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General Negative Case
» First Negative
» Counter Plan
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Second Negative: Further Attacks on the Affirmative Approach
Note: the arguments of this section are contingent upon the particulars of the affirmative plan. Here we anticipate some common defects. In the first speech, the negative made some general objections to the affirmative approach. Having heard the affirmative plan, you may now be in a position to argue that the affirmative approach is even worse than what you originally suspected.
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I. Needs that matter less at the expense of needs that matter more.
A. Scope of the Problem
Has the affirmative focused on a very narrowly defined need (e.g., mental health for prisoners, for the homeless, etc.)? If so, you can ask why this need is more important than other unmet mental health needs:
- In any given year, three-fourths of people with a mental health disorder are not in therapy. Of those who are, 40 percent are not seeing a professionally trained therapist. (Mental Health Economics, p.10) Why are the needs of the group selected by the affirmative more important than all those other unmet needs?
- Some mental health professionals believe there is an epidemic of narcissism (a DSM-IV disorder) among the CEOs of our nation's largest companies. This is offered as an explanation of why there have been so many recent accounting scandals, including criminal behavior. (Tim Race, "Like Narcissus, Executives are Smitten and Undone, by their Own Images," New York Times, July 29, 2002) Why are the needs of those identified by the affirmative more important than the mental health of people who run the U.S. economy?
B. Ability to Meet the Need
Did the affirmative plan offer any provision that would expand the overall number of providers (doctors, nurses, etc.)? If so, then they are devoting more overall resources to health. If not, then they implicitly are encouraging an expansion of mental health at the expense of other health - even as they increase the nation's annual health care bill.
1. Assuming the affirmative case is a demand-side only case:
More spending does not necessarily mean more services. Among developed countries, the history of health economics teaches one clear lesson: If you increase demand without increasing supply, you end up paying higher prices for the same services you had to begin with. Other countries experienced severe health care inflation when they adopted national health insurance. We experienced it after creating Medicare and Medicaid.
An increase in the demand for mental health services will not produce an increase in supply unless there are unemployed or underutilized doctors, nurses, facilities, etc. There is no problem in increasing the supply of pharmaceuticals. But where are all the underutilized doctors and nurses?
It is possible, through economic incentives, to induce personnel to switch to mental health from some other health care field. But the result is more money spent without any more overall health care. The extra services received by some (mental health) patients will be offset by fewer services available to other (physical health) patients.
2. Assuming the affirmative case calls for supply-side expansion:
- The result would be more real resources devoted to health care in a country that already spends more than all others. The problem: all the evidence points to the fact that, overall, we are spending too much on health care, not too little.
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II. Wrong Vehicle
Has the affirmative committed on the approach to health care they propose to subsidize and expand? If not, the negative must continue to press. Is it the population-oriented approach characteristic of the traditional public health service with its emphasis on prevention and containment? Or is it the patient centered approach typical of other health care, with its emphasis on diagnosis and cure.
- If the latter, then the negative should continue to stress that the public health service is the wrong agency with the wrong set of skills.
- However, some affirmative teams may argue for the traditional public health model, in which case the negative must argue that this is the wrong approach. (By end of August NCPA will have a complete rebuttal for this approach.) Even before the affirmative acts, there is already evidence that the public health approach to mental health is causing a great deal of harm - with thousands of children being overmedicated for supposed mental disorders. (See the new Gorman study.)
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III. Fragmentation of health services.
Did the affirmative propose a very narrow plan to meet a very limited need? If so, it is vulnerable to the charge that it has overlooked more important mental health needs. For example, most of the statistics on the economic costs of mental illness refer to broad based problems, such as depression. An affirmative case that focuses, say, only on the homeless arguably ignores more economically important and more easily corrected problems, such as depression.
Did the affirmative plan propose any way to keep people being helped in their current health plan (or usher them into a new one)? If not, the affirmative approach is vulnerable to the charge that it will encourage a fragmented service at the expense of integrated services.
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IV. Public provision at the expense of private provision.
Does the affirmative plan propose to offer public health services free of charge, or at subsidized prices? Then it is encouraging public provision at the expense of private provision. On the other hand, if the affirmative plans to charge market prices - reflecting the full cost of the services delivered - then why do we need government in the first place?
Does the plan call for an increase in system-wide medical personnel? If not, it is encouraging resources to leave the relatively more efficient private sector for the relatively less efficient public sector.
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V. Encouraging moral hazard and/or rent seeking.
In general, the affirmative is on the horns of a dilemma on what to do about the twin problems of moral hazard and rent seeking. They are twin problems because they are connected. The less you do to constrain moral hazard (say, by making services free at the time of consumption, the more you must do to constrain provider rent seeking and vice versa.
The worse position for the affirmative is to not take a position on how to solve these problems. That would allow the negative to erect all the bad alternatives ("on the one hand… on the other hand…), capping it off with the observation that worse than either "hand" is the fact that the affirmative has apparently not thought about these problems at all.
A. Price charged to patients:
1. If the service for mental illness is provided for free, the affirmative faces the problem of how to control unlimited demand. Specifically, if the prize is zero, patients have an incentive to use the service until its value to them is almost zero. Note: this is extremely wasteful from a social point of view, because the cost of the service is well above zero. Unconstrained demand inevitably means that the social benefits of the service provided (which is mainly the benefits derived by the patient) is going to be well below the social cost. Unconstrained demand, therefore, inevitably leads to a waste of resources. And the more patients that are served and the more services that are provided, the greater the waste will be.
2. If patients are charged for services, the charges will deter demand. Specifically patients will tend to use services until the value of each service is worth to them the price they are asked to pay. If the price charged is equal to the marginal cost of providing the service then there will be no waste of resources. But since this is what tends to happen in the marketplace anyway, a policy of charging prices that reflect actual costs begs the question of why the government should be involved in the first place.
B. How providers are paid:
1. If providers are paid on a fee-for-services basis, they will have an economic incentive to overprovide. This is precisely the incentive that encourages providers to continue to supply services as long as a third-party payer is paying the bill.
2. If provider incomes are unrelated to what they do, they will have an incentive to underprovide services so long as they value alternative uses of their time (e.g., golf, chatting with colleagues, spending time with family, etc.)
3. If provider incomes rise as they perform fewer services - as is the case under many managed care contracts - they will have an economic incentive to underprovide in addition to the value-of-time incentive.
About half of Medicaid enrollees nationwide are enrolled in managed care. In such states as Tennessee and Colorado, where virtually the entire Medicaid mental health population has been pushed into managed care, services are down and quality is down even though costs are up.
(Note: all these problems are inevitable whenever resources are allocated by nonmarket mechanisms.)
C. Other techniques for controlling costs:
Government programs have a history of avoiding the newest and most effective drugs. In fact, in 1991 things were so bad that the federal government actually had to order state Medicaid programs to cover clozapine - a breakthrough drug for treating schizophrenia. Among the techniques state Medicaid programs use to avoid expensive mental health drugs are:
- Leaving the drug off the state's formulary (list of approved drugs.)
- Requiring doctors to get prior approval before use (which usually means requiring doctors to try less expensive drugs first).
- Refusing to pay for "off label" uses ("on label" therapies are uses the FDA originally approved the drug for; but in time doctors and medical journals report other valuable uses. For example 25% of all anti-cancer drugs are "off label".)
- Requiring generic substitution (even though drugs for treating schizophrenia and other mental problems are among the categories where patients are most sensitive to the negative effects of substitution.)
- Economic incentives to underprovide (a la managed care).
Overall, one study estimated that Medicaid patients had access to new drugs available in the private sector less than 40 percent of the time.
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