees, employers are given incentives such as tax credits to
cover employees voluntarily. The attempt of some states to implement this type of voluntary approach has failed to significantly
reduce the numbers of uninsured workers.¶ THE INDIVIDUAL-MANDATE MODEL OF NATIONAL HEALTH

INSURANCE¶ In 1989, a new species of national health insurance appeared, sponsored by the conservative Heritage Foundation: the
individual mandate. Just as many states require motor vehicle drivers to purchase automobile insurance, the Heritage plan
called for the
federal government to require all US residents to purchase individual health insurance policies. Tax credits
would be made available on a sliding scale to individuals and families too poor to afford health insurance
premiums (Butler, 1991). Under the most ambitious versions of the individual mandate, employer-sponsored
insurance and government-administered insurance would be dismantled and replaced by a universal,
individual mandate program. Ironically, the individual insurance mandate shares at least one feature with the single-payer,
government-financed approach to universal coverage: Both would sever the connection between employment and health insurance, allowing
portability and continuity of coverage as workers moved from one employer to another or became self-employed.

Violation---the Indian Health Service is a health care provider, not an insurer

Mark Trahant 14, Atwood Chair at the University of Alaska Anchorage, “A Call to Reform the Indian
Health Service,” 8/4/14, http://nativenewsonline.net/opinion/call-reform-indian-health-service/

But the
IHS is a health care delivery system, not an insurance regime . And, unlike the entitlement
programs of Medicare, Medicaid, and Children’s Health Insurance, the IHS is funded through congressional
appropriations. So the agency’s primary source of funding is subject to the whims of a Congress that is deeply divided about priorities and the
role of government.

Vote neg:
First---limits---they allow the aff to regulate, subsidize, or establish hospitals and other health care
providers---that blows the lid off the topic by shoehorning-in entirely new literature bases
Second---ground---they obviate the debate over public vs. private health insurance for the health care
system---all neg offense is premised on the broad economic question of guaranteed insurance
 OFF
Tax reform will pass now – bipartisanship, budget deal, and Trump push are creating an enormous
amount of momentum
Bloomfield 9/21/17 (Mark, The Hill, "The bumpy road to tax reform is still driveable")

A word of caution to anyone preparing to throw dirt on the prospect of tax reform this year: Don’t break out
your shovels just yet. Tax reform is still alive because of a strategic decision by the White House and Republican congressional leaders.¶ The
path to passing comprehensive tax reform is becoming clearer. Step one was for the “Big Six” — the White House, Treasury secretary,
House speaker, Senate majority leader and the chairmen of the congressional tax writing committees — to get Republicans on one page. ¶ This was achieved in their
joint statement released in July with more detailed consensus principles expected the week of September 25. With unified principles in hand,
advancing tax reform should avoid the pitfalls and intraparty fractures that plagued repealing ObamaCare.¶ While it might be
hard to fathom in today’s populist and often divisive climate that broad agreement can be reached on an issue as politically-charged as tax reform, there is

nonetheless consensus among most Republicans , including the key players .¶ Permanent, comprehensive tax reform is a major part
of fixing the American economy. After all, the U.S. tax rate on businesses is the fourth-highest rate in the world, placing American firms at a disadvantage against
their global competitors. ¶ It’s also long overdue. House Speaker Paul Ryan (R-Wis.) recently illustrated this point, commenting that the last time Congress fixed the
tax code was the same year he got his first driver’s license. Ryan’s anecdote would be funnier if it weren’t horrifyingly true. ¶ The trillion dollar question is how to pay
for making taxes competitive.¶ The consensus plan to make tax reform permanent includes moving the U.S. to “a system that encourages American companies to
bring back jobs and profits trapped overseas.” In other words, repatriated earnings would help offset any anticipated revenue losses. ¶ The “Big Six” proposal aims to
reform international tax treatment for U.S. businesses and prevent inversions so that American companies are no longer tempted to move abroad. As ex-Treasury
Secretary George Shultz and other former Treasury officials stated, “Inversions are a symptom. The disease is America’s anomalous international tax code.” ¶ The
path to permanent and long-lasting tax reform will involve at least three steps. Step one has largely been accomplished. Step two, the passage of a budget that paves
the way for debate on tax reform, is critical. That’s why the White House recently dispatched Treasury Secretary Steven Mnuchin and National Economic Council
Director Gary Cohn to meet with key congressional leaders. ¶ Given the recent ruling by the Senate parliamentarian that temporary budget rules will expire after
September 30, many Republicans are worried that the absence of a new budget could derail tax reform efforts this
year.¶ As a result, Mnuchin and Cohn’s trip to Capitol Hill likely signaled the beginning of a full court press

toward budget passage. After all, no budget means Republicans can't count on reconciliation to pass tax reform. For a president and a Congress eager
to deliver a key victory, the passage of a budget is an obstacle that simply must be cleared. ¶ The fate of tax reform is inextricably linked to the reconciliation process
— the path Majority Leader Mitch McConnell (R-Ky.) indicated the Senate will pursue. The Republican majority needs 51 votes, instead of 60, to pass tax reform
through reconciliation. ¶ Factoring in the possibility that some Republicans could defect, President Trump has attempted to win over
Democrats. Successfully doing so would demonstrate bipartisanship and would be politically effective.¶ In the coming weeks,
he will travel to up to 13 states — many where a Democratic senator is up for re-election and where the president won big. There won't be
a vote to spare and Trump’s objective makes it more possible to get 51 votes in the case of Republican defections. ¶
With a new budget in hand and potential Democratic support , Step three on the path to comprehensive tax reform will eventually
be a fait accompli when Trump signs the “The Big Six Tax Reform Act of 2017” into law.

Aff triggers massive political fallout that derails tax reform

John Blakeley & Jenny Kim Park 04, attorney advisors to the U.S. Commission on Civil Rights, September
2004, “Broken Promises: Evaluating the Native American Health Care System,”
http://www.usccr.gov/pubs/nahealth/nabroken.pdf
Restrictions on Funding Failing to raise appropriations to an adequate level is the obvious way in which Native Americans are deprived of necessary funds, but it is
not the only way. Federal rules and regulations governing how money is allocated and spent can also contribute to underfunding or an irrational distribution of
funds. The most controversial of these and, as mentioned earlier, perhaps the most misunderstood, is entitlement status. To the tribes located in regions with
significantly lower per capita spending by the IHS, how funding increases are distributed can be no less important. Finally, to those urban Indians who have lost funds
designated for their use via regulations granting discretionary authority to tribal programs, appropriations regulations hold particular interest. Each consideration is
discussed below. Entitlement Status The first of the issues surrounding federal rules and regulations with a potential impact on health services is the status accorded
to the entire program in the appropriations process. The status of the program determines whether funding will be provided at levels defined by Congress on an
annual basis (discretionary appropriations) or whether funding will be provided to cover actual need (entitlement programs). Independent of these government
labels, a perception has been created among Native American peoples over the years that health care is an entitlement for Native Americans. In simple terms, many
Native Americans believe that they bargained for health care when they signed treaties giving up their land. Therefore, whether the government should finance the
IHS is not the question; annual appropriations decisions should not be subject to congressional discretion. When the federal government accepted the responsibility,
it became an “entitlement” for Native American peoples. From the federal government perspective, the argument against entitlement status is obvious: granting
that status would be prohibitively expensive.105 As an entitlement similar to Medicaid, care would be provided, if necessary, and the government would be

responsible for payment, subject to certain limitations. Passing legislation to formally transform Native American health
care into a Medicaid-like entitlement would appear to be completely untenable . In the current fiscal
environment, advocates must lobby unceasingly merely to obtain increases to keep pace with
inflation. From a Native American perspective, the entitlement question is not answered so simply. The individual Native American is unconcerned with the
cost to the federal government. That the contract has already been acted upon ends the discussion. Some advocates for Native Americans, though, hesitate to

embrace entitlement for both political and policy reasons.106 Politically , calling for entitlement status may act as a “ poison
pill ” if pursued as part of the Indian Health Care Improvement Act.107 It may be such a contentious issue that its inclusion
woulddelay passage and foster opposition to other provisions that would have
otherwise passed . Even if passed, its controversy may lead to a limitation on services or the
attachment of unacceptable eligibility criteria .108 Some programs, currently operating at an above
average level, might be compressed to an average or minimum level .109

Political capital is key –Trump needs to rally his base and control the messaging
Becker and Bade 8/30/17 (Bernie Becker and Rachel Bade, Politico, "Trump's populist message on taxes
comes with heavy dose of corporate rate cuts")

That’s because Hill Republicans will need Trump to use his bully pulpit for tax reform to cross the finish
line , and GOP leaders believe Trump is uniquely able to reach the entire electorate in a way Hill leaders
never could . As one House GOP leadership aide put it, the speech shows the White House is rowing in the same
direction as the Hill, reassuring lawmakers that tax reform is possible. But the ultimate test will come when
the House, which is expected to move first on taxes, drops its bill. There are questions, following the health care debacle, over whether
the White House will embrace the legislation as its own — or distance itself from the plan as a House effort once the critics and special interests
start getting louder. GOP
leaders on the Hill say the weekly tax reform meetings with administration officials
suggest that the White House and Congress will stand firm in their unity behind the jointly laid plan .
Meanwhile, top Trump aides and advisers, like Gary Cohn, the director of the National Economic Council, have made it clear
that lawmakers will take the lead on actually writing the tax bill. “The administration has been very well
represented in this process,” a senior White House official said Tuesday.

Tax reform is key to renewable energy---solves warming

Philip Rossetti 17, data analyst at the American Action Forum who specializes in energy policy, with an
emphasis on clean energy, 8/30/17, “Tax reform: Full expensing could make clean energy competitive,”
http://www.washingtonexaminer.com/tax-reform-full-expensing-could-make-clean-energy-
competitive/article/2632749

Fixing the nation's tax code is not only smart economic policy. It can also be good energy policy . There is a
longstanding, often-heated debate over how the federal government should treat energy subsidies in the tax code. While one side hauls the small pot of fossil fuel
subsidies before the court of public opinion, the other accuses the wide array of renewable energy subsidies of tipping the scales. Such arguments miss the point .

The fundamental problem with the U.S. system of energy tax preferences is that it preserves the status
quo, locking Americans into a system that keeps energy costs high and stifles innovation toward cleaner,
safer, and cheaper energy alternatives. Indeed, if a magic wand was waved and all $94 billion of existing energy subsidies were eliminated
(exemptions of corporate tax for natural gas pipelines, investment tax credits for solar power, production tax credits for wind, etc.), the tax code would still be biased.
That's because investments are taxed, while the costs of goods sold (like fuel) are not. In other words, a business with high expenses (wages, cost of goods, etc.) can
be more profitable than one that has the same lifetime costs and lifetime income, but which faces mostly capital costs. The
incentive under the
current tax system is to narrow your taxable income with expenses, and to avoid capital investments that
tie up your funds and don't offer a tax write-off . This affects the energy industry because the newest (and cleanest)

sources of energy tend to be very capital intensive , and are thus less attractive as investments. As an example,
the nuclear power plant project that was just abandoned in South Carolina had an estimated capital cost of around $11.5 billion. But of course, the money invested
in this venture is taxed. And given the statutory rate of that tax, an investment of $11.5 billion requires earnings of $17.7 billion -- $6.2 billion to pay the taxes
involved, leaving $11.5 billion after taxes. Although the depreciation of the investment over time would narrow the tax base of the investment by 87 percent, the
taxes paid for $11.5 billion of capital investment at a 35 percent tax rate are still $800 million – certainly not a sum to sneeze at. Further, even when investors can
deduct 100 percent of their investment under the current system, it can only be done over a period of anywhere between 3 and 50 years, discouraging investors who
prefer near-term profits. The solution is simple: Eliminate investments from the tax base in a reliable manner, via full and immediate expensing. I explained how this
would work in recent research from the American Action Forum. Under full expensing, that tax for a new nuclear power plant is zero. The capital costs of a$11.5
billion nuclear power plant would be exactly $11.5 billion. Meanwhile, ambitious projects like NetPower (a zero-emission natural gas power plant), NuScale (a small
modular nuclear reactor that is 5,000 times less likely to have an incident than today's reactors), and others would no longer pay higher taxes than incumbents in the
industry, on top of the costs of being early adopters. Global energy demand is expected to climb 48 percent between 2012 and 2040, and addressing the

environmental concerns of tomorrow will require innovation-friendly policies today. History tells
energy-security and

us that innovation takes time, and it takes even longer if policies stifle competitiveness and profitability.
Arguably, the greatest disadvantage of expensing is that it frontloads the loss of revenue from deducted investments, placing them all in the first year. But budget
hawks should rest easy. At the proposed 20 percent corporate tax rate, full-expensing for projected new power plants over the next ten years would be $54 billion,
nearly equal to the revenue we could raise by eliminating permanent energy tax breaks that would no longer be needed. For energy, at least, full-expensing can be a
revenue-neutral policy that finally helps to stop penalizing innovators. The bottom line is that the U.S. approach to energy innovation gets it exactly backwards, as if
Henry Ford's first cars had been taxed and horses were subsidized in order to avoid losing access to horses. Tax
reform offers an opportunity to
break free of the energy status quo, and remove the roadblocks to a future of cleaner , safer, and cheaper
energy alternatives.

Extinction
Phil Torres 16, Affiliate Scholar at the Institute for Ethics and Emerging Technologies, and founder of the
X-Risks Institute, 7/22/16, “Op-ed: Climate Change Is the Most Urgent Existential Risk,”
https://futureoflife.org/2016/07/22/climate-change-is-the-most-urgent-existential-risk/

Climate change and biodiversity loss may pose the most immediate and important threat to human
survival given their indirect effects on other risk scenarios. Humanity faces a number of formidable challenges this century. Threats to our
collective survival stem from asteroids and comets, supervolcanoes, global pandemics , climate change ,
biodiversity loss, nuclear weapons , biotechnology, synthetic biology, nanotechnology, and artificial
superintelligence. With such threats in mind, an informal survey conducted by the Future of Humanity Institute placed the probability of human extinction
this century at 19%. To put this in perspective, it means that the average American is more than a thousand times more likely to die in a human extinction event than
a plane crash.* So, given limited resources, which risks should we prioritize? Many intellectual leaders, including Elon Musk, Stephen Hawking, and Bill Gates, have
suggested that artificial superintelligence constitutes one of the most significant risks to humanity. And this may be correct in the long-term. But I would argue that
two other risks, namely climate
change and biodiveristy loss, should take priority right now over every other
known threat. Why? Because these ongoing catastrophes in slow-motion will frame our existential predicament on
Earth not just for the rest of this century, but for literally thousands of years to come. As such, they have the capacity to raise or
lower the probability of other risks scenarios unfolding. Multiplying Threats Ask yourself the following: are wars more or less
likely in a world marked by extreme weather events, megadroughts, food supply disruptions, and sea-
level rise? Are terrorist attacks more or less likely in a world beset by the collapse of global ecosystems ,
agricultural failures, economic uncertainty, and political instability? Both government officials and scientists agree that the
answer is “more likely.” For example, the current Director of the CIA, John Brennan, recently identified “the impact of climate change” as one of the
“deeper causes of this rising instability” in countries like Syria, Iraq, Yemen, Libya, and Ukraine. Similarly, the former Secretary of Defense, Chuck Hagel, has described
climate change as a “threat multiplier” with “the potential to exacerbate many of the challenges we are dealing with
today — from infectious disease to terrorism.” The Department of Defense has also affirmed a connection. In a 2015 report, it states, “Global
climate change will aggravate problems such as poverty, social tensions, environmental degradation, ineffectual leadership and weak political institutions that
threaten stability in a number of countries.” Scientific studies have further shown a connection between the environmental
crisis and violent conflicts. For example, a 2015 paper in the Proceedings of the National Academy of Sciences argues that climate change was a causal
factor behind the record-breaking 2007-2010 drought in Syria. This drought led to a mass migration of farmers into urban centers, which fueled the 2011 Syrian civil

war. Some observers, including myself, have suggested that this struggle could be the beginning of World War III , given the complex
tangle of international involvement and overlapping interests. The study’s conclusion is also significant because the Syrian civil war was the Petri dish in which the
Islamic State consolidated its forces, later emerging as the largest and most powerful terrorist organization in human history.
 OFF
Text: The United States Federal Government should enter into prior, binding consultation with
indigenous tribes concerning <plan>, implementing the results of the consultation. In the event
indigenous tribes refuse the policy, its possibility will be banned.
The aff is concessionary---extending funding to the HIS without binding consultation provisions
perpetuates marginalization and genocide. The process is important.
Stephen J. Kunitz 08. Stephen J. Kunitz is Professor Emeritus, Division of Social and Behavioral Medicine,
Department of Community and Preventive Medicine, University of Rochester School of Medicine,
Rochester, New York; and Clinical Professor, Department of Family and Community Medicine, University
of New Mexico, School of Medicine, Albuquerque, New Mexico.. 2008. Healthcare Policy for American
Indians since the Early 20th Century. Brooks World Poverty Institute. Open WorldCat,
http://www.bwpi.manchester.ac.uk/resources/Working-Papers/bwpi-wp-6608.pdf.
The question is whether access to adequate health services should be held hostage to the success or failure of tribal enterprises, and whether a
means test should be imposed for services that are understood to be a treaty right. Should the federal government
acknowledge and meet its obligation to provide adequate services, no matter what the success or failure of
tribal enterprises?71 In light of the experience of the past 100 years, it is unlikely that all or part of the budget for Indian
health and other programmes will be made mandatory .72 For conservatives who support self-determination are likely to
believe that such a guarantee would promote dependency and discourage privatisation and integration of Indian communities into the larger
economy, and they may well prevail. The issue is not whether self-determination is inherently a good or bad policy as far as health is concerned.
As usual, the devil is in the details . For the policy of termination led to the creation of a programme that had very beneficial
results, and the policy of self-determination has, so far at least, had at best equivocal results. The issue is how programmes are
funded and supported. With adequate support, it is likely that self-determination can be very
successful , resulting in health programmes that are responsive to the particular needs of individuals
and communities . Without such support, however, it seems likely that the growing inequality that has
characterised the United States generally will also increasingly characterise Indian country. More broadly, this
case study suggests two points. First, politically attractive and unattractive labels can be misleading. The content of programmes – how they are
funded, and how effectively, equitably, and efficiently they serve the people they are meant to benefit – is what is important. Second, it is an
unspoken assumption that it was necessary for the building of the ‘good’ institutions that have made economic
development so successful in the United States and the other Anglophone liberal democracies73 that the virtual extermination of
the indigenous people of each country should occur . Whether necessary or not, it happened , and the
legacy has been the continued marginalisation and relative poverty and ill health of those who have survived .
One manifestation of marginalisation is the relative lack of influence of American Indians on
health and development policies that affect them , at least until recently. And what influence
they have even now is limited , for despite the existence of treaties and the support of many non-
Indians, the right to self-determination exists at the sufferance of the federal government and can be taken away or rendered
meaningless unilaterally . Indians and other indigenous peoples may lobby , demonstrate , seek redress in the

courts, complain to the United Nations, and engage in what has been called the politics of embarrassment,74 but in the end
they are considered by many people both within and outside government to be just one more interest
group ,75 unique in some ways but not entitled to any special consideration. In 1832 Chief Justice Marshall described Indian tribes as
dependent domestic nations, a concept that Indian legal scholars reject,76 but that unfortunately is still an accurate description of the true state
of affairs.
advantage
 funding fails
IHS funding fails---mismanagement means more money is useless
Bob Herman 16, health care writer for Modern Healthcare, “Wounded Care: Failure at one Indian Health
Service hospital reveals troubled system,” 12/3/16,
http://www.modernhealthcare.com/article/20161203/MAGAZINE/312039988

While members of the Omaha and Winnebago tribes know extra federal funds would help, they—like many on Capitol Hill—fear new
money would continue to be mismanaged. Tribal members are convinced deeper, more meaningful change will
only come with a top-to-bottom overhaul of agency leadership. “ You could throw all the money you want at
IHS , and it probably won't function any better,” Bass of the Winnebago Tribal Council said. “If they knew how to use this money
appropriately, they could fix this problem themselves.” The leadership and staffing 'merry-go-round' The small IHS facility in
Winnebago, which is only a little over a decade old, has a glistening lobby with decorative native art and wide, tidy hallways leading
from the emergency room to the inpatient area. A spacious spiritual room offers comfort to grieving families. Yet this same hospital also
had an untrained staff person who sent a patient home from the ER last year even though tests showed the
patient's kidneys were shutting down, according to the CMS report from 2015. The patient died. Seneca Smith, a short man with
broad shoulders who serves in the U.S. Public Health Service Commissioned Corps, is the hospital's acting CEO. Smith wasn't around when the
hospital lost its federal funding. He has been at the helm for less than a year, giving him the difficult task of changing the culture at a facility that
has endured frequent management turnover. The Winnebago hospital has had eight permanent or acting CEOs over the past five years. “I'll take
whatever time is needed to make sure the patient safety is where it needs to be,” Smith said. Other IHS facilities have had serious patient safety
violations. The Pine Ridge and Rosebud hospitals in South Dakota nearly lost their funding this year for substandard conditions. The Sioux San
Hospital, also in South Dakota, had its emergency room shut down in September. IHS hammered out agreements with the Pine Ridge and
Rosebud hospitals in May to avoid rescinding certification that would shut down its ability to bill Medicare and Medicaid. Smith said
Winnebago's quality and safety record has improved in the past year. But the hospital's quality data on Medicare's Hospital Compare website
are scant and often rank below average for measures that have enough data. Smith's reassurances fall flat with people who
have heard similar statements many times in the past. “IHS is trying to fix the problem with the same old tools
that crippled the situation,” Winnebago Tribal Council member Ken Mallory said. “ It's just a merry-go-round of ineffective,
inefficient and unprofessional people that continue, especially in the Great Plains area.”
 flattening
Their framing argument ontologizes settlerism, which reifies settler political control and is used to
justify evading political action – settler violence is not inevitable and not all actions are settlerist, so
judge our DAs based on their relative truth
Alissa Macoun 13, Researcher @ Indigenous Studies Research Network, The Ethical Demands of Settler
Colonial Theory, Settler Colonial Studies, 3(3-4), pp. 426-443

*SCT=Settler Colonialism Theory

Despite these powerful contributions, we also identify some important issues associated with SCT in Australian academic debates about the NT intervention. The

first is a direct consequence of one of SCT’s vital contributions , arising from the theory’s present tense
iteration of settler colonialism. By emphasizing continuities in colonial relationships between the past
and the present, SCT can depict colonization as structurally inevitable, and can be deployed in ways that
re‐inscribe settler colonialism . We suggest that SCT’s struggle to narrate its own ending can be countered by
approaching the theory as an account of settler desires which makes visible our own frames of reference .
This in turn exposes a range of possibilities and political visions outside these frames. Such an approach is significant in countering

potentially problematic misuses of SCT that erase its location as a settler discourse . Such erasures problematically
empower academics to speak with neutral descriptive authority over both settler and Indigenous realities. Firstly, by disturbing settler colonialism’s narratives of
progress, SCT attributes a peculiar suspended temporality to the settler project. This can portray settler colonialism as an inevitable structure likely to exist across
time – the fact that the past persists in the present implies that this past will also persist in the future. Foundational scholar Patrick Wolfe has been labelled ‘very
much a structuralist stuck in a poststructuralist world’.63 As we have outlined, this structuralism is particularly useful in identifying the operation of political

hierarchies. However, it can also excuse us from human political action in the present by presenting this action
as futile or already determined .64 The role of political activists is to wait for the structurally determined
future , and at most to prepare others for its arrival . The particular challenge of SCT’s analysis is that it
does not give an account of such a transformed future , or of the conditions for settler colonialism’s
demise . This can lead to a theoretical and political impasse and result in a kind of colonial fatalism .
Such fatalism can be deployed to imply a moral equivalence between different forms of settler
political interaction with Indigenous people , and, at its worst , to deny the legitimacy of Indigenous
resistances . Structuralist narratives are able to posit radical change , but only if this change is built into
the structures they describe – for example because these structures are subject to internal contradictions or
are inherently unstable. Settler colonial structures, however, appear as highly stable and ‘relatively impervious to regime change’.65 Therefore, at the
same moment settler scholars finally see the depth and reach of settler colonialism in the present they feel unable to find ‘postsettler colonial passages’.66 This

tendency is reinforced by SCT’s capacity to identify significant commonalities in the objectives of

conservative and progressive policy approaches, as discussed above. It shows that traditional ‘decolonizing’ pathways such as treaty
making, reconciliation and formal apologies may also serve colonial ends by absorbing and extinguishing Aboriginal political difference without disturbing the
foundational structures of settler dominance. As Australian anthropologist Deborah Bird Rose notes, this makes it ‘difficult to offer a critique of the colonizing

features without calling into question the whole decolonizing project’.67 If every settler action is framed as always
already colonizing , then individuals are excused from anti‐colonial action in the present
and Indigenous people are destined to be victims of an unstoppable colonizing state .68 As bell hooks
argues in relation to US race relations, this is useful to those in a position of dominance : ‘so many
White people are eager to believe racism cannot be changed because internalizing that assumption downplays the issue of accountability. No
responsibility need be taken for not changing something if it is perceived as immutable .’69 Is it
possible that settlers are particularly attracted to SCT precisely because it gives us a sense of being
intellectually committed to the end of colonialism while simultaneously unable to act
against our own privilege? As a recent article concluded about the prospects for decolonization: I can only assess this with a degree of
gloom. I am yet to be convinced that we can prevent indigenous disadvantage remaining structurally embedded in society and through the state even after any kind
of ‘transition’ or ‘transformation’. At the same time, I fear decolonization. I am myself a settler, like several of my ancestors before me, and I have nowhere else to
belong.70 SCT’s
structuralism may serve these conflicted interests , in allowing us to feel we have done all we
can while facing the ‘reality’ of an inevitable settler colonial future . This structuralism gives many within
settler colonial studies a particular orientation towards Indigenous resistance and scholarship . Australian
scholar Tim Rowse argues that critical settler perspectives on colonialism can ‘reproduce that sorrowing form of attention in which defeat and marginality are

He and others
highlighted at the expense of understanding the nature and limits of the Indigenous agency that circumstances afforded’.71

suggest that this sort of analysis caricatures Indigenous responses, presenting a false
binary between resistance/sovereignty and co-optation in the colonizing process .72 This,
they suggest, leads scholars to position one sort of Indigenous response as more valid and authentic
than others, re‐performing the authority settlers have always claimed over definitions of Indigenous
reality. Joanne Barker identifies a ‘troubled focus within settler colonial studies on structure to the erasure
of Indigenous experiences and perspectives about colonialism even within analyses of the “logic of
elimination” that fuels colonial processes of social formation. ’73 SCT may be revelatory to many settler scholars, but Indigenous
people have been speaking for a long time about colonial continuities based on their lived experiences.74 Some SCTs have sought to connect with these discussions
and to foreground Indigenous resistance, survival and agency.75 Others, however, seem to use SCT as a pathway to explain the colonial encounter without engaging
with Indigenous people and experiences – either on the grounds that this structural analysis already conceptually explains Indigenous experience, or because

Indigenous resistance is rendered invisible. In these cases, the structuralism of SCT theory can be mobilized to actively
reinforce settler colonial authority and to participate in the attempted erasure of Indigenous
independence . We argue that Australian scholar Dirk Moses76 deploys SCT in his analysis of the NT intervention in ways that clearly demonstrate this
potential re‐inscription of colonial authority.77 Moses, perhaps more than some others, recognizes the radical implications of settler colonial analysis. He
acknowledges that because ‘Australia remains a settler colonial entity,’ the Indigenous ‘experience of disintegration is intense … in the face of a White settler colony
determined to assimilate the “Native” other. Cultural survival is, then, a pressing issue for Indigenous leaders and intellectuals’.78 In his recent pieces on
contemporary Australian Indigenous policy, Moses deploys postcolonial and SCT to evaluate the responses of Indigenous intellectuals and political leaders,
leveraging theory and his status as a settler intellectual to provide an account of Indigeneity. He seeks to both encompass Indigenous experiences of colonization and
offer an assessment of appropriate Indigenous survival strategies. Ultimately, Moses uses SCT to argue that, for their own good, Indigenous people must give up the
struggle for survival in order to release themselves from violence and find freedom and policy agency. In what Moreton‐Robinson has labelled a form of ‘racial
ventriloquism’,79 Moses uses the work of African postcolonial theorist Achille Mbembe to suggest that Aboriginal people should ‘inculcate an ethics of responsibility
by recalling, mourning, accepting and transcending the trauma of colonialism’.80 Moses acknowledges Mbembe is speaking in a formally decolonized context while
Australian Indigenous people are subject to ongoing colonialism, yet argues that the ‘much discussed crisis of remote communities has led some Indigenous leaders
to abandon the liberation narrative’ and therefore the Indigenous
 consequences
Evaluating consequences is key to ethics
David Runciman 17, Politics, Cambridge University, “Political Theory and Real Politics in the Age of the
Internet,” The Journal of Political Philosophy, Volume 25, Issue 1, March 2017, Pages 3–21
Contemporary political realism carries echoes of this line of argument and of Bentham's shift from the weaker to the stronger version of it, even though Bentham's direct influence is rarely in
evidence. Critics of the current ubiquity of the language of human rights often point out that in the absence of a robust account of the power relations that are needed to underpin any rights
regime—in particular, an answer to the question of who does the enforcing—all such talk is a massive distraction from the real business of improving the situation on the ground to which
human rights are meant to apply.9 But for more radical critics the emptiness of human rights talk is too convenient to be merely a confusion: it serves as the perfect cover for the sinister
interests of those engaged in neo-colonial projects of exploitation and expropriation.10 However, these two poles of the Benthamite case against moralism—from inadvertent confusion to
deliberate deception—do not exhaust the range of explanations for what is wrong with it. There is another answer, drawn from an alternative intellectual tradition, which appears more

moralism does not so much obscure what politicians are really

frequently in the current realist literature. This is the Weberian idea that

up to, as conceal the truth about their personal motives from political actors themselves. In other words,
political moralism is less a form of deception than of self-deception: it lets politicians avoid looking
political reality squarely in the face because it allows them to believe they have their eyes set on
something higher . Conviction politicians think they can transcend the messy reality of politics . That
belief is dangerous because their response when they encounter the messy reality is to deny it , or to
ignore it , or to insist they can mould it to their higher purposes , which only makes the mess worse .
Weber's case against allowing an ethic of conviction to trump an ethic of responsibility in politics—which
requires, among other things, that politicians face up to the unintended consequences of what they do—remains
compelling.11 But it does not map onto any sharp distinctions between realism and moralism. That is because the convictions that can breed self-
deception are not necessarily moralistic beliefs ; they can be beliefs about anything , including beliefs
about how contingency trumps moral certainty . On the Weberian account it is not what you believe but how you
believe it that makes the difference. Realists, too, can be self-deceived, because the strength of their convictions against moralism produces its own self-
deceptions and blind spots. This is the case that can be made against Bentham, who was so thoroughly dogmatic about the vapidity of all talk of rights that it served to blind him to what was
missing from his own understanding of politics. Macaulay made the point in his celebrated takedown of the Benthamites published in the Edinburgh Review in 1829: ‘They surrender their
understandings … to the meanest and most abject sophisms, provided these sophisms come before them disguised with the externals of demonstration. They do not seem to know that logic
has its illusions as well as rhetoric—that a fallacy may lurk in a syllogism as well as a metaphor.’12 Bentham was insufficiently sensitive to the ways in which the attempt to ground political
argument in the language of force neglects the capacity of other sorts of arguments to move people successfully. Conviction politics is not simply the preserve of the moralisers. Likewise, it is
not the case that moral political philosophy is itself incapable of seeing the merit of arguments that point towards the unavoidability of unintended consequences. Just as realists can be blind to
contingency, so moralists can be alive to it. Take the example of Robert Nozick, the most prominent early critic of Rawlsian political philosophy from within the discourse of rights. Nozick's ‘Wilt
Chamberlain example’ was designed to highlight the inability of Rawlsian schemes of justice to accommodate the unintended consequences of cumulative instances of contingent rightful action
on the part of individuals (in this case, their willingness to hand over small amounts of their own money to watch the best basketball player around ply his trade, which would generate
unjustifiable inequalities of wealth—Chamberlain becomes very rich—unless the state intervenes to circumscribe their choices).13 The challenge to Rawls is to adapt his patterned view of
justice to a world in which events inevitably take place that will break up the pattern. But this challenge does not come from a realist; it comes from a moralist (and a self-professed utopian to
boot). There are many possible ways to push back against the apparent force of the Wilt Chamberlain example.14 A realist response would be to challenge the assumptions behind the case
itself. We live in societies that enrich leading sportspeople on a scale that even Nozick might have found hard to imagine (Nozick envisages Chamberlain earning $250,000; his contemporary
equivalent—LeBron James—earned more than $50,000,000 in 2015). But the players’ wealth is not simply the cumulative consequence of the unfettered choice of large numbers of people to
hand over small amounts of money to watch them play. Any such relationship—between fans and performers—is mediated by vast institutional structures of commodification and exchange,
which make it very hard to follow the money from individual consumers to the pockets of the superstars. It passes through the hands of many others—broadcasters, agents, advertisers, and
administrators—such that the path of justice may be at best obscured and more likely undermined (recent revelations about how FIFA operates do not inspire confidence that this is a
transparently just business). A further iteration of the realist response would indicate that an example drawn from the world of sports is itself a misleading one. Though polling evidence
suggests that in our increasingly unequal societies it is sporting celebrities and their like who are widely believed to be reaping the most outsize rewards—on the assumption that there is at
least some correlation between reward and measurable talent—most of the superrich in fact come from the financial services industry, where visible talent is much harder to identify.15 Tracing
the just transfer of money in Nozick's terms from individual consumers to the pockets of bankers would be a thoroughly thankless task. In that sense, the Wilt Chamberlain example appears
designed to play into our unwarranted presuppositions about the workings of the free market. It serves as a smokescreen. So realists can respond to Nozick's argument about contingency with
some contingencies of their own. But so too can Rawlsians. It is possible to turn Nozick's argument on its head. He purports to grant Rawls his ideal society in order to show that no political

what if Nozick is granted his ideal society—his utopia—in which there is no political eventuality
ideal can survive eventualities for which it was not designed. But

that cannot be justified in terms of the underlying individual rights that must remain un-breached for
any social arrangement to count as just. That society will also be subject to unforeseen contingencies ,
including emergent monopolies and other market failures. Correcting for those failures will require breaches of rights in Nozick's terms;
but sitting back and doing nothing will make the preservation of the conditions of justice—which includes the ability
much more difficult . There is a real world variant of this
to track the distribution of wealth through a series of free exchanges—

argument that illustrates what can be at stake. Critics of the most urgent demands to address the threat
of climate change tend to argue that pre-emptive responses will preclude the sort of market innovation that offers the best chance of finding a solution.16 In
 patterned state intervention forecloses the opportunities provided by being open to unforeseen
other words,

contingencies. But equally, openness to contingency can be its own form of limitation , if it forecloses
the opportunities provided by state intervention in the face of failure. Putting one's faith in an
unforeseen future to generate outcomes that will in due course solve the problems of the present rules
out the possibility of an unforeseen future that requires action in the present to solve its looming
problems. Those whose convictions blindly favour contingency and the free exchange of ideas can be as self-deceived in Weber's sense as those who want to intervene in the name of a
better politics. All convictions, however adaptable, have an edge of fatalism to them.17
 extinction
Ethical responsibility to stop extinction—human beings are ends in themselves—extinction outweighs
ontology
Angela Michelis 17 University of Turin “The roots of human responsibility,” Rev. Filos., Aurora, Curitiba, v.
29, n. 46, p. 307-333, jan./abr. 2017
The common elements making both phenomena paradigmatic and original are retraceable, according to Jonas, through the concepts of “totality”, “continuity” and “future” in relation to the

existence and happiness of human beings. Human beings, like all other living beings , are ends in themselves ; however, only
human beings are able to carry out strategies which safeguard their being ends in themselves . Therefore,
their very capacity for action implies an objective obligation in the form of external responsibility . For
these reasons they can be defined as moral beings; that is, as capable of carrying out morally responsible or morally irresponsible behaviours33. Jonas reaffirms in any case that the archetype

the relationship of responsibility is

of every responsibility is that of human beings for human beings, in which the subject-object connection in

irrefutable , and through this the responsibility for every living thing becomes clear. The totality of responsibility may be
characterized by the paradigmatic examples of parents and of the statesman, which combine as the opposite poles of the greatest particularity and the greatest generality. In particular, the
educational sphere demonstrates how the responsibility of parents and of the State are related, and how the private and public spheres integrate reciprocally, encompassing all aspects of the
life of human beings. As Jonas describes, the education of the child includes socialization, beginning with speech and progressing with the transmission of the entire code of societal convictions
and norms, through whose appropriation the individual becomes a member of the wider community. The private opens itself essentially to the public and includes it in its own completeness as
belonging to the being of the person. In other words, the ‘citizen’ is an immanent aim of education, thus a part of parental responsibility, and this not only by force of the state’s enjoining it.
From the other side, just as the parents educate their children ‘for the state’ (if for much more as well), so does the state assume responsibility for the education of the young. The earliest
phase is left in most societies to the home, but everything after that comes under the supervision, regulation, and aid of the state – so that one can speak of a public ‘educational policy’.34 The
continuity of responsibility depends on its own very nature since, for example, neither the care of parents nor the care of the government can cease, as they must respond to the ever new
needs of life, which is rooted in the past and moves towards the future. Of course, political responsibility is greater in both temporal directions in relation to the greater duration of the

historical community with respect to individual existence. Responsibility is projected beyond the present and today’s care into the
future , despite life’s unpredictability ; therefore, responsibility must have the function of making possible
more than determining the present . Jonas writes: The object’s self-owned futurity is the truest futural aspect of the responsibility, which thus makes itself the
guardian of the very source of that irksome unpredictability in the fruits of its labors. Its highest fulfillment, which it must be able to dare, is its abdication before the right of the never
anticipated, which emerges as the outcome of its care […] In the light of such self-transcending width, it becomes apparent that responsibility as such is nothing else but the moral complement

to the ontological constitution of our temporality35. Thus, every total responsibility, such as that of a parent or that of statesman or stateswoman – beyond its
specific and important duties – is always also the preservation of the future possibility of responsible
actions and of politics itself . Jonas affirms that by means of the difficult journey through the various regions of responsibility, he also found the answer to the question
that at the beginning seemed to represent “the critical point of moral theory”: how to transform the will into the “ought”. The transition is mediated by the phenomenon of power in its
uniquely human sense, in which causal force joins with knowledge and freedom. [...] Only in man is power emancipated from the whole through knowledge and arbitrary will and only in man
can it become fatal to him and to itself, his capacity is his fate, and it increasingly becomes the general fate. In him, therefore, and in him alone, there arises out of the willing itself the ‘ought’ as

the self-control of his consciously exercised power36. Human beings, as an epiphenomenon of nature capable of determining
for itself the aims of actions and to carry them out autonomously , have reached even within nature the point
at which their own self-destruction is possible . This imposes upon them the duty to pay special
attention to not destroying , through irresponsible use, what exists , what has come about , and all the other living
things , which are somehow in their power. Therefore, it is clear that, at the present time , human power not
only requires the union of will and obligation, but also undeniably places responsibility at the centre of
morality . Ethics and politics are necessarily interwoven , and Hans Jonas – in a situation where survival is
threatened , of emergency, owing to the exponential development of technological power, and in the conviction that human beings cannot adapt themselves to everything – declares:
“For the moment, all work on the ‘true’ [hu]man must stand back behind the bare saving of its precondition ,
namely, the existence of [hu]mankind in a sufficient natural environment ”37. Responsible politics turns
towards the future with the consciousness that it must guarantee the very possibility of responsible
action and the existence of future generations , as well as the right to life of the world . It urges a limitation of
technological development and the pursuit of a moderate and equitable use of resources.
block
states
 2nc ov
State action empirically spills up – solves the case, later
Madison, Professor of Law and Health Sciences @ Northeastern, 14

(Kathryn, “BUILDING A BETTER LABORATORY: THE FEDERAL ROLE IN PROMOTING HEALTH SYSTEM
EXPERIMENTATION”, Pepperdine Law Review, Vol. 41, No. 4)

States as Laboratories Scholars have devoted considerable effort to analyzing the roles of state and
federal governments in the development and diffusion of health care policy.15 Much of this literature refers to and amplifies upon the Brandeis state-as-policy-laboratory
metaphor,16 but the meanings that scholars attach to the metaphor vary. Michael Sparer and Lawrence Brown identify four “images” of state policy laboratories: The first image is state officials
and policy analysts working together to test theoretical policy hypotheses. The second is the image of states looking at and learning from other states, and adapting imported ideas to their own
conditions. The third image pictures federal officials adopting national reforms that have been pioneered and tested in the states. The fourth, and most “lab-like,” image is that of social

states might be said to

scientists studying state policy initiatives, evaluating programs, and suggesting improvements.17 These four images capture several different ways that

function as laboratories . First, they share a presumption that at least one state is willing and able to
adopt an innovative policy . States cannot serve as laboratories unless some are mavericks. Second, all four images include references to testing or evaluation processes
of some sort, and the first and fourth images highlight these processes. Finally, the second and third images focus on policy transmission. When one state adopts a new

policy that appears to achieve some success, its model will be studied and may be replicated by other
states as well as by the federal government . States clearly have the potential to serve all of these
functions. States frequently adopt innovative policies; these policies are often assessed in some way and
then replicated at the state or federal level . Managed care regulations, for example, spread quickly from state to state.18 Key health-
related parts of the federal statutes COBRA 19 and HIPAA 20 can be traced to state initiatives, as can the federal Medigap
program21 and the federal diagnosis-related group hospital payment method.22 In fact, the ACA can be traced to a state program: Massachusetts provided a model for the ACA’s state-based
exchanges as well as for its individual mandate.23
 at: jurisdiction
Distinction between formal legal jurisdiction and the CP is irrelevant – obviously tribes would not
REFUSE the states funding – to win this jurisdiction claim, they need to win a SEPARATE argument
about litigation or backlash to the states on part of the tribes

Legal certainty isn’t key---states and tribes can form pragmatic relationships anyway---the
counterplan’s fiat means it still solves
Erich Steinman 4, Assistant Professor of Sociology at Pitzer College, “American Federalism and
Intergovernmental Innovation in State-Tribal Relations,” Publius: The Journal of Federalism, Volume 34,
Number 2, Spring 2004, pp. 95-114

Since the end of the 1990s, the concept of applying the language of the tribal-federal " government-to-government"
relationship to state-tribal relations, and of developing such relationships on broad principles in addition to functionally narrow
agreements, has been the conventional approach of those attempting to extend the work of the Commission on State-
Tribal Relations. 71 Formalized overarching intergovernmental sovereignty accords or policies clearly signal that tribes should be treated as
legitimate and independent governments. Even though such accords are always at risk of becoming more symbol than substance, and even

though states' perceptions of the scope of tribal sovereignty differ from that claimed by tribes, accords
contribute to a partial normalization of state-tribal relations . Although the acceptance of tribal
governments is very incomplete even with such sovereignty agreements and policies, the default stance by states is no
longer one of complete denial of tribal status. Because of this, rather than being paralyzed by legal ambiguities
or continuing conflict , tribes and states are figuring out ways to function inter-governmentally even on
an unclear and unstable legal and political landscape .

Cooperative relationships exist between states and tribal governments---the counterplan takes
advantage of existing channels to help improve tribal health
Erich Steinman 4, Assistant Professor of Sociology at Pitzer College, “American Federalism and
Intergovernmental Innovation in State-Tribal Relations,” Publius: The Journal of Federalism, Volume 34,
Number 2, Spring 2004, pp. 95-114
Although many state officials undoubtedly preferred complete jurisdiction over disputed issues, the actions of the tribal entrepreneurs described above identified
plausible alternatives to this control and to the unwavering struggle required to pursue it. These alternatives highlighted how states and their agencies
could benefit from cooperation on specific matters . Promoting alternatives could not force state officials to accept them, but they at
least were available for active consideration. These alternatives appealed to officials with preferences less set on maintaining absolute state control. Tribes'

demonstration of their growing governmental capacity in natural-resources protection and other spheres also gave
increasing credibility to their claims that they should be treated as peer-like governments , and built
additional trust with state-agency officials substantively concerned about their respective regulatory domains. For these various reasons,
many states or state officials began to revise how they dealt with tribes , along the lines suggested by the CSTR. But additional steps were
needed to further establish these viewpoints and to reorient more common combative responses. Expansion of Intergovernmental Relations The largely informal
intergovernmental agreements highlighted by the CSTR were over time joined by a growing number of more formal agreements. Although it is difficult to quantify
the growth of either informal or formal agreements, many indicators suggest that in the ten years following a 1981 CST R report of state-tribal agreements, state-

tribal relations became somewhat more stabilized and formally established as intergovernmental in
nature. As documented by a 1991 study, a growing number of states passed acts authorizing public agencies and local
governments to enter into cooperative agreements with tribal governments . 48 In another study conducted that year the
National Conference of State Legislatures reported that "a key focus of [state] legislation was the enactment of new

authorization for cooperative agreements between state agencies and tribes in a variety of policy areas,
including law enforcement, hazardous and solid waste disposal, allocation of tax revenues, economic development, and allocation of water rights. "49 In 1991, 220
bills and resolutions were introduced in state legislatures, with 77 of them passing.50 In 1992, 106 such bills were enacted.51 In some areas, such as water rights in
the Southwest, negotiated agreements were replacing litigation as the preferred method of resolving conflict.52 Relatedly, states
began to create a
variety of executive and legislative mechanisms for state-tribal communication and policy development . In
some cases, these were new entities, such as the Colorado Commission of Indian Affairs, created in 1976. As in the case of many such commissions, it functioned as
a liaison with tribes and also addressed more general issues of the state's Indian citizens. Some efforts were temporary;53 in other cases, the missions of existing
"Indian affairs" organizations were expanded or changed to focus on a mutual intergovernmental relationship. "In 1986, the Arizona Legislature gave ACIA (Arizona
Commission of Indian Affairs) a new mission, as the State's liaison with the 21 Federally recognized Indian Tribes/ Nations. "54 Amidst such innovation, many states
studied the models used by other states in their relations with tribes.
 at: perm do both
Perm links to the net benefit –

State action avoids politics – but the plan gets drawn into partisan wrangling
Beilenson, M.D., CEO and President of the Evergreen Health Cooperative, 10

(Peter, “Let the states lead”, http://articles.baltimoresun.com/2010-01-31/news/bal-

op.health31_1_national-health-care-reform-health-status-hospital-and-emergency-room)

An additional benefit of reforming health care at the state level first is simply getting the debate out of
Washington , where any good-faith effort at figuring out what works for everyday Americans is completely
overwhelmed by partisan firefights . In contrast, at the state level , the partisan gridlock and rule by
lobbyists is less entrenched , and the media glare that brings out excess partisanship is less extreme .
Instead of imagining what a proposal might mean, we could see and weigh results , as we've done with Healthy Howard;
the country could then follow the lead of "pioneer" states, saving money and time in the process .
Maryland is well-positioned to be among those chosen.
 at: 50 state fiat bad
Topic literacy – federalism is the core controversy of health policy – the CP’s key to robust education
Doonan, professor @ Brandeis, 16

(Michael, Obamacare Wars: Federalism, State Politics, and the Affordable Care Act, Series: Studies in
Government and Public Policy, by Daniel Béland, Philip Rocco, and Alex Waddan”, Publius (2017) 47 (1):
e2.)

Obamacare Wars: Federalism, State Politics and the Affordable Care Act provides insight into policy and program implementation of a complex and politically contentious law. One
cannot understand contemporary health policy or most U.S. social welfare policy absent a
detailed examination of federalism and intergovernmental relations . Implementation research is
critical because it is where programs become real ; where policy impacts people. Béland et al. provide this type of analysis through case studies of
elements of the Affordable Care Act (ACA). A review of the main themes of the book is followed by a critique and thoughts about how the book could build on existing work toward a more
comprehensive theoretical framework for understanding intergovernmental relations across the policy process.
politics
 2NC Wall - Top Level
Tax reform will pass now – it’s the top priority for the administration and Republicans are united
around all of the key principles regarding the legislation that’s Bloomfeld
It’ll pass now because of Trump’s support
Reuters 9/26/17 ("Trump shows interest in bipartisan tax reform as Obamacare repeal collapses")

President Donald Trump told U.S. lawmakers on Tuesday he wants bipartisan cooperation on tax reform, as
pressure on him to produce a legislative victory on any front escalated with the collapse of the latest
Republican push to repeal Obamacare .¶ The administration and Republicans in Congress are due to unveil a tax
plan on Wednesday. The plan has been developed over several months by six White House and congressional Republicans working
behind closed doors and with no input from Democrats.¶ On the eve of its unveiling, Trump told members of the House of
Representatives tax committee from both parties: “I’ve asked lawmakers of both parties to join us to
discuss our framework. ... It’s time for both parties to come together .”¶ He said lawmakers should expect a “very, very
powerful document” that would deliver a big tax cut for the middle class. ¶ “We will cut taxes tremendously for the middle class - not just a little
bit, but tremendously,” said the president, who is set to travel to Indianapolis on Wednesday to unveil the plan.¶ Republicans, who control the
White House and both chambers of Congress have been unable to deliver a significant legislative win on any topic since Trump took office in
January.¶ Senate Republicans admitted failure on Tuesday in their latest push to replace the 2010 Affordable Care Act, popularly known as
Obamacare,, raising pressure on the party to overhaul the tax code this year, although that difficult effort has repeatedly been delayed. ¶
Republicans and Democrats who met with Trump on Tuesday said afterward that the president indicated
an interest in working with Democrats on both tax reform and healthcare going forward.¶ “He said you get a
better deal if it’s bipartisan ,” said Representative Richard Neal, the panel’s top Democrat.

The balance is delicate – Trump has to walk a tightrope of courting Democrats without angering the
GOP
Thomas and Lucey 9/24/17 (Ken and Catherine, "Trump aims to achieve congressional balancing act on
taxes")

President Donald Trump

says he wants to lure Democratic lawmakers to sign on to a Republican-crafted tax
overhaul plan but negotiators must deal with the reality that any handouts to Democrats could quickly
turn into turnoffs for the GOP .¶ The White House and tax-writing Republican leaders are expected to begin filling in some of the details this
coming week on Trump's plan to simplify the tax system, a legislative priority for the president. The White House views this as a once-in-a-lifetime opportunity to
simplify taxes and cut rates, while giving Trump a much-needed victory as the Republicans struggle to overturn the Obama health care law. ¶ The
specifics
are taking shape. Trump's efforts to draw in a few Democrats could mean "you're going to lose a few
Republicans," said Mark Weinberger, CEO of the accounting firm EY. But he added: "He wants to get 51 votes period in the
Senate ... so it is possible you might lose a few Republicans and pick up a few Dem ocrats who are in
states that Trump won."¶ While the plan is not finalized, Trump is already planning to promote it heavily . He will travel to
Indiana on Wednesday, and aides are discussing a televised speech, according to people familiar with White House plans. ¶ People familiar with the plan being
written entirely by Republicans said the administration is considering lowering the corporate tax rate from its current 35 percent to somewhere in the low 20s. The
plan probably would seek tax cuts across the board for individuals and reduce the number of tax brackets from seven to three. The administration is considering
whether to repeal the estate tax, long a Republican cause, according to these people, who spoke on condition of anonymity to discuss internal deliberations still
underway.¶ Republican leaders had promised an overhaul that would not add to the deficit. Republicans are talking about cuts whose costs would be justified by
assumptions of greater economic growth.¶ Lawmakers on the House Ways and Means Committee planned to meet Sunday night and Monday to discuss taxes, and
House Republicans are set to meet privately away from the Capitol on Wednesday, according to aides familiar with the plans. ¶ The
White House
initially pushed hard to overhaul taxes with only Republican support. But in recent months, people
involved with tax discussions have found that Republican lawmakers — beyond a general desire to cut
rates and simplify the tax system — also have their own divisions . The result is that Trump has been unable to deliver a tax
overhaul with concrete details.¶ "There are Republicans, there are base Republicans, there are Trump Republicans, there are progressive Democrats, there are Blue
Dog Democrats," said Douglas Holtz-Eakin, former director of the Congressional Budget Office. " There is no way to move one way or the
other and not lose someone on the other end of the spectrum ."¶ Trump has bargained on other issues with Senate Democratic
leader Chuck Schumer of New York and House Democratic leader Nancy Pelosi of California. But the tax plan has been developed in private with Treasury Secretary
Steve Mnuchin, White House economic adviser Gary Cohen, House Speaker Paul Ryan, Senate Majority Leader Mitch McConnell and the two Republicans leading the
major tax-writing committees — Sen. Orrin Hatch of Utah and Rep. Kevin Brady of Texas.

Tax reform will pass – Trump is investing capital and Republicans are united on getting it to the finish
line.
Killough 9/3/17 (Ashley Killough and Lauren Fox, "Tax reform near the top of congress' length to-do list")

When lawmakers return this week from the August recess, they'll face a bevy of must-do tasks, but chief
among them is a long-held Republican agenda item: comprehensive tax reform. Enthusiasm levels are
high for the mountainous challenge , as tax reform is a widely popular idea, and Republicans are
desperate for a major legislative accomplishment they can tout in next year's midterm elections. And it
would be major: The last time Congress successfully passed a comprehensive tax overhaul was in 1986.
While lawmakers in the tax-writing committees have been working on it for years, the current legislative
effort is still in its infancy. Broad principles have been established, and President Donald Trump has
begun to use his bully pulpit to make the case to the American people for the overhaul. But few details
have been released to the public -- in large part because they are still getting hammered out among
Republicans. Behind the scenes, staffers in the House Ways and Means Committee have been fleshing
out the bullet points laid out by the White House in its call for a lower corporate tax rate, lower income
tax rates and policies aimed at encouraging American businesses to bring overseas profits back home.
But it's still unclear how Congress intends to pay for any tax cuts, or at least spare the deficit from taking
a massive hit. Treasury Secretary Steven Mnuchin told The Wall Street Journal Thursday that the Trump
administration and congressional leaders plan to release a more detailed tax plan in the next few
weeks. In the meantime, the White House will continue its messaging campaign to ramp up public
support for a tax reform push -- something Trump wasn't as active in doing during the failed attempt to
repeal and replace President Barack Obama's health care law. It's one of the many lessons learned by
both lawmakers and the administration .They're also painting a more united front than they had on
Obamacare. Already, House and Senate leaders have formed a group called the "Big Six," alongside
Mnuchin and White House chief economic adviser Gary Cohn. The small group agreed to a set of shared
goals ahead of the drafting process as part of a strategy to prevent the same kind of intra-party strife
that helped take down the health care effort. Trump, who's scheduled to meet with all six leaders this
week, said Wednesday in Missouri that he was "fully committed" to working with Congress on the
issue, but still took the liberty to poke at lawmakers and throw more pressure their way. "I don't want to
be disappointed by Congress," he said in the tax reform speech. "Do you understand me?"

And, Republican unity, lobbying assistance, and lack of Democratic opposition ensure that passage will
be smooth
Norquist 8/7/17 (Grover Norquist, President of Nonprofit Americans for Tax Reform, The Hill, "6 reasons
Congress shouldn't have any trouble passing tax reform")

There are six reasons tax reform will pass "easily" unlike ObamaCare repeal. First, on taxes, the GOP is
united. Speaker Ryan says that "we had agreement on 80 percent of tax reform (before jettisoning
border-adjustability) and we are now 97 percent in accord." All agree that the business tax rate must
come down to 15 percent or at worst 20 percent to be internationally competitive. Abolition of the
death tax and alternative minimum tax have universal appeal. Full and immediate expensing has the
backing of most Republicans and heavy manufacturing. Second, while Republicans have little experience
in repealing/reforming entitlements they are very good at cutting taxes. Every single House and Senate
Republican (except Vermont Sen. Jim Jeffords) voted for the 1981 tax cuts. In 2001 every single
Republican except McCain and Sen. Lincoln Chafee voted for Bush's first tax cut. And in 2003 every
Republican (except McCain, Chafee, and Sen. Olympia Snowe) voted for Bush's second tax cut. Third, the
Trump/GOP tax proposal is very pro-family and helpful to middle class voters. It reduces the number of
tax credits from seven to three. It doubles the standard deduction from $6,000 to $12,000 and a family
of four’s standard deduction from $12,000 to $24,000. And the reform so simplifies the tax code that 95
percent of American taxpayers will not have to itemize. Fourth, the business community is united in
support of the major components of tax reform. Larger American businesses that compete
internationally demand that the 35 percent rate fall to 15 or 20 percent so that when one adds the
average state income tax of 5 percent we can compete with European firms facing an average of 23
percent tax rates. And equally important for Republican elected officials, smaller firms that are organized
as Subchapter S corporations and pay taxes through the personal income tax demand that they see their
tour ate now 40 or 44 percent fall to 15 or 20 for equity the big companies. Two powerful lobbies,
larger companies and smaller business leaders are united . For the first time in income tax history, all
agree that we must bring the tax on Subchapter S corporations – so-called pass through where smaller
businesses pay their business taxes through the personal income tax – to parity with larger businesses.
Fifth, there is an election in November 2018. Annual economic growth since the recession ended in July
2009 has been an anemic 2 percent or less. Reagan won his 49 state 1984 landslide after his tax cuts had
taken effect in January 1983 and delivered 4 percent growth for almost two years. All 240 Republican
congressmen are up for election, 10 senators are up. They want strong economic growth starting in the
first quarter of 2018 – not the third quarter. (Bush lost in 1988 with solid growth – in the third quarter of
1988.) The focus will be on growth because it is good for the country, but perhaps also because it is life
or death for the Republican majorities. Republicans had hoped to have two bragging points in November
2018: ObamaCare repeal and pro-growth tax reduction. Now the tax victory must be "huge" and
provide solid growth to carry the narrativ e. Sixth, Democrat opposition will be hysterical and universal,
but oddly muted. Everyone fully understands that not a single Democrat will vote for any tax cut.
Period. The party has swerved hard left from the days when 37 Democrat senators voted for the tax cut
of 1981 and 33 supported Reagan’s tax reform of 1986. Still, Democrat senators have long been telling
their corporate donors and small business constituents that they “feel their pain” of high business taxes.
Many Democratic congressmen have friends that pay the alternative minimum tax and the death tax.
Democrat opposition will in some cases be transactional. They have to sound and look “progressive,” yet
signal to their voters that they understand the need for lower business taxes , all while never admitting
the Republicans are doing what they could not or would not do for the past eight years.

Republicans will get the core of tax reform done – they’ll ditch the divisive portions to get unity – BAT
debate proves
Waldman 7/31/17 (Paul Waldman, contributor to The Plum Line, "Why Republicans May succeed at tax
reform where they failed at health care reform")

But most important is this: Republicans really, really want to cut taxes for the wealthy and corporations.
There is not a single policy goal that is more important to them. This is what they come to Washington
for. If they do nothing else with their time in control of Congress and the White House, they will do this.
That doesn’t mean it’ll be easy. There will be conflicts among business interests about the details. But
there’s another difference between tax reform and health care: When the going gets tough, there’s a
fallback plan. Republicans can set aside that complex reform that overhauls the entire system, and just
cut the corporate tax rate and some personal tax rates — bring down income taxes, maybe get rid of
the inheritance tax, toss in a couple of other goodies for the wealthy, and they’re done. They’ve already
dropped the idea of a border adjustment tax, because while some Republicans wanted it, it proved too
divisive. Manufacturers might have liked it, but retailers were opposed, and arguing about it for the next
year was a miserable prospect.
 AT: GOP Split
The GOP will rally around tax reform – they need a win
Ferrechio 9/9/17 (Susan Ferrechio, "Republicans look to accelerate tax reform after averting spending
and debt crisis")

Trump, who endorsed the three-month debt limit deal to make room for tax reform, has stepped up
pressure on the GOP on taxes, which so far has failed to pass a major agenda item . "Republicans must
start the Tax Reform/Tax Cut legislation ASAP." Trump tweeted Friday. "Don't wait until the end of
September. Needed now more than ever. Hurry!" Rep. Bill Flores, R-Texas, a top lawmaker on the
conservative Republican Study Committee, said he believes the GOP will advance a bill, despite internal
divide. "I don't see it causing any problems on tax reform," Flores said. " I think we can get something
passed ." House, Senate and White House key players met twice on tax reform last week and plan more
meetings in the days ahead. In the meantime, House lawmakers next week will continue debating an
unfinished package of 2018 spending bills and associated amendments that will fund the Agriculture
Department and the Food and Drug Administration, among other agencies.

They’re divided but they’ll get behind a compromise

Jagoda 9/11/17 (Naomi, The Hill, "Trump scrambles tax reform")

Notably, Republicans are divided over how deeply to cut the corporate tax rate . Trump has said he ideally
wants to lower the rate from 35 percent to 15 percent, while Speaker Paul Ryan (R-Wis.) said Thursday
that Trump’s goal would be hard to achieve and that he’s aiming for a rate in the low to mid-20s. Another
major challenge is how to fund tax cuts without bloating the debt, especially after the GOP took a
proposal to tax imports, which would have raised considerable revenue, off the table. Despite the
challenges, GOP leaders insist the prospects of passing major tax legislation are still goo d . And even
after Trump made the debt-limit deal with Democrats, Ryan said at an event hosted by The New York
Times that the president is a good partner on taxes. "On tax reform, he's very, very, engaged ," Ryan
said.

The political survival of the GOP depends on it – they’ll get something done
Rainey 9/11/17 (Michael, "Trump wants speedy tax reform. Here are 5 reasons it won't happen, and one
big one that it will")

But Judd Gregg, the Republican former governor and senator from New Hampshire, points to one big
reason Congress may still find a way to overcome the many obstacles complicating tax reform: “It is
called political survival. The passage of a true, significant tax reform bill is the last, best hope for this
Republican Congress and this unusual President to claim they should continue to be entrusted with our
nation’s wellbeing. Political survival trumps (no pun intended) all other hurdles, procedural and
substantive. A way will be found to get to tax reform. You can bet your re-election on it — if you are a
Republican.”
 at: tip point
Tech exists to slow warming---tipping points can be avoided with immediate reductions
James Hansen 16 – is director of the NASA Goddard Institute for Space Science, (James Hansen,
8/19/16, "Global Warming: it's not too late," No Publication, accessed 1-4-2017,
http://eartheasy.com/article_global_warming_not_too_late.htm)

The Earth's climate is nearing , but has not passed , a tipping point beyond which it will be impossible to
avoid climate change with far-ranging undesirable consequences. The Earth's temperature, with rapid global warming over the past 30
years, is now passing through the peak level of the Holocene, a period of relatively stable climate that has

existed for more than 10,000 years. Further warming of more than one degree Celsius will make the Earth warmer
than it has been in a million years . Business-as-usual scenarios, with fossil fuel (CO²) emissions continuing to increase at 2 percent
per year as in the past decade, will yield additional warming of two or three degrees this century. That implies

practically a different planet. The Earth's climate is nearing, but has not passed, a tipping point beyond which it will be impossible to avoid climate
change with far-ranging undesirable consequences. These include not only the loss of the Arctic as we know it, with all that implies for wildlife and indigenous
peoples, but losses on a much vaster scale due to rising seas. Ocean levels will increase slowly at first, as losses at the fringes of Greenland and Antarctica due to
accelerating ice streams are nearly balanced by increased snowfall and ice-sheet thickening in the ice sheet interiors. But as Greenland and West Antarctic ice is
softened and lubricated by melt-water, and as buttressing ice shelves disappear because of a warming ocean, the balance will tip toward the rapid disintegration of
ice sheets. The Earth's history suggests that with warming of two to three degrees, the new sea level will include not only most of the ice from Greenland and West
Antarctica, but a portion of East Antarctica, raising the sea level by 25 meters, or 80 feet. Within a century, coastal dwellers will be faced with irregular flooding

associated with storms. They will have to continually rebuild above a transient water level. This grim scenario can be halted if growth of
greenhouse gas emissions is slowed in the first quarter of this century . That requires two things: first, flattening
out and then decreasing the rate of growth of CO² emissions, primarily through improvement in energy efficiency; second, an absolute
decrease in emissions of non-CO² gases that also affect warming , particularly methane and carbon monoxide, and therefore
The action must be prompt . Otherwise, CO²-producing infrastructures
tropospheric ozone and black carbon (soot) aerosols.

that may be built within a decade will make it impractical to keep further global warming under one
degree. Of top concern is the large number of coal-fired power plants that China, the United States and India are planning to build without CO² sequestration
(the process whereby CO² is separated and stored in the ground). CO² is a greenhouse gas. It absorbs the Earth's infrared radiation, reducing the emission of heat to
space. This causes a temporary imbalance between the amount of solar energy absorbed by the Earth and the energy emitted to space, so the Earth will warm up
until it restores energy balance. The good news is that about 40 percent of annual fossil fuel emissions continue to be soaked up. And if we decrease CO² emissions
and improve reforestation and agricultural practices, we could probably increase that percentage. The bad news is that to stabilize the amount of CO² in the
atmosphere may require reducing emissions by 60 to 80 percent. Yet, emissions have increased at the rate of 2 percent per year in the past decade. In the long run,
satisfying energy needs while decreasing CO² emissions will require developing renewable energies, sequestering CO² produced at power plants and perhaps a new
generation of nuclear power. But emissions
can already be reduced now with improved energy efficiency. It is
important that the United States, as a leader in technology and as the largest producer of CO² in the
world, take the lead. In general, industrial emissions of CO² are declining. The problem is emissions from
power plants and vehicles. The solution in both cases depends on efficiency . We need to avoid building fossil fuel power
plants unless and until sequestration is a reality. For vehicles, efficiency is critical because of the rapidly growing global number of vehicles. In the United States, even

though the number of vehicles on the road increases every year, we could stop increasing emissions by accepting even modest
improvements in efficiency of about 30 percent by 2030. This could be done with available technology ,
and there's ample time to phase it in. The accrued benefit in 35 years, even without the introduction of hydrogen-powered vehicles, is a
savings of oil equal to more than seven times the estimated amount of oil in the Alaska National Wildlife Refuge. Keeping the rise of global

temperature below one degree Celsius is technically within reach . Everything depends on an informed
public to bolster the political will of leaders across this warming globe.
case
 ihs fails
alt cause
Gurr 14
(Barbara Gurr, assistant professor in residence in the Department of Women’s, Gender, and Sexuality Studies @
University of Connecticut at Storrs, Reproductive Justice: The Politics of Health Care for Native American
Women. New Brunswick; New Jersey; London, Rutgers University Press, 2015 pg(s). 35-36 DH)

As the IHS Budget Workgroup asserts, " The federal budget is a moral, fiscal document as well as a . The nation's budget priorities are a demonstration of its core values and, in the case of the Indian Health

the greatest limitations imposed on IHS is its

Service, of its commitment to addressing the health needs of American Indian and Alaska Native people” (HHS2O11). Yet one of by Congress and the president

persistent and stark underfunding annual budget appropriation is consistently below identified levels of
. The for IHS

need , and in fact is consistently below that of other, similar federal programs such as the Veterans Administration and the federal prison system (Harvard Project on American Indian Economic Development 2008; NPAIHB 2009). Federal appropriations for Tribal nations deeply

To date, this relationship has been one

influenced by the broader political economy in which they are deed, they also reflect shifting conceptualizations of the relationship be State and the Native nations within its borders.

of dominance, control, and neglect, wherein assimilation of Native people into the collective of the
national body serves both the clad economic goals of the State. The Indian Health Service was granted formal agency status in 1988, following declining social service
appropriations during the first half of Reagan's presidency. The US Commission on Civil Rights found in 2003, that Sa never been adequately funded, and that "the anorexic budget of the IHS can only lead one to deduce that less value is placed on Indian health half other populations" (US

the
Commission on Civil Rights 2003, 49). This commission's findings in 2004 assert unequivocally that " federal government has failed to satisfy explicit trust obligations" to
Native people, Specifically in the provision of health care (US Commission on Civil Rights 2004, 95). Given the much lower rate of budgetary growth for IHS in comparison who federal health programs such as the Veterans Administration

intentional
and the federal prison system, the commission concludes that the failure of Congress to fund Native health care adequately while other, similar programs experience slightly greater growth rates is attributable at least in part to either "

discrimination or gross negligence Although decreasing appropriations for Native health care in the
" (2004, 96).

late 1980s and early 1990s can be attributed in part to the fiscally conservative Reagan-Bush years,
Congress's lack of understanding about the capacities and purposes of IHS information management
and billing systems all responsible . Appropriations during these years were made with the
assumption that IHS would bill Medicare, Medicaid, and private insurance when Native patients were
eligible for these. However, IHS systems designed to generate billing, as IHS was not originally
intended to serve as a paid provider. Therefore these funds could not be accessed in the ways
Congress imagined, and IHS was forced to operate with increasing budget shortfalls. Not only have
allocations been insufficient, but IHS's ineffective billing system has resulted in a further loss of
revenue on the other hand well; a recent Government Accountability Office (GAO) study reported that
IHS has been paying a majority of their contracted health billed rates rather than the mandated
Medicare rates, resulting in overpayment of millions from an annual budget that is already too Small
(GAO 2013). Upgrading and updating these billing systems continues to be a priority for IHS, and
constitutes a varying but consistently substantial portion of the annual budget. However, lower
budgetary appropriations and reliance on reimbursement through billing continue to create significant
funding uncertainties, particularly in light of recent congressional cuts to Medicaid, increasing needs in the Veterans Administration since 2002, and inaccurate billing systems.

IHS echoes earlier legislative mainstreaming of Native identity and

Increasing reliance on third-party payers by both Congress and thus serves to potentially

reduce federal responsibilities to Native people as a distinct collective interest. Donna, a sixty-one-year-old enrolled

member of the Oglala Lakota Nation, described IHS's reliance on private insurance and Medicare to
cover the cost of medical care as "totally unfair . The government is supposed to be paying for this, not
us. reliance on Medicaid compromises her status as an enrolled member of a
They're just trying to find ways not to pay for us.” Donna understands that

federally recognized Native nation and inserts her into a class-based, rather than Tribally based, instead

collective identity. She offers an accurate assessment of the State's fiduciary relationship with Native
also

nations, which has been marked by ongoing efforts to reduce the financial cost to the State of
regular and

indigeneity within its national body. IHS is underfunded,

Other informants shared this view, both in formal interviews and informal conversations, and it is well known on the reservation that
as patients are frequently directed to make an appointment with a contracted facility in order to access certain tests, or must
endure long wait times due to understaffing . The Obama administration has demonstrated a strong commitment to improving the delivery of health care to Native people through increased funding. For example,
the American Recovery and Reinvestment Act of 2009 included close to $500 million for IHS to complete needed construction projects as well as update its health information technology system. Additionally, in one of his earliest acts in the Executive Office, President Barack Obama
included just over seven million dollars for IHS to further develop its outreach advocacy programs in Native communities in the Omnibus Appropriations Act of 2009. Importantly, a major portion of the funds were intended to expand domestic violence and sexual assault projects already in

This funding is essential to providing care and

operation, including further training and the purchase of forensic equipment to support the Sexual Assault Nurse Examiner program (see Chapter 8).

services to survivors of sexual assault, which is egregiously high in Indian Country, and will potentially
have an impact on the reproductive health care of these women . The president's consistent proposed budget increases for IHS reflect the Executive Office's overall commitment
to health care as well as recognition of the specific needs of Native communities, and Native organizations such as the National Indian Health Board continue to praise Obama for his commitment to Native health care. However, the Affordable Care Act's requirement that Native people
purchase health insurance or pay a fee is likely to affect IHS's upcoming budget appropriations in ways that are reminiscent of Congress's uninformed budgetary justifications in the late 1980s and early 1990s, as public or private health insurance will be expected to pay a portion of
expenses. Although the budget increases, coupled with additional funding from the 2009 Recovery and Reinvestment Act and 2009 Omnibus Appropriations, were necessary (and in fact represent the greatest increase in real terms allocated to Native health care since the late 1970s), they
were not sufficient to fully meet accumulated and ongoing needs in Indian Country. Additionally, the allocation and use of some of these resources by IHS itself has come under scrutiny by Congress as well as nongovernmental organizations such as Amnesty International and the American
Civil Liberties Union, as discussed below and in Chapters 7 and 8. Lateral offices in the Department of Health and Human Services have also noted fiscal mismanagement in IHS; for example, in the fall of 2009 the Department of Medicaid and Medicare threatened to withdraw funding from
Pine Ridge Hospital due to noncompliance involving both medical treatment and administrative issues. At that time, Pine Ridge Hospital received approximately 66 percent of its funding from the Department of Medicaid and Medicare. A satisfactory plan was submitted by IHS, and funding
has continued.

politicization and gaming means money just disappears inside the system
Harold Monteau 17, Chippewa Cree Economic Development Consultant, Time for Tribes to Own Indian
Health Service,” 6/18/17, https://indiancountrymedianetwork.com/news/opinions/time-tribes-indian-
health-service/
We all know that there are good people who work within Indian Health Service who really care about their Indian patients and other health care
recipients served through congressional appropriations for Indian health care. We also know there are a few bad
eggs who need to be
weeded out, which can be very hard to do under the federal personnel system. They pretty much have to commit a crime to get
weeded out. We also know that the Indian Health Service bureaucracy sucks up a lot of monetary resources
and personnel and encourages engagement in what I call empire building, especially at the regional and
national level of the bureaucracy. The accompanying protectionism encourages the politicization of the
entire system from top to bottom . It becomes a political basketball in a game of who can control the ball to score the
most political points, but with everyone supposedly playing on the same team and playing defense on each other. It encourages the
formation of little teams within the team to help each other score or keep the others from scoring.

Physical and economic barriers prevent people from accessing services---it’s not just IHS funding
Daniel R. Levinson 11, Inspector General, Department of Health and Human Services, “ACCESS TO
MENTAL HEALTH SERVICES AT INDIAN HEALTH SERVICE AND TRIBAL FACILITIES,” September 2011,
https://oig.hhs.gov/oei/reports/oei-09-08-00580.pdf

Approximately 69 percent of the facilities that provide mental health services (353 of 514) reported that AI/ANs face physical,
personal/social, or economic barriers in obtaining mental health services at IHS and tribal facilities. See Table 5 for
the individual barriers related to access to mental health services. Approximately half of facilities reported that physical
barriers affect clients’ access to services Approximately 53 percent (274 of 514) of facilities reported that transportation was a
barrier to accessing services. More than one-third of the facilities reported that physical barriers, such as poor roads, distance, or

weather , prevented clients living on rural reservations from obtaining mental health services. During interviews,
providers and clients related concerns about dangerous travel through remote areas to access facilities. Twenty
facilities reported that their clients may use alternative means of transportation—including snowmobile, dogsled, tractor, horse, or boat—to get
to facilities. Approximately one-third of facilities reported that personal and social issues affect clients’ access to services Approximately 30
percent of facilities reported that work and personal schedules affected clients’ access to mental health services. Survey
responses from 34 percent of the facilities that provide mental health services indicate that their clients have limited access to these services
because of lack of child care. During onsite visits, providers and clients in 24 communities related other personal and social
barriers that affect access. According to respondents, domestic violence and sexual abuse, addiction to drugs and alcohol, and
the personal stigma associated with seeking help for mental illness limited clients’ ability and willingness to obtain mental
health services. Clients in small communities were particularly concerned about confidentiality, fearing that their mental health treatment
would become common knowledge. Nearly one-third of facilities reported that economic issues affect clients’ access to services Twenty-eight
percent of IHS and tribal facilities reported that their clients’ financial situations may limit their access to mental health services.
For example, 11 percent of the facilities reported that copayments may present a barrier to care when the AI/AN clients
are referred to non-IHS/nontribal facilities .35 The financial condition of clients also was mentioned in interviews with clients
and staff. In many instances, economic issues combine with personal and social factors to affect access to services. In rural areas, clients may
not have enough money for transportation or other personal costs associated with trying to obtain services. For
example, in several of our interviews, clients and providers cited clients’ inability to pay for child care and the cost associated with clients’ taking
leave from their jobs as socioeconomic problems that serve as barriers to services.
 2nc – consequences

Consequentialism’s inevitable, most logical, and key to effective healthcare analysis

Joanne Grainger et al 15, Clinical Research Project Manager, Drug Information Scientist, “Foundations of
Healthcare Ethics”, google books

There is something appealingly intuitive about consequentialism and its offshoot, utilitarianism. Our daily lives are
filled with choices, and unless we are prepared to simply act at random , in order to make the best choice we need to
be able to evaluate them all. While in some cases there may be little to distinguish between choices, we normally try to choose the
option that affords us most satisfaction. We choose a new car, a new phone or a new job by first working
out a set of criteria that will help us to make up our minds and then by applying these to the available choices. For example, in
buying a car we might compare different models on engine size, fuel economy, reliability and other
relevant factors. In the end, our deliberations lead us to buy the particular car that best satisfies the set of
criteria we have chosen. It would be odd if we chose a car we did not like or that we knew had major
faults , such as bad brakes or poor steering. Our deliberation is directed towards weighing up our options in terms of
good or optimal consequences . Similarly, when we are thinking about what we should choose to do in a particular situation, we choose
what we think is the best choice, and this will be in terms of what we think the best outcome will be , all
things considered. Consequentialism takes seriously the consequences of choosing a particular course of
action. Weighing up courses of action, and deciding what to do in the hope of alleviating pain and
suffering , is a staple requirement of healthcare practitioners , and consequentialism is
beguilingly attractive. While consequentialism considers and assesses the consequences of an action, utilitarianism — an offshoot of consequentialism
— tries to assess consequences in a more quantitative fashion.
 2nc – extinction
Outweighs
Bostrom 11 — Nick Bostrom, Professor in the Faculty of Philosophy & Oxford Martin School, Director of
the Future of Humanity Institute, and Director of the Programme on the Impacts of Future Technology at
the University of Oxford, recipient of the 2009 Eugene R. Gannon Award for the Continued Pursuit of
Human Advancement, holds a Ph.D. in Philosophy from the London School of Economics, 2011 (“The
Concept of Existential Risk,” Draft of a Paper published on ExistentialRisk.com, Available Online at
http://www.existentialrisk.com/concept.html, Accessed 07-04-2011)

Holding probability constant, risks become more serious as we move toward the upper-right region of figure 2. For any fixed
probability, existential risks are thus more serious than other risk categories . But just how much more serious
might not be intuitively obvious. One might think we could get a grip on how bad an existential catastrophe would
be by considering some of the worst historical disasters we can think of —such as the two world wars, the Spanish flu
pandemic, or the Holocaust—and then imagining something just a bit worse. Yet if we look at global population
statistics over time, we find that these horrible events of the past century fail to register (figure 3). [Graphic
Omitted] Figure 3: World population over the last century. Calamities such as the Spanish flu pandemic, the two world wars, and the Holocaust
scarcely register. (If one stares hard at the graph, one can perhaps just barely make out a slight temporary reduction in the rate of growth of the
world population during these events.) But even this reflection fails to bring out the seriousness of existential risk.
What makes existential catastrophes especially bad is not that they would show up robustly on a plot like the one in figure
3, causing a precipitous drop in world population or average quality of life. Instead, their significance lies primarily in the fact that they
would destroy the future . The philosopher Derek Parfit made a similar point with the following thought experiment: I believe that if
we destroy mankind, as we now can, this outcome will be much worse than most people think. Compare three outcomes: (1)
Peace. (2) A nuclear war that kills 99% of the world’s existing population . (3) A nuclear war that kills
100%. (2) would be worse than (1), and (3) would be worse than (2) . Which is the greater of these two differences?
Most people believe that the greater difference is between (1) and (2). I believe that the difference between (2) and (3) is very

much greater . … The Earth will remain habitable for at least another billion years. Civilization began only
a few thousand years ago. If we do not destroy mankind, these few thousand years may be only a tiny
fraction of the whole of civilized human history . The difference between (2) and (3) may thus be the
difference between this tiny fraction and all of the rest of this history . If we compare this possible
history to a day, what has occurred so far is only a fraction of a second . (10: 453-454) To calculate the loss
associated with an existential catastrophe, we must consider how much value would come to exist in its
absence. It turns out that the ultimate potential for Earth-originating intelligent life is literally
astronomical . One gets a large number even if one confines one’s consideration to the potential for biological human beings living on
Earth. If we suppose with Parfit that our planet will remain habitable for at least another billion years , and we
assume that at least one billion people could live on it sustainably , then the potential exist for at least
10^( 18) human lives . These lives could also be considerably better than the average contemporary
human life , which is so often marred by disease, poverty, injustice, and various biological limitations
that could be partly overcome through continuing technological and moral progress . However, the relevant
figure is not how many people could live on Earth but how many descendants we could have in total.
One lower bound of the number of biological human life-years in the future accessible universe (based on
current cosmological estimates) is 10 34 years .[10] Another estimate, which assumes that future minds will be mainly implemented in
computational hardware instead of biological neuronal wetware, produces a lower bound of 1054 human-brain-emulation subjective life-years
(or 1071 basic computational operations).(4)[11] If we make the less conservative assumption that future civilizations
could eventually press close to the absolute bounds of known physics (using some as yet unimagined technology),
we get radically higher estimates of the amount of computation and memory storage that is achievable
and thus of the number of years of subjective experience that could be realized .[12] Even if we use the
most conservative of these estimates , which entirely ignores the possibility of space colonization and
software minds, we find that the expected loss of an existential catastrophe is greater than the value
of 10^( 18) human lives . This implies that the expected value of reducing existential risk by a mere
one millionth of one percentage point is at least ten times the value of a billion human lives . The more
technologically comprehensive estimate of 1054 human-brain-emulation subjective life-years (or 1052 lives
of ordinary length) makes the same point even more starkly. Even if we give this allegedly lower bound on the
cumulative output potential of a technologically mature civilization a mere 1% chance of being correct ,
we find that the expected value of reducing existential risk by a mere one billionth of one billionth of
one percentage point is worth a hundred billion times as much as a billion human lives . One might
consequently argue that even the tiniest reduction of existential risk has an expected value greater than that
of the definite provision of any “ordinary” good, such as the direct benefit of saving 1 billion lives . And,
further, that the absolute value of the indirect effect of saving 1 billion lives on the total cumulative amount
of existential risk—positive or negative—is almost certainly larger than the positive value of the direct benefit
of such an action.[13]
T: Insurance
 AT: Jost
Jost evidence is straight up out of context---read that in CX, will reinsert the highlighting
Timothy Stoltzfus Jost 4 Robert L.Willett Family Professor of Law at Washington and Lee University. He
has published many books and articles about health care law and comparative health law and policy.
Journal of Law, Medicine & Ethics 32 J.L. Med. & Ethics 433 SYMPOSIUM ARTICLES: PART III:
REFLECTIONS FROM THE EXPERTS: Why Can't We Do What They Do? National Health Reform Abroad

Many nations have adopted the national health insurance model of public health insurance in the past half
century, although, again, in each nation the model looks somewhat different. n28 Canada, Australia, the Scandinavian

countries, Spain, Portugal, Italy, and some Latin American and Asian countries have national health
insurance systems . Other countries, particularly less developed countries , provide services through
public hospitals and clinics without necessarily [*435] developing a full and comprehensive
national system of health care finance that would be essential to make such a network of
services accessible to all persons. Our own Medicaid program , as well as our veterans' , military , and
Indian health services , resemble the "national health insurance" model , in that all use
general revenue funds to pay for health services , but they are different in that their
coverage is limited to certain narrowly delineated populations , which may even, as with Medicaid,
vary from state to state. In virtually all countries, voluntary private health insurance of the sort sold in the
U.S. to both groups and individuals continues to exist , although it serves different functions in different countries. In
some, such as Germany and the Netherlands, it covers wealthy people who are not covered by social insurance. n29 In others, such as Canada,
it covers services such as Pharmaceuticals, which are not universally covered by public insurance. In yet others, such as France, it covers cost-
sharing obligations, much like our own Medigap policies. In still others, such as the U.K. or Australia, it allows privately insured persons to jump
the queue and get sendees faster or more conveniently than publicly insured patients.

Toth evidence on the other page proves NHI and NHS are not the same
Toth 16 24th World Congress of Political Science Poznań, July 23-28, 2016 Panel RC 25.10 - The
Problematic Politics of Raising Revenue for Delivering Health Care: Who Pays Who Cares? (Who Cares
Who Pays?) Classifying Healthcare Systems: A New Proposal Federico Toth University of Bologna
Department of Political and Social Sciences e-mail: federico.toth@unibo.it

The label "national health insurance" has been used in the lit erature with multiple meanings (Evans 1981; Frenk
and Donabedian 1987; OECD 1994; Lee et al. 2008; Böhm et al. 2013). It is therefore necessary to immediately clear up possible
misunderstandings. In this work, national health insurance (NHI) is understood as the principle according to which the
state requires all residents to take out a private health insurance policy covering essential healthcare
services, using individual resources. There not being one single public scheme into which contributions can be paid, the policy has
to be taken out with different, for-profit or non-profit insurers in competition with one another. The NHI is therefore a multi-payer
system, in which citizens can choose their insurers . The state may provide subsidies for low-income
citizens (who might otherwise find it difficult to pay the insurance premium regularly), and may impose a
regulation, even a very strict one, of the insurance market. The insurance packages usually differ from one another , and
may provide coverage additional to the minimum required by law; we must therefore bear in mind that there may be differences between the
services provided to individual healthcare users. Universal system The universal system, as we shall see later, is not
synonymous with the National Health Service . A universal system is defined as a single-payer insurance
scheme (therefore, one for the entire population) covering all residents and financed through taxation. Compared with other
insurance schemes, the universal system is marked out by the fact that the right to healthcare is not linked with payment of a
premium or a contribution, but to residing in a given country. Healthcare is therefore a right of the citizens of that country .
From the point of view of those who have to contribute financially, the universal system does not grant freedom of choice. Aside from the few
countries where some form of opting out is possible, residents
cannot choose whether or not to finance the universal
scheme: they are required to pay taxes, and therefore also to finance the progr am. And, given that (direct) taxes
are usually paid more than proportionally with respect to income, the universal scheme turns out to be a typically progressive financing system
(Mossialos and Dixon 2002; Hussey and Anderson 2003). It is important to underscore that, unlike the SHI model, the universal system envisages
taxation not only on earned income, but on all forms of income. Financing of the universal scheme therefore has a clear redistributive intent:
the richest end up paying, at least in part, the healthcare services provided to the poorer citizens.
 AT: Ulrich
Ulrich evidence doesn’t say the word insurance in it---we command the preponderance of legal
evidence, their card concedes the limits DA
Ulrich 1 Hofstra Labor & Employment Law Journal Fall, 2001 19 Hofstra Lab. & Emp. L.J. 173 LENGTH:
48151 words ARTICLE: YOU CAN'T TAKE IT WITH YOU: AN EXAMINATION OF EMPLOYEE BENEFIT
PORTABILITY AND ITS RELATIONSHIP TO JOB LOCK AND THE NEW PSYCHOLOGICAL CONTRACT NAME:
Katherine Elizabeth Ulrich* BIO: * Employee Benefits Analyst, Xerox Corporation. B.S., Cornell University
School of Industrial and Labor Relations, 1996; J.D. Candidate, Yale Law School, 2002. mmm
Whereas COBRA ""guarantees' portability, as it allows workers to maintain their current health insurance plan," HIPAA ""improves' portability as
it makes it easier [for individuals with pre-existing conditions] to get new health insurance on job change." n266 Health insurance plans "often
restrict[] or exclude[] plan coverage for the treatment of health conditions that existed prior to the time the participant enrolled in the plan."
n267 HIPAA's core provision for preventing job lock was a limit on the length of time for which pre-existing health condition clauses can restrict
coverage. n268 HIPAA requires that group health plans reduce the duration of a pre-existing-condition waiting period by one month for every
month that an individual previously had health insurance coverage in another plan. n269 HIPAA uses a broad definition of
creditable coverage encompassing almost any type of health plan, including those through private
employers, government group health plans, individual health insurance, COBRA coverage, Medicare
and Medicaid, the military, the Indian Health Service, and the Peace Corps . n270 This creditable coverage is
forfeited, however, if the participant has a lapse in coverage of sixty-three or more days. n271

Even the IHS defines itself as not an insurance program

IHS no date – Indian Health Service, “Frequently Asked Questions,” https://www.ihs.gov/forpatients/faq/

A: TheIndian Health Service is funded each year through appropriations by the U.S. Congress. The Indian
Health Service is not an entitlement program, such as Medicare or Medicaid . The Indian Health Service
is not an insurance program . The Indian Health Service is not an established benefits package.

IHS facilities are reimbursed by insurers---the aff is a provider, not an insurer

Cristina Boccuti 14, Associate Director of the Program on Medicare Policy at The Henry J. Kaiser Family
Foundation, “The Role of Medicare and the Indian Health Service for American Indians and Alaska
Natives: Health, Access and Coverage,” December 2014, http://files.kff.org/attachment/report-the-role-
of-medicare-and-the-indian-health-service-for-american-indians-and-alaska-natives-health-access-and-
coverage

Reimbursements from third-party insurers , including Medicare, are important revenue sources for IHS
facilities , in light of IHS funding constraints.33 As the payer of last resort, IHS facilities are expected to collect
reimbursements for services from patients’ third-party payers, including Medicare. In the aggregate, IHS facilities will
collect an estimated $217 million in reimbursements from Medicare for services they provide to Medicare beneficiaries in 2014. While Medicare
payments make up a relatively small share of facilities’ operating budgets, these reimbursements are not insignificant, given the fiscal pressures
inherent in IHS’s overall funding. When caring for Medicare patients who have no supplemental coverage, IHS facilities receive
Medicare’s full payment for the service, but forego the portion that would otherwise be attributable to beneficiary cost-sharing,
such as the 20-percent co-insurance for physician services. In contrast, IHS facilities may seek payment for cost-sharing from
patients’ supplemental insurers when applicable, including Medicaid, the Medicare Savings Programs, the Part D Low-Income
Subsidy Program, VA coverage, or private supplemental insurers, including health plans in the Medicare Advantage program. Similarly, when
American Indian and Alaska Native beneficiaries have Medicare prescription drug coverage, I/T/Us may seek reimbursement for applicable costs
from beneficiaries’ Part D plans.34
Insurance programs are clear policy alternatives to the Indian Health Service
Jayme Fraser 16, writer for the Billings Gazette, “Insurance giving Native Americans more health care
choices,” 9/4/16, http://billingsgazette.com/news/local/insurance-giving-native-americans-more-health-
care-choices/article_107ed36b-d80d-538f-b294-16951626fd50.html

Thousands of Montana tribal members have sought subsidized insurance, public or private , in recent years. Like
Lamebull, many say it’s because of frustrations with the I ndian Health Service.

Although the federal agency is tasked with fulfilling treaty promises to provide health care for members of more 560 recognized tribes, Congress
has consistently underfunded it, forcing hospital administrators to limit the services offered. To match even the level of care provided to federal
prisoners, funding would have to nearly double, according to an analysis by the National Congress of American Indians. It would
need to
be even higher to match the benefits guaranteed by programs such as Medicaid. As a result, tribal members have
a different health care reality than other U.S. citizens.

Experts hope improved access to insurance could help bridge the gap between the two systems , making it
more seamless for tribal patients to choose how and where to receive their care. Some speculate that private providers might be
more interested in opening offices on or near reservations if they knew patients would have insurance to
bill.
Federal and state reforms also have expanded revenue opportunities that tribal clinics can use to grow services. But barriers remain for both
patients and health providers looking to leverage coverage.

First, more people have to sign up. Even with insurance, IHS rules sometimes can limit the care patients receive. Other realities — like
unaffordable premiums, or the cost of traveling to another hospital — can keep families from care. Clinics report other challenges, too: lack of
physical space, trouble with recruitment and retention, and burdensome federal rules.

From D.C. to St. Ignatius, health leaders say they are trying to find solutions.

“The big picture goal is to provide more access to quality health care for our patients and to give our patients more options,” IHS Principal
Deputy Director Mary Smith said upon announcing a Medicaid and Medicare enrollment pilot project at the Browning Community Hospital in
July, part of a broader agency push to evaluate insurance usage. “The more our patients are enrolled, the more we’re able to leverage dollars ...
and provide more services.”

For some Native Americans, insurance coverage has been a passport out of the IHS system . Because of
patient privacy laws, it is impossible to know how many tribal members exclusively access care at non-IHS facilities. For the roughly 40,000
people in Montana who live off-reservation, residency rules sometimes make them ineligible for IHS care.

For others, insurance

helps them receive treatments not available at an IHS clinic, or at least not without
waiting on a referral review that might end in denial . Given the isolation of most reservations in Montana and the distances
to other hospitals, insured families might still go to IHS for care even if they have coverage.
 AT: Cerasano and Hart
Hart and Cerasano cards says IHS is a provider---that it is discretionary is one current difference
between the IHS and insurance programs, but there are other important ones, namely that insurers do
not provide care. Making me two years older would not turn me into Callahan even if it makes us
more similar.
Hart 10 Wisconsin Journal of Law, Gender & Society Fall, 2010 Wisconsin Journal of Law, Gender &
Society 25 Wis. J.L. Gender & Soc'y 209 LENGTH: 24692 words ARTICLE: NO EXCEPTIONS MADE: SEXUAL
ASSAULT AGAINST NATIVE AMERICAN WOMEN AND THE DENIAL OF REPRODUCTIVE HEALTHCARE
SERVICES NAME: Rebecca A. Hart* BIO: * Legal Fellow, Center for Reproductive Rights. J.D., School of
Law, University of California, Berkeley, mmm

As mandated by the IHCIA, IHS administers and delivers healthcare services to Native Americans. n81
The mission of IHS is "to assure that comprehensive, culturally acceptable personal and public health
services are available and accessible to American Indians" n82 and "to uphold the Federal Government's
obligation to promote healthy American Indian and Alaska Native people, communities, and cultures and
to honor and protect the inherent sovereign rights of Tribes." n83 IHS provides medical services to any
enrolled member of a federally recognized tribe . n84 In addition to providing direct healthcare services,
IHS functions as a healthcare advocate for Native Americans within the federal government. n85 In
testimony before the United States Commission on Civil Rights, Dr. Charles Grim, then-director of IHS,
described the healthcare services of IHS as "a program of "universal eligibility but limited availability .'"
n86 The distribution of healthcare funds does not mimic the entitlements common in most United States
health insurance programs. Typically, someone with health insurance expects that their health insurance
provider will cover necessary doctor visits, tests, and procedures and that the insurance provider will
have the funds required to cover the cost of necessary services. However, in the case of IHS, the funds
are discretionary in nature, and "consequently, IHS provides health care services only to the extent
appropriated funding allows." n87 That is to say, due to the extraordinarily low level of federal funding
for IHS, there is no guarantee IHS will pay for doctor visits, tests, and/or procedures deemed necessary
because IHS may not have sufficient funds to pay for the medical service.
 AT: WM Funding
This is like…topic 101. Insurance is a contract that reimburses providers against a specific risk, not just
like “paying money for something”
Investopedia no date – http://www.investopedia.com/terms/i/insurance.asp

Insurance is a contract , represented by a policy, in which an individual or entity receives financial protection or
reimbursement against losses from an insurance company. The company pools clients' risks to make payments more
affordable for the insured.
 AT: C/I---Cover Expenses
Counterinterp card says they’re extra-topical because it includes funding the provision of health
services via the government
Medical News Today 16
(Medical News Today, January 2016, What Is Health Insurance?,
https://www.medicalnewstoday.com/info/health-insurance, JKS)

Health insurance is a type of insurance coverage that covers the cost of an insured individual's medical
and surgical expenses. Depending on the type of health insurance coverage, either the insured pays
costs out-of-pocket and is then reimbursed, or the insurer makes payments directly to the provider. In
health insurance terminology, the "provider" is a clinic, hospital, doctor, laboratory, health care
practitioner, or pharmacy . The "insured" is the owner of the health insurance policy; the person with
the health insurance coverage.
 AT: Native Education Good
In case they cross apply the set col DA, our interp solves it
Jayme Fraser 16, writer for the Billings Gazette, “Insurance giving Native Americans more health care
choices,” 9/4/16, http://billingsgazette.com/news/local/insurance-giving-native-americans-more-health-
care-choices/article_107ed36b-d80d-538f-b294-16951626fd50.html

Thousands of Montana tribal members have sought subsidized insurance, public or private , in recent years. Like
Lamebull, many say it’s because of frustrations with the I ndian Health Service.

Although the federal agency is tasked with fulfilling treaty promises to provide health care for members of more 560 recognized tribes, Congress
has consistently underfunded it, forcing hospital administrators to limit the services offered. To match even the level of care provided to federal
prisoners, funding would have to nearly double, according to an analysis by the National Congress of American Indians. It would need to be even
higher to match the benefits guaranteed by programs such as Medicaid. As a result, tribal members have a different health care reality than
other U.S. citizens.

Experts hope improved access to insurance could help bridge the gap between the two systems, making it
more seamless for tribal patients to choose how and where to receive their care. Some speculate that private
providers might be more interested in opening offices on or near reservations if they knew patients
would have insurance to bill.
Federal and state reforms also have expanded revenue opportunities that tribal clinics can use to grow services. But barriers remain for both
patients and health providers looking to leverage coverage.

First, more people have to sign up. Even with insurance, IHS rules sometimes can limit the care patients receive. Other realities — like
unaffordable premiums, or the cost of traveling to another hospital — can keep families from care. Clinics report other challenges, too: lack of
physical space, trouble with recruitment and retention, and burdensome federal rules.

From D.C. to St. Ignatius, health leaders say they are trying to find solutions .
“The big picture goal is to provide more access to quality health care for our patients and to give our patients more options,” IHS Principal
Deputy Director Mary Smith said upon announcing a Medicaid and Medicare enrollment pilot project at the Browning Community Hospital in
July, part of a broader agency push to evaluate insurance usage. “The more our patients are enrolled, the more we’re able to leverage dollars ...
and provide more services.”

For some Native Americans, insurance coverage has been a passport out of the IHS system . Because of
patient privacy laws, it is impossible to know how many tribal members exclusively access care at non-IHS facilities. For the roughly 40,000
people in Montana who live off-reservation, residency rules sometimes make them ineligible for IHS care.

For others, insurance

helps them receive treatments not available at an IHS clinic, or at least not without
waiting on a referral review that might end in denial . Given the isolation of most reservations in Montana and the distances
to other hospitals, insured families might still go to IHS for care even if they have coverage.
 AT: Aff Ground/Overlimiting
First, Ground – national health insurance is a middle ground approach between free market and
socialized medicine – those two are clear examples of negative ground in the literature
Charles J. Dougherty 90 academic who served as the 12th president of Duquesne University in
Pittsburgh, Pennsylvania. An expert in the field of health care ethics, Dougherty has published two books
on the subject. The Moral Case for National Health Insurance From: Biomedical Ethics Reviews· 1990
https://link.springer.com/chapter/10.1007%2F978-1-4612-0471-8_3

National health insurance must be contrasted to two alternative arrangements :

socialized medicine and free market distribution of health insurance. Under socialized medicine, as in
Great Britain, the national government is the owner of most health care facilities and the institutional
provider of most care. The national government owns hospitals and employs physicians. In contrast,
national health insurance does not give the government an ownership role . Instead, the
government functions as a third party payer, enabling its citizens to pay for care provided by other
institutions and individuals. National health insurance is not socialized medicine; it is
socialized health insurance. A free market approach keeps the government out of health
insurance, except to tax and to regulate against fraud, abuse, anticompetitive practices, and so on.
Health insurance arises out of the interactions of supply-private insurance companiesand demand-
employers and individuals. Considerations of access and equity would be secondary to the pressure of
market forces. As with all marketplace models, patterns of distribution and the quality of products and
services distributed will be shaped by ability and willingness to pay. National health insurance can be
seen as a middle ground between these two extremes of government ownership of health care
resources and government exclusion from a health insurance marketplace . On this broad middle stand
nearly all of the industrialized democracies of the world. In the West, only Great Britain and, to some
extent, Italy have chosen to socialize medicine. The US stands alone among the industrialized
democracies for having chosen a largely marketplace model for health care and health insurance.2

Second, precision is key – sloppy interpretations trigger policy failure

Journal of Public Health Policy 86 Editorial Toward a National Medical Care System: I. Semantic Problems
Source: Journal of Public Health Policy, Vol. 7, No. 2 (Summer, 1986), pp. 152-155
https://www.jstor.org/stable/pdf/3342251.pdf?refreqid=excelsior
%3A8b5250b3fc52cbd08b705fbaf7282016

The recent resurgence of interest in a national medical care system for the United States has several major causes: l) the increasing restrictions
on, and resultant disillusionment with, Medicare and Medicaid, particularly among the 65 years and over age group; 2) the persistence of high
rates of unemployment and consequent loss of medical care insurance by large numbers of individuals; 3) the continuing escalation of medical
care costs; and 4) the growing familiarity with the benefits and achievements of the Canadian medical care system. This is the first in a series of
editorials on the scope, content, and procedures of such a system, designed to elaborate on positions taken in a previous editorial, published in
1984, on “A National Health Program for the United States: The Need for a Citizens Coalition” (1). Those positions were for the most part merely
stated; there was no attempt to discuss them in detail, provide the rationale for each recommendation, or review the reasons for rejecting
alternative proposals. It is essential to begin with semantic problems . Some will cavil at the necessity to do
so; to them, it is the issues that are important, not the words used to define them. At the risk of being

considered a purist who is interested more in words than in action, the editor insists that the use of words reflects the concepts
which are acted upon and determines the policies that are adopted . Examples of the damage done by
careless confusions of words and concepts have been cited in other editorials in this Journal on ‘‘The Distinction
between Public Health and Community /'Social / Preventive Medicine” (2) and “What is Health Promotion?” (3). One of the major

obstacles to achieving a national medical care system in the United States is the current misuse of the
term “national health service” to include a wide variety of proposals for federal action . A national health
service has always been defined as a system in which medical care for the entire population is provided by salaried employees of the national
government. Fairly complete national health services are found in the 14 socialist countries which represent about a third of the world’s
population. Examples among industrial capitalist nations are the British National Health Service and the newly developing national health
service of Italy. It should be noted, however, that the British National Health Service is only partial, since general practitioners are not salaried
government employees; they are independent professionals who maintain their own offices and have a contractual arrangement with the
government to provide services to a defined group of individuals at a fixed amount per capita. In the Scandinavian countries, hospital services
are provided by salaried physicians and other employees of local governments, but out-of-hospital care is furnished primarily through fee-for-
service payment to independent practitioners. The social security systems of Spain and Portugal, which employ salaried physicians, represent
incomplete national health services; this is also true for many developing nations, in which the salaried National Health Service provides care for
only a limited part of the population. Among these nations, Costa Rica is moving toward a fairly complete national health service.
AT: Reasonability
T: Subsets
 Overview---2NC
Topic Education – Incremental versus radical reform is at the heart of the debate
U.S. Department of Commerce, Bureau of the Census, 1991

Proceedings: ... Annual Research Conference, Volume 7 p.336 Google Books

HEALTH INSURANCE COVERAGE The United States is the only major western country without a
system of universal national health insurance . Instead, receipt of health care and
corresponding payment mechanisms are a patchwork quilt of private and government programs . Most
Americans receive health insurance coverage (hereafter, despite the potential confusion with the sampling usage of the term, simply coverage)
as a fringe benefit or an employment relation; either their own employment, or that of a spouse or parent. Most Americans over the age of 65
receive coverage through Medicare. Some poor Americans are covered by Medicaid. Many Americans fall into the cracks between these systems
and are left without any health insurance coverage. The standard information on levels and sources of coverage is the Current Population Survey
(CPS). Since 1980, the March Demographic Supplement to the CPS has included a battery of questions on health insurance coverage. Table 1
summarizes a set of results from the 1988 CPS. They suggest that over 30 million Americans, more than ten percent of the population, is not
covered by any health insurance. Table 2 presents similar tabulations for blacks, who are the focus of the empirical work that follows. The
numbers are from Long (1987) and are based on the March 1985 CPS. They suggest that compared to whites, blacks are less likely to have
employer based insurance and more likely to have public insurance. In addition, they are considerably more likely to be uninsured: 23% vs. 16%
in the 18-64 age group. Beyond the sheer size of the uninsured population, there has been a marked shift in the trend over time. As a result of
the implementation of Medicaid, the percentage of the non-elderly population without health insurance fell sharply from 30.4% to 13.9% over
the period 1963 to 1986 (Swarz 1984). The later figure appears to have been a trough. Since that time non-coverage rates have drifted up to the
16.6% figure implied in Table 1 (Swarz 1986). To advocates this arresting of the previous decline and possible increase are causes for
considerable concern. General concern for the welfare of the working poor and the apparent failure of the situation to improve over time has

proposals range from calls for radical

resulted in a plethora of proposals to ameliorate the situation. These to

reform , proposals for incremental extensions of the current system to fill the gaps
between the various pieces . Radical reforms usually involve some form of national
health insurance . Incremental proposals often involve requiring all employers to
provide health insurance for their employees (Monheit and Short 1989).
 AT: We Meet---Cover All Natives
Their interpretation moots “National” in “National Health Insurance”
Cody Yiu 4 Staff Reporter Taipei Times

http://www.taipeitimes.com/News/taiwan/archives/2004/11/24/2003212340

Researchers discuss gaps in medicare

FAIR CARE Academics and activists discussed changes to the health insurance program to ensure that all
citizens receive medical coverage

The Council of Grand Justices provides legal interpretations of the Constitution. Based on the
interpretation, the academics said that the term national health insurance should be
defined more clearly. “In Taiwan, the emphasis of this health insurance policy is placed
on the word insurance, and not on the word national [universal]. Therefore, it is an
insurance system, not a social welfare system. However, what this particular interpretation by the
Grand Justices says about national health insurance is in contrast with the actual
practice ,” said Lin Wan-I, a professor of social work at National Taiwan University. The National Health
Service (NHS) of the United Kingdom, Lin said, functions as a social welfare system. “The NHS does not
work like an insurance program, but as a social welfare system, and the focus of the UK’s system is on
all,” Lin said. Lin suggested that a portion of tax revenues be allocated to Taiwan’s national health
program if the program was in fact meant to serve the entire population. “In Sweden, about 7 percent of
one’s income goes to the national health program. Taiwan could adopt this structure in which money
flows out of one’s income [as tax] and into the program, instead of actually having to pay for premiums.
This way, the entire population would be included in the health program,” Lin said. Michael Chen a social
welfare associate professor at National Chung Cheng University, suggested treating the three groups that
fall outside the system like the unemployed in terms of insurance coverage. Chen explained that the
current national health insurance policy covered unemployed people for a maximum of 30 weeks.
However, at least half of the unemployed population was actually out of work for a longer period, and
therefore the policy should be re-adjusted.

National Health Insurance is universal

Medical Dictionary 9

http://medical-dictionary.thefreedictionary.com/national+health+insurance

national health insurance

A form of health insurance coverage whereby all of a country's citizens receive care financed by their
government . Countries with national health insurance include Canada and the United Kingdom.

Medical Dictionary, © 2009 Farlex and Partners

National Health Insurance can have exceptions for medical costs not covered --- that doesn’t mean
subsets are topical
Laura Cunningham 95 Associate Professor of Law, Benjamin N. Cardozo School of Law

50 Tax L. Rev. 237

ARTICLE: NATIONAL HEALTH INSURANCE AND THE MEDICAL DEDUCTION

As a matter of health care policy and fiscal policy, no national health insurance program would cover all health care
expenses, so it is inevitable that any such program must grapple with the problem of distinguishing expenses covered by the mandatory
insurance program and those not. It is therefore safe to assume that if a program of national health insurance were adopted, it

would provide for the mandatory purchase 90 of a baseline level of health insurance, that is, a
"standard benefit package ," 91 and would permit the private purchase of insurance for expenses not within the baseline
("excess medical expenses") as well as permitting the purchase of uncovered services directly from the provider. 92 The
separation of
health care into two categories, that covered by the standard benefit package and that not covered,
would create a [*260] distinction that should be relied upon to distinguish essential from nonessential
medical care for income tax purposes. A national health insurance program would provide an administrable method of separating
health care into these two categories, and would serve as a proxy for separating the medical and personal elements of mixed motive expenses.
There are obviously political and economic factors that determine which expenses should be covered by
the standard benefit package and which should not. For example, it is conceivable that, for political
reasons, abortions might not be covered, even if essential to the mother's mental or physical health. In
addition, some medically accepted and useful procedures may not be covered because of their cost, for
example magnetic resonance imaging. If the tax system were to use the coverage of the standard benefit package as a proxy for
distinguishing between essential and nonessential care, it is inevitable that procedures that some would argue constitute truly essential care
mistakes at the margin should be tolerated because of the advantages of having an
would be taxed. These
administrable system to make these difficult distinctions . It is appropriate for the tax system to defer to
the health care policymakers who arrive at the standard benefit package, as that package would
represent the best available view of society's definition of essential medical care . In addition, as discussed
below, there are additional and compelling reasons for taxing medical care not covered by the standard benefit package, having to do with the
continued resource misallocations which would result. I therefore would advocate using the standard benefit package as a means to identify
those medical expenses that should be excluded from taxation.

Single group plans are not National Health Insurance – their interpretation is antiquated
Gail Henderson 97 Department of Medicine UNC School of Medicine

The Social Medicine Reader p.418

Glossary: National Health Insurance —A national program of social insurance that finances medical care
for all or part of the population. Usually the term "national health insurance” refers to
programs that cover most of a country's population (for example, 64% in the Netherlands,
85% in Belgium. 89% in Germany, 97% in Canada). It is not any longer, as it was in Lloyd George’s day
used to describe compulsory social insurance programs that cover only industrial workers or some other
minority of the citizens of the country (for example, Americans aged 65 and older who are covered by
Medicare). Under national health insurance, the government, either directly or through private sector
agents, makes payments to physicians, hospitals, pharmacies, laboratories, etc.. which themselves
operate privately. How- ever, in order to participate (be paid by the pro- gram) these private entities
must meet the standards that have been set by the national insurance plan.
 AT: We Meet---Clinics
Their clinics evidence is negative---aff creates 18 of them which is clearly not a policy of universal
coverage---even full funding is a patchwork approach clearly distinguished from our evidence
IHS.gov no date Indian Health Service, https://www.ihs.gov/urban/aboutus/
About Us The IHS Urban Indian Health Program supports contracts and grants to 34 urban health programs funded under Title V of the Indian Health Care Improvement Act. Approximately
100,000 American Indians use 23 Title V Urban Indian health programs and are not able to access hospitals, health clinics, or contract health services administered by IHS and tribal health
programs because they either do not meet IHS eligibility criteria or reside outside of IHS and tribal service areas. Another 49,000 AI/AN use 11 Title V programs in cities that are located in IHS or
tribal service delivery areas. Recent studies on the urban AI/AN population documented poor health and revealed that the lack of adequate health care was a serious problem for most families.
Since 1972, the IHS has gradually increased its support for health related activities in off-reservation settings aimed at assisting AI/AN populations to gain access to available health services, and
also to develop direct health services when necessary. In its 1992 amendments to the Indian Health Care Improvement Act, the Congress specifically declared the policy of the Nation "in
fulfillment of its special responsibilities and legal obligations to the American Indian people to assure the highest possible health status for Indians and urban Indians and to provide all

resources necessary to affect that policy." The IHS addresses this responsibility by funding 34 urban Indian health organizations operating at 41 sites
located in cities throughout the United States . Primary care clinics and outreach programs provide culturally acceptable, accessible, affordable,
accountable, and available health services to an underserved urban off-reservation population. The 34 programs engage in a variety of activities, ranging from the provision of outreach and
referral services to the delivery of comprehensive ambulatory health care. Services currently include medical services, dental services, community services, alcohol and drug abuse prevention,
education and treatment, AIDS and sexually transmitted disease education and prevention services, mental health services, nutrition education and counseling services, pharmacy services,

health education, optometry services, social services, and home health care. Fifteen of the programs are designated as Federally
Qualified Health Centers (FQHC) and provide services to Indians and non-Indians . Ambulatory medical care
services are provided throughout the off-reservation Indian health programs, including: prenatal and postpartum care; women's health; immunizations for both children and adults; pediatrics;
chronic disease (geriatric health and diabetes) clinics; adult health; maintenance; acute medical care, infectious disease treatment and control (tuberculosis, sexually transmitted disease); and
referral to specialized providers when needed. Dental care services are provided by many programs, including direct patient care - preventative and restorative. Dental education and screening
for both children and adults are provided in both the clinic and community settings. When needed, referrals are made to specialists for orthodontics, periodontics, selected restorative
procedures, and oral surgery. Community outreach services are provided throughout the urban off-reservation health programs, including: patient and community education; patient advocacy;
outreach and referral; and transportation. The outreach worker serves an important function as a liaison between the off-reservation health program and the community, and works to make
health services more available and accessible to those community members who need them. Alcohol treatment services are provided at 10 off-reservation Indian sites that were originally
funded by the National Institute of Alcohol Abuse and Alcoholism. Funds were transferred into the Urban Indian Health Program in FY 1993 to continue these Urban treatment centers under
Title V of the Indian Health Care Improvement Act. At least 28 additional NIAAA programs are in the process of being transferred. The AIDS and sexually transmitted disease (STD) information is
provided at conferences, seminars, workshops, and community meetings at all of the IHS Title V funded off-reservation Indian health programs. These education and prevention services include
culturally sensitive information provided to a variety of audiences through the use of posters, pamphlets, presentations, and community education. Additional AIDS services include HIV testing,
pre- and post-test counseling, family support groups, and referral for additional treatment for AIDS if needed. Mental health and social services include individual family and group counseling
and support groups to address the problems of abuse, self-esteem, depression, and other emotional problems and conditions. Additional services available at various off-reservation Indian
health programs include primary and secondary prevention activities, i.e., diabetes, maternal and child health, women's health, men's health, nutrition education and counseling for prenatal
care and chronic health conditions, social services, community health nursing and home health care, and other health promotion and disease prevention activities. Significant Items: The Urban
Indian Health Program participates in line item increases as appropriated by Congress. The contracts and grants are awarded pursuant to a DHHS/IHS class Justification for Other than Full and
Open Competition (JOFOC) for Title V, Urban Indian Contracts. The applicable statutes are the Snyder Act of 1921 (25 U.S.C., 13) and Title V of the Indian Health Care Improvement Act (PL 94-
437), as amended. The JOFOC is also pursuant to Federal Acquisition Regulation 6.302-5 and 41 U.S. C., 253 (c) (5) and the use of set asides under the Buy Indian Act, 25 U.S.C., 47. Full and
open competition need not be provided for when a statute expressly authorizes or requires that the acquisition be made from specified sources such as identified by Title V and pursuant to the
Buy Indian Act. The Urban Indian Health Program line item is distributed through contracts and grants to the individual Urban Indian Health programs. The distribution is based upon the

historical base funding of these programs. The funding level is estimated at 22% of the projected need for primary care services. Eighteen (18) additional cities
have been identified as having an urban population large enough to support an Urban Indian Health
Program.

Clinics are not universal – limited by Medicaid eligibility

CDC 14, no date given but this issue brief includes laws enacted through September 2014 “Medicaid
Service Delivery: Federally Qualified Health Centers,” https://www.cdc.gov/phlp/docs/brief-fqhc.pdf
Federally Qualified Health Centers (FQHCs) The FQHC program is intended to increase the provision of primary care services in underserved
communities.3 Individuals receiving care from FQHCs are mostly low income and uninsured or covered by
Medicaid .4 Increasing primary care capacity through FQHCs in underserved communities is expected to decrease use of costly healthcare
services, such as emergency room visits and hospitalizations, and result in savings to state Medicaid programs.5

That’s not NHI

Phillip Lee et al 6 MD Stanford 17 Stan. L. & Pol'y Rev 7 SYMPOSIUM: HEALTH CARE IN AMERICA: A NEW
GENERATION OF CHALLENGES: Politics, Health Policy, and the American Character
The most significant health care financing reform actually adopted in the United States, the enactment
of Medicare and Medicaid under President Johnson, was thought by advocates to be a step toward
national health insurance . By starting Medicare on behalf of a demonstrably needy and deserving
population, advocates believed it would set in place a program that could then be extended to other
groups, such as children, and eventually the entire population. Others at the time, and certainly in
hindsight, saw the addition of Part B of Medicare, designed as a voluntary supplemental medical
insurance to cover physician services, and certainly Medicaid, as initiatives that would broaden the
original proposals for hospital insurance but would possibly prevent an even larger federal role in the
financing of medical care in the future .
AT: C/I---Portion
 AT: Toth
National health insurance is a term of art – their interpretation conflates it with any “federal” health
insurance program---that blows the lid off the topic --- this is even more dangerous than usual because
there is no increase or substantial in the resolution --- Here is our limits DA
Nate Silver 9 founder and editor in chief of FiveThirtyEight.

https://fivethirtyeight.com/features/congress-good-place-for-health-care-to/

Congress: A Good Place for Health Care To Die

A more recent and perhaps equally relevant precedent is that established during the selling of Obama’s
most significant achievement to date, that of the economic stimulus package. That bill, initially rather
popular, came dangerously close to failing when the White House went dark as it tried to navigate the
Tom Daschle mini-crisis and let Congress take the lead; only some last-minute salesmanship efforts by
Obama may have resuscitated it. And the stimulus package was simple as compared with
health care — it was really just a matter of agreeing on two numbers, the overall amount of the bill
and the proportion devoted to tax cuts.

In contrast, the health care debate is multidimensional , requiring the resolution of a series of
disputes ranging from the presence or absence of a public plan, to the best way to pay for it, to the
wisdom of an employer mandate. There are an effectively infinite number of possible health
care bills based on the way these parameters are resolved, and indeed there seem to be
dozens of permutations on health care reform working their way around the Hill: a non-exhaustive list
would include the HELP Committee’s partially-unformed version, the Finance Committee’s largely
unformed version, Conrad’s version, Max Baucus’s version (which might or might not be different from
the Finanice Committee version), the Dole-Daschle compromise, the Schumer Plan, the Rockefeller Plan,
the House Democratic version (of which there may be several), Wyden-Bennett, AmeriCare, Mike Enzi’s
quasi-serious Republican alternative, and Olympia Snowe’s “trigger”. Notably absent seems to be any
version from the White House itself, even though Obama campaigned on and won with a health care
framework that offered relatively specific proscriptions to many of these questions.

They don’t meet their Toth evidence which says NHI requires every citizen to be covered
Toth 16 24th World Congress of Political Science Poznań, July 23-28, 2016 Panel RC 25.10 - The
Problematic Politics of Raising Revenue for Delivering Health Care: Who Pays Who Cares? (Who Cares
Who Pays?) Classifying Healthcare Systems: A New Proposal Federico Toth University of Bologna
Department of Political and Social Sciences e-mail: federico.toth@unibo.it

The label "national health insurance" has been used in the lit erature with multiple meanings (Evans 1981; Frenk
and Donabedian 1987; OECD 1994; Lee et al. 2008; Böhm et al. 2013). It is therefore necessary to immediately clear up possible
misunderstandings. In this work , national health insurance (NHI) is understood as the principle according to which
the state requires all residents to take out a private health insurance policy covering essential
healthcare services, using individual resources. There not being one single public scheme into which contributions can be paid,
the policy has to be taken out with different, for-profit or non-profit insurers in competition with one another. The NHI is therefore a
multi-payer system, in which citizens can choose their insurers . The state may provide subsidies for low-
income citizens (who might otherwise find it difficult to pay the insurance premium regularly), and may
impose a regulation, even a very strict one, of the insurance market. The insurance packages usually differ from one
another, and may provide coverage additional to the minimum required by law; we must therefore bear in mind that there may be
differences between the services provided to individual healthcare users. Universal system The universal system, as we shall see later, is
not synonymous with the National Health Service . A universal system is defined as a single-payer
insurance scheme (therefore, one for the entire population) covering all residents and financed through taxation. Compared with
other insurance schemes, the universal system is marked out by the fact that the right to healthcare is not linked with payment of a
premium or a contribution, but to residing in a given country. Healthcare is therefore a right of the citizens of that country .
From the point of view of those who have to contribute financially, the universal system does not grant freedom of choice. Aside from the few
countries where some form of opting out is possible, residents cannot choose whether or not to finance the universal scheme: they are required
to pay taxes, and therefore also to finance the program. And, given that (direct) taxes are usually paid more than proportionally with respect to
income, the universal scheme turns out to be a typically progressive financing system (Mossialos and Dixon 2002; Hussey and Anderson 2003). It
is important to underscore that, unlike the SHI model, the universal system envisages taxation not only on earned income, but on all forms of
income. Financing of the universal scheme therefore has a clear redistributive intent: the richest end up paying, at least in part, the healthcare
services provided to the poorer citizens.

AND says universality requires that everyone is covered

Toth 16 24th World Congress of Political Science Poznań, July 23-28, 2016 Panel RC 25.10 - The
Problematic Politics of Raising Revenue for Delivering Health Care: Who Pays Who Cares? (Who Cares
Who Pays?) Classifying Healthcare Systems: A New Proposal Federico Toth University of Bologna
Department of Political and Social Sciences e-mail: federico.toth@unibo.it

The label "national health insurance" has been used in the literature with multiple meanings (Evans 1981; Frenk and
Donabedian 1987; OECD 1994; Lee et al. 2008; Böhm et al. 2013). It is therefore necessary to immediately clear up possible misunderstandings. In this work, national
health insurance (NHI)
is understood as the principle according to which the state requires all residents to take
out a private health insurance policy covering essential healthcare services, using individual resources .
There not being one single public scheme into which contributions can be paid, the policy has to be taken out with different, for-profit or non-profit insurers in
competition with one another. The NHI is therefore a multi-payer system, in which citizens can choose their insurers .
The state may provide subsidies for low-income citizens (who might otherwise find it difficult to pay the
insurance premium regularly), and may impose a regulation, even a very strict one, of the insurance market. The insurance
packages usually differ from one another , and may provide coverage additional to the minimum required by law; we must therefore bear in
mind that there may be differences between the services provided to individual healthcare users. Universal system The universal system, as we shall see

later, is not synonymous with the National Health Service . A universal system is defined as a single-payer

insurance scheme ( therefore, one for the entire population ) covering all residents and
financed through taxation. Compared with other insurance schemes, the universal system is marked out by the fact that the right to healthcare is

not linked with payment of a premium or a contribution, but to residing in a given country. Healthcare is therefore a right of the citizens of

that country. From the point of view of those who have to contribute financially, the universal system does not grant freedom of choice. Aside from the few
countries where some form of opting out is possible, residents cannot choose whether or not to finance the universal scheme: they are required to pay taxes, and
therefore also to finance the program. And, given that (direct) taxes are usually paid more than proportionally with respect to income, the universal scheme turns
out to be a typically progressive financing system (Mossialos and Dixon 2002; Hussey and Anderson 2003). It is important to underscore that, unlike the SHI model,
the universal system envisages taxation not only on earned income, but on all forms of income. Financing of the universal scheme therefore has a clear redistributive
intent: the richest end up paying, at least in part, the healthcare services provided to the poorer citizens.
 Natives – Topical Version
Turns their offense – Native American health care should be foregrounded in single-payer debates –
health inequality is rooted in American’s fundamental misunderstanding of health care --- academic
settings provide an important place to advocate for universal access.
Dominic F. Caruso et al 15, MD/MPH Candidate

http://www.pnhp.org/news/2015/july/single-payer-health-reform-a-step-toward-reducing-structural-
racism-in-health-care

Single-Payer Health Reform: A Step Toward Reducing Structural Racism in Health Care

http://www.pnhp.org/news/2015/july/single-payer-health-reform-a-step-toward-reducing-structural-
racism-in-health-care

Harvard Public Health Review, July 20, 2015

Racial and income equality are too often absent from conversations about health care financing. Research
continually exposes
alarming health disparities in the United States, particularly impacting African Americans and Native
Americans. These groups have lower life expectancies than non-Hispanic white Americans, and experience higher rates of most major
causes of death including infant mortality, trauma, heart disease, and diabetes. Yet despite their greater need, access to care is worse for
minority populations by most measures. Unequal medical care is often viewed as a consequence of broader social
inequalities, but the current health financing system also reinforces and institutionalizes
inequality ; unequal care may be viewed as a form of structural racism. While most Americans rely on private insurance, rates of private
coverage are much lower for minorities and the poor. The Patient Protection and Affordable Care Act (ACA) offered subsidies to expand private
coverage, making insurance more affordable for many families. However, many of these new private plans carry high deductibles and co-
payments. Deductibles for the ACA’s bronze and silver plans average over $5000 and $2900, respectively, for single coverage, and over $10,000
and $6,000, for family coverage. Deductibles have also soared in employer-sponsored plans; in 2014, more than 40% of such plans carried a
deductible of more than $999, up from just 10% in 2006. Moreover, while Medicaid traditionally imposed virtually no cost-sharing, several
conservative state governors have extracted waivers from the Centers for Medicare and Medicaid Services allowing the imposition of cost-
sharing on recipients as a condition for implementing the ACA’s Medicaid expansion. High cost-sharing particularly impacts minority families,
whose average incomes are far lower than those of non-Hispanic whites. Yet even figures on income disparities understate minorities’
disadvantage when confronted with high out-of-pocket costs. With medical bills often reaching into the thousands for even routine care such as
childbirth and appendectomy, many families must tap savings or other assets like housing equity, and racial/ethnic disparities in assets dwarf the
differences in income. African American and Hispanic median household income was 58 percent and 70 percent, respectively, that of non-
Hispanic whites in 2011. In contrast, the median net worth of black and Hispanic householders was $6,314 and $7,683, respectively, vs.
$110,500 for non-Hispanic whites, a 15-fold difference. Hence, the average family deductibles for bronze and silver plans would bring financial
ruin to most African American and Hispanic households. Even the lower cost-sharing now increasingly common under Medicaid may be
prohibitive for poor families, many of whom have zero or negative net worth. The ACA’s drafters erred in relying on private, for-profit insurers to
fund health care. Health insurance’s social purpose is to pay for care in order to promote access to health services and prevent financial
hardship. For-profit insurers’ purpose is to maximize shareholders’ profits, a goal that provides strong incentives to maximize premiums and
minimize the health care they pay for. Historically, this incentive led to such practices as denying coverage for pre-existing conditions and
canceling policies for expensive enrollees. Although the ACA prohibits these tactics, recent evidence indicates that insurers are finding ways to
subvert these regulations, e.g. through tiered pharmacy benefits that discriminate against enrollees with potentially expensive illnesses such as
HIV, Parkinson’s, seizures, psychosis and diabetes. The
persistence of our corrupt and irrational insurance system may
stem in part from the way Americans (and particularly health professional students) are taught to think about health
care. In a recent conversation with a Canadian student at Harvard’s school of public health, he expressed
surprise that many of his U.S. classmates perceive health care interactions as business transactions, and
reflected that Canadians, who have a publicly-funded universal coverage system, view health care as a
fundamental right to be provided for all. Should we in the U.S. continue to treat health care as a commodity distributed
according to financial ability, or shift to a financing system that assures it as a right equally available to all without regard to income, health
status, race or ethnicity? While market theorists might claim that a commodity-based approach to care breeds efficiency, facts on the ground
argue otherwise. At present, we have the world’s highest per-capita health care expenditures, yet tens of millions remain un- and under-insured,
and our health outcomes trail most other wealthy nations. This isn’t just an indication of failed policy, it’s a national embarrassment. We
have the resources to provide everyone in the U.S. with access to health care . And Canada provides a
working model for how to put those resources to good use: a public, single-payer, national health
insurance program, similar to an expanded and improved Medicare for all . In our view a national single-
payer health insurance program offers the best possibility for equitable financing of U.S. health care . It
would eliminate the motive to deny needed care or discriminate against the expensively ill for the sake
of profit. A national public insurance system would provide coverage based on residence in the U.S., not employment status, income level or
ability to pay, as in the current regime. A program that abolished co-payments and deductibles would level the playing field for minorities and
the poor who generally lack the assets to surmount these barriers. A single-payer system would also offer economic benefits. A federally-run
financing system would have far lower administrative costs than private insurance, as the Medicare program consistently demonstrates. A
universal public model would lift a significant financial burden from businesses that currently fund health insurance for their employees. Finally,
a single-payer program would largely eliminate the financial burden of illness, a leading cause of bankruptcy and debts sent to collection.
Perhaps most importantly, asingle-payer system would make a clear statement that health care is a human
right. This framework recognizes health care as a universal necessity, not a commodity reserved for those lucky enough to have won the
economic lottery, and most definitely not a scheme for denial and discrimination. While implementing a single-payer insurance program will not
solve all of our nation’s health, racial or social inequities, it is clearly a step in that direction.
 AT: Overlimit
The topic is about the mechanism debate which is expansive – captures their innovation arguments
Marie Gottschalk 2k University of Pennsylvania Studies in American Political Development, 14 (Fall
2000), 234–252. https://www.sas.upenn.edu/polisci/sites/www.sas.upenn.edu.polisci/files/SAPD.pdf
“It’s the Health-Care Costs, Stupid!”: Ideas, Institutions, and the Politics of Organized Labor and Health
Policy in the United States

The term national health insurance has many meanings . As used here, it refers to health-care
reform proposals modeled on the Canadian experience in which the government replaces private
insurance with its own public insurance system, thus eliminating the commercial health insurers.
Commonly referred to as “single payer” plans today, proposals for national health insurance
can vary enormously on important details like financing, budgeting, taxation, and the
role of individual states .
Universality preserves room for affirmative innovation without creating a limits explosion
Charles J. Dougherty 90 academic who served as the 12th president of Duquesne University in
Pittsburgh, Pennsylvania. An expert in the field of health care ethics, Dougherty has published two books
on the subject. The Moral Case for National Health Insurance From: Biomedical Ethics Reviews· 1990
https://link.springer.com/chapter/10.1007%2F978-1-4612-0471-8_3

The
In this article, the moral case for establishing a program of national health insurance in the US will be articulated and defended.

phrase “national health insurance” is not meant to refer to any specific program or
proposal. It is meant generically to refer to any arrangement for the financial pooling of health care
risks that provides universal basic health insurance coverage to all Americans and is operated at least in
part by the federal government. “At least in part” means that state and local governments, as well as
private insurers and employers, may play key roles in financing and administering such a national
program. In Canada, for example, the so-called national health insurance program is really a collection of ten provincial health insurance
programs, regulated and partly funded by the national overnment. 1Recent American proposals to mandate employer-
provided health insurance might also lead to what is here called national health insurance, so long as the
federal government assured both equity by regulating the coverage of the employer plans and
universality by arranging for health insurance for the unemployed and their dependents. The point is
that national health insurance does not mean just one thing . Alternative models abound worldwide.
The core of what it must mean , the essence of national health insurance , is the use of
the authority of the national government to arrange for equitable and universal
health insurance . For ease of reference, the simplest model of national health insurance will often be used here: a
program in which the federal government establishes a program like Social Security to insure all Americans
and finances it through progressive taxation. It is important to remember, though, that this is
the simplest model of national health insurance, not the only one . For many practical political
reasons it may not be the model best suited to the US at this time. Nevertheless, the moral arguments for national health
insurance are largely the same whether the program is administered by the federal or state
governments or by private insurers , and whether it is financed exclusively by the
federal government or in partnership with states, the business community, and
individual Americans .