Sunday, February 24, 2013

PF March 2013 Health Insurance - Con Position

Resolved: The U.S. government should not require its citizens to have health insurance.

For part 1 of this analysis, click here.

Con Position

I am posting the Con position first. It advocates for health insurance which, in March 2013 is the position represented by the status quo.  As much as possible I have tried to avoid a defense of "Obamacare".  The resolution does not demand a debate about Obamacare even though Obamacare is a law which does require citizens to have health insurance.  While it may be difficult to avoid all mention of Obamacare, the strategy for doing so is to deemphasize any possible negative views the judge may hold based on her political views.  Con needs to emphasize, the debate is not about Obamacare. It is about government mandated health insurance.  Con will be arguing the government SHOULD require its citizens to have health insurance because the advantages outweigh the negative outcomes of incomplete insurance coverage.

There are many ways to advocate for universal health insurance and I have selected a few key contentions to help you get started in your research.  For the most part you will see that I am presenting the contentions as ideas.  By this, I mean they will need to be fully developed into complete arguments.  If you get up and simply read some of these cards there is a very good chance you will lose.  In many cases you will need to add text which completes the impact of the evidence and tells the judge why the evidence is significant to her life.

Contention: Requiring health insurance protects the vulnerable

For this contention the basic argument is certain groups of individuals are particularly vulnerable due to the lack of adequate health insurance.  Such groups include, children, the disabled, immigrants (both legal and illegal), elderly and poor.  The evidence will show that while some of these groups do have access to insurance, often the coverage they have is inadequate to fully cover their needs and the needs of the families which support them.  Examples:

Protection for Children
Kenney & Dorn (2009):
While children have higher coverage rates than adults, millions of children remain uninsured. They could gain health insurance under health care reform, increasing their access to needed care. Over two-thirds of uninsured children are already eligible for Medicaid or CHIP, and the vast majority have parents who say they would enroll their children in public programs if they were eligible. Thus, addressing barriers to enrollment and retention in public programs will be essential to achieving universal coverage for children. Achieving that goal will also require affordable coverage options for the families with uninsured children whose incomes are too high to qualify for CHIP but who lack access to employer-sponsored insurance.
Children would also benefit if health care reform increases their parents’ health insurance coverage. It is expected that uninsured children will be more likely to enroll in coverage if their parents become eligible for subsidized coverage through health care reform. By reducing barriers to needed care, increased coverage for parents would also improve their health status and functioning, leading to gains in their children’s health status, health care use, and general well-being.

Protection for Immigrants
Ku (2006):
Because so many immigrants lack the protections of health insurance, the cost of even a single hospitalization can drive many into debt and financial insolvency. The Institute of Medicine, a component of the National Academy of Sciences, has estimated that lack of health insurance in the United States costs between $65 and $130 billion per year, due to health impairments and years of productive life lost of all uninsured, not just immigrants.

Immigrants, both legal and unauthorized, often rely on a patchwork system of safety-net clinics and hospitals for free or reduced-price medical care, including state- and county-owned facilities, as well as charitable and religiously affiliated facilities. Their reliance on this system has led many states and communities to be concerned about uncompensated health care costs for uninsured immigrants and the state and local fiscal burdens that result.
Recent immigrants are more likely to be uninsured. Over time, their rates of insurance improve and their incomes grow. This is partly because immigrants tend to find better-quality jobs with time, and partly because both citizens' and immigrants' incomes increase with age and greater job experience. The main reason immigrants are less insured than native-born citizens is that, despite their high rates of employment, fewer immigrants have employer-sponsored health insurance.

Contention: Health outcomes are better for the insured

This contention argues that insured people tend to be healthier for obvious reasons.  This may seem intuitive but I think it must be mentioned in order provide additional advantages which favorably impact the Con case.  This advantage links to many other arguments, including the idea that healthier people are more productive contributing more to the GDP.

Improving Outcomes
Bernstein, et al (2010):
Uninsured people generally receive much less care, either preventive or for acute and chronic conditions, than insured people. In particular, uninsured adults report lower levels of self-perceived wellness and functioning. Estimating the number of premature deaths attributable to lack of insurance presents methodological challenges, but some research indicates that as many as 44,500 deaths per year in the United States are linked to lack of insurance.
Research on the use of preventive services, which has focused separately on children and adults, suggests that:
• Uninsured young children have lower immunization rates than insured children.
• Uninsured adults are less likely than insured adults to receive preventive services or screenings, such as mammograms, pap smears, or prostate screening.
In turn, inadequate prevention and screening increase the likelihood of preventable illness, missed diagnoses, and delays in treatment. When uninsured people seek emergency care for severe illness or injury, their health outcomes generally are poorer—whether they are children or adults.
For example:
• Uninsured children are 70 percent less likely than insured children to receive medical care for common childhood conditions, such as sore throat, or for emergencies, such as a ruptured appendix.
• When hospitalized, uninsured children are at greater risk of dying than children with insurance.
• Uninsured adults are 20 percent less likely than insured adults to receive care following an automobile accident and are at greater risk of death.
• At-risk adults without insurance have higher rates of stroke and greater risk of death than at-risk adults with insurance.
• Adult stroke victims without insurance are more likely to have neurological impairment and longer hospitals stays, and are at greater risk of dying, than adult stroke victims with insurance.

People with chronic illnesses who lack insurance have limited access to both health care services and effective care management. In addition, children with special health care needs who do not have adequate insurance coverage are more likely to go without needed care. For example:
• Parents of uninsured children are more likely to report unmet need for mental health services for their children.18 Uninsured children are also less likely to receive treatment for chronic conditions such as diabetes and asthma.
• Uninsured children have less access to a usual source of care, community-based services, and services to make transitions to adulthood
Because uninsured people are less likely to have a usual source of care, they generally have poorer control of chronic conditions, such as hypertension. Even when they are aware that they have a chronic condition, uninsured adults are less likely than adults who are insured to have a usual source of care or regular checkups. As a result, they have more emergency department visits and report greater short-term reductions in health; if they return to full health, they take longer to do so. The prognosis for uninsured cancer patients also is worse than that for insured patients. In general, uninsured cancer patients die sooner after diagnosis, largely because they are less likely to be diagnosed in early stages of the disease. However, even when diagnosed at similar stages, uninsured patients with certain types of cancer die sooner than insured patients.

Contention: Universal health insurance improves the economy

Several key economic benefits can be isolated.  In the previous contention we see how favorable health outcomes result in a healthier and more productive workforce.  We can also isolate direct impacts based on increased spending in the health care industry and reduction of government spending.  For these advantages one may look to the Congressional Budget Office studies but the Cutler, et al evidence I provide below, represents an independent evaluation which corroborates the CBO estimates and improves upon them.

Economic Benefits
Cutler, et al (2009):
Extending health insurance coverage to essentially all Americans will increase medical spending, at least in the short run. (Some argue that increased coverage will lower spending over time by making it possible to pursue more-aggressive cost-containment policies without risking access to care for the uninsured, but in this analysis we do not consider such effects.) From previous studies, data are available to estimate the magnitude of the increase in spending. Hadley and colleagues, for example, estimated that each uninsured individual who gains coverage will incur annually an additional $1,600 of medical care expenses—an increase of 70 percent. The Congressional Budget Office estimated that spending for uninsured individuals, if they become insured, will increase by 25 percent to 60 percent. The actual increase will depend in part on the rates that are paid to health care providers for treating currently uninsured patients.
For our estimates, we increase the $1,600 figure over time with expected increases in medical costs. We then multiply the revised amounts by the number of newly insured resulting from health reform to produce a total estimate. Fully phased in, incremental coverage costs about $75 billion per year to cover 60 percent of the uninsured, or 2 percent of total health care spending. This is comparable to Davis and Schoen’s projection that covering all of the uninsured would add 3 percent to medical spending,7 and Schoen, Davis, and Collins’s finding that covering all of the uninsured would add 2 percent to medical spending.8 This methodology suggests that the new law will lead to a 10-year cumulative medical spending increase of $415 billion over the period 2010–2019.

Federal Budget Impact
Cutler, et al (2009):
The Congressional Budget Office estimates that the reform law will reduce the federal deficit by $143 billion over the 10 years, 2010–2019. Our estimates of the federal deficit impact differ from CBO’s in two ways. First, we include savings to Medicare and Medicaid resulting from health system modernization. In addition, reductions in employer spending for health insurance lead to increases in wage and salary payments, which are taxed by the federal government. While CBO accounted for some of this effect in recent estimates, further reductions in employer spending for health insurance can be expected from modernization and lower administrative costs. We assume that 90 percent of private health insurance savings are passed on to employees through increased wages, which are taxed at an average marginal rate of 28 percent.
The net effect is a federal deficit reduction of $400 billion over 2010–2019 (Exhibit 4). This reduction results from several factors. As estimated by CBO, the federal cost of insurance coverage expansion is $788 billion. Savings from payment and system reform provisions are projected to generate $682 billion—more than is estimated by CBO, owing to the reasonable estimates of health system modernization provisions. Our federal tax revenue projection mirrors that of CBO’s, though we also add in the additional revenue from employer savings and increased wages from modernization and lower administrative costs—projected to raise $86 billion over the 10-year, 2010–2019 period.

Answer: Employers will not drop employee health insurance

Since a majority of the insured receive their coverage as a benefit of their employment, a decision by employers to cease offering the benefit could greatly impact the evaluation of advantages for the Con.  For this reason, a common argument for the Pro and one we have heard in the political campaigns of the last Presidential election may be the idea that employers will stop offering health insurance to their employees due to costs or any number of possible reasons as a reaction to the government mandate for insurance.  This CBO report disputes that argument.  It it a fairly specific answer to an anticipated Pro claim.

Employers will continue to offer Insurance
CBO 2012:
On the basis of both economic theory and empirical evidence, CBO and JCT also
think that employers generally construct compensation packages to attract the best available workers at the lowest possible cost.6 That is, firms attempt to offer the mix of wages and nonwage benefits—such as vacation time, retirement benefits, and health insurance—that will be most attractive to their current and potential
employees while having the lowest cost. The attractiveness and cost of different mixes of compensation depend on the relative price and availability of services (such as health insurance) when provided by firms or purchased separately by workers. That relative price and availability depend partly on features of private
markets and partly on the structure of government programs and the tax rules applying to firms and workers. The fact that many firms currently offer health insurance coverage to their workers despite the high cost of premiums and rapid growth in those premiums for many years shows that many firms continue to find health insurance coverage to be a worthwhile element of their compensation packages. If firms could have attracted employees more cheaply by dropping health benefits and adding wages or other benefits that cost less, then they would have done so. One reason that the
provision of health insurance by firms remains cost-effective is that the price of health insurance with a given scope and comprehensiveness of benefits is often higher in the individual (nongroup) market than in the employer (group) market, owing to higher administrative costs for individual policies. A second reason that firms continue to provide health insurance is that wages received by workers are subject to both individual income taxes and payroll taxes, whereas health insurance benefits received by workers are generally not taxed. Finally, individual market coverage may not be viewed by employees as a good substitute for employment-based coverage because of the possibility of coverage exclusions or premium surcharges due to specific health conditions of a family member.

For the Pro position, click here


Health Care Reform for Children with Public Coverage: How Can Policymakers Maximize Gains and Prevent Harm?
Timely Analysis of Immediate Health Policy Issues
June 2009
Genevieve M. Kenney and Stan Dorn

Why Immigrants Lack Adequate Access to Health Care and Health Insurance
Leighton Ku
Center on Budget and Policy Priorities
September 2006

Annotated Bibliography
Health Care and Children in Immigrant Families Project
January 2007

How Does Insurance Coverage Improve Health Outcomes?
Mathmatica Policy Research, Inc., April 2010
by Jill Bernstein, Deborah Chollet, and Stephanie Peterson

Baker Institute Policy Report, James A. Baker III, Institute for Public Policy, Rice University
June 2009
The Economic Impact of Uninsured Children on America

CBO and JCT’s Estimates of the Effects of the Affordable Care Act on the Number of People Obtaining Employment-Based Health Insurance, Congressional Budget office, 2012

Center For American Progress
The Impact of Health Reform on Health System Spending
David M. Cutler, Karen Davis, and Kristof Stremikis

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