1AC

1AC Plan
New Plan: The United States federal government should establish single-payer health
care, establishing a low-threshold negligence standard of care for federally
reimbursed medical providers to prohibit discrimination, restoring private causes of
action for disparate impact cases, increasing reimbursement rates for
disproportionate share hospitals, and prohibiting the use of pharmacogenomic data
collection and race-based classification for drugs and medical services.
 1AC Advantage
Disparities in access to quality health care contribute to race and income-based death
gaps. The aff ensures universal access and substantive redistribution.
Himmelstein et al 17 – David U Himmelstein, distinguished professor of public health and health policy in the CUNY School of
Public Health at Hunter College, adjunct clinical professor at Albert Einstein College of Medicine, lecturer in medicine at Harvard Medical
School, M.D. from Columbia University, Steffie Woolhandler, distinguished professor of public health and health policy in the CUNY School of
Public Health at Hunter College, adjunct clinical professor at Albert Einstein College of Medicine, and lecturer in medicine at Harvard Medical
School, M.D. from Louisiana State University, MPH from University of California, Samuel L Dickman, Resident Physician, University of California
San Francisco School of Medicine, M.D. from Harvard Medical School (“Inequality and the health-care system in the USA,” The Lancet, Volume
389, No. 10077, p1431–1441, Series on health and inequality in the USA, April 8th, http://www.thelancet.com/journals/lancet/article/PIIS0140-
6736(17)30398-7/fulltext)

Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the
wealthiest Americans now exceeds that of the poorest by 10–15 years. This report, part of a Series on health and inequality in the USA, focuses
on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this
Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor
Americans have worse access to care than do wealthy Americans, partly because many remain
uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance,
rising premiums and cost sharing have undermined wage gains and driven many households into debt
and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has
risen. Additional reforms that move forward , rather than backward, from the ACA are sorely needed to
mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by
non-wealthy Americans.
Introduction

As economic inequality in the USA has deepened, so too has inequality in health. Almost every chronic condition, from stroke to heart disease and arthritis, follows a predictable pattern of
rising prevalence with declining income.1 The life expectancy gap between rich and poor Americans has been widening since the 1970s,2 with the difference between the richest and poorest
1% now standing at 10·1 years for women and 14·6 years for men.3 The health of poor communities is often neglected: for example, in Flint (MI, USA), a de-industrialised, impoverished, and
predominately African-American city, public officials dismissed evidence that children were being exposed to toxic levels of lead in the city's drinking water for several months.4

Attention to economic inequality intensified after the Occupy Wall Street movement decried the rising wealth and power of the richest 1%. This movement popularised research by the
economists Piketty and Saez5 that revealed levels of income inequality unrivalled since the stock market bubble of the 1920s. The share of total income going to the top 1% of earners has
more than doubled since 1970 (figure 1),6 while most workers in the USA have experienced slow income growth.7 As measured by the Gini coefficient, a standard metric of income inequality,
the USA is now more unequal than all but three other countries (Chile, Mexico, and Turkey) in the Organization for Economic Co-operation and Development (OECD). The most equal countries
are Denmark, Slovenia, Norway, and Slovakia.

The surge in top incomes has magnified inequality in wealth (ie, assets). Since 1986, the top 0·1% of households (those with assets exceeding US$20 million) has accumulated nearly half of all
new wealth, and now controls as much wealth as the bottom 90%, whose share has fallen steadily.8

Wealth inequality between racial and ethnic groups in the USA is especially striking, and is several times
greater than income inequality. In 2013, median family wealth for the non-Hispanic white population
was ten times that of Hispanics and more than 12 times that of African-Americans .9 The racial wealth gap
results from historical factors dating back to slavery—many of which persist—including legalised racial segregation in the pre-civil rights era,
pervasive job and housing discrimination, exclusionary city zoning laws, unequal education, and inheritance laws that perpetuate past
inequalities.10

Although top incomes have risen, so has extreme poverty . More than 1·6 million households in the USA,
including 3·5 million children, survive on incomes of less than $2 per person per day — WHO's
definition of extreme poverty ; this number has more than doubled since the 1990s.11

The health-care system could soften the effects of economic inequality by delivering high-quality care
to all . Yet the institutions and financing patterns of the health-care system in the USA—by far the world's most
expensive12–cause it to fall short of this ideal. Although inequalities exist to some extent in every health-care system, they are
particularly stark in the USA. Unequal access to medical services is likely to contribute to disparities in health
status , while rising costs (for both the insured and uninsured) reduce disposable incomes, particularly burdening
low-income households.

Many patients cannot afford the care they need, and often forgo medical care altogether . For example,
19% of non-elderly adults in the USA who received prescriptions in 2014 (after full implementation of the
Affordable Care Act [ACA]) could not afford to fill them .13 Millions of middle-class families have been bankrupted by

illness and medical bills.14 Meanwhile, very wealthy Americans are turning to so-called concierge practices that offer lengthy office
visits and unfettered access to specialists.

This Series paper examines how the health-care system in the USA contributes and responds to inequality . We
focus our attention on the association between inequality and the medical care system.

We first review how social position influences Americans' access to medical services and the quality of those services. The uninsured face the
greatest barriers to care, but many insured Americans are also unable to afford medical care because of cost sharing. Although race-based
disparities in quality are well documented, the low quality scores of doctors and hospitals serving poor communities might reflect patients'
deprived social circumstances rather than their providers' performance. We also review how the health-care costs borne by households—in the
form of insurance premiums, taxes, and out-of-pocket payments—exacerbate income inequality, forcing many Americans to cut back on food
and other necessities, and contributing to most personal bankruptcies. We conclude by discussing the historical context for today's health-care
inequalities, and propose options for reform.

Inequality and access to care

Income-related disparities in access to care are far wider in the USA than in other wealthy countries.15 Before the 2010 passage of the ACA,
39% of Americans with below-average income reported not
which progressively expanded health insurance coverage,

seeing a doctor for a medical problem because of cost, compared with 7% of low-income Canadians and 1% of those in
the UK.16 Inequality in access to care is particularly stark in Southern states . For example, in Texas, Mississippi, and
Florida, adults on a low income are more than twice as likely to face cost-related barriers to care as their counterparts in Maine (a relatively
poor New England state) and Massachusetts.17

Disparities in access are largely due to high rates of uninsurance or inadequate health insurance
among low-income Americans, although Americans with above-average incomes probably also have worse access to care than do
their peers in other countries.16 Today, despite gains due to the ACA, 27 million Americans (down from 50 million before the passage

of the ACA) remain uninsured. Most of the uninsured have annual incomes near or below the official
poverty line ($11 770 for an individual in 2016).

The uninsured are far more likely than the insured to forgo needed medical visits, tests, treatments,
and medications because of cost. Cost barriers are especially severe for the millions of uninsured Americans with chronic
conditions.18 For example, middle-aged adults with no coverage for eye care report difficulties in reading or recognising a friend across the
street more frequently than do comparable individuals with coverage.19 Uninsured individuals with diabetes spend, on average, $1446 out of
pocket for medical services each year, and more than 30% do not have a primary care provider.20 Similarly, low-income
and
uninsured Americans with psychiatric disorders are far more likely than the insured and those on
higher incomes are to experience difficulties obtaining care.21 For poor Americans, gaining insurance boosts
access to care (although it does not fully close the gap between poor and affluent patients), leading to more visits for
preventive screenings and greater satisfaction with care than before gaining coverage .22
Medicaid insurance for low-income Americans

Medicaid, the public insurance programme that covers 58 million low-income Americans, improves health outcomes and
access to care for its beneficiaries.23 Gaining Medicaid coverage reduces rates of clinical depression ,24
financial problems due to illness,24 and mortality .23 The generosity of the Medicaid programme, which is
largely controlled by state governments, is a key determinant of access-related disparities . Before the passage of the ACA,
most states restricted Medicaid eligibility to poor children and pregnant women, disabled people, and the poorest adults with children.
Childless adults and parents with incomes above stringent state-specific thresholds (eg, 10% of the poverty level in Alabama) were generally
excluded.

The ACA's expansion of Medicaid to all citizens with annual incomes at or below 138% ($16 643 for an individual in 2017) of the
poverty level promised to cover millions of previously uninsured Americans . However, the US Supreme
Court ruled in 2012 that states could opt out of the Medicaid expansion, and the Trump administration
is likely to further erode or repeal it . As of 2016, 19 states (mostly in the South) have opted out, cutting the
number of citizens who would otherwise have gained coverage by about 5 million . An additional 5–6
million undocumented immigrants do not have insurance because the ACA specifically excluded them
from its coverage expansion,25 perpetuating major constraints on their access to care.26 Fortunately, the ACA increased funding for
community health centres, which deliver much-needed care to millions of low-income Americans, and extended mental health parity
regulations aimed at improving insurance coverage for mental health and addiction treatment.

Although Medicaid improves access to care, specialist care is often unobtainable because the programme pays low fees to physicians,27 who are free to turn away Medicaid patients. For
example, 76% of orthopaedists' offices in a nationwide audit study refused to offer an appointment to a Medicaid-insured child with a fracture, whereas only 18% refused a child with private
insurance.28

Cost sharing and private insurance

In the private insurance market, cost sharing by patients (ie, through user fees) has increased substantially since the 2000s.29 Many plans now impose co-payments of more than $30 for
primary care and more than $45 for specialist visits.30 More than 80% of employer-based plans include an annual deductible (the amount a patient must pay before insurance covers
additional costs), which averaged $1478 in 2016, an increase of 2·5 times since 2006.30 Cost sharing by patients is even higher in plans sold through the insurance exchanges created by the
ACA. In mid-level, so-called silver tier plans (which account for about 70% of exchange coverage), deductibles averaged $3064 in 2016,30 although some subsidies were available to cushion the
deductibles for enrollees with incomes 100–250% of the poverty level.

Many private plans also reduce premium costs by restricting patients' choice of providers to narrow networks of doctors and hospitals, which often exclude academic and cancer referral
centres.31 Enrollees who seek out-of-network care (either by choice or because of medical necessity) generally must pay the entire bill out of pocket.

Predictably, patients' use of care declines as their cost-sharing obligation rises , and people with the worst
health are most likely to cut back on care.32 Paradoxically, this reduction in care-seeking can fail to cut
system-wide use , instead shifting care from the sick and poor to the healthy and wealthy . At least in some
cases, when poor patients avoid care, doctors and hospitals fill the empty appointment slots and beds
with patients who are less price-sensitive33—an example of supply-sensitive demand.34 Strikingly, the USA has the
world's highest health-care expenditures despite extensive cost sharing by patients.

Additionally, care forgone because of cost sharing might ultimately raise costs by increasing downstream
health problems . When the Medicare programme (the public coverage for people aged 65 or older and those with long-term-
disabilities) added new co-payments, outpatient visits decreased but hospital admissions increased .35
Among patients who developed a myocardial infarction, elimination of medication co-payments after the cardiac event increased compliance,
and (for racial and ethnic minority patients) led to a 35% reduction in major vascular events and a 70% reduction in total health-care
spending.36 Similarly, among children aged 5–18 years with asthma, those whose insurance required higher co-payments used fewer
medications but had a 41% greater risk of asthma-related hospital admissions than did children with lower co-payments.37 For nearly a third of
children with asthma from low-income families with high cost-sharing coverage through the Kaiser Health Plan, parents reported delaying or
avoiding outpatients visits, and 14·8% reported non-adherence to medications because of cost; 15·6% of all parents (including those with higher
incomes) reported borrowing money or cutting back on necessities to pay for their children's asthma care.38

Defining underinsurance

Rising deductibles and other forms of cost sharing by patients have eroded the traditional definition of insurance: protection from the financial harms of illness. The term underinsurance
describes this problem, but it does not have a standard definition. Some studies of underinsurance have focused on financial vulnerability (eg, measurement of deductibles as a fraction of
income),39 others on out-of-pocket costs incurred (either in absolute dollars or relative to income),40 whereas others have highlighted barriers to care (because of cost or narrow insurance
networks).41 No standard quantitative thresholds exist for these different concepts.

The various definitions of underinsurance highlight two related but distinct problems: people with inadequate insurance risk financial harm when they receive medical services, and they are
therefore less likely to obtain needed care. Despite the absence of consensus on the definition of underinsurance, it is clear that these problems affect many Americans with private coverage
and have increased.
Between 2004 and 2013, high rates of uninsurance, rising cost sharing (ie, underinsurance), and stagnant incomes all contributed to a decline in overall health-care consumption (as measured
by the total amount spent by insurers and patients) for poor Americans, a trend that was reversed in 2014 when the major provisions of the ACA came into effect (figure 2).42 For the first time
since the 1970s, per-capita medical expenditures for the poorest fifth of Americans (who are, on average, much sicker than the wealthiest 20%) dipped below those of the wealthiest 20%.42 In
Canada, by contrast, the poorest citizens receive the most medical services, commensurate with their increased health needs.45 Meanwhile, health-care expenditures for the wealthiest 20%
of Americans accelerated, raising their share of overall health-care consumption. The ACA, fully implemented in 2014, led to a surge in health-care expenditures for the bottom 20%, but
expenditures for the middle class have flattened while health-care consumption by the wealthiest Americans continues to grow.

Access problems

Geography often affects access to care. Because physicians are concentrated in cities and affluent suburbs, many Americans living in rural areas find it difficult to obtain primary46 and specialty
care.47 Many rural and Southern states also have a shortage of adequate family planning resources. Texas, for example, has imposed onerous regulations and funding cuts on family planning
clinics, causing closure of many48 and a subsequent increase in unwanted pregnancies.49 Since the closure of the last local abortion clinic in 2013, women in Lubbock, Texas (population 244 
000), are now more than 250 miles away from the nearest abortion provider.

Women are also at a financial disadvantage because of their greater health-care needs (including reproductive care) than those of men. Although fewer women than men are uninsured, those
with insurance have higher out-of-pocket costs. For example, among people with employer-sponsored coverage, women's out-of-pocket costs were $233 higher than men's in 2013;50 among
Medicare enrollees, such costs were $640 higher for women than they were for men in 2011.51 These costs are especially burdensome because women's median incomes are 39% lower than
those of men.52

Illness-based disparities are particularly stark for mental illness and substance abuse. Historically, a large share of psychiatric care was paid for out of pocket or provided in underfunded public
institutions. Jails remain the largest so-called inpatient mental health facilities in the USA. Although the 2008 Mental Health Parity and Addiction Equity Act mandated that most insurance
plans provide equivalent coverage for mental and physical illness, implementation of this requirement was delayed until 2015, and its enforcement has proven difficult.53 Moreover, most
Medicaid programmes (which cover many people with mental disorders) are exempt from these regulations. Psychiatric—and particularly substance abuse—providers are in short supply on a
national scale, especially in poor and rural areas;53 these areas have been particularly hard hit by the epidemic of drug overdoses and self harm, which pushed up the overall death rate in the
USA in 2015. The ACA, which applied the parity requirement to the plans sold through the exchanges, increased access to mental health, but not to substance abuse treatment; substantial
racial and ethnic disparities persist.54

Inequality and quality of care

For many conditions, increased quality is implied by, and inseparable from, improved access to care. An increased
frequency of primary care visits, for example, is associated with improved control of diabetes .55
Similarly, among patients who developed an acute myocardial infarction , the uninsured were 38% more
likely (and the underinsured 21% more likely) than the well insured to delay seeking emergency care.56
Yet it is unclear whether income-related disparities in access to care are accompanied by other gaps in global quality, which are harder to measure. Poverty itself causes ill health, compromises
non-medical social supports and resources that improve medical outcomes, and is associated with worse satisfaction with care.57 Hence, differences in the socioeconomic profile of patients,
rather than true differences in quality of care, might explain why hospitals58 and physicians59 caring for poor patients score lower on some quality metrics than do health-care providers
serving affluent areas.

Assessment of quality differences is increasingly difficult because tying quality indicators to financial incentives can induce so-called gaming, which distorts measurement.60 Nonetheless,
payers have implemented pay-for-performance schemes that reward providers on the basis of proxy measures of quality, and facilities serving poor patients have been disproportionately
penalised. For example, safety-net hospitals have seen their payments reduced under Medicare's Hospital Readmission Reductions,61 Hospital-Acquired Condition Reduction,62 and Hospital
Value-Based Purchasing programmes.63 Disturbingly, such programmes introduce perverse incentives to avoid poor patients, while shrinking funding for hospitals and physicians continuing to
care for them.

In view of the pitfalls of quality measurement, what can be said about the association between social disadvantage and the quality of medical services? A classic study of patients admitted to
hospital in 1984 found that uninsured patients were at higher risk (odds ratio 2·35) of receiving substandard medical care than their insured counterparts.64 However, safety-net hospitals (and
hospitals in the Veterans Administration [VA] system, which serves mostly non-affluent veterans) have risk-adjusted mortality rates for older patients similar to those of other hospitals. By
contrast, small hospitals serving isolated rural areas appear to deliver a lower quality of care for medical conditions than other hospitals do, as measured by both process-of-care metrics and
mortality.65 Studies of differences in surgical quality and safety are inconclusive,66 although risk-adjusted outcomes appear worse for poor patients across a range of surgical procedures.67
Poor patients are more likely than affluent patients to receive dangerous drugs: 27% of low-income Medicare beneficiaries with dementia, hip or pelvic fracture, or chronic renal failure
received contraindicated medications compared with 16% of higher-income individuals.17 Poor Americans older than 50 years are also far less likely than their affluent counterparts to receive
recommended influenza and pneumonia vaccinations, and cancer screening tests,17 although cost-related barriers might underlie these differences.

There is strong evidence showing that quality of care is worse for racial and ethnic minorities,68 although racial disparities in the quality of hospital care could have narrowed between 2005
and 2010 as a result of improvements among hospitals serving patients from minority backgrounds and more equitable care within all hospitals.69 Yet unequal access to care, along with
institutional racism, remain important drivers of persistent disparities in health-care quality for racial and ethnic minorities. For example, although African-Americans tend to live closer than
white patients to high-quality hospitals, they are less likely to have their surgeries there.70 The intersection of race, racism, and the health-care system in the USA is reviewed elsewhere in this
Series.

Health-care financing inequality

The USA finances medical care through a complex network of public and private insurance programmes, as
well as substantial direct payments by patients. Figure 3 shows the proportion of Americans covered by the main insurance programmes, and
the major sources that fund health care. Taken together, government
insurance programmes—principally, Medicare, Medicaid,
and military health care—account for 42% of personal health-care expenditures .72 Yet this figure substantially
understates the government's share, because it excludes two large, tax-funded outlays for private insurance: government agencies'
expenditures to purchase private insurance for public-sector employees (representing 28% of all employer payments for private coverage) and
tax subsidies for private firms' purchase of insurance for their employees. Taking into account these two additional categories boosts the public
share of total health funding in the USA to 65%.73 Total
health-care expenditures by the government in the USA
exceed the total public and private spending per head of any other country except for Switzerland .73 In
light of this fact, the stark inequalities in health care faced by millions of Americans seem particularly
unjust .

The complexity of health-care financing in the USA obscures not only the magnitude of public funding
but also the regressive pattern of who ultimately pays . In fact, health care takes a substantially larger
share of income from the poor than from the wealthy , exacerbating inequalities in disposable
income .74 Although comparative international studies are scarce and mostly old, financing schemes in other wealthy countries are
generally less regressive (although cost sharing is rising in some European countries75). Health-care systems financed primarily
through income taxes, as in Ireland, the UK, and Portugal, tend to be the most progressive, whereas those
relying on private insurance and out-of-pocket payments , as in Switzerland and the USA, are more regressive .76
The redistributive effect of specific health-care financing programmes

Direct out-of-pocket spending is the most regressive form of health-care financing. The uninsured (who are disproportionately poor) pay for much of their care out of pocket and, because they
do not have insurers' negotiating leverage, are charged the highest prices.77 As noted previously, insured patients often bear a heavy (and regressive) out-of-pocket burden for deductibles, co-
payments, and out-of-network care. Even older patients, almost all of whom are covered by Medicare, face high out-of-pocket costs for their share of the premiums, as well as co-payments
and deductibles,78 a burden that falls most heavily on low-income senior citizens. For Medicare enrollees, out-of-pocket medical expenses consume 11·2% of income among those with
incomes above 300% of the poverty level, and between 22·7% and 26·8% among those with incomes below 200% of the poverty level.51

In an effort to reduce the burden of catastrophic medical bills, the ACA imposed limits on out-of-pocket medical costs in private plans ($6850 per year for individual plans and $13 700 for
families in 2016), Yet these limits, which do not apply to out-of-network and so-called non-essential services, vastly exceed most families' savings.79

Private insurance premiums are also regressive74 and have risen faster than earnings (figure 4); premiums for employer-based plans increased by approximately three times between 1999 and
2016.29 The poorest fifth of Americans spend, on average, 6% of their income on private insurance premiums, while the wealthiest fifth spend just 3·2%.74 Although employers typically make
sizeable contributions to their employees' premium costs, economists believe that this expense is mostly passed on to employees in the form of lower wages.

Medicaid is the most progressively redistributive health insurance programme in the USA. It requires little cost sharing by patients, is financed through federal and state taxes (with progressive
income taxes providing the largest share),81 and most of the benefits go to poor citizens.

Medicare is funded largely through federal general revenues and a payroll tax, which remains less progressive than Medicaid's funding base (despite the ACA's extension of the payroll tax to
some investment income). Medicare covers both affluent and poor senior citizens, but its high and regressive cost-sharing requirements discourage many low-income beneficiaries from
seeking care.82 Moreover, the growing gap in life expectancy between the rich and the poor means that wealthier Americans will, on average, live to enjoy many more years of publicly funded
benefits after becoming eligible at the age of 65 years.83 As a result, among men born in 1960, lifetime Medicare outlays are expected to be 28% higher for the wealthiest fifth than for the
poorest fifth, a reversal of the pattern 30 years earlier.83 Similarly, immigrants (especially the undocumented) collectively contribute billions more in taxes to Medicare each year than they
receive in benefits.84

Medical bills and financial hardship

The health-care financing system in the USA leaves millions of Americans facing medical bills that deplete their assets and drive them into debt. One in four non-elderly adults younger than 65
years (and one in three with annual household incomes <$50 000) reported difficulty paying medical bills in 2015; more than half of these individuals owe more than $2500.85 People with
deductibles higher than $1500 (or families with deductibles >$3000) and worse health than the overall population are particularly at risk85, 86 (figure 5), as are African-Americans and
Hispanics.86

Medical bills are a major contributor to household debt and bankruptcy,14 comprising more than half of all unpaid personal debts sent to collection agencies87 (figure 6). One in ten families
with medical bill problems has declared bankruptcy.88 Although the uninsured are at greater risk than the insured of declaring bankruptcy,39 most medical bankruptcies involve debtors who
are insured.14

Financial hardship is especially common among people with serious illness .89 Among non-elderly adults with
cancer, more than a third borrowed money or went into debt because of their treatment, and 3% filed for bankruptcy.90 Such financial

catastrophe appears to increase mortality for treatable cancers,91 perhaps because it leads to forgone care.
Medicare92 and Medicaid93 coverage provide better (although still imperfect) protection from financial hardship.

Medical bills force families to make difficult choices : 34% of insured Americans with difficulty paying medical bills were
unable to pay for food, heat, or housing, 15% took out high-interest payday loans,94 and 42% took on extra jobs or worked additional hours.85
Most people reporting problems with medical bills say they have skipped or delayed needed medical care.95 Moreover, defaulting
on
medical bills and medical bankruptcies often has long-term repercussions; these blemishes remain on
credit reports for many years, compromising access to credit, insurance, housing, and employment .
Although medical costs impoverish many Americans, this issue is not captured by the US Census Bureau's official measure of poverty. In
response, the US Census Bureau has introduced alternative poverty measures that subtract medical costs and other mandatory expenses from
income, and add non-cash government aid (eg, housing vouchers). These alternative measures indicate that more Americans
experience poverty than are reflected in official statistics,96 with medical costs being the largest
contributor to the difference between the official and alternative measures, pushing an additional 10
million Americans below the poverty line .97
The medical system in the USA also influences inequality as an employer of nearly 17 million Americans. Although physicians and nurses are
generally well paid, many other health-care workers are not. The health-care system employs more than 20% of all black female workers; more
than a quarter of these health-care workers subsist on family incomes below 150% of the poverty line, and 12·9% of them are uninsured
(Himmelstein DU; unpublished analysis of the 2015 Current Population Survey).

A longer lens on health reform

A century ago, medical care in the USA had little influence on health or wealth. Burgeoning medical capabilities and costs in the 20th century
made health care an industry ripe for corporate investment and profit. The transformation from a largely charitable service to a market-driven
enterprise ensued.

Markets distribute goods on the basis of purchasing power , and for mostly non-discretionary
purchases, such as medical care, this results in particularly lopsided financial burdens . In many other
wealthy countries, social democratic and labour parties have successfully implemented policies that
offset these market tendencies by creating national health programmes, or by tightly regulating
private insurers and health-care providers. The USA does not have such a party, perhaps because the low-
income voters most buffeted by the market are divided by racial animosities. After the 2010 passage of the ACA, congressional

stalemates blocked incremental reforms that might have restrained medical markets and
democratised care . Republicans, now in control of both houses of Congress and the executive branch in Washington, DC, promise to
replace the ACA with measures that are even more market-friendly than the ACA, which would tilt care further towards the wealthy.

The health-care dilemma in the USA, characterised by unequal access and unfair financing, echoes that of the 1950s and 1960s, prior to the passage of Medicare and Medicaid, when one in
four Americans (and half of older people and minorities) did not have health coverage.

After 8 years of Republican rule, the Democratic President Kennedy was inaugurated in 1961. The impetus for reform was bolstered by the popular mobilisation for civil rights and enabled by
the Democratic Party's landslide victory in the 1964 election. The 1965 passage of Medicare and Medicaid vastly improved access to care and desegregated hospitals. But these health-care
initiatives were just one part of a broad legislative agenda that transformed American society, including the Civil Rights and Voting Rights Acts, laws that improved opportunities for women in
universities and the military, the first major federal aid programmes for local (particularly poor) public schools and college students, fairer immigration laws, and the establishment of the
National Endowment for the Arts. The redistributive agenda, dubbed the War on Poverty, also vastly expanded non-cash benefits such as food subsidies, free pre-school programmes for poor
children, and community health centres, and boosted social security benefits, lifting 2·5 million senior citizens out of poverty. When President Kennedy came into office in 1961, 40 million
Americans were poor. When his sucessor President Johnson left office in 1969, that number had fallen to 24 million. In 1972, the gap in remaining life expectancy at the age of 60 years was
only 1·2 years between men with incomes above and below the median.2

Half a century on, neoliberal policies have eroded these gains. Today, 43·1 million Americans are poor , many
health and social inequities persist, and some have worsened . Even after the ACA's coverage expansion—reviewed
elsewhere in this Series— 27 million Americans remain uninsured and, for many with insurance, access to affordable

care remains elusive. At the same time, unneeded and even harmful medical interventions remain common (due, in part, to the
fragmented health-care delivery system), bureaucracy consumes nearly a third of health spending, and wealthy
Americans consume a disproportionate and rising share of medical resources .
Conclusion

Many physicians in the USA are working to advance health-care justice. But increased efforts in this direction are needed. The brave cadre of colleagues who face constant threat for delivering
abortion services (which are disproportionately needed by poor women) must be supported and augmented, especially as anti-choice politicians now hold sway in Washington, DC. Doctors
should follow the lead of trainees, such as those in the WhiteCoats4BlackLives movement, who have spoken out against the structural racism that still tarnishes many medical institutions and
policies that deny care to immigrants. Physicians should reflect on the ways we—and the institutions we practice within—embrace or evade the responsibility to care for the disadvantaged.

Doctors should also join in demanding reforms that move forward, not backward, from the ACA. Republicans aspire to roll back the law's coverage expansions, fully privatise Medicare and the
VA, and give state governments free rein to cut Medicaid—changes that must be resisted to avoid a public health disaster.

However, Hillary Clinton's 2016 presidential election defeat suggests that defending
the health-care status quo cannot win
the day. Moreover, proposals for incremental steps that could cushion the worst inequities —such as
tighter insurance regulations, allowing a government insurance plan to compete in the market,
regulation of drug prices, and extension of public coverage to immigrants — failed to excite voters . Until
November, 2016, mainstream politicians and pundits deemed such steps politically feasible, and more thoroughgoing reform unattainable.
Now, a more inspiring and egalitarian vision —a health-care reform that address the problems felt by
most insured Americans—seems a more effective rebuttal to the Republican mantra of “Repeal and replace
[the ACA]”. A
bolder step towards health-care equality—straight on to universal public insurance —could
offer the best way forward.98

Disparities for people of color and poor folks in the quality of care emerge from many
factors. First, de facto segregation in health care drives death gaps through a multi-
tiered system of provision – the plan solves.
Carrasquillo and Torres 14 – Olveen Carrasquillo, M.D. from New York University School of Medicine, MPH from Harvard
School of Public Health, Professor of Medicine and Public Health Sciences, Director of the Division of Health Services Research and Policy in the
Department of Public Health Sciences at the University of Miami, Jaime Torres, M.D. from New York College of Podiatric Medicine, M.S. in
Community Health from Long Island University-Westchester Campus, VP of Community Relations & Partnerships at Urban Health Plan, one of
the largest community health networks in New York State, former Regional Director of the U.S. Department of Health and Human Services,
Region II, covering New York, New Jersey, Puerto Rico and the US Virgin Islands (“Reducing Health Care Disparities,” chapter in Divided: The
Perils of Our Growing Inequality, edited by David Cay Johnston, The New Press, pgs. 174-177)

The annual statistics published by the Census Bureau portray a dismal picture of health-insurance coverage
among minorities . The data show that one-third of Latinos in the United States lack health- insurance coverage
and 20 percent of both blacks and Asians in the United States are uninsured as well. In contrast, only 10 percent of
NHWs are uninsured. Further, from 1987 to 2005, the proportion of the uninsured population in the United States that is

minority has increased from 42 percent to 53 percent.

Among Latinos and Asians, the most vulnerable are immigrants. Over half of noncitizen Latinos and nearly a third of non-citizen Asians in the
United States lack health coverage. It is also estimated that nearly 80 percent of undocumented immigrants lack insurance. However, even U.S.-
born Latinos (over 60 percent of all Latinos are U.S. born) are twice as likely as NHWs to lack coverage.

Thus, immigration status by itself does not explain a large proportion of the disparities in health coverage between minorities and NHWS in the
United States.

Medical Apartheid in the United States

In the absence of a system of universal health care, a multi-tier health care system has developed in the
United States, one that results in what can be described as health care segregation . In the highest tier are
those who have private insurance coverage, usually through their employer or Medicare. These insurance programs are
widely accepted by physicians and hospitals. At the other end are the uninsured . In theory, they can pay for their health care

services out of pocket. In reality, as most of the uninsured are either poor or middle class, they often forgo

necessary care . Their alternative is to rely on a safety-net patch-work of providers, including community health
centers, outpatient departments of public and some not-for-profit hospitals, and emergency rooms. While an important source of care for the
uninsured, such patched-together systems are a far cry from the care received by privately insured and
Medicare populations. In particular, access to subspecialty care and a stable source of out-patient medications are
major barriers to care in these safety-net systems. While 85 percent of NHWs in this country belong to the highest tier of health care,
only 63 percent of blacks and 50 percent of Hispanics belong to this top tier of access. Further, while racial and ethnic minorities

make up less than a third of the US. population, over half of all persons in this lowest tier of health
care are minorities .
In the middle tier are those covered through the various insurance programs serving the poor such as Medicaid and the State Children’s
Health Insurance Programs (SCHIP). These programs are critical components of the health care safety net and cover 40 million children and

suffer chronic underfunding and applicants face

adults. Unfortunately, as is true for most other poverty programs, they

onerous eligibility and recertification requirements . In some states, over half of all persons who enroll are
disenrolled in under a year. Further, when facing budgetary difficulties, limiting enrollment in these programs or
rationing health care services through cutbacks of services covered is a favorite ploy of many legislators. Thus, for
many enrollees, such programs are a far cry from the comprehensive, ongoing health care access that persons
in the first tier enjoy.

The real reason that these underfunded programs are segregated is that in most states providers are paid at levels much
lower than Medicare. As an example, in New York a private physician can be paid six times more to see a patient with Medicare versus
Medicaid. As a result, fewer than half of all providers nationally choose to accept Medicaid patients. In many localities, this forces most
Medicaid patients to receive care through the same network of safety-net clinics that exist for the
uninsured. Further, access to subspecialty care in these settings is often as problematic as it is with the
uninsured. In one large hospital in New York City, the wait for a Medicaid patient to see a gastroenterologist is eight months. In contrast, a
patient with Medicare could be seen within two weeks in the private offices that are part of the same medical center but do not accept
Medicaid patients. The
government also reinforces this segregated system of care , because it provides
additional subsidies or grants for designated safety-net providers and clinics to see Medicaid patients
but does not make such funds available to providers in private practice . This segregationist system is
quite effective at ensuring that those in the first tier receive a different level of care from those in the
second and third tiers. A report by one advocacy coalition, Bronx Reach Coalition, extensively described this system of
segregated care and unequal access faced by poor and predominantly minority patients as “ Medical
Apartheid .”

Among the report’s conclusions were that people who are uninsured or publicly insured (through Medicaid, Medicaid
Managed Care, Family Health Plus, and Child Health Plus) are often cared for in separate institutions from those who

are privately insured. The coalition also found that even within health care institutions, separate and unequal
systems of care exist. The uninsured, people covered by Medicaid, and sometimes even those enrolled in Medicaid
Managed Care, Family Health Plus, and Child Health Plusreceive poorer care in different locations, at different times,
and by less trained physicians than those who are privately insured. Finally, the report shows that when patients are
sorted according to their insurance status, this segregated care leads to different health outcomes .

Under a comprehensive national health-insurance plan, a wealthy NHW male would have the same
level of coverage as a low-income black female . Detractors claim this one-size-fits-all approach is not consistent with
American values and that individuals should have the freedom to choose the level and quality of care they wish to receive. However, such
detractors have a hard time identifying persons who would want to receive low-quality health care. Clearly, under
the mantra of
choice, it would be minorities who would disproportionately be stuck in the lowest levels of health
care . From a perspective of basic fairness, it is clear that having one system of care in which access to high-quality
health care would be a right of all is far superior to one in which quality of coverage is determined by
income.
Second, lack of insurance poses financial barriers to care. The consensus of
experimental studies supports the thesis that expansions in health insurance coverage
reduce mortality and improve health outcomes
For what it’s worth, one of the authors of this paper, Katherine Baicker, was one of the authors of the Oregon Health Care Experiment study.
Negative readings of that study are clearly misinterpretations of the data.

Sommers et al 17 – Benjamin D. Sommers, PhD in Health Policy from Harvard and an MD from Harvard Medical School, associate
professor of health policy and economics in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and
an assistant professor of medicine at Brigham and Women’s Hospital, both in Boston, Massachusetts, Atul A. Gawande, M.D. from Harvard
Medical School, M.P.H. from Harvard T.H. Chan School of Public Health, practices general and endocrine surgery at Brigham and Women's
Hospital, professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O.
Thier Professor of Surgery at Harvard Medical School, and Katherine Baicker, C. Boyden Gray Professor of Health Economics in the Department
of Health Policy and Management at the Harvard T.H. Chan School of Public Health, Ph.D. in economics from Harvard (“Health Insurance
Coverage and Health — What the Recent Evidence Tells Us,” The New England Journal of Medicine, June 21st,
http://www.nejm.org/doi/full/10.1056/NEJMsb1706645#t=article)

Perhaps no research question better encapsulates this policy debate than, “Does coverage save lives?”
Beginning with the Institute of Medicine’s 2002 report Care without Coverage, some analyses have suggested that lack of

insurance causes tens of thousands of deaths each year in the United States.44 Subsequent observational studies had
conflicting findings. One concluded that lacking coverage was a strong independent risk factor for death ,28 whereas
another found that coverage was only a proxy for risk factors such as socioeconomic status and health-related behaviors.27 More recently,
several studies have been conducted with stronger research designs better suited to answering this question.

The Oregon study assessed mortality but was limited by the infrequency of deaths in the sample . The
estimated 1-year mortality change was a nonsignificant 16% reduction, but with a confidence interval of −82% to +50%, meaning that the study
could not rule out large reductions — or increases — in mortality. As the authors note, the study sample and duration were not well suited to
evaluating mortality.

Several quasi-experimental studies using population-level data and longer follow-up offer more precise estimates of coverage’s effect on
mortality. One
study compared three states implementing large Medicaid expansions in the early 2000s to
neighboring states that didn’t expand Medicaid, finding a significant 6% decrease in mortality over 5
years of follow-up.22 A subsequent analysis showed the largest decreases were for deaths from “health-care–amenable”
conditions such as heart disease, infections, and cancer, which are more plausibly affected by access to
medical care .29 Meanwhile, a study of Massachusetts’ 2006 reform found significant reductions in all-cause mortality and health-care–
amenable mortality as compared with mortality in demographically similar counties nationally, particularly those with lower pre-expansion
rates of insurance coverage.9 Overall, the study identified a “number needed to treat” of 830 adults gaining coverage to prevent one death a
year. The comparable estimate in a more recent analysis of Medicaid’s mortality effects was one life saved for every 239 to 316 adults gaining
coverage.29

How can one reconcile these mortality findings with the nonsignificant cardiovascular and diabetes findings in the Oregon study? Research
design could account for the difference: the Oregon experiment was a randomized trial and the quasi-experimental studies were not, so the
latter are susceptible to unmeasured confounding despite attempts to rule out alternative explanations, such as economic factors, demographic
shifts, and secular trends in medical technology. But — as coauthors of several of these articles — we believe that other explanations better
account for this pattern of results.

First, mortality
is a composite outcome of many conditions and factors . Hypertension, dyslipidemia, and
elevated glycated hemoglobin levels are important clinical measures but do not capture numerous
other causes of increased risk of death. Second, the studies vary substantially in their timing and sample
sizes. The Massachusetts and Medicaid mortality studies examined hundreds of thousands of people
gaining coverage over 4 to 5 years of follow-up , as compared with roughly 10,000 Oregonians gaining
coverage and being assessed after less than 2 years . It may take years for important effects of
insurance coverage — such as increased use of primary and preventive care, or treatment for life-threatening conditions such as cancer,
HIV–AIDS, or liver or kidney disease — to manifest in reduced mortality, given that mortality changes in the other
studies increased over time.9,22

Third, the effects

on self-reported health — so clearly seen in the Oregon study and other research — are themselves
predictive of reduced mortality over a 5- to 10-year period.42,43 Studies suggest that a 25% reduction in self-
reported poor health could plausibly cut mortality rates in half (or further) for the sickest members of
society, who have disproportionately high rates of death . Finally, the links among mental health, financial stress, and
physical health are numerous,45 suggesting additional pathways for coverage to produce long-term health effects.

DIFFERENT TYPES OF COVERAGE

In light of recent evidence on the benefits of health insurance coverage, some ACA critics have argued that private insurance is beneficial but
Medicaid is ineffective or even harmful.46 Is there evidence for this view? There is a greater body of rigorous evidence on Medicaid’s effects —
from studies of pre-ACA expansions, from the Oregon study, and from analyses of the ACA itself — than there is on the effects of private
coverage. The latter includes studies of the ACA’s dependent-coverage provision, which expanded only private insurance, and of
Massachusetts’ reform, which featured a combination of Medicaid expansion, subsidies for private insurance through Medicaid managed care
insurers, and some increase in employer coverage. But there is no large quasi-experimental or randomized trial demonstrating unique health
benefits of private insurance. One head-to-head quasi-experimental study of Medicaid versus private insurance, based on Arkansas’s decision
to use ACA dollars to buy private coverage for low-income adults, found minimal differences.11,19 Overall, the evidence indicates that having
health insurance is quite beneficial, but from patients’ perspectives it does not seem to matter much whether it is public or private.47 Further
research is needed to assess the relative effects of various insurance providers and plan designs.

Finally, though it is outside the focus of our discussion, there is also quasi-experimental evidence that Medicare
improves self-
reported health48 and reduces in-hospital mortality among the elderly,49 though a study of older data from Medicare’s
1965 implementation did not find a survival benefit.50 However, since universal coverage by Medicare for elderly Americans is well
entrenched, both the policy debate and opportunities for future research on this front are much more limited.

IMPLICATIONS AND CONCLUSIONS

One question experts are commonly asked is how the ACA — or its repeal — will affect health and mortality. The
body of evidence
summarized here indicates that coverage expansions significantly increase patients’ access to care
and use of preventive care, primary care, chronic illness treatment, medications, and surgery . These
increases appear to produce significant, multifaceted, and nuanced benefits to health . Some benefits
may manifest in earlier detection of disease, some in better medication adherence and management of
chronic conditions, and some in the psychological well-being born of knowing one can afford care when one gets sick. Such
modest but cumulative changes — which one of us has called “the heroism of incremental care”51 — may not occur for

everyone and may not happen quickly. But the evidence suggests that they do occur, and that some of
these changes will ultimately help tens of thousands of people live longer lives . Conversely, the data suggest
that policies that reduce coverage will produce significant harms to health , particularly among people with lower
incomes and chronic conditions.

Do these findings apply to the ACA? Drawing on evidence from recent coverage expansions is, in our view, the most reasonable way to estimate
future effects of policy, but this sort of extrapolation is not an exact science. The ACA shares many features with prior expansions, in particular
the Massachusetts reform on which it was modeled. But it is a complex law implemented in a highly contentious and uncertain policy
environment, and its effects may have been limited by policies in some states that reduced take-up,52 Congress’s partial defunding of the
provisions for stabilizing the ACA’s insurance marketplaces,53 and plan offerings with high patient cost sharing. Furthermore, every state’s
Medicaid program has unique features, which makes direct comparisons difficult. Finally, coverage expansions and contractions will not
necessarily produce mirror-image effects. For these reasons, no study can offer a precise prediction for the current policy debate. But our
assessment, in short, is that these studies provide the best evidence we have for projecting the impact of the
ACA or its repeal.
The many benefits of coverage, though, come at a real cost. Given the increases in most types of utilization, expanding coverage leads to an
increase in societal resources devoted to health care.8 There are key policy questions about how to control costs, how much redistribution
across socioeconomic groups is optimal, and how trade-offs among federal, state, local, and private spending should be managed. In none of
these scenarios, however, is there evidence that covering more people in the United States will ultimately save society money.

Are the benefits of publicly subsidized coverage worth the cost? An analysis of mortality changes after Medicaid expansion suggests that
expanding Medicaid saves lives at a societal cost of $327,000 to $867,000 per life saved.29 By comparison, other public policies that reduce
mortality have been found to average $7.6 million per life saved, suggesting that expanding health insurance is a more cost-effective
investment than many others we currently make in areas such as workplace safety and environmental protections.29,54 Factoring in enhanced
well-being, mental health, and other outcomes would only further improve the cost–benefit ratio. But ultimately, policymakers and other
stakeholders must decide how much they value these improvements in health, relative to other uses of public resources — from spending them
on education and other social services to reducing taxes.

There remain many unanswered questions about U.S. health insurance policy, including how to best structure
coverage to maximize health and value and how much public spending we want to devote to subsidizing coverage for people who cannot afford
it. But whether enrollees benefit from that coverage is not one of the unanswered questions . Insurance
coverage increases access to care and improves a wide range of health outcomes . Arguing that health
insurance coverage doesn’t improve health is simply inconsistent with the evidence.

Robust anti-discrimination laws combined with universal access can combat implicit
bias.
Matthew 15 – Dayna Bowen Matthew, William L. Matheson and Robert M. Morgenthau Distinguished Professor of Law at UVA School
of Law, F. Palmer Weber Research Professor of Civil Liberties and Human Rights, previously served on the University of Colorado law faculty as a
professor, vice dean and associate dean of academic affairs, J.D. from the University of Virginia (Just Medicine: A Cure for Racial Inequality in
American Health Care, “A Structural Solution,” New York University Press, pages 183-193)

Long-Lasting Protective Interventions: Universal Coverage Reforms at the third tier of the health impact pyramid
represent long-lasting protective interventions . These are large-scale , often one-time changes that
may address some structural issues, but do so by reaching people as individuals rather than changing their collective economic or medical
contexts. The third tier interventions are the societal changes that are likely to have some impact on

improving health disparities ; however, these reforms are also unlikely to fundamentally transform the
history and culture of racial and ethnic discrimination in health care . The American effort to achieve universal health
insurance coverage is one such example. U.S. presidents throughout America’s political history have futilely engaged in the rhetoric of health equality and justice for
over a century. In 1912—ironically, the year the British Parliament passed that country’s National Insurance Act—President Teddy Roosevelt introduced “social
insurance” in an effort to provide universal medical coverage “against the hazards of sickness” as part of the Progressive Bull Moose platform, which declared, “The
supreme duty of the Nation is the conservation of human resources through an enlightened measure of social and industrial justice.”31 In 1945, President Harry
Truman delivered a special message to Congress recommending a comprehensive national health program as part of an Economic Bill of Rights that ensured “the
right to adequate medical care . . . the opportunity to achieve and enjoy good health . . . [and] the right to adequate protection from the economic fears of
sickness.”32 When President Lyndon Johnson signed the Social Security Act of 1965 into law, establishing the Medicare and Medicaid health insurance programs, his
words described a reform aimed at eliminating “the injustice that denies the miracle of healing to the old and to the poor.”33 President Richard Nixon, speaking to
Congress in 1974 to introduce his Comprehensive Health Insurance Plan, began by declaring that “one of the most cherished goals of our democracy is to assure
every American an equal opportunity to lead a full and productive life”34 as he implored the legislature to expand Medicare, Medicaid, and mandatory employer-
based insurance coverage. In 1979, President Jimmy Carter proposed a “National Health Plan,” citing the challenge to “secure for all Americans access to quality
health care as a matter of right.”35 A decade later, President Bill Clinton introduced the Health Security Act of 1993 in a bid to achieve universal coverage through
managed competition.36 Most recently, upon passage of the Patient Protection and Affordable Care Act which enacts insurance reforms intended to expand health
coverage to 25 million previously uninsured Americans, President Barack Obama declared, “Tonight’s vote is not a victory for any one party—it’s a victory . . . for the
American people.” The president’s remarks reinforced the equality objectives that underlie this act, calling the new reform a “system that works better for the
American people.”37 The American political effort to achieve health justice through universal access has spanned decades and crossed the political spectrum.
Nevertheless, our nation’s focus has been on achieving equal access to health care, not on achieving equal health care quality for all Americans. The political goal
has been to expand access to health insurance so that a larger number of Americans can purchase health care. While achieving equitable access to health care
encounters is essential, true equality in health care demands more. Equal access to health care will not change the disparate health outcomes that minority patients
suffer as long as the quality of the care to which they are afforded access remains substantively inequitable. Political leaders have given little attention to the
injustices that will persist even if we succeed in universalizing access to medical insurance. These include the systemic inequities that affect minority health, such as
poor housing, employment, education, and food security, as well as inferior medical treatment. Interventions to correct inequities in these social determinants of
health are at the bottom-most tier of Frieden’s health impact pyramid. The effort to universalize access to health insurance, in contrast, represents a protective
intervention situated in the center of the health impact pyramid. Universal health insurance importantly will reach individuals needing access to health care
services, but it will not change the collective attitudes that permeate the health care services they access. In point of fact, the theory of distributive justice that
motivates efforts to enact universal coverage actually supports a much broader view of the nature and the moral importance of health and health care equity than
our legislative efforts have addressed. Recognizing that it is beyond the capacity of any health care system to guarantee all its citizens will get all the health care that
they want, or even all that they need, ethicists have explored the principles that must guide any society’s difficult decisions concerning the fair distribution of scarce
yet life-saving medical resources. Health justice advocates recognize there is a difference between the obligation to guarantee just and equal access to health care
and the impossible goal of guaranteeing just and equal access to health itself. Some differences in health care and health outcomes are inevitable and are neither
the evidence for nor the result of injustice. Norman Daniels provides one of the most widely accepted descriptions of the nature of true health justice. He argues
that just access to health and health care needs is especially important because it allows each individual member of society equal enjoyment of the normal range of
all other opportunities the society has to offer. Daniels goes further to identify the level of responsibility for ensuring just health care: I shall urge a normative claim:
we ought to subsume health care under a principle of justice guaranteeing fair equality of opportunity. . . . If an acceptable theory of justice includes a principle
providing for fair equality of opportunity, then health-care institutions should be among those governed by it.38 Importantly, Daniels’s concept of health justice
does not focus or operate exclusively on the individual level, but instead also incorporates institutional accountability. Even though Daniels’s is a theory of
distributional justice—arguing that society must fairly allocate health care in order to equip all members of society to participate in the normal range of life’s
opportunities—his theory requires systemic, institutional level changes in order for justice to be achieved. Daniels admits to the need for exogenous governance to
achieve health justice. In short, distributional fairness alone will not eliminate racial and ethnic health disparities. Establishing a just health care system will require
rooting out implicit biases that affect patients differentially. The goal must be to achieve substantive as well as distributive justice in American health care. Neither
expanded MCAT testing, nor additional research, nor complex clinical regulations, nor principled professional standards, nor political efforts to expand health care
access has proved effective to reduce, much less eliminate, racial and ethnic health care disparities. These reforms address disparities through interventions at the
top three tiers of the health impact pyramid. Although the fundamental reforms in socioeconomic factors are beyond the scope of this book, the need to change the
context in which health care is delivered—the fourth tier of the health impact pyramid—is well within reach and acutely indicated by the data and narratives
collected in this book. The physician and patient narratives assembled here qualitatively describe the injustice and daily damage visited upon minority patients by
health care disparities. Furthermore, the enormity of these inequities can also be quantified. One source has estimated that over 30 percent of the direct medical
costs that African Americans, Hispanics, and Asian Americans incur are excess costs due to health inequities—nearly $230 billion over a three-year period between
2003 and 2006.39 In 2005, Dr. David Satcher estimated that 83,570 deaths occur each year as a result of racial and ethnic health disparities.40 In other words,
inferior, racially biased health care kills people of color and costs them lots of money while doing so! Improvements in the overall quality of medical care in the
United States have narrowed persistent gaps in some key disparities indicators.41 Yet, our nation is making disturbingly little progress finding an effective solution
to the structural nature of these injustices. Evidence of a Structural Problem Despite the serious responses to a serious disparities problem, in 2012, for the tenth
year in a row, the United States Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) released evidence that the fight
against health disparities is stalled. AHRQ’s annual report on National Healthcare Quality and Disparities gives data that describes the progress American health care
has made in reducing health care disparities. The 2012 report records changes in disparities over the period from 2002 to 2010 by racial and ethnic groups, basing
these changes on measures of quality such as the number of deaths due to cancer and heart attacks and the incidence of end-stage renal disease due to diabetes.
The AHRQ also reports changes in disparities in access to health care for the period from 2002 to 2009. Figure 8.2 depicts the lack of progress. The graph on the left
shows the number of quality measures that represent a gap between health care delivered to minority and white Americans and how those measures are changing.
The graph on the right shows the number and extent to which measures of disparaty have improved. Both graphs also show changes in the gap between high- and
low-income groups for the quality and access measures. The disquieting message presented is that the overwhelming majority of disparities by race and ethnicity
are static. In spite of focused attention from law- and policymakers, health care providers, and scholars, figure 8.2 paints a dispiriting picture of how far we have not
come. According to figure 8.2, well over 80 percent of the measures that describe quality and access disparities for health care have remained unchanged or have
grown worse over the report period. Disparate health care quality measures have improved in absolute terms between 2002 and 2010. However, the gap between
quality improvements for whites and people of color has been relatively constant. A few disparities in quality of care are getting smaller. The disparity quality
measures that are improving generally have to do with acute hospital care. However, the rates at which minority and white adult surgery patients receive
preventative care are not improving. Some examples of widening gaps between whites and minority patient quality outcomes include the number of maternal
deaths in childbirth, the number of infants who receive vaccines, the number of diabetic adults who get their glucose levels tested annually, the incidence of breast
cancer diagnosed at advanced versus early stages, the number of adults over age fifty who receive preventative care in the form of colonoscopy or other diagnostic
procedures, and the number of children for whom a health provider gave advice about using car safety seats. Perhaps there is some comfort in the fact that a
greater number of measured disparities are improving than are worsening. Still the short and troubling story is that most disparities in the quality of health care
delivered to whites as compared to patients of minority racial and ethnic groups are not changing at all. Sadly, the data shows that even less progress is being made
equalizing disparities related to access to care. The access gap between Asians and whites grew smaller for four of the nineteen categories measured, improving
disparities for that group by 21 percent. But over the period between 2002 and 2009, virtually none of the disparities between other minority populations and white
Americans have improved. I submit that the only reforms that will significantly and effectively narrow the health disparities that AHRQ has reported over the last
decade must fit into the bottom tiers of Frieden’s health action pyramid. I propose a fourth tier intervention that will change the
health delivery context to make individual physicians’ default decisions healthier . My proposal aims to
change the social norm surrounding unconscious racism and to affect the context in which health
decisions are made, following the tradition of public health successes. For example, when a municipality fluoridates its water supply or implements clean
air regulations, individuals in the community can benefit without having to exercise their individual agency to choose a health-enhancing option. I propose

changing the context in which health care delivery occurs by reforming antidiscrimination law . Legal
reforms will impact social norms and will incentivize long-lasting protective interventions by
institutional health care providers. Institutions will create a climate for change because they will be corporately
incentivized to articulate nondiscriminatory goals clearly and adopt compliance policies, procedures,
and infrastructure to implement nondiscriminatory training, assessment, and enforcement . The
solution I propose is designed to maximize the population-wide impact of reducing implicit biases , while
also requiring individual effort to address the cognitive formation of these biases and the discriminatory conduct that they inspire. The Courage to Make

Bad laws allow discrimination to flourish , harming the health

Unconscious Racism Illegal Let us return to the theme raised in chapter 1:

and shortening the lives of racial and ethnic minorities. Good laws can reduce discrimination in health care and ultimately
change the social climate in the way that civil rights laws eventually made explicit prejudice intolerable. Throughout this book we have seen the
tenacity of health disparities and the serious injuries they cause. The Biased Care Model identified six mechanisms through which implicit biases operate to produce
health disparities. The literature on malleability defined the types of interventions that can alter the cognitive processes that form implicit biases and translate them
into harmful discriminatory conduct. However, we have yet to see how these interventions can be generalized to affect broad contextual changes in the health care

industry. We have yet to see how this information can be brought to bear to reduce health disparities. I propose that making discrimination due
to unconscious racism illegal —forbidden by explicit and enforceable law—will change the context, incentives, and
outcomes in health care, and will thereby reduce health disparities . A legal prohibition against the
unconscious racism that causes health and health care disparities would accomplish a paradigmatic
and structural change in the way American health care is delivered in three ways. An anti-implicit bias discrimination law
would first signal a societal commitment to equality and justice in health care. This would be a paradigm shift, redefining the social

norm around health disparities generally, but more specifically removing the ambivalence concerning the
culpability of health disparities caused by unconscious racism. Laws effectively influence social norms by
reflecting underlying social values that exist but about which there is incomplete information or
uncertainty. Law serves to reflect commonly endorsed beliefs so that a community or society can live in accordance with
collectively shared values. In health care, a law against unconscious racial discrimination would reflect the community consensus that we have seen among
physicians who explicitly prefer equality and fairness in health care, but are surprised by the presence and influence of their unconscious biases. Moreover, an anti-
implicit bias law in health care would extend the general disapprobation that Americans feel toward overt racial prejudice, bigotry, and discrimination. Conversely,
an antidiscrimination law that accounts for implicit bias would endorse the generally shared value
that favors equal rights and opportunity for all people of all racial and ethnic backgrounds. However, legal expression of these
values is particularly important and necessary in health care where the discrimination arises from the
unconscious biases that are not well understood by most. In the health care context, this uncertainty arises in large part from the limited understanding
that physicians and health care providers have about the connection between their implicit biases and the inequitable health outcomes that minorities suffer. As
seen in the experiment by Dr. Alexander Green, physicians who are “clued into” the impact their implicit biases have on their medical decision-making want to
change. Certainly anyone who reads this book or undertakes to systematically review the empirical social science literature about implicit bias in health care will

have the information needed to understand the connection between unconscious racism and the inferior health care that minorities experience. However, only
legal intervention will serve to generalize this information and signal to health providers and all others
that the connection exists but will not be allowed to persist . A legal intervention prohibiting
unconscious racism would serve the same purpose that legal bans and restrictions on smoking have
served. To the extent that there was uncertainty or incomplete information about the health harms caused by second-hand smoke, legislative enactments sent
a strong message that the dangers had been sufficiently proven to require legislative action to protect against a serious public health threat. Enacting

prohibitory laws served as a collective signal to increase certainty .42 The same collective signal is
needed to establish a new contextual understanding of the devastating health harms caused by
unconscious racism. Secondly, an express, enforceable legal prohibition against unconscious racism in
health care will incentivize behavior changes by health care providers who are in the best position to eliminate the effects of
unconscious bias. Such a law would empower providers as a group to address discrimination from a position that
economists describe as the “cheapest cost avoiders.”43 Providers occupy this position because they are best suited to bring about the changes in health care
delivery that are required to minimize the harms being caused to patients. This is the essential role of a “cheapest cost avoider.” Physicians seeking to conform to
shared egalitarian values in order to enhance their personal standing and reputations, and institutional providers seeking to avoid secondorder sanctions such as
shaming or ostracizing by critics of discriminatory medical systems, are in a position to reform medical education curricula, change physician credentialing
requirements, mandate stereotype negation training, meaningfully diversify all ranks of the health care workforce, and take other steps to structurally address
unconscious bias in health care. Again, the case of legislative bans on smoking is instructive. These laws gave permission to nonsmokers to insist that smokers
remove themselves or their cigarettes to conform their behavior to laws that government actors were nowhere in sight to enforce. Smokers themselves largely
comply with designated smoking areas to avoid the hassle of personal chastisement. Similarly, empirical evidence presented in chapter 7 showed that a legal
prohibition could operate as a Type C intervention to change the consensus signals that cause even overtly prejudiced individuals to check their discriminatory

behavior. A law prohibiting unconscious racism in health care would also incentivize Type A training and
Type B diversification interventions by raising the cost of remaining indifferent to the effects that
unconscious racism has on minority health outcomes .44 The goal of an antidiscrimination law directed
at implicit biases would be to make discrimination due to unconscious racism so costly that a would-
be discriminator would take steps to avoid the financial and reputational impact of being negatively
perceived by his peers or penalized by the state. In short, legally prohibiting unconscious racism will make ignoring the prevalence of this form
of discrimination an irrational choice. Finally, an antidiscrimination law that expressly incorporates discrimination due

to unconscious racism would provide a direct or first-order sanction by which the state could impose
fines and penalties sufficient to disrupt the self-fulfilling prophecy of negative racial and ethnic
stereotypes. For those whose preferences or tastes for unconscious discrimination remained unaltered by a legally communicated social norm against such
attitudes and behavior, the law would interrupt the cycle of discrimination based on an erroneously perceived

justification. According to the Biased Care Model, providers’ negative perceptions of minority patients as noncompliant, uneducated, and uncooperative lead
to inferior communication, minority patient dissatisfaction, statistical discrimination, and ultimately inequitable treatment decisions. All these mechanisms produce
disparate health outcomes. Some advocates then use these disparate
outcomes as license to argue biological,
behavioral, and even genetic inferiorities that justify the discrimination and biased perceptions that feed

Law could interrupt this cycle of discriminatory behavior and outcomes ,

into beginning the discriminatory cycle again.

thereby reducing the social and moral costs that health care disparities impose on the provider, the
patient, and society at large.45 There is no better time than now to abandon the failed educational, political,
administrative, and self-regulatory approaches that have left health care disparities essentially unchanged for as

long as they have been measured. There is no graver legal problem than saving the lives of tens of
thousands of minority patients from the inequity of disparate outcomes in disease and death . We have
seen that law can both harm and help the cause of health care equality . Although law has helped bring

about some of the greatest successes in achieving equality, as in the case of desegregation during the civil rights era, the fact that it has
done so does not argue convincingly for resorting to the same institution that also consigned blacks to segregated housing squalor ,

exposed Asians to dangerous vaccines, and facilitated the introduction of infectious diseases that wiped out
entire populations of Native Americans in order to eradicate health discrimination today. But my argument here begins and ends with
only a radical and fundamental transformation of the context in which biased health care
the conviction that

is currently practiced will undermine the Biased Care Model that dominates modern American health
care, and only a well -conceived and enforced body of law can accomplish such a paradigm shift .

The plan solves – incorporating anti-discrimination law into universal health care is
necessary to reduce health inequity. The aff’s negligence standard and disparate
impact provisions change social norms and incentivize equitable provision of care.
Matthew 15 – Dayna Bowen Matthew, William L. Matheson and Robert M. Morgenthau Distinguished Professor of Law at UVA School
of Law, F. Palmer Weber Research Professor of Civil Liberties and Human Rights, previously served on the University of Colorado law faculty as a
professor, vice dean and associate dean of academic affairs, J.D. from the University of Virginia (Just Medicine: A Cure for Racial Inequality in
American Health Care, “A New Normal,” New York University Press, pages 208-212, underlining in original)

I have shown that Congress originally intended to empower private parties and public officials in the fight
against invidious racial and ethnic discrimination in the United States and that several Supreme Court cases have

recognized the need to do so as well. Therefore, the first restorative step is to expressly prohibit unintentional
discrimination under Section 601 of Title VI. In addition to reversing the Sandoval court’s break with
Supreme Court disparate impact precedent “in separate lawsuits spanning several decades,” 52
restoring private causes of action for disparate impact cases will have important practical
ramifications . Private enforcement will expand the government’s ability to stretch scarce
enforcement resources and provide needed assistance to uncover subtle forms of discrimination . In fact,
most of the statutory language needed to restore private enforcement for disparate impact claims under Title VI has already been proposed
before Congress, in June 2012, during the 112th Congress. In 2012, the Senate Committee on Veterans’ Affairs considered but did not enact
language to amend Title VI.53

Using that proposed language as a starting point, I next suggest creating a new cause of action to prohibit
discrimination due to implicit bias by expressly adding “rights-creating language” to Section 601, based on a negligence
standard of care. A new negligence cause of action will empower the government as well as private
victims directly impacted by unconscious racism to challenge the policies and programs that result in
discrimination against minorities. At the same time, such a measure would also provide an affirmative defense to protect federal
aid recipients from liability by showing they took reasonable steps, based on the available scientific evidence of which interventions effectively
combat discrimination from unconscious or implicit bias. Thus the negligence-based cause of action will fully incorporate the current knowledge
scientists have amassed about preventing harms due to implicit biases or unconscious racism. A new negligence action will
augment existing disparate impact claims . For example, in accordance with the current Title VI burden-shifting regime, the
proposed amendments will leave current disparate impact jurisprudence in place, allowing plaintiffs to
prevail by discharging the burdens of production and persuasion to show disparate impact from a policy for which there

is no substantial and legitimate nondiscriminatory goal, or by making out a prima facie case that the defendant rejected
an existing, less discriminatory practice or policy than the one challenged. Finally, I propose adding language to the end of Section 602 of Title
VI to restore the public-private enforcement model for any and all Title VI causes of action authorized under Section 601.

In order to accomplish these reforms of Title VI, Congress

must amend the legislative language to add a provision to
Section 601 of the current statute, and add a provision to Section 602 . After denoting the existing language in these
Sections as subparagraph (a), I propose to delineate the additional provisions as Section 601(b) and Section 602(b)–(c). The text of the resulting
amended statutes follows, with the additional language I proposed underlined.54

The proposed revised version of Section 601 would read as follows:

(a) No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the
benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.

(b) Discrimination based on disparate impact with respect to a program or activity is established under this section only if—

(1) a Federal department or agency, or any person aggrieved, demonstrates that an entity subject to this title has a policy or practice with
respect to the program or activity that causes a disparate impact on the basis of race, color, or national origin; and

(2) the entity fails to demonstrate that it has taken reasonable steps to reduce discriminatory harms due to unconscious or unintentional
biases; and

(3) the entity fails to demonstrate that the challenged policy or practice is related to, and necessary to achieve, the substantial and legitimate
nondiscriminatory goals of the program or activity; or

(4) a Federal department or agency, or the person aggrieved, demonstrates that a less discriminatory alternative policy or practice exists, and
the entity refuses to adopt such alternative policy or practice.

The revised version of Section 602 would read as follows:

(b) Any person aggrieved by the failure of an entity to comply with section 601 may bring a civil action in any Federal or State court of
competent jurisdiction to enforce such person’s rights and may recover equitable relief, reasonable attorney’s fees (including expert fees), and
costs. The aggrieved person may also recover legal relief (including compensatory and, from nongovernmental entities, punitive damages) in
the case of noncompliance based on evidence of intentional discrimination. In an action brought by an aggrieved person based on evidence of
disparate impact, the aggrieved person may recover equitable relief, reasonable attorney’s fees (including expert fees), and costs.

(c) Nothing in subsection (b) limits the authority of a Federal department or agency to enforce Section 601.

These changes to the plain language of Title VI will fully restore the recovery and relief that Congress has
consistently indicated it intended to provide under the Civil Rights Act of 1964, will add a negligence-based
claim to prohibit discrimination due to implicit biases , and will encourage all government contractors
to protect against the discriminatory injustice that Congress has historically deplored. The advantages and benefits of these
reforms are worth reviewing in detail.

Benefits of Restoring the Public-Private Enforcement Model

The public-private litigation model has historically proved to be an indispensable weapon in the
attack against subtle and complex racial discrimination .55 However, one seminal case in Title VI jurisprudence provides
a particularly vivid illustration of the importance and necessity of both public and private enforcement under this statute. In United States v.
Fordice (1992),56 the United States sued the governor of Mississippi, alleging that the state’s failure to dismantle its racially segregated public
university system violated Title VI and the Fourteenth Amendment. However, the United States only entered the lawsuit on a Motion to
Intervene filed after black private citizens had initiated a class action lawsuit alleging violation of the Fifth, Ninth, Thirteenth, and Fourteenth
Amendments, the civil rights statutes codified at 42 U.S.C. §§ 1981 and 1983, and Title VI. A
close look at the tortured procedural
history of that case reveals the importance of the public-private litigation model in prosecuting complex
civil rights cases.
Initially, the Department of Health, Education, and Welfare (HEW)57 filed suit against Mississippi in 1969, after its Title VI investigation had
revealed persistent and pervasive segregation and after its administrative efforts to develop a satisfactory compliance plan had failed. HEW
refused to continue to fund Mississippi’s segregated school system under Title VI and then wrestled with a recalcitrant Mississippi Board of
Trustees of State Institutions of Higher Learning over an eighteen-year period while the board repeatedly resisted desegregation. This bears
repeating: The administrative process to integrate Mississippi schools lasted over eighteen years. For nearly two decades, the board submitted
complicated but ineffective compliance agendas identifying missions, faculty hiring plans, intricate admissions targets, and elaborate changes in
their degree programs. At one point, the board defiantly implemented a compliance program that had been twice rejected, despite HEW’s prior
objections to the plan. Yet, according to the Fordice court’s description, by the mid-1980s, 99 percent of Mississippi’s white students were still
enrolled in the state’s five white colleges, and 71 percent of the state’s black students still attended one of the state’s three segregated black
institutions.58

Ultimately, the Fordice plaintiffs successfully challenged the State of Mississippi for failing to desegregate its state university system nearly forty
years after Brown v. Board of Education . When Justice White wrote for the Fordice court, his decision, on the one hand, awarded the black
citizens of Mississippi the integrationist goals they had fought to obtain through over twenty years of litigation. Justice White wrote, “To the
extent that the State has not met its affirmative obligation to dismantle its prior dual system it shall be adjudged in violation of the Constitution
and Title VI.”59 Reaching this decision took the combined effort of public and private litigators, and there can be no doubt that the
desegregation objectives would not have been possible without the work of private black litigants pursing disparate impact claims directly to
enforce Title VI. However, on the other hand, the legacy of the Fordice case remains deeply controversial and stands as an example of nuances
of social change that litigation alone cannot achieve.60 The court failed to equalize funding for Mississippi’s historically black universities, and
the litigation itself took years. Yet the case demonstrates that, to
the extent that civil rights litigation successfully signals
a change in social norms and incentivizes publicly funded actors to change, public and private action
to enforce well-crafted civil rights law remains an important and necessary tool for achieving social
justice and equality in America.

This means the aff induces a radical sea change in health care delivery to ensure high-
quality care and prohibit discriminatory practices
Matthew 15 – Dayna Bowen Matthew, William L. Matheson and Robert M. Morgenthau Distinguished Professor of Law at UVA School
of Law, F. Palmer Weber Research Professor of Civil Liberties and Human Rights, previously served on the University of Colorado law faculty as a
professor, vice dean and associate dean of academic affairs, J.D. from the University of Virginia (Just Medicine: A Cure for Racial Inequality in
American Health Care, “A New Normal,” New York University Press, pages 216-219)

Under a reformed Title VI, the entire record of social science knowledge will become relevant to informing changes in health care delivery by
federally funded providers. A hypothetical plaintiff’s claim will demonstrate how the revised law could be the catalyst for these institutional
reforms. Under the new law, a plaintiff may contend that a provider’s patient selection criteria , record-
keeping practices , or failure to provide translation services systematically and disparately burdens
minority patients in violation of Title VI. As part of her prima facie disparate impact case, the plaintiff in this hypothetical case may
rely upon authoritative social science data to evince the association between the allegedly
discriminatory practices and health outcomes for affected minority groups. This plaintiff will act as a private
attorney general—an individual bringing a case to remedy a public harm, in her capacity as a private citizen—and call upon evidence from the
implicit bias studies described in chapter 2 or the health disparities literature summarized in chapters 3, 4, and 5 to support allegations against
the defendant health care provider. The objectives of raising such claims are fourfold. First, the
plaintiff seeks to recover
individual damages, and second the plaintiff may seek injunctive relief to stop the defendant’s discriminatory
practices from harming future patients. Third, this lawsuit would signal to other providers who wish to
avoid liability that they too must stop discriminating . Fourth, the plaintiff’s lawsuit will incentivize
health care providers to enact ex-ante changes in their medical care delivery systems to address
unconscious bias before litigation . As courts incorporate the evidence-based interventions into the negligence litigation model as
defenses, the law will credit those providers who make anti-bias changes in their programs and practices, and will broadly signal

the value of the reasonable efforts an institution may take to mitigate exposure to being sued for
permitting unconscious racism to flourish.
Continuing this hypothetical case, the defendant provider would be able (and encouraged) to raise new defenses to the Title VI allegations by
showing that the provider organization had implemented all reasonable interventions scientifically shown to combat discrimination due to
implicit bias. Courts may examine the defendant’s policies at each juncture of the health delivery process that the Biased Care Model identifies
is relevant to the plaintiff’s hypothetical claim. The effectiveness of these defenses will turn on the scientific record. In other words, to the
extent that a defendant is able to show that reasonable steps were taken to implement the interventions supported by the malleability
literature presented in chapter 7, that defendant would have satisfied the standard of care required of reasonable and similarly situated health
care providers. As
the social science evidence evolves to develop better interventions to alleviate bias-
driven discrimination, the standard of reasonable care will also evolve . To use Tristin Green’s parlance again, by
reforming Title VI as I propose, we can expect health providers to adopt best practices identified by social scientists,
because we have framed the law to embed social science as a social and legal authority.67

A defendant under a reformed Title VI could identify these evidence-based best practices as part of a defense
that would replace the generalized assertion that has guided the burden-shifting analysis in disparate
impact cases historically. In an evidence-based approach to disparate impact under a reformed Title VI, the plaintiff would bear the
initial burden of showing that the defendant health care organization had a facially neutral practice that resulted in a racially disparate impact
on minorities. Then, the defendant health provider could respond by showing that it had acted reasonably to reduce health disparities by taking
steps that have been empirically demonstrated to reduce implicit bias. A showing that matches the scientific evidence would replace the vague
and self-serving representations that the defendant provider had a “legitimate nondiscriminatory reason” or a “substantial, legitimate
justification” for its policy. Instead, challenged practices must be reasonable in light of the scientific evidence in order to pass muster. If the
defendant provider discharges the burden to show evidence-based reasonableness, then the burden would return to the plaintiff, who could
prevail in a disparate impact case only by showing that the defendant health provider’s actions were unreasonable based on the social science
evidence of what steps mitigate implicit bias-driven disparities, as well as on what other similarly situated organizations have done.

This new addition to the Title VI burden-shifting regime would be evidence-based and reflect the
prevailing standard of care in light of available scientific knowledge. Examples of effective defenses may include
evidence the defendant provided stereotype-negation training for physicians, made doctors aware of their personal implicit bias scores using an
IAT (or other scientifically valid, personalized instrument), and educated providers concerning the demonstrated impact their biases are likely
to have on health care delivery. These defenses would be based on evidence that increasing awareness of biasing potential may evoke
selfcorrection.68 Stereotype-negation training should specifically address each of the Biased Care Model’s six mechanisms, which describe the
pathways through which implicit bias travels to affect health disparities; it should also include training specifically directed toward exposure to
counter-stereotypes based on the evidence that this type of training weakens racial, ethnic, and gender stereotypes.69

The defendant provider could show it took reasonable steps to promote workforce diversity through programs to hire, promote, and retain
physicians from racial and ethnic minority backgrounds in positions of leadership and authority. This defense would be based upon the
evidence that fewer negative stereotypes operate following interactions with minority physicians and others in authority.70 Alternatively, were
the defendant provider to base its defense on evidence that implicit biases are related to high cognitive load, another intervention that would
demonstrate reasonableness may be related to efforts to reduce workloads placed on health care providers. A defendant may show that
implicit biases have been addressed by clinical scheduling changes, employing the well-documented evidence that physicians will reduce their
dependence on negative stereotypes when they are able to spend adequate time to focus and learn about the attributes of the individual
patient with whom they are interacting.71 These are examples of actions that could form the basis of a sea
change in the way that physicians, hospitals, clinics, and indeed all federally funded actors address
unconscious racism . The contours of changes in delivery, as well as legal actions and defenses, will take shape
based on evolving scientific evidence.

Robust social psychology evidence confirms that implicit biases are malleable and
open to interventions – changes in social norms and political transformations like the
aff can intervene in and prevent the formation of implicit biases.
Matthew 15 – Dayna Bowen Matthew, William L. Matheson and Robert M. Morgenthau Distinguished Professor of Law at UVA School
of Law, F. Palmer Weber Research Professor of Civil Liberties and Human Rights, previously served on the University of Colorado law faculty as a
professor, vice dean and associate dean of academic affairs, J.D. from the University of Virginia (Just Medicine: A Cure for Racial Inequality in
American Health Care, “From Inequity to Intervention,” New York University Press, pages 155-158)

Evidence that Implicit Biases Are Malleable

Social scientists have developed a body of empirical evidence that shows implicit biases are malleable
over the past quarter century.2 The empirical record is now well established and offers strong evidence that
implicit attitudes are neither inaccessible nor inescapable ; they are not impossible to control ; they are not
out of reach. In fact, implicit associations can be influenced both by the individual who unconsciously holds
these stereotypes and prejudices and by external factors . Researchers have reported and reviewed numerous studies3
that put two important misconceptions about implicit biases to rest. First, the evidence demonstrates that unconscious
implicit attitudes are responsive to the deliberate choices and influences of an individual even though
that person is not consciously experiencing the bias. Second, implicit biases are not impervious to relatively short-term
change even though they arise from social knowledge that was acquired slowly, and over a lifetime. In fact, the evidence reveals that
learning can continue to take place and alter social group knowledge , after initial attitudes and associations are
formed. Take, for example, a person who developed bad driving habits over time and subconsciously incorporated those habits into driving
behavior for many years. If this person chooses to be mindful of improving his or her driving, either out of a conscious decision to do so or in
response to external influences, those bad habits can be altered. External authorities may incentivize improvement through a media campaign,
new rules of the road, prosecution for reckless driving, or a driver’s education class. Thus, malleability
describes an ongoing
learning process in which people with old, objectionable implicit biases learn to respond to newer,
more appropriate attitudes and beliefs. Put another way, longstanding and unconscious thinking can
change.

This understanding of malleability is called the “connectionist” model of implicit bias. Unlike
the prior notion that implicit
associations are static and inaccessibly fixed, the empirical record reveals that stereotypes and
prejudicial beliefs to which we may adhere at any given time are “states” of thinking that form based on past
experiences and current inputs. Biases can be revised depending upon current informational inputs gathered

and weighed with each new encounter. This flexible view of stereotyping replaces an outdated rigid
one and allows for the evidence that individuals can constantly update the stored group knowledge that produces implicit biases.

The connectionist model explains that a stereotype is merely a pattern of activation that, at a given point in time, is jointly determined by
current input (i.e., the context) and the weight of the new information’s connection to existing and underlying beliefs.4 Psychologists now
conclude that “stereotypes are quite elastic and thus any individual could hold and even change an infinite
number of representations of social category’s members, when viewed across time and place .”5 The
connectionist model contrasts with early theories of implicit bias , which focused on their automaticity. “Automaticity”
refers generally to the way that individuals make associations without any awareness, without intentionality, and without responsibility for the
influence the associations have in directing their conduct and choices.6 Early researchers concluded that automaticity
meant inevitability . For example, one researcher said, “a crucial component of automatic processes is their inescapability; they occur
This view is no longer correct . Over the past twenty years,
despite deliberate attempts to bypass or ignore them.”7

researchers have collected a strong record to contradict this notion that implicit attitudes change
slowly, if at all, simply because they develop slowly over time. This idea has been replaced by what Dr. Irene Blair has
called “the now-bountiful evidence that automatic attitudes—like self-reported attitudes—are sensitive to personal, social, and situational
pressures.”8 Blair points out that “the
conclusion that automatic stereotypes and prejudice are not as inflexible
as previously assumed is strengthened by the number and variety of demonstrations . . . . The fact that the
tests were conducted in the service of many different goals, and by the similarity of findings across different measures.”9

The importance of understanding that implicit biases are malleable cannot be overstated. First, malleability
means that
interventions may be strategically introduced to provide current inputs that alter implicit biases . Thus,
we can expect that implicit biases can be reduced . To say that biased attitudes may be “reduced” is to say that current
informational inputs can be adjusted so that the resulting stereotype patterns no longer conform to traditional, discriminatory, or inequitable
stereotypes, but instead lead individuals and institutions to more equitable judgments and more equitable conduct. Furthermore,
malleability also means that the discriminatory impacts that result from implicit biases also may be
reduced. The research that gave rise to the connectionist model has provided important insights concerning the several methods available
to individuals and institutions wishing to ameliorate the discriminatory impact of decisions and conduct informed by implicit biases,
stereotyping, and prejudice. Finally, by
demonstrating that even subconscious racial biases are within reach and
control, researchers have provided a sound basis for holding individuals and institutions responsible
for reducing implicit racial and ethnic biases and for reducing the discriminatory harms caused by
unconscious racism.

Appeals for universal health care are a critical precondition for the politics of
transforming the world – analyzing and challenging the state is necessary for
establishing a better health care system
McGee ‘9 (Patrick, McElveen Professor of English at Louisiana State University, Theory and the Common from Marx to Badiou, pp. 161-
200)

In Logics, Badiou develops the notion of resurrection by which the truth of an event resurges in a new context, a new world, through the
incitement of a new event.133 In my own history, the names of these events would include Wittgenstein, Marx, Nietzsche, Wilde, Lawrence,
Derrida, Lacan, Gramsci, Bourdieu, and Badiou (more or less in that order), though this would be to limit the events of my intellectual history
through which the subject of a truth has been resurrected and kept alive. Furthermore, this
generic truth that unbinds me from
the categories of everyday social existence creates the condition for a universal address that
recognizes the one thing that all human beings have in common, the foundation of their existence on
the void of infinite possibilities, however different the import and significance of the events that force human
beings into the subjective formation of a truth. For example, the Holocaust survivor, the victim of torture
in Iraq, the political prisoner, the innocent and probably the guilty at Guantanamo, the terrorists and those who survive
their terror, the cancer patient whose insurance won’t cover a treatment, the bulimic who has to lie in
order to get health care, the raped woman and possibly the rapist, not only the victims of child abuse but the perpetrators who were
themselves abused, the displaced and exiled, and all the usual suspects that would include the poor, the exploited, the homeless, and so forth
— such people are not merely victims or perpetrators but potential subjects of truth , even though the
truth they bear is usually prescribed to inexistence by the hegemonic state of the situation that names
them. Even they themselves usually evade the truth by accepting the categorical judgments of the

State. It is always easier and more negotiable to be a victim or a perpetrator than to insist on the
methodical exposition of the truth that has derived from the event, however negative, that transformed a person into a subject.
I don’t mean to say that all these experiences are the same or of equal value in the world as it currently exists. Still, there is no reason to wait
for an apocalyptic event that would guarantee the universal disclosure of the truth. The events that make truth possible by forcing the
inexistent into existence are everywhere, and the only true universal is the subtractive power of the void that has the creative-destructive
power to force a change of base, a change of the transcendental ordinary.134

In the earlier chapters of this book, I exposed myself to the accusation of resentment and tried to challenge or interrogate its truth. My
argument was not that I am a man without resentment, since if we have learned anything since Nietzsche, who in his last works proved himself
to be everything he criticized, we have learned that there is no resistance or critical ground for challenge to any
situation without resentment. However, the larger point and purpose of this essay is to suggest that the truth of
an event will not persist at the level of mere resentment. The truth of an event is precisely what
constitutes the subject as the power to overcome resentment in the struggle to transform the world
itself , which is always one of an infinite number of possible worlds. Ironically, because the truth is infinite, there can never be of the
inconsistent multiple that is being in itself and the variation of its worldly unfolding in appearance.135 Marx’s class struggle, Nietzsche’s self-
overcoming, Wilde’s perversity and paradox, Lawrence’s sexual folklore, Gramsci’s counterhegemony, Wittgenstein’s curve, Lacan’s ellipsis,
Derrida’s deconstruction, Bourdieu’s reflexive sociology, and Badiou’s metapolitics—these are all the names of truth procedures that aim at the
transformation of the transcendental ordinary. No doubt, in the lives of all these thinkers, there were events that incited them to the
procedures that laid out the consequences of a truth. Sometimes these may have been great historical events, and at other times events that
would have gone unnoticed had not a truth impressed itself on a particular person. It seems naïve to claim that any truth procedure necessarily
invalidates the possibility of another. In my own case, if my mother had not gone mad, I might have found a truth in some other way. But it was
my mother’s madness that forced me into the process of interrogating the values of my society and world. It gave me the means to understand
my father and the working class with which he would always be associated in my mind. It taught me that all human beings are more than their
material conditions, and that whatever their condition in a particular world they are all capable of the thought that allows them to transform
themselves as well as their world. It taught me that the only property common to all human beings is the singularity of the truth that says, We
are nothing, so let us be everything.

E P I L O G U E NOT A MANIFESTO

A manifesto is what we need, but this is not it. Such a writing, like Marx’s famous manifesto, is an event in itself, something that decides an
undecidable and forces the emergence of a truth. Nonetheless, it seems to me that it is cowardly not to risk a few postulations about what such
a manifesto might contain. This is risky because it anticipates the alteration of a world without identifying the event that would occasion it.
Furthermore, the more specific you are about the political program that confronts the current state of
the situation, which also means the State, the more likely you are to say something that will seem
ridiculous to the vast majority who currently cannot imagine any other world. Even Marx had to take this risk
at the end of section two of his great manifesto when he listed ten practical measures that the victorious proletariat would need to implement
after it had won the battle for democracy and centralized production in the State.1

Today, in light of the failures of actually existing socialist states, it is difficult not to see this moment as Marx’s most critical error, but an error
that arose precisely from the universality of his address and the attempt to traverse the field of common sense with a transformative truth.
Badiou has argued for a radical principle of democracy that operates by keeping itself at a distance
from the State and by affirming the truth of a collective freedom that subtracts itself from the common sense and consensus that the
State enforces.2 Nonetheless, he does not argue for withdrawal to some kind of utopia beyond the control of the

State but rather for a political organization that struggles based on axiomatic principles, or prescriptions,
to force the State into rewriting its norms, regulations, and policies. 3 He valorizes democracy only as far as it is
something distinct from the State, something that is bound to the universality of a political prescription.4 In effect, democracy is not the
rule of the majority through the mediation of the State. It is the struggle to transform a specific situation through the
implementation of a political prescription that is universally addressed. Even a minority—indeed even a single
individual—can formulate a universal political prescription that derives from a truth procedure. In this epilogue, I will try to elucidate a few
political prescriptions that have a universal address but do not overshoot the field of common sense. One can easily formulate more
ostentatiously radical principles; but the ones I’ve formulated here, in my judgment, have the power to force a
transition that can produce radical effects in the political field of the United States. Since the United
States is the last superpower, transformation of its political field inevitably has global impact.
Despite their political differences, both Badiou and Negri have argued for the necessity of going beyond class politics in the traditional Marxist sense of the term.5 I will not enter into the details of their differences, except to say
that they seem to me far from insurmountable once you get outside the field of academic disputation. For the purposes of what I want to say here, however, I will accept Negri’s concept of the multitude, which consists of all those
who are dominated by capitalist social relations and resist its rule.6 As far as I’m concerned, that means anybody—even the rich—who can be won to the support of a political prescription that is universally addressed. The more
serious and problematic question that derives from the notion of politics at a distance from the State, however, has to do with violence. Peter Hallward has argued, in a tentative way, that a true break from the State and its
monopoly of violence is not to practice another form of violence but rather to commit oneself to an organized form of nonviolence.7 This strikes me as a very bold statement, but Hallward does not draw out its full implications.

First, nonviolent struggle in the name of a political prescription that derives from a truth procedure makes sense because if a truth becomes the rationale for violence against another who refuses to accept it, then the truth has
effectively betrayed itself by subverting the universality of its address and insisting on a distinction between the elect who can see and the preterites who are blind. The State, after all, operates through a hegemony that dominates
common sense, so that it is never simply the bureaucracy, the police, and the military that one opposes but the population that tacitly consents to the legitimacy of their authority. Second, nonviolent political struggle can be
effective only when there is a willingness on the part of the militant to risk the possibility of injury or death without violent resistance. Personally, I don’t see any point to revolutionary suicide, so there has to be a principle of
tactical retreat in a situation that can produce no positive result; and since nonviolence, as I understand it, is not a religious principle but a political axiom, I see no reason why people shouldn’t engage in defensive violence when
they are confronted with a violent State that has foregone any universal address or justice. Of course, it is notoriously easy to justify aggressive violence as defensive, witness George W. Bush on one side and those who promote
suicide bombing as a political tactic on the other. My point is simply that a truly effective act of nonviolent struggle will not always be able to predict the response of power. The more effective the political act is, the greater the risk
of brutal response from the State. Third and finally, the organization of a nonviolent struggle can never be fully identical with a political mass movement, for once it has reached the level of a mass movement the discipline required
to engage in active nonviolence is severely limited. Things could go peacefully in the unlikely event that the State accepts the need for change, or they could erupt into a revolutionary event that would no longer limit itself to
disciplined nonviolent political action. The organization of nonviolent militants could put pressure on the mass movement as well as on the State, but it should never presuppose the identity of the mass movement with itself. This
simply means that nonviolence as a political prescription addresses the masses with its truth but betrays that truth if it tries to substitute itself for the political goal of the masses. It produces a simulacrum of itself that substitutes
the means for the end of social liberation.

Nonviolent struggle is consistent with political goals that have a universal address. There’s no way to struggle
nonviolently for a U.S. way of life that depends on that population’s disproportionate consumption of energy vis-à-vis the rest of the world, but
it is possible to struggle nonviolently for national and global health care. One can postulate as
axiomatic that medicine and quality health care belong to everyone. This is not a right based on some
appeal to transcendent authority, but a prescription whose address is unequivocally universal. Furthermore,
one can argue that the wealth of the world belongs to everyone. This goes beyond the narrow principle that wealth is the product of labor and should be redistributed fairly among its producers. Even Marx recognized that capital
was the product of a social activity that included everyone in society, and since his time it has become increasingly apparent that the production of capital requires unemployment, underemployment, and alternative sources of
cheap labor in order to control the demand for higher wages and to subordinate labor as a whole to the interests of capital.8 Furthermore, in the manifesto that represented Marx’s most sustained attempt to transform the
common sense of his world, he said that the proletarian movement was the autonomous movement of the majority.9 Since the industrial proletariat was nothing like a majority of the population at the time that Marx was writing,
it follows that he understood by that term, at least on some occasions, something like what Negri means by the multitude. Therefore, it follows that those of us in the United States who seek the universal address of justice should
struggle for a living wage that would replace what is currently called the minimum wage and, furthermore, for the institutional organizations that would allow the masses to determine the true definition of the economic standard
of living, which would be a social standard and not mere subsistence. The goal would be to guarantee as high a quality of life as is consistent with our collective resources and wealth. Such a wage should apply to everyone in the
country who works, including immigrants, whether they are legal or illegal. Furthermore, the definition of work itself must be socially determined, so that it no longer means labor that produces wealth for another but any creative
activity that is consistent with the well-being of the multitude. Inevitably, people would want to come to this country for a wage that would guarantee a high quality of life, and if the axiom that wealth belongs to everyone derives
from a truth, then it should also be true that national borders are not the natural divisions of wealth or labor. Though the ultimate address of such an axiom must be the globe, one can begin, as a matter of practice, with the
demand for a North American Union of States that would work toward equalization of wages, health care, and education.

These propositions surely sound ridiculous to those who believe that there is only one world and that
any change is a monstrosity or a form of terror. I doubt that I am the best person formulate a political program, but you
have to begin somewhere. Though it would be the betrayal of any truth to limit its address to
something purely local, it seems to me more of a betrayal never to begin a truth procedure or a
political sequence with the argument that unless you can immediately embrace the whole world with
your truth, you shouldn’t embrace anyone or do anything. Every beginning is necessarily local, and one has
to struggle within the framework of a political sequence to keep its address universal by formulating
prescriptions that genuinely can and should apply to all people. I don’t see anything to be gained
from accepting a local injustice because universal justice cannot be achieved immediately. For me, the local
situation is the field in which I work. Though it is a myth that nearly all professors are liberals or even Marxists, it is true that there is a significant cadre of political intellectuals who at least claim some connection with progressive
thought and who have repeatedly associated themselves with the demand for social change. These cadres need to organize; and, furthermore, they need to create some organizational structures that can be inclusive of as broad a
range of teachers, intellectuals, scholars, and artists as possible. Though I believe that a small organization of intellectuals committed to a nonviolent political struggle for some of the goals that I have already suggested would be an
important development, I also believe that one of the goals of such a movement from within the community of intellectuals and teachers should be the unionization of the national professoriate in affiliation with other teachers’
unions. Though this sort of proposal is often labeled by traditional Marxists as reformism, it seems to me that the very concept of a profession that organizes itself in order to achieve political and economic goals is democratic in
the sense that it postulates the relation of equality as the condition of its own movement or organization of people for the immediate transformation of a situation or world. Though there are numerous ways in which unions can be
corrupted by the State, that is no reason to block such an organization that could become a new field of struggle for other truth procedures and their axioms. Unions in their current form are not effective political organizations
because of their centralization. In this way, they imitate the structure of the State and subordinate the interests of their constituencies to the goals of State power. Radical unionization, whether it takes place inside or outside
traditional organizations, should aim to transform this situation by decentralizing organizational structures and enhancing the autonomy of constituencies.

For example, if there were a national union of professors, this would be a field in which one could struggle for a transformative understanding of education and scholarship that could include axioms such as the following: 1.
Knowledge belongs to everyone, and everyone should have access to as much knowledge as they desire and are capable of. Therefore, education should be equitable and free. 2. Knowledge is not static and constantly undergoes
transformation through its encounter with truth procedures or thought. Therefore, all teachers, at every level of education, need time for research and thought; and since truth operates outside the norms, common sense, and self-
evident knowledge propagated by the State, time for research and thought should be liberal, unaccountable, and equitable. 3. In line with the previous axiom, the goal of education should not be static knowledge but truth that
critically addresses the current state of knowledge. Therefore, achievement should be assessed not by objective measurements that normalize knowledge outside the field of truth but by the actual consequences of the educational
process. If individuals seem to achieve nothing, then one should look at the broader social context, and not exclusively at the educational institutions themselves. 4. Since intellectual work cannot be performed in isolation from
other forms of work, an organization of intellectuals and teachers should address the situation of all those workers who make intellectual work possible. They should facilitate the organization of all workers, the multitude, in order
to maintain both the local autonomy of organizational structures and the global unity of the multitude through the affiliation of organizations. 5. Since all people are intellectuals, as Gramsci stressed, a national union of professors
should facilitate constant dialogue and intellectual exchange between people from different social locations and areas of work. 6. A national union, though its structure ought to be decentralized, should still seek affiliations and
cooperative relations across national borders in the effort to propagate axioms of education, scholarship, aesthetic production, and political organization that are universally addressed. If something is good for us, it should be good
for everyone. If it is not good for everyone, or if the universal realization of a principle is considered to be bad for us, then either the axiom itself is flawed or the truth has been betrayed.

I realize how outlandish these proposals will sound to the bureaucratic mind, including the minds of knowledge bureaucrats. Perhaps they are even more outlandish to the political radical who sees anything short of total revolution
as temporizing. Furthermore, the astute reader is likely to see a contradiction in the idea of a national union of professors. Why limit it to professors? Why not include everyone involved in the teaching profession under one
umbrella, including teachers at all levels of education, as well as janitors, cooks, secretaries, and all the other employees of the universities and schools? I’ve heard this argument many times over the years, and it usually turns out
to be a rationalization for not organizing rather than the opposite. The goal ultimately should be ―one big union,‖ as the Wobblies used to say, but not a centralized union, which lends itself much more easily to corruption and
cooptation by the State. A decentralized organization of the multitude means that every organizational division is autonomous, though the different locals and unions can affiliate and work toward common projects that are related
to the universal axioms that derive from their own local struggles. Such decentralized autonomy is necessary because a political truth must traverse the field of common sense, and it would be naive to ignore the self-interest of
different groups promoted by the current division of labor. Self-interest is the common sense that truth traverses and attempts to transform. There is no guarantee that any organization of those who work within a given field will
not betray itself, or the truth that founded it. When a group formulates a demand for equality, such as the demand of women for equal wages or the demand of African-Americans for equal access to education, they are positing
their own generic humanity beyond racial, gender, class or other social divisions. To limit the address of their demand would be to undermine the principle of generic humanity on which the demand was based. Though interest
must be engaged in the organization of women or other groups to resist exploitation, it is ultimately engaged only to be transformed by the universal address of its generic truth. Two great examples of this thought in U.S. history
can be found in the political truth procedures of Martin Luther King and Malcolm X. Though these leaders were quite different in their political techniques and commitments, they both gradually came to the position that specific
group interests, which they had struggled to organize in different ways, must be transcended, without the surrender of autonomy, in the direction of a universal address to generic humanity. To put it rather simply, the demand for
a concrete form of freedom constitutes a truth only if it is addressed universally. As Badiou stresses, equality is not the goal but the axiom of a political struggle.10

The question still remains about what to do with the State. Neither Badiou nor Negri nor any of the hard theorists of
the State seem to be able to imagine a world beyond it. Soft theorists, like Wilde and Lawrence, postulate the concept of the State as a glorified
housekeeper, and while I frankly admit that such a view appeals to me, one can hardly imagine that any concentration of power in a managerial
body or institution will not inevitably lend itself to corruption from the perspective of true democracy. Expediency
and self-interest
will always enter into the procedures of management and politicize them. If true democracy is the
struggle of people for political prescriptions that are universally addressed, then there will always be a
tension if not contradiction between democracy and the State, which means that the only form of
social revolution worth considering must be a permanent revolution that takes the State, as long as it is impossible to
live without it, as a necessary compromise that must be subjected to constant challenge and revision. The
State should never be confused with democracy in itself. Though voting may be a necessary tool for reaching collective decisions and
compromises, the U.S. system powerfully demonstrates the ease with which a plutocratic order that controls mass media can dominate
democratic procedures when they are seen as nothing more than the right to vote. Furthermore, though I can’t embrace Badiou’s argument
that political militants should not vote, stand for office, or affiliate with political parties, there must never be confusion between democracy as a
political sequence and representation through electoral politics.11 Democracy lies in the content of the political prescription and not in the
procedure through which it is implemented or defeated. It seems to me that voting and some intervention in electoral politics can be a tactic
within the political sequence of democracy, but only if it is seen not as an end in itself but as an element within a larger strategy that recognizes
the State as a form of inertia that must be galvanized by the force of true democracy that exists outside of it and its procedures.

The history of Medicare supports our thesis – federal reimbursement and regulatory
control brings the delivery of care into the public arena, forcing transformative shifts
in equitable provision of health care.
Quadagno 2000 Jill Quadagno, Pepper Institute on Aging and Public Policy, 224 Pepper Center, Florida State University “Promoting
Civil Rights through the Welfare State: How Medicare Integrated Southern Hospitals” SOCIAL PROBLEMS, Vol. 47, No. 1,pages 68-89.

The welfare state can transform patterns of class stratification by buffering workers from the insecurity of the market and thus, empowering
them to challenge employers over wages and conditions of work. The welfare state can also reconstruct gender relations by providing women
with a livelihood that allows them to establish an autonomous household and by offering social services that increase their access to paid work.
This case study of hospital inte- gration suggests that, under certain conditions, the
welfare state can also reconstruct race
relations by intervening in the social institutions that produce and sustain racial inequality . What are those
conditions? The evidence indicates that the following four conditions are required. First, racial minorities must garner sufficient political
resources to challenge institutionalized patterns of racial discrimination. Since racial minorities cannot, by definition, mobilize voting power
through their numerical superiority, they must rely on other forms of political influence that are more transient and episodic. Second, the
institutions that maintain the racial order must be incorporated into the public sphere so that they
can be subject to the regulatory authority of the state . The redefinition of the public sphere is thus an
inherently political act whose effectiveness in reducing inequality will vary according to its scope. Third, the funds and
regulatory apparatus of the welfare state must be directed toward the objective of promoting racial
equality . This objective cannot be achieved by simply providing benefits to individuals, but must also
involve institutional change. Fourth, the benefits provided through the welfare state must be
continuous and universal. If the benefits are not enduring, and if they allow some institutions to
"escape" from coverage, then they will promote tokenism and noncompliance . During the 1960s, the
welfare state had an impact that varied across institutional spheres depending on how fully these
conditions were met. Civil rights advocates sought to expand equality of opportunity in employment and to end racial discrimination in
housing. The law supported these objectives and the welfare state provided funds for job training and housing that might have provided the
leverage to implement them. However, these funds were tar- geted to specific projects or programs and limited in their reach to those few
arenas that were incorporated into the public sphere. Most
employers, contractors, and homeowners did not receive
federal funds. As a result, federal officials were only minimally successful in integrating the labor
market and the housing market because jobs and neighborhoods remained in the "private" sphere,
outside the regulatory jurisdiction of the state. In the health care system, by contrast, civil rights
advocates mobilized their limited political resources to end racial inequality in access to health care. They litigated to transform
the definition of hospitals from private to public institutions ; they also engaged in demonstrations and lobbying to alter
public opinion and pressure state bureaucrats to promote compliance with civil rights objectives. These efforts only succeeded,

however, because they coincided with the implementation of Medicare, a universal program of
health insurance for the aged that not only provided benefits to individuals, but also to institutions. Medicare funds proved to
be a powerful mechanism to undermine resistance and promote compliance with equal opportunity
initiatives because funds were payable to all hospitals and the flow of dollars was continuous .

The aff is a valuable instance of scholarship of consequence – knowledge generation

based on analysis and presentation of constructive strategies is necessary to challenge
oppression, especially in the context of health disparities
Galea 18 – Sandro Galea, Professor of Public Health at Boston University (Healthier: Fifty thoughts on the foundations of public health,
(date is correct), pages 116-7)

How should we in academic public health engage with the issue of racism , at both interpersonal and structural
levels? How might we best mitigate its effects? I suggest four possible approaches. First, we must tackle racism at the
community level. In this capacity, some of us may choose to express solidarity with affected groups,
participating in public shows of support. Such actions ensure that the issue of racism moves to the
forefront of the public debate and stays there. Indeed, peaceful public statements of concern about a
pressing social issue always have a place in an open society , and our responsibility to make these statements is not in
any way inconsistent with our role as members of an academic community. Given that we are members of this community, my second
suggestion relates to how our scholarship may pave the way for progress on this issue. The work of knowledge generation can
help inform acute social needs , developing constructive strategies to help solve the urgent problems
of our time—problems such as racism . This nudges us toward a scholarship of consequence, where
we aim to shed light on the root causes of racial divides and the link between racism and the health
of the public . To do this, we must prioritize our research questions accordingly . By focusing on what
matters most, and orienting our scholarship toward areas of inquiry that tackle the foundational
drivers of population health, we stand to make a real difference in creating a fairer, less racially
fraught society. Third, we are charged at our various institutions with fostering an education environment that both teaches the
foundations of our field and prepares students to engage with evolving issues of contemporary public health importance. That calls for an
education that is dynamic and reflexive, but also one that is encouraging and respectful of the sharing of ideas. Such an academic climate does
much to advance the goals of engendering mutual understanding and identifying solutions grounded in diversity of experience, opinion, and
perspective. It is not enough to merely acknowledge disparities; we need to engage in difficult, sometimes uncomfortable discussions about
these issues in order to understand one another and improve the often unacceptable conditions our scholarship makes all too apparent to us.
Finally, insofar as public health centers around shaping the conditions that make people health, and insofar as those conditions depend on the
introduction of health in all sectors, we need to work toward a health conversation that extends well beyond the walls of academia. This
agitates for an engagement with the public conversation around the issue of racism wherever the conversation may arise. Public health’s
unique perspective, informed by its scholarship, is well positioned to influence how we understand
racism and its consequences for the well-being of populations . By clarifying the links between racism
and health by making them unignorable in the public debate, we can then begin to advance solutions .
Needless to say, racism and hate of any kind are intolerable, even when we do not take into account their health consequences. But health,
as a universal aspiration, can serve as a clarifying lens for action, elevating the importance of creating
a society free of racism, where health will no longer be determined by the color of a person’s skin. The
actions of a committed, activist public health will go far toward bringing this about.

Debate should be a site for role experimentation that promotes contesting the
consequences of imagined policy proposals. Our utilization of this space is a good way
to amplify resonant energies to counter the forces, creating planetary destruction.
--in a hyper connected world, we should err toward optimism, engagement, and assuming that discussions and advocacies can spill up – we
never know if the propagation of moments of resonance that can scale up politics

Yee 15. Aubrey Yee, futurist and freelance writer, “The Fragility of Things and Capacities of the Micro-Political Experiment”, Theory & Event
Volume 18, Issue 3, 2015

To escape the crocodile death roll of modernity thus requires the calm serenity of fluid movement paired with the speed of instinct and
reaction. Such instinctual reaction in the face of certain death can only be born of militant and repetitive practice until the reaction is finally,
purely instinctual. Like the surfer who survives a wipe-out on a 100’ wave, the calm that allows your body to go limp and ride out the
excruciating minutes of chaotic tumbling and lack of air can only come from a thoroughly practiced and steady mind. Finding
joy and
purpose in political practice becomes critical to the longevity and intensity of commitment . In words
frequently attributed to him, Gary Sirota explains why he surfs: “There are no more committed people on the planet than surfers. We fall down
a lot. We turn around, paddle back out, and do it over and over again.”9 In this same way, we
must become addicted to the high
of engagement. The accumulation of political role experimentations espoused by Connolly become a path
for amplifying connection and perception and as each experiment makes a small difference , the
natural amplification of effects “may prepare us to participate with others in yet more adventurous
activities ” that counteract the insistent amplification of neoliberal ideological forces .10 In this prescription,
as we learn to surf the ceaseless waves of climate change , species loss , socio-economic inequality ,
refugees , war , surveillance and depression , we find the moments of joy and connection in the
work that keep us coming back , each time more prepared and capable of surfing bigger waves with
confidence. To begin cultivating the necessary qualities, Connolly’s imagination of the ‘micro’ is instrumental .
He argues that, “Capitalism writ large… sets too large and generic a target… The point today is not to wait for a revolution that
overthrows the whole system .”11 To reinforce this hypothesis, Connolly connects his vision of a vigilant micro-political commitment to our daily
entanglement with the microbiota within and all around us, “because human and nonhuman systems regularly infuse and impinge upon one another – both at the
microscopic level within human bodies and at the macroscopic level between disparate systems.”12 We can see this phenomena manifested clearly with the
increasing prevalence of Toxoplasma gondii, an intracellular parasitic protozoan typically found in cat poo and implicated in a whole host of disorders perhaps most
notably and symbolically schizophrenia.13 Or in the way that a newborn child is robbed of their very first protective microbial force field when birthed by caesarean,
a trend reaching upwards of 40 percent in some countries like Chile.14 These and myriad other micro-biological processes remind us daily that “We are not unique;
we are merely distinctive.”15 Embracing that level of humility is crucial as we are forced to evolve rapidly and transformatively in a not-so-distant future filled with
environmental wierding, socio-economic upheavals and chaotic technological advances all underwritten by a neoliberal world order. Humility, in this post-
normal world becomes an invaluable asset, allowing us to productively accept, understand and enhance our positively parasitic partnership
with unseen micro-realities rather than becoming mired in the ego-ic experience of neoliberal individualism. Community
is today
more critical, and in fact more endangered, than it has ever been . The realities that a parasite could induce delusions
of grandeur in the human mind, and that commodification of health has led to children entering the world devoid of their first microbial allies
are significant for our understandings of modern neoliberal politics. “Capitalist modes of acceleration, expansion, and intensification that
heighten the fragility of things today also generate pressures to minoritize the world along multiple dimensions at a more rapid pace that
heretofore.”16 Reversing this neoliberal tendency to loosen beings from their connection to the web of existence is the work of our time.
Rebuilding our ability to sense connection and resonance when it occurs, to hear our na’au when it speaks to us in new languages, these are our
challenges and our calling. Connolly mirrors and re-resonates this value for micro-processes in his evaluation of political will. By
positioning role performance as political experiment , Connolly subtly argues for the microbial infection
and amplification of day-to-day activity, indicating that small deliberate choices can lead to
entrenched behaviors much in the same way that ingestion of the toxoplasma microbe can eventually lead to schizophrenia. He
clearly argues that “role experimentations and the shape of the pluralist assemblage thus infect one

another.”17 To ignore the tacit role performances with which we engage constantly is to then
succumb to the habitual nature of practices that “ condense previous relations of overt power .”18
Instead, we are being asked by the inherent fragility of things to intentionally foster micro-political-
performances that enhance our militant democratic possibilities . Coincidentally these same
performances will likely be the ones that inspire the most joy within us; a joy that creates a space for
us to persist and practice despite a mounting understanding of catastrophe . Whether it is a small group of
scholars gathering to discuss the fragility of things, or a blog one of us writes later to critique neoliberal ideologies, or a smile given to a stranger
in a crowded public space, or a garden, planted in an abandoned city lot to grow food and feed a neighborhood, these microscopic
daily acts of political will reaffirm that “there is no zone of complete neutrality in a world of role
performances” and that there are “significant relays between role performance, self-identity, and the
formation of larger political constellations.”19 In the same way that we are constantly made and re-made by the microbial
biological realities at work within our bodies, our politics are constantly made and re-made by the micro-political

choices and identifications we collectively propagate . And yet, despite this insistence on micro-political performativity,
there is an equally urgent call to reengage with the state as a site of activism. Treading lightly in his
prescriptions, Connolly is nonetheless explicit in his concern for the mounting pressures to discard the state
altogether . Instead, he explains that, “the fragile ecology of late capital requires state interventions of
several sorts . A refusal to participate in the state today cedes too much hegemony to neoliberal
markets .”20 The scale of the challenges we face and their planetary ubiquity require state
intervention as much as they require the resonance of community based micro-politics. We need a
revolution at all scales to reverse the trends that have brought us a world where small island
nations are being swallowed by a rising ocean ; a world where many say the sixth extinction is
already underway ; a world where most Americans have little or no connection to most of their closest neighbors. The severity
and ubiquity of the crisis demands an equal amount of amplification and resonance from the other
side of the pendulum and this will only come if we engage “a multisited politics designed to infuse a
new ethos into the fabric of everyday life.”21 The political economy of late-late capitalism is a moving assemblage – its loose
joints and disparate edges tearing at the fragile fabric of communities in the midst of their struggle to hold a center. And we must become
painfully aware, if we have not already, that in this day and age, the very notion of community and the heterogeneity that deeply place-based
community cultivates is under heated attack from many sides. This is the fate of our neoliberal embrace, for as Connolly suggests,
“neoliberalism is a form of biopolitics that seeks to produce a nation of regular individuals, even as its
proponents often act as if they are merely describing processes that are automatic and individual
behavior that is free.”22 This is perhaps the ultimate deception of the Anthropocene epoch and a
delusion that could very well be our undoing . Participation in this delusion is partially a survival
instinct, “since total immersion in the dangers of the future and the contemporary condition can lead
you to neglect daily duties and needs.”23 These realities coalesce to form an ever-greater argument for
the capacity of micro-processes as change agents . Harnessing the “potential power of these
subterranean flows” will allow us the fortitude to continue persisting in a world entrenched in
neoliberal schizophrenia while simultaneously building the capacity for self-organization and feedback
loops that allow “a self-amplification system to emerge ”, what Connolly calls a “creative resonance machine” – one to
counter and unbalance the machine that is literally consuming the planet and all its natural
resources .24 This resonance machine would have micro-political communities forming in various places around the world which would
then find connections among one another to build ever-greater alliances that en masse have the potential to enact Connolly’s vision of the
militant politics that are necessary to “defeat neoliberalism, to curtail climate change, to reduce inequality, and to instill a vibrant pluralist
spirituality into democratic machines that have lost too much of their vitality.”25 In
the short term at least, it seems that we
still very much need the institutions of the state as final safe guards against the pervasive and
divisive individuality that neoliberalism would have us believe is paramount to freedom. It is then
within this call to role performance as political experiment that I believe Connolly offers us a compelling
way forward. Imagining our daily micro political maneuvers as part of a larger resonance machine
embroiled in the best that a complex universe has to offer is the only way we may find the fortitude to relax
ride the chaos of this massive wave until the set has
our breath, conserve the last bits of oxygen we have left and

passed and we find our way to the sky for a quick and critical breath. Remembering with calm confidence that another
set of waves with equally chaotic power is very likely on its way. At our constant aid is the innate human appreciation
for aesthetic experience. We may want to seriously consider the idea that aesthetics are in fact a basic and physiological form of
communicating ethics between modes of existence such as living/non-living or human/non-human. Joseph Campbell called this ‘the problem of
beauty,’ and in an interview with Bill Moyers he asked, “When a spider makes a beautiful web, the beauty comes out of the spider’s nature. It’s
instinctive beauty. How much of the beauty of our own lives is about the beauty of being alive?”26 Re-instilling our ethical imaginary with this
positioning allows for incorporation of both humility and reverence, two concepts critical to the task of managing our fragility. Cultivating our
sensitivity to the inherent aesthetic communication of non-human beings and things requires specific courage in a world full of apparent
suffering, but I believe that this courage is crucial and we can no longer afford to deny our complicity in the state of things as they are. Where I
disagree with Connolly is primarily in his assessment of thinking about and envisioning the future(s). Arguing for dedication to an ‘interim
agenda,’ Connolly suggests that “in a world of becoming the more distant future is too cloudy to engage.”27 While this may be true on face
value, the cloudiness of the more distant future must not preclude our engagement with it. Instead, at
this point in history it is more crucial than ever to hone our capacity for engaging with uncertainty
and becoming comfortable in the fog. It is through the repeated and consistent practice of
imagining and envisioning preferred and alternative futures that we will polish and strengthen our
capacity for performing militant and productive micro-politics in the present. The future is destined
to be the artifact of those with the most militant imaginings and we cannot afford to forego that
commitment for a focus solely on the interim present . Getting good at experiment is part of this
process. In fact ethical experiment and resilience may be the words best suited to replace the outdated and misused meme of sustainability.
Micropolitical experiment like microbial contagion will shape and reshape our path as we charge
forward into an increasingly chaotic future in a “cosmos of becoming.” 28
2AC Case
 2AC Overview
Low quality and inaccessible health care kills a hundred thousand people each year, including immigrants, poor folks, and people of color.
The plan solves disparities – first, it scraps the two-tiered system that drives poor folks into safety net hospitals. Second, it bans intentional
and unintentional discrimination based on a negligence standard of care – that results in a sea change in how hospitals and doctors
approach racial equality in health care.
 2AC AT Selmi – “Disparate Impact Fails”
All their case defense doesn’t assume the aff’s radical transformation of the legal
standards.
Selmi votes Aff
1. Selmi concludes disparate impact was effective – their card cites the intro, but this
comes later in the article:
Selmi 6 Michael Selmi, Professor of Law, George Washington University Law School, Was the Disparate Impact Theory a Mistake?, 53
UCLA L. Rev. 701 (2006).

By now, it should be clear that the disparate impact theory has produced limited results in the courts and has rarely
been successfully extended beyond the testing context. Yet, as noted in the introduction, this
does not necessarily establish that
the theory was a mistake; rather, it only shows that the theory has been less transformative than many scholars and advo- cates
assume. Equally important, it also substantiates my earlier claim that had the Supreme Court ruled differently in Washington v. Davis, the
results would have been nearly identical, at least in the courts. Scholars recently have suggested that social change can occur even
in the face of significant legal defeats , as the cases can prod employers to make changes and increase
awareness among the public and employers, while providing a tool for personnel departments to alter
employment structures they find problematic. For example, Michael McCann has shown that the comparable
worth movement produced significant change in certain locales despite near unanimous defeat in the
courts, as the legal cases were used to help mobilize effective political action . 99 It is quite possible
that the disparate impact theory had a similar indirect effect on workplace equality ; if so, that effect ought to
be considered when calculating the gains produced by the theory, in this instance, outside of the courts. In addition, there is little

question that the disparate impact theory proved successful in challenges to written tests at least
through the early 1980s, and those successes are also an important legacy of the theory .

2. DA to the Alt. The card supports fighting intentional discrimination. Selmi thinks we
should pursue claims of intentional claims of discrimination in the courts – this is now
a DA to the alt, which prevents those claims from ever being made
Selmi 6 Michael Selmi, Professor of Law, George Washington University Law School, Was the Disparate Impact Theory a Mistake?, 53
UCLA L. Rev. 701 (2006).

In lieu of the disparate impact theory, what was needed was a broad social movement designed to
delineate the many ways in which intentional discrimination – defined so as not to be limited to animus-based
discrimination—continues to influence life choices for so many individuals, particularly minorities and women. Without a
sense that discrimination was pervasive, it was simply too difficult for courts to see discrimination other than in the obvious.
 AT Courts Bad
Each case arg is a test case for the k – it proves the world can get worse and that the
aff’s action disproves their sweeping ontological thesis.
Aff solves implicit bias in the court room – it gets rid of jury-based trials and sets a
floor for penalties. Judges can only make judgements based purely on the observation
of a disparate impact. Any disparity in moribidity or mortality triggeres the statute.
The court rules against racial bias and setting precedent is an effective strategy
Totenberg 17 Nina Totenberg is NPR's award-winning legal affairs correspondent. Her reports air regularly on NPR's critically acclaimed
newsmagazines All Things Considered, Morning Edition, and Weekend Edition.“Supreme Court Allows Prying Into Jury Deliberations If Racism Is
Perceived” http://www.npr.org/2017/03/06/518877248/supreme-court-allows-prying-into-jury-deliberations-if-racism-is-perceived

The U.S. Supreme Court ruled Monday that when clear evidence emerges after a jury verdict that there
was racial bias during deliberations, the trial judge must make an exception to the usual rule
protecting the secrecy of deliberations in order to determine whether the defendant was denied a fair
trial. The vote was 5-to-3.

Writing for the court majority, Justice Anthony Kennedy said that racial discrimination is unlike other types of
misconduct that may occur in the jury room because it "implicates unique historical, constitutional
and institutional concerns."
Tense jury deliberations

The ruling came in the case of Miguel Peña-Rodriguez , a Colorado horse trainer arrested in 2007 after two teenage girls
identified him as the man who groped them in a darkened restroom at a horse barn.

At trial, the prosecution rested its case on the victims' identification of the defendant. The defense highlighted the short time the girls actually
saw the attacker, the suggestibility of the way police brought the girls to see the suspect — through the window of a police cruiser, at the
roadside where the suspect was detained.

The defense also presented an alibi witness ,who testified that Peña-Rodriguez was with him in another barn when the attack occurred. The
alibi witness, like Peña-Rodriguez, was Hispanic.

The jurors initially deadlocked, unable to reach a verdict. The judge told them it was their duty to try again.

After 12 total hours of deliberations — and much shouting that could be heard outside the jury room — the jury found the defendant guilty on
two misdemeanor counts, but failed to reach an agreement on the felony. The state subsequently dismissed the more serious charge.

Peña-Rodriguez was sentenced to two years' probation and was required to register as a sex offender.

On the day the trial ended, two of the jurors told the defense lawyers that during deliberations, one
of the other jurors, identified in court records as H.C., repeatedly had expressed a bias against the
defendant and his alibi witness because of their Hispanic ethnicity .

With the trial judge's permission, the

lawyers then obtained affidavits in which the two jurors quoted H.C. as
saying that, from his experience as an ex-law enforcement officer, he suspected the defendant was
guilty because Mexican men "believe[d] they could do whatever they wanted with women," and that
where he used to patrol, "nine times out of ten Mexican men were guilty of being aggressive toward
women and young girls."
The affidavits also quoted H.C. as saying that the alibi witness wasn't credible because, among other things, he was "an illegal." In fact, the alibi
witness had testified at trial that he was a legal resident of the United States.
After receiving the affidavits, the trial judge ruled that there could be no questioning of jurors to see if a new trial would be justified because
Colorado, like most jurisdictions, has a rule barring inquiry into what happens in the jury room. The Colorado Supreme Court, by a 4-3 vote,
agreed.

Racism "especially pernicious in the administration of justice"

On Monday the U.S. Supreme Court reversed those decisions, declaring that "the central purpose" of
the Fourteenth Amendment guarantee to equal protection of the law was to eliminate racial
discrimination emanating from official sources in the states .

Writing for the five-justice majority, Kennedy

said that even after ratification of the Fourteenth Amendment, it
became clear that racial discrimination in the jury system posed a particular threat, both to the
amendment's promise and to the "integrity of the jury trial."
After the Civil War, he wrote, the South began a practice that would long endure: All-white juries punished black defendants "particularly
harshly, while simultaneously refusing to punish violence by whites, including Ku Klux Klan members, against blacks and Republicans."

Citing one example, Kennedy noted that in the years 1865 and 1866, all-white juries in Texas heard a total of 500 prosecutions of white
defendants for killing African-Americans. In all 500 cases, the white defendants were acquitted.

Since 1880, Kennedy said, the Supreme Court has sought with ever greater intensity to prevent the
exclusion of jurors on the basis of race.

"The unmistakable principle underlying these precedents is that discrimination on the basis of race,
odious in all aspects, is especially pernicious in the administration of justice ," he wrote, adding that
permitting racial prejudice in the jury system damages both the fact and the perception of the jury's
role as a vital check against the wrongful exercise of power by the state .
At the same time, Kennedy conceded, the Supreme Court consistently has refused to allow post-trial probing of jury deliberations — both to
protect the secrecy and candor of deliberations, and to protect the finality of jury judgments.

Indeed, in
the past the court has even refused to allow post-trial probing of jury deliberations in cases
involving evidence that some jurors may have been under the influence of drugs or alcohol while
deciding a case.

It would not be possible, Kennedy said, to rid the jury system of "every irregularity," but " the same
cannot be said about racial bias , a familiar and recurring evil that, if left unaddressed, would risk
systemic injury to the administration of justice."
 2AC AT Matthews
The aff is not vanilla single-payer and it can’t be coopted by white nationalists – it
explicitly broadens civil rights laws to lower the threshold for disparate impact
litigation, forcing all corporations and entities to eliminate disparate impacts and
provides extra funding for black community hospitals – that’s literally the opposite of
what white nationalists like Richard Spencer want.
 AT Courts Link
Legal victories in courts are meaningful and good for movements and mobilization
against racist institutions
Pavone 15 (Tommaso Pavone is a 5 year Ph.D. candidate in the Department of Politics at Princeton University and is a Graduate
th

Associate in the Program in Law and Public Affairs , reviewing Michael McCann 1994 Right at Work literature. McCann is Gordon Hirabayashi
Professor for the Advancement of Citizenship at the University of Washington. Michael served as Chair of the Political Science Department for
five years in the late 1990s and again for a brief stint in 2010-11. He was the leading architect and advocate of the Law, Societies, and Justice
Program as well as the Comparative Law and Society Studies (CLASS) Center at UW starting in the late 1990s; he served as Director of both for a
decade, until 2011. McCann also has been a teacher and leader in the UW LSJ Rome Program in Comparative Legal Studies for a number of
years. McCann’s research focuses on the politics of rights and rights-based struggles for social justice, with an emphasis on challenges to race,
gender, and class hierarchies. “Michael McCann, Rights at Work: Pay Equity Reform and the Politics of Legal Mobilization.” 2015.
https://scholar.princeton.edu/sites/default/files/tpavone/files/mccann-_rights_at_work.pdf)

6 Concluding Remarks 6.1 Against “Neo-realist” Portrayals of Litigation as a “Hollow Hope”. At its core, McCann’s is a
rebuke of Gerald Rosenberg’s skeptical analysis of courts’ ability to provoke social change due to their impotence to
autonomously bring about large-scale, top-down public policy revisions. First, such a “neo-realist approach. . . tends to
discount the reciprocal, interactive, relational terms of laws constitutive power. By reducing legal agency to
judicial elites, the top-down approach obscures the subtle but significant ways that judicial actions shape the
strategic landscape within which citizens (including elites) negotiate relations with each other as legal subjects . . .
Likewise, the neo-realist model of impact greatly privileges attention to direct over indirect effects of
courts. . . [as well as a] tendency. . . to isolate and compare tactics in zero-sum terms ” (Ibid: 291). Second,
by focusing solely on public policy outcomes rather than the identity-forging experiences, neo-realist scholars
ignore an important potential outcome of legal mobilization, and “without directly examining those various
meanings, tactics, and goals - i.e. the legal consciousness - of activists themselves, it is rather presumptuous to
judge the relative effectiveness of their actions” (Ibid: 292). Finally, neo-realist accounts greatly “exaggerate” the
“ideological cooptation of movement activists by law” and the demobilization resulting from litigations
strategies: In fact, “there is little evidence that litigation did in fact undermine grassroots activation
anywhere to any significant degree ” (Ibid: 232; 83).
2AC K
 Framework
The role of the ballot is to evaluate the plan vs a competitive alternative as advocacies for challenging oppression and violence. Aff-centric
rejoinder is best – avoids later-breaking debates that wish away the 1AC and are less-educational, so floating PIKs are a voting issue.

The 1AC’s scenario analysis is valuable. Single-payer is a serious possibility and it’s important for us as scholars to learn how to advocate for
it – that’s key to spill up to meaningful advocacy and facilitate transformative movements. The 1AC is a part of the activist tradition
forwarded by the Medicare integration and AIDS movements – they effectively used images of suffering and protest based around advocacy
to get progressive transformations in AIDS treatment accessibility.

It’s not enough to present a grammar of suffering or surrender to blackness – any counter-example disproves their broad, sweeping
framework arguments. Furthermore, human pain and suffering may be beyond comprehension, but that doesn’t mean they can’t be
addressed through intersubjective politics. The alt makes infinite analysis in search for a perfect grammar of suffering the enemy of good
political resistance.

Perm – do both. Perm do the aff and surrender to blackness, advocate the end of America – any revolution that doesn’t include the plan is
incomplete because it doesn’t guarantee equal, high-quality health care.
 AT Hamilton
1. Reading the Hamilton evidence loses them the debate – Hamilton thinks single-
payer is a necessary part of the social movement for racial and economic justice. He
also thinks analysis of political demands and formulating political opinions are good
strategies!
Also, he argues that audits of employers to detect racial discrimination and prosecution of discriminating firms are important parts of the New
Social Contract. The aff’s change to Civil Rights Law literally does that

Hamilton 17 – Darrick Hamilton, Associate Professor of Economics and Urban Policy at The New School (“Professor Darrick Hamilton's
10-Point Plan for a New Social Contract,” National Economic & Social Rights Initiative, March 6th,
https://www.nesri.org/news/2017/03/professor-darrick-hamiltons-10-point-plan-for-a-new-social-contract)

Hamilton , Associate Professor of Economics and Urban Policy at The New School, joined us on March 6, 2017 for a
Professor Darrick

moderated discussion: “A New Social Contract: Guaranteeing Dignity in a Precarious Economy. He shared a 10-point agenda that

he believed could form the basis this new social contract . Because we have received several requests for those 10
points we list them below.

(1) Reparations for slavery, Jim Crow and exclusion from New Deal and post WWII policies, all which decimated wealth in Black
communities;

(2) Baby Bonds – This program is analogous to a social security program for young adults. By giving every child a bond at birth, it would
provide capital finance to begin a lifetime of building assets and economic security independent of the financial positioning and decision-
making of the families in which they are born;

(3) Federal Job Guarantee -- By creating enough jobs for all, this program offers the economic security of a living wage to all,
investment in public physical and human infrastructure, as well as provides implicit floor on wages and other worker amenities, jobs for socially
stigmatized workers, and increases bargaining power for all workers by removing the threat of unemployment;

(4) Federalize Credit Scores – A metric so determinant of individual life chances should not be left to the for-profit private sector.
Government should be responsible and accountable to how these scores are decided through a transparent and understandable process;

Postal Banking to provide banking services and short and long-term loans particularly for
(5)

unprivileged individuals who financially have to rely on predatory check cashing institutions and payday lenders, and basically put a
floor on financial product availability;

(6) EEOC should conduct employment audits to detect racial discrimination and prosecute discriminating firms;

(7) Federal subsidy to HBCUs to the tune of the present value of support reached for other colleges and universities from post WW II
G.I. Bill (which was on the scale of the financing of the Marshall Plan). It is evident that Black students still need safe environments that
mitigate hostility and provide curriculum more relevant to their experiences;

(8) Eliminate tracking in grade school and offer universal talented and gifted educational programs to
all ;

Single payer health insurance -- Medicare for all would contribute significantly to economic justice
(9)

by spreading risk equitably across society for the cost of illness and injury ;

Stop mass incarceration of non-violent offenders , hold police criminally and civilly responsible for
(10)

abusive police practice, and legalize marijuana to end the practice of imprisoning people for non-violent low-level
infractions.
2. The Hamilton article they read doesn’t link to us – it’s critiquing post-racial,
neoliberal rhetoric. The aff is the opposite of both of those – it refuses private
insurance markets and says racial discrimination in medicine is rampant. The aff isn’t
exclusive focus on disparate resource distribution but makes the law consider
disparate impact.
3. That Hamilton article concludes that Canada’s approach was good – it wasn’t
perfect, but it actively fought against neoliberalism and seriously reduced health
disparities
Hamilton 17 – Darrick Hamilton, Associate Professor of Economics and Urban Policy at The New School (“Post-racial rhetoric, racial
health disparities, and health disparity consequences of stigma, stress, and racism,” Washington Center for Equitable Growth, October 2017)

Siddiqi et. al. (2013) provides a comparative analysis between the United States and Canada ; two
countries that experienced global structural change towards economic and sociopolitical neoliberal
reforms with Canada providing a case of social resilience to buffer the consequential impact on health
disparity in relation to the U.S. “Specifically, (Siddiqi et. al., 2013) examine(s) “ neoliberalism ” as one of the
fundamental social phenomena underlying contemporary socioeconomic inequalities in health .” The
authors argue that this political movement contributes to health disparity in two ways:…“(f)irst, neoliberal

policies tend to link the resources required for health and development (e.g., health care, education, safe living
conditions) to individual and/or family socioeconomic resources, rather than providing these resources

more equitably, as a right of citizenship…(and) (s)econd, the sheer widening of socioeconomic inequalities associated with
neoliberalism can create a context in which social cleavages are more pronounced, reducing the sense of belonging, citizenship,
collectivity, and social cohesion.”

Ultimately, Siddiqi et. al., (2013) finds that Canada’s

greater equity promoting labor market and tax and transfer
polices, provisions for more equity in health care and education, and, social sense of cohesion across
race/ethnicity and class, as well as a lower intensity of neoliberal reform, all served to buffer against trends
towards greater health disparity relative to the U.S.

4. Hamilton cites Nancy Krieger several times in building the case about racial health
disparities
Hamilton 17 [For Reference] – Darrick Hamilton, Associate Professor of Economics and Urban Policy at The New School
(“Post-racial rhetoric, racial health disparities, and health disparity consequences of stigma, stress, and racism,” Washington Center for
Equitable Growth, October 2017)

Some pioneering work that expands beyond individual explanations to structural explanations related to racism and discrimination include
Williams and Collins (1995), Krieger and Sidney , (1996), Williams (1999), Krieger (1999), and Krieger (2000). Williams
Krieger (2000) surmise that racial health inequality is primarily attributable to disparities in
(1999) and

SES and additional effects of racism/discrimination, noting that racial difference in SES is also
manifest, at least in part, from racism/discrimination. Ultimately, racism becomes a “fundamental cause” of health disparity (Phelan et. al.,
2015, and Williams and Mohammed, 2013).
Krieger is definitely an aff author – racial health disparities are neither inevitable nor
immutable – serious health policy changes over the last 100 years explain the
overwhelming majority of changes in racial health disparities. The aff is a critical
intervention.
Krieger, 10—Professor of Social Epidemiology, Department of Social and Behavioral Sciences, Harvard School of Public Health (Nancy,
“The Science and Epidemiology of Racism and Health: Racial/Ethnic Categories, Biological Expressions of Racism, and the Embodiment of
Inequality — an Ecosocial Perspective,” What’s the Use of Race? Modern Governance and the Biology of Difference, Chapter 11, edited by Ian
Whitmarsh and David S. Jones, ebook)

At one level, our finding that risk of premature mortality increased with economic deprivation and racial
inequality obviously is not new; research documenting these social facts easily extends back to the late eighteenth century ( Rosen
1958/1993 ; Krieger 2000d). That said, what our results newly underscore is that contemporary U.S. inequities

are not immutable : they shrunk considerably between 1965 and 1980, and increased or stagnated
thereafter. The early trends give grounds for hope; the latter augur poorly for the Healthy People 2010 objective
of eliminating U.S. socioeconomic and racial/ethnic health disparities.

In our published study, we exhaustively consider competing hypotheses that might explain our findings
( Krieger et al. 2008b ). Here, I summarize them, and I start by noting that the finding of a declining — then increasing —
gap is unlikely to be an artifact of inaccurate numerator or denominator data . Since 1960, 99 percent of all U.S.
deaths and births have been registered (Hetzel 1997). The U.S. census undercount (disproportionately affecting lower-income populations and
populations of color) has declined considerably (e.g., for blacks, from 6.6% in 1960 to 2.8% in 2000), a trend that would increasingly reduce, not
infl ate, estimates of social disparities in mortality (Clark and Moul 2004). Results are also unlikely to be affected by
racial/ethnic misclassification, given the broad groupings employed; rather, demographic trends should have lowered risk of
premature mortality among U.S. populations of color, given the increase in foreign-born U.S. populations of color and their associated “ healthy
immigrant ”effect, and the corresponding proportional decline in the U.S. African American population (from 92% of U.S. populations of color in
1960 to 72% in 2000; Singh and Siapush 2001 ; U.S. Bureau of the Census 2009b ).

What, then, might explain the observed trends? First, the rising U.S. per capita gross domestic product (GDP) likely
contributed to the overall decline in premature mortality rates (e.g., GDP grew by 32% during 1961 – 1970, 23%
during 1970 – 1980, 25% during 1980 – 1990, and 22% during 1990 – 2000; Centre for the Study of Living Standards 2009). But this rising

GDP cannot explain the observed pattern of a diminishment and then increase in the socioeconomic
gradient. Nor can the observed trends be explained simply by relative positioning in a social
hierarchy , a hypothesis some have proposed to explain social gradients in health ( Phelan and Link 2005 ;
Wilkinson 2005 ; Adler and Rehkopf 2008 ), because such an explanation would not account for either the overall
falling rates of premature mortality or the shrinking and then widening of the gap . It is also unlikely that
purely individual-level behavioral factors can explain the faster and then slower decline in premature mortality among persons in the lower
income quintiles, unless an argument can be made that health promotion efforts in this group were more successful in the earlier, rather than
later, time period, which is unlikely.

As an alternative explanation, the most plausible one involves two likely major societal determinants
of health: economic priorities and civil rights ( Krieger et al. 2008b ). Likely contributing to the 1965 – 1980
improvements are the positive impact of the “ War on Poverty ” and the civil rights legislation that expanded
economic opportunity and resources , and also availability of health services , for both the poor and
populations of color , especially African Americans ( Davis and Schoen 1978 ; O ’ Connor 2001 ; Fairclough 2001 ; Quadagno
and McDonald 2003 ; Almond, Chay, and Greenstone 2006 ; Lefkowitz 2007 ). Conversely, the subsequent slowdown likely

reflects the adverse impact of post-1980 neoliberal and neoconservative policies to roll back the
welfare state ( O ’ Connor 2001 ; Auerbach, Card, and Quigley 2006 ; Navarro 2007). Here, I mean cutting federal
responsibility and funds for public health and antipoverty programs, opposing affi rmative action, blocking rises in
the minimum wage, and selectively decreasing taxes on the wealthy, coupled with rising medical uninsurance and
persistent racial/ethnic disparities in quality of care ( O ’ Connor 2001 ; Smedley, Stith, and Nelson 2003 ; Auerbach, Card,
and Quigley 2006 ; Navarro 2007).

To summarize, our results refute the view that widening health disparities necessarily accompany
improvements in population health . Death is inevitable; premature mortality is not . One potentially
hopeful hypothesis accordingly prompted by our findings is that if addressing social injustice and its
embodied health consequences becomes a priority, we can make progress . Another implication is that we
need to understand not only how class inequalities harm health within each and every racial/ ethnic group, but also how racial
inequality harms health, including within and across class strata . As our data illustrate, the point is not race
versus class — both matter , and we need data on both . The implication is that we need more than simply indirect
studies to investigate how racism harms health: it is also necessary to consider the direct impact of racial discrimination on health, including
within and across socioeconomic strata.
Direct Approach: Self-Reported Experiences of Racial Discrimination and Health

The next set of examples accordingly focuses on the inclusion of data on self-reported experiences of racial discrimination in public health research. I begin with a description of an instrument to measure exposure to racial
discrimination and then discuss its application in two studies.

The Experiences of Discrimination (EOD) instrument (see table 11.3 ), which we validated (in both English and Spanish) in 2005 ( Krieger et al. 2005b ), is based on an instrument I fi rst developed in 1990 ( Krieger 1990 ; Krieger and
Sidney 1996 ) and have used with slight modifi cation since. It is among the two most widely used self-report measures in empirical studies on self-reported experiences of racial discrimination and health ( Krieger 2000a ; Paradies
2006 ). The approach of the EOD is to ask participants, explicitly, about whether they have “ experienced discrimination, been prevented from doing something, or made to feel inferior in any of the following situations because of
your race, ethnicity or color. ”The nine situations then listed each pertain to commonly identifi ed domains in which people report having experienced racial discrimination, that is, involving education, work, housing, health care,
public settings, and the police. Respondents who answer yes to any given item are then asked a follow-up question about frequency. Additional questions ask about response to unfair treatment. As shown in the validation study,
which was conducted among a cohort of low-income workers in the greater Boston area, the EOD has a high Cronbach ’ s alpha (0.8 or higher among black Americans and Latinos), high test-retest reliability (over 0.7), and no
response item bias; moreover, confi rmatory factor analysis indicated that there was an acceptable fi t to the data for a single underlying factor ( Krieger et al. 2005b ). Also of note, we included several single-item measures of
experiences of discrimination in the validation study, all of which we found had very low test-retest reliability (correlations of 0.4 or less), a result that cautions against using single-item questions about exposure to racial
discrimination, as currently used, for example, in the U.S. Behavioral Risk Factor Surveillance Survey ( National Center for Chronic Disease Prevention and Health Promotion 2009 ).

Relevant to the question, what ’ s the use of race? in the validation study, all three racial/ethnic groups reported having experienced racial discrimination, albeit at different frequencies. Thus 38 percent and 24 percent of the black
and Latino participants reported having experienced discrimination in three or more of the nine situations, versus only 12 percent of the white participants; a similar difference in magnitude was evident for the frequency score
( Krieger et al. 2005b ). Moreover, self-reports of racial discrimination were associated with the odds of having smoked cigarettes only among the black and Latino workers, but not among the white workers; self-reports also
tended to be associated with the risk of being psychologically distressed among the black workers and, to a lesser extent, the Latino workers, but once again, not the white workers. These fi ndings, along with the literature on “
reverse discrimination ” ( Pincus 2003 ; Bonilla-Silva 2003 ; Crosby 2004 ), underscores a key problem with the suggestions offered by some researchers to “ abandon ”( Fullilove 1998 ) race as a variable in health research and to
instead use only measures pertaining to racial discrimination ( Fullilove 1998 ) or other social measures (e.g., socioeconomic position; Bhopal and Donaldson 1998 ; Stolley 1999 ): without data on race/ethnicity, it becomes
impossible to offer meaningful interpretation of the self-report data on racial discrimination or to analyze if it is similarly or differentially associated with health status across all racial/ethnic groups. Thus, as increasingly recognized
in the literature distinguishing between the use of race/ethnicity as a descriptive versus ascriptive category (Kaplan and Bennett 2003; Braun et al. 2007 ), studies that ask about self-reported experiences of discrimination for the
purpose of testing causal hypotheses necessarily must also employ appropriate descriptive racial/ethnic categories.

Also important to note is evidence indicating that people with fewer resources tend to report less racial discrimination compared to those with more resources. In the case of the EOD, for example, self-reports of having ever
experienced racial discrimination were notably higher, compared to self-reports by the low-income, working-class participants in the EOD validation study ( Krieger et al. 2005b ), in three investigations with more affl uent
populations: the proportion was nearly one and a half times higher in the CARDIA study (52%), a multicity, population-based, longitudinal investigation concerned with black-white differences in risk of cardiovascular disease
( Krieger and Sidney 1996 ), and over two times higher (80%) in both a study of pregnant women with health insurance ( Dominguez et al., 2009 ) and a Web-based study in which 60 percent of the respondents had a bachelor ’ s
degree or higher (Krieger et al., in press). The positive association between socioeconomic resources and self-reports of racial discrimination is a robust fi nding ( Krieger 2000a ; Paradies 2006 ; Williams and Mohammed 2009). One
possible explanation is that people with more power and resources may be more able and willing to identify experiences of racial discrimination ( Krieger 1990 ; Krieger and Sidney 1996 ; Krieger 2000a ; Blank, Dabady, and Citro
2004 ). An important implication is that research on racial discrimination cannot be concerned only about race/ethnicity, but must also take into account socioeconomic position.

Demonstrating that it does make a difference, empirically, to include data on selfreported experiences of racial discrimination in epidemiologic research are results of a CARDIA study on racial discrimination and risk of preterm
delivery, in which I was a coinvestigator ( Mustillo et al. 2004 ). Motivated by the unanswered question of what accounts for higher rates among U.S. black women, as compared to white women, of preterm delivery — a major
determinant of low birth weight and infant mortality ( Krieger et al. 1993 ; Schempf et al. 2007 ) — in this study, we sought to assess whether including data on self-reported experiences of racial discrimination, in addition to major
known conventional risk factors, would affect the magnitude of the observed black-white disparities.

The study population consisted of 367 women who gave birth between the year 7 and year 10 CARDIA exams ( Mustillo et al. 2004 ). From the year 7 exam, we obtained prospective data on self-reported experiences of racial
discrimination (using a prior version of the EOD), socioeconomic position, and other relevant baseline characteristics; from the year 10 exam, we obtained data on birth outcomes. The four key results were as follows (see table 11.4
):

1. As shown in model 1, overall, the odds of black women having a preterm delivery were two and a half times higher as compared to white women.

2. When we additionally added data on self-reported experiences of racial discrimination, we found that the black excess risk was reduced to 1.7, and also that increased exposure to racial discrimination was associated with a
twofold higher odds of risk of preterm delivery (model 2).

3. In analyses that controlled for other major risk factors for preterm delivery, such as income, education, smoking, alcohol, and depression (model 3), we found that adjusting for these risk factors somewhat reduced the initially
observed black-white difference (model 1), but the odds of black women having a preterm delivery were still about two times more than compared to white women.

4. Last, when we additionally included the data on self-reported experiences of racial discrimination (model 4), we found that there was no longer any racial/ethnic difference in risk: the odds of black women and white women
having a preterm delivery were the same (model 4). We also found that, as compared to women reporting no racial discrimination, the odds of having a preterm delivery were two times higher among women who reported
experiencing moderate racial discrimination (in one or two situations) and three times higher among those reporting high exposure (in three or more situations).

Thus what our results showed — for the fi rst time — was that experiences of racial discrimination not only predicted risk of preterm delivery, but also explained the excess black-white risk that the other conventional risk factors
could not.

Prior to our investigation, however, most studies had included only conventional risk factors, like those we included in model 3, thereby concluding that the remaining unexplained black excess risk of premature delivery must be
due to some innate biological difference between black and white women ( Krieger et al. 1993 ; Giscomb éand Lobel 2005 ). But we show that this interpretation is wrong because our study clearly demonstrated that by including
information on experiences of racial discrimination, we could explain the observed black-white disparities. This is a very powerful fi nding — and it adds further evidence to the claim that the source of racial/ethnic disparities is the
injustice in our society, not innate biology.

The last empirical example serves as a reminder that racial discrimination, however important it may be as a determinant of racial/ethnic health inequities, is not the only adverse type of social hazard to which people of color are
exposed. Thus, drawing on the full cohort of 1,202 low-income employed workers that served as the population with which we validated the EOD, we found that participants reported not only racial discrimination, but also
workplace abuse and sexual harassment ( Krieger et al. 2006 , 2008a ). More specifi cally, among the black workers, the two most common combinations, together reported by over half the women and men, were, fi rst, racial
discrimination combined with workplace abuse, followed by all three types combined, with the latter most common among the black women. Among the Latino workers, a different set of combinations were the two most common,
again reported by over half the women and men: fi rst, racial discrimination plus workplace abuse, followed by workplace abuse alone. Last, among the white workers, the most common category by far was workplace abuse alone,
reported by slightly over 40 percent of the women and men. Additional analyses showed that, in the case of sexual harassment, one additional social category was relevant: that of sexuality, with the lesbian, gay, bisexual, and
transgender (LGBT) workers reporting twice as much sexual harassment as their heterosexual counterparts.

The net implication is that racial discrimination matters — and does not occur in isolation. This, too, is the point of the ecosocial construct of embodiment and its recognition that each and every day, our bodies daily integrate our
experiences. Hence, to analyze the determinants of health inequities, including racial/ethnic health disparities, we have to remember that we are not one day a woman or a man, another day white or a person of color, another day
working class or a professional, another day straight or LGBT, and still another day U.S. born or foreign born: we are all of these at once, with the implication being that our research must reckon with diverse, yet combined and
embodied, aspects of social position ( Krieger 1994 , 2005b , 2006 ).

Conclusion: From “What’s the Use of Race” to the Need for Research and Action on Racism and Health

As the arguments and examples of this chapter make clear, in the case of population health and racial/ethnic health inequities, the meaningful
question becomes, what’s the use of race in research on racism and health? This is because (1) racism and the social categories of
race/ethnicity that it creates are socially real and (2) racism harms health, and does so differentially by race/ethnicity, thereby producing
racial/ethnic health inequities. Consequently, to measure the impact of racism on health, we need to employ (1)

appropriate racial/ethnic categories to distinguish its targets — and perpetrators — and (2) relevant
measures of exposure to structural, institutional, and interpersonal racism . These same considerations pertain to
research regarding the links between class and health, gender and health, and any other social construct implicated in health inequities: we

need categories to identify the populations defined by these social relations, and we need data to
quantify the relevant measures of exposure to adverse conditions. The corollary is that calls for
being color-blind in data collection are not color neutral ; rather, they are an expression of denial and
bias about the seriousness of how racism harms individuals and societies .

One fi nal question, then, ought be asked: what’s the use of research on racism and health? The clear-cut answer is that this
research is
necessary to understand and provide evidence relevant to addressing racial/ethnic health
inequities . Although scientific knowledge, like any knowledge, can by itself change nothing , when
people organize to apply it , change can happen . The example I have provided regarding the shrinking of
U.S. socioeconomic and racial/ethnic health inequities between the mid- 1960s and 1980 is a case in point :
descriptive and analytic knowledge about the existence of these inequities and their causes was
critical to spurring and guiding action to rectify them .

Consider, too, the recent the Public Broadcasting Service series Unnatural Causes . . . Is Inequality Making Us Sick? (California
Newsreel 2009), aired nationally in spring 2008 (and for which I served, by way of disclosure, as one of the scientifi c advisors and participants).
The series ’ s clear message is that racism and economic deprivation harm health and can be
challenged and countered . Widely acclaimed, it was bestowed the prestigious 2009 Alfred I. duPont – Columbia University Award,
broadcast journalism ’ s equivalent of the Pulitzer Prize (California Newsreel 2009). Its power derived in part from its ability to

link the findings of extant research about racism , economic deprivation , and health to individual
stories that simultaneously illuminated and gave credence to the experiences of those now suffering the brunt of health inequities. The
series likewise succeeded in breaking through the individualism so rampant in our society, by making clear that — in the old-fashioned language
of the day — the personal is, in fact, political. By this I mean that the series revealed how people’s health woes — including those involving
racial/ethnic health inequities — are at once individual and societal: we experience them as the unique individuals we are, within a context of
societally structured options and constraints. Already shown at over twelve thousand community and organizational meetings by the end of
2008 (California Newsreel 2009), the series is being used by health professionals and health advocates, nationally and locally, to educate the
broader public and affected communities about how social injustice harms health — and what can be done to change this. As should be
obvious, the series’s insights, evidence, and recommendations for action are premised on meaningful use
of data about race/ethnicity, racism, and health; without using categories of race/ethnicity , the
series would not have been possible .

In conclusion, the use of “race” — that is, racial/ethnic categories — is essential for the science and epidemiology of
racism and health. The rationale for this work is to generate knowledge that, if put into action , can
inform current efforts to eliminate health inequities and improve population health . To do this work, it is
not an option either to ignore categories of race/ethnicity or to analyze them without reference to
their societal context and the impact of racism on health. Only by grappling with the paradox of using
categories of race/ethnicity to vanquish racial injustice , rather than attempting to proscribe their
use , do we stand a chance in furthering our goals of racial justice and social equity in health.
 2AC – Gaffney
Anti-blackness is contingent and health has no singular definition. There’s a
meaningful difference between a black activist dying due to a preventable disease and
that same activist advocating challenges to civil society because they could get free
treatment. Even if the aff doesn’t eliminate all disparities, it removes a huge structural
barrier to life-saving care and closes most death gaps.
Adam GAFFNEY 16, Division of Pulmonary and Critical Care Medicine at Massachusetts General Hospital and Harvard Medical School
[“Is the Path to Racial Health Equity Paved with “Reparations”? The Politics of Health, Part II,” Los Angeles Review of Books, March 7, 2016,
https://lareviewofbooks.org/article/is-the-path-to-racial-health-equity-paved-with-reparations-the-politics-of-health-part-ii/]

More broadly, the recommendations of both Tweedy and Matthew ultimately seem inadequate. Neither gives
much credence to the notion that further increasing the universalism of the health system might play
an important role in reducing inequalities . Moreover, Tweedy says nothing, and Matthew only a little,[20] about the
notion of economic redistribution as a tool against racial health inequalities . In fairness, these concerns are not
the focus of their books. However, to my mind, they are crucial considerations in the larger discussion of racial

health care justice.

4. Health equity and health system universalism

Martin Luther Kings Jr.’s statement on the evils of health inequality is frequently quoted, but not usually in its full form. In his 1966 speech at
the annual meeting of the aforementioned Medical Committee for Human Rights, he said, “Of all the forms of inequality,
injustice in health is the most shocking and the most inhuman because it often results in physical
death.”[21] Indeed, studies have shown a statistical association between lack of insurance and mortality .
Removing the boundaries between individuals and the health care system is a critical step in the
movement toward health care equality .

Tweedy, for instance, sees firsthand the harm inflicted on the uninsured when he works at the rural health clinic described earlier. But, even so,
like Matthew, he gives insufficient attention in his book to the fact that, even
with the reforms of the Affordable Care Act, we
will continue to lack universal health care .[22] For instance, under current reforms, 27 million are expected
to remain uninsured 10 years from now, according to an approximation of the Congressional Budget Office. We
know that Hispanics and blacks are disproportionately represented among the uninsured .[23] Covering
these excluded millions seems critical. Moreover, neither author discusses the fact that the US health care system
imposes substantial financial burdens at the “point of use,” in the form of copayments, deductibles,
and co-insurance for medical care, which may deter care for those who need it . Some have legitimately
suggested that these forms of cost-sharing disproportionately harm minorities, who have lower median
income and net wealth.[24] In other words, the potential harm of, say, a $2,000 medical deductible is dependent on your income and
assets: those with fewer resources may lose out on important health care. And finally, though Tweedy refers to the shortcomings of Medicaid,
neither he nor Matthew emphasizes that a health care system with a separate tier of access for the poor may be
inherently unequal.

But would “true” universal health care do much to combat racial health inequalities, if it were, say, a
single-payer system that eliminated out-of-pocket expenses and was equally accessible by all, without
tiers or walls?[25] Or would it replicate current biases and inequalities? To some extent, the answer is yes to both
questions. But even so, a body of research has suggested that, even if these biases persist, a fully universal

system might nonetheless be a powerful tool in reducing racial health care inequalities . That
evidence comes from what is arguably a quasi-single-payer system located in the US: the Veterans’ Administration (VA).
Notwithstanding recent scandals that are indeed of great concern, the modern-era VA has justifiably earned praise for
delivering a high — indeed, comparatively superior — quality of health care.[26] There is also evidence that it may
indeed effectively reduce, even potentially eliminate , some racial health inequalities .

Last fall, a
study published in Circulation, the premier journal of the American Heart Association, received wide coverage
in the media for some provocative findings. “The
US Veterans Health Administration (VHA),” as the study notes in its introductory
section, “is a healthcare system that does not impose the typical access barriers of the US healthcare
system that may disproportionately impede enrollment of blacks.” The investigators therefore hypothesized that
racial inequalities in cardiovascular outcomes and mortality found in the general population might be reduced in the VA, a “healthcare system
that allows enrollment independent of race or socioeconomic status.”[27] Consistent
with previous studies, in their analysis of
data from the general (non-VA) population, they
found racial inequalities much as they expected to find them:
blacks had a much higher mortality (after adjusting for various other factors) as compared to whites
(indeed, approximately 40 percent to 50 percent higher).[28]

In striking contrast, in the VA population, even though the risk of stroke was either higher or similar among blacks as compared to
whites depending on which statistical adjustments were used, the risk of coronary heart disease as well as overall death

was actually lower among blacks . This is, of course, only a single study, albeit a rather large one with more than three million
subjects. An accompanying editorial concedes that a number of factors may be at play. Nonetheless, the fact is

that, as described by the investigators, these findings build on an existing literature consisting of multiple studies
that together point to a reduction of racial health inequalities within the VA for critically important outcomes
like mortality.[29]

No doubt, there are still discriminatory practices in some or all of these facilities, and we can assume that there
are conscious or unconscious biases at work in the minds of some of its clinicians, as there are elsewhere. Indeed, other studies clearly
show that, even after the significant reorganization and reform of the VA in the late 1990s, there are still racial disparities in the VA.[30] If we
moved to a single-payer system on a national level, such biases would still need to be addressed along
the lines Matthew argues. But the point is that a more egalitarian structure of the health care system itself might
go even further in reducing them. Indeed, in light of this research, it seems fair to say that health care universalism could
be a very powerful tool in combatting ubiquitous racial health inequities . Attaining health care
equality, in other words, requires true equality of access. And yet this simple notion is all too often ignored entirely in any
discussion of health “disparities.”

No link to Baucom – it’s describing slave insurance as a kind of property insurance –

the aff challenges that structure, but health insurance is good as a means of making
medical care free!
 2AC AT Alt Causes – UHC = Paradigm Shift
Universal health care is a strategic lever that forces the broader expansion of the
social safety net – forcing the government to pay for health care costs requires
improvements in other relevant arenas, like housing, education, and environment.
Rudiger 16 – Anja Rudiger, Ph.D. in Political Theory from the University of Kiel, former Director of Programs at the National Economic &
Social Rights Initiative (“Human Rights and the Political Economy of Universal Health Care,” Health and Human Rights, Vol. 18, No. 2, pgs. 67-78,
https://www.hhrjournal.org/2016/12/human-rights-and-the-political-economy-of-universal-health-care-designing-equitable-financing/)

This focus on equity coincided with the Occupy movement’s protests

against rising inequality, which catalyzed an ongoing
debate in US politics about the largest concentration of wealth since the 1930s and the greatest
income inequality since the late 1970s.19 Regressive health care financing is a significant contributor
to economic inequality , producing an inverse correlation between household income and household
health care spending.20 Conversely, a redistributive universal health care system in the United States
would deliver significant financial relief to lower- and middle-income families .21 Providing health care
as a public good could also pave the way for a broader paradigm shift toward universal public
programs, replacing the threadbare safety net of means-tested benefits . Health care could function as
a strategic lever for building a more equitable society through the universal provision of the goods
and services needed to exercise economic and social rights. In turn, increased equity would further
improve health outcomes .22 It follows that health reform goals should reflect the direct correlation between health and equity by
measuring not only health but also equity indicators.

This broader equity vision characterizes the HCHR campaign’s approach to financing, which aims to disrupt the
vicious circle of inequity and poor health fueled by unequal access to care based on income, wealth,
and employment. International health systems research confirms that commercialized health systems with significant
private sector involvement both impede access to care and deepen inequities .23 The market-based insurance
system in the United States demonstrates that private pre-payment schemes are neither intended nor equipped to guarantee equity in access
to and payment for care. Any redistributive potential of pre-payment is lost when the insurance business model incentivizes access restrictions
by means of cost-sharing, narrow provider networks, and prior authorization processes, and when even a slightly more progressive premium
structure for low-income policyholders, as mandated by the ACA, requires the channeling of sizable public subsidies to private insurance
companies.
 AT Pessimism
Their thesis is wrong – anti-black racism is a contingent function of institutionalized
social power, which can be dismantled through the transformation of these
institutions
Gordon ‘17 (Lewis, professor of philosophy with affiliations in Judaic studies, Caribbean and Latina/o studies, and Asian and Asian
American studies at UCONN-Storrs, The Oxford Handbook of Philosophy and Race, pp. 296-298)

Should the analysis remain at white and black , the world would appear more closed than it in fact
is. For one, simply being born black would bar the possibility of any legitimate appearance. This is a position that has been taken by a growing

group of theorists known as “Afro-pessimists” (Wilderson 2010; Sexton 2011). Black for them is absolute “social death:’ it is outside
of
relations. Missing from this view is; however, is at least what I argued in Bad Faith and Antiblack Racism, which is that no
human being is “really” any of these things ; the claim itself is a manifestation of mauvaise foi . The
project of making people into such is one thing. People actually becoming such is another. This is an
observation Fanon also makes in his formulation of the tone of nonbeing and his critique of Self—Other discourses in Peau noir, masques blancs
(Black Skin, White Masks). Fanon distinguishes between the zone of nonbeing (nonappearance as human beings) and those of being. ‘The latter
presumes a self-justified reality, which means it does not call itself into question. The former faces the problem of illegitimate appearance
(Fanon 1952, chapters; Gordon 1999; AIcoir 2006; Yancy 2008). Thus, even the effort “to be” is in conflict as the system in question presumes
legitimate absence of certain groups. Yet, paradoxically, the human being comes to the fore through emerging from being in the first place.
Thus, the assertion of being is also an effort to push the human being out of existence, so to speak. The racial conflict is thus changed to an
existential one in which an existential ontology is posed against an ontology of being. Existential ontology pertains to human being, whereas
ontological being pertains to gods. This is why Fanon concludes that racism is also an attack against human being, as it creates a world in which
one set stands above others as gods and the rest as below human. Where, in this formulation, stand human beings? The argument itself gains
some clarity with the etymology of “existence” which is from the Latin expression exsístere (to stand out, to emerge -that is, to appear). Blacks
thus face the paradox of existing (standing out) as nonexistence (not standing out). The system of racism renders black appearance illicit. This
conundrum of racialized existence affects ethics and morals. Ethical relations are premised on selves relating to another or others. The others
must, however, appear as such, and they too, manifest themselves as selves. Implicit in such others as other selves is the formalization of
ethical relations as equal. as found in the thought of Immanuel Kant and shifted in deference to the other in that of Emmanuel Levinas, Racism,
however, excludes certain groups from being others and selves (if interpreted as being of a kind similar to the presumed legitimate selves).
Thus, theschema of racism is one in which the hegemonic group relates to its members as selves and
others, whereas the nonhegemonic groups are neither selves nor others. They, in effect, could only be such in relation to
each other. It is, in other words, a form of ontological segregation as a condition of ethics and morals .
The fight against racism, then, does not work as a fight against being others or The Other . It is a fight
against being nonothers. Fanon’s insight demands an additional clarification. Racists should be distinguished from racism. Racists are

people who hold beliefs about the superiority and inferiority of certain groups of racially designated people. Racism
is the system of
institutions and social norms that empower individuals with such beliefs. Without that system, a
racist would simply be an obnoxious, whether overtly deprecating or patronizing, individual. With that system, racist
points of view affect the social world as reality . Without that system, racists ultimately become
inconsequential and, in a word, irrelevant beyond personal concerns of saving their souls from unethical
and immoral beliefs and choices. Fanon was concerned with racists in his capacity as a psychiatrist (therapy, if necessary). but he
was also concerned with racism as a philosopher, social thinker, and revolutionary (Fanon 1959/1975). The latter, in other words, is a system,
from an antiracism perspective, in need of eradication. An
objection to the Afro-pessimistic assertion of blackness as
social death could thus be raised from a Fanonian phenomenological perspective : Why must the
social world be premised on the attitudes and perspectives of antiblack racists? Why don’t blacks
among each other and other communities of color count as a social perspective? And if the question
of racism is a function of power , why not offer a study of power , how it is gained and lost, instead of
an assertion of its manifestations as ontological? An additional problem with the Afro-pessimistic model is that its
proponents treat “blackness” as though it could exist independent of other categories. A quick examination of double consciousness (Du Bois
1903)—a phenomenological concept if there ever were one by virtue of the focus on forms of consciousness and, better, that of which one is
conscious, that is, intentionality would reveal why this would not work. Double conscious ness involves seeing oneself from the perspective of
another that deems one as negative (for example, the Afro-pessimistic conception of blackness). That there is already another perspective
makes the subject who lives through double consciousness relational. Added is what Paget Henry (2005) calls polemic, ted double
consciousness and Nahum Chandler (2014, 6o—6i) calls the redoubled gesture, which is the realization that the condemnation of negative
meaning means that one must not do what the Afro pessimist does. Seeing
that that position is false moves one
dialectically forward into asking about the system that attempts to force one into such an identity:
This relational matter requires looking beyond blackness ironically in order to understand blackness .
This means moving from the conception of meaning as singular, substance-based, fixed, and
semantical into the grammar of how meaning is produced. Such grammars, such as that of gender, emerge in
interesting ways (Gordon 1999, 124—129; 1997,73—74). However, as all human beings are manifestations of different

dimensions of meaning, the question of identity requires more than an intersecting model; otherwise
there will simply be one (a priori) normative outcome in every moment of inquiry: whoever manifests the
maximum manifestation of predetermined negative intersecting terms . That would in effect be an
essence before an existence indeed, before an actual event of harm. This observation emerges as well
with the Afro-pessimist model when one thinks of pessimism as the guiding attitude . The existential
phenomenological critique would be that optimism and pessimism are symptomatic of the same
attitude: a priori assertions on reality. Human existence is contingent but not accidental

, which means that the social world at hand is a manifestation of choices and relationships in other words,
human actions. Because human beings can only build the future instead of it determining us, the task
at hand, as phenomenology-oriented existentialists from Beauvoir and Sartre to Fanon, William R. Jones, and this author have argued,
depends on commitment . This concern also pertains to the initial concerns about authenticity discourses
with which I began. One could only be pessimistic about an outcome, an activity. It is an act of forecasting what
could only be meaningful once actually performed. Similarly, one could only be optimistic about the same. What
however, if there were no way to know either? Here we come to the foi element in mauvaise foi. Some actions are

deontological, and if not that, they are at least reflections of our commitments , our projects. Thus, the point of
some actions is not about their success or failure but whether we deem them worth doing . Taking
responsibility for such actions—bringing value to them— is opposed to another manifestation of
mauvaise foi: the spirit of seriousness.

Framing issue – if anti-blackness is axiomatic and fixed, the alternative doesn’t reverse
that, and if anti-blackness is malleable, voting neg only cements anti-blackness and
entrenches racism.
 AT Implicit Bias = Fixed/Libidinal Economy
We solve their Hoffman evidence about implicit bias regarding black pain – the article
is even titled “racial bias in pain assessment.” That bias bias is malleable and
interventions work – that’s Matthew. This is offense – rejecting the malleability of
implicit bias causes individuals to prefer color-blind strategies instead of
acknowledging and combatting racial oppression. Telling white folks to dwell in the
uncomfortability of fixed antiblack violence enables colorblind violence.
Incremental theorists = “those who believe racial bias is malleable;” Entity theorists = “those who believe racial bias is fixed”

Neel and Shapiro 12 – Rebecca Neel, Assistant Professor of Psychology, Ph.D., Arizona State University, Jenessa R. Shapiro,
Associate Professor in the Psychology Department in the Social Psychology and the Diversity Science at UCLA, Ph.D. Social Psychology, 2008,
Arizona State University (“Is Racial Bias Malleable? Whites’ Lay Theories of Racial Bias Predict Divergent Strategies for Interracial Interactions,”
Journal of Personality and Social Psychology, Vol. 103, No. 1, pages 101-120,
http://shapiro.psych.ucla.edu/Papers_files/NeelShapiroJPSP2012.pdf)

The present findings highlight that majority group members approach difficult interracial interactions with
different strategies (see also Plant et al., 2010; Trawalter & Richeson, 2006). Although the increasing diversity in the United States

enhances the likelihood that individuals will engage in interracial interactions, the
strategies that majority group members
use in interracial interactions that are not going well may differ as a function of whether they see racial bias
as malleable or fixed . That is, if incremental theorists—those who believe racial bias is malleable —tend to
engage in more learning-oriented behaviors, they are likely gaining the experience and practice that
previous research has cited as being valuable to improving intergroup interactions (e.g., Johnson, Mitchell,
Bean, Richeson, & Shelton, 2010; Johnson & Richeson, 2009). In contrast, if entity theorists— those who believe racial bias is
fixed—tend to engage in more performance-oriented behaviors, they are likely to be focused on hiding
any appearance of bias and looking for opportunities to escape , thereby not gaining the benefits of the
experience for future interracial encounters.
Furthermore, the specific learning and performance strategies that incremental and entity theorists use likely influence the overall quality of
the interaction. For example, entity
and incremental theorists reported different beliefs about whether the
salience of race harms interracial interactions, with entity theorists favoring strategic color blindness ,
or ignoring race in intergroup interactions . However, strategic color blindness has been shown to have a
number of negative consequences

for interracial interaction. When Whites adopt a color-blind approach in interracial interaction, they tend to
believe this communicates less prejudice (Apfelbaum & Sommers, 2009), even though they also tend to
become more biased with this mindset (Richeson & Nussbaum, 2004), and Blacks tend to view Whites who take this approach
as more prejudiced, not less (Apfelbaum et al., 2008; Apfelbaum & Sommers, 2009). Thus, although entity theorists may believe they are
reducing the likelihood of appearing biased by taking a color-blind approach, they may be increasing this likelihood.
Their diagnosis of racism in the libidinal economy exposes its contingent nature.
Johnson 05 – (2005, Adrian, PhD from SUNY-Stony Brook, Professor in the Department of Philosophy at the University of New Mexico at
Albuquerque and a faculty member at the Emory Psychoanalytic Institute in Atlanta, “Time Driven: Metapsychology and the Splitting of the
Drive,” p. 340-1)

Despite the apparent bleakness and antiutopianism of an assessment of human nature as being perturbed
by an irreducible inner antagonism, there is, surprisingly, what might be described as a liberating aspect to this splitting of
the drives. Since drives are essentially dysfunctional, subjects are able to act otherwise than as would
be dictated by instinctually compelled pursuits of gratification, satisfaction, and pleasure . In fact, subjects are
forced to be free , since, for such beings, the mandate of nature is forever missing. Severed from a strictly
biological master-program and saddled with a conflict-ridden, heterogeneous jumble of contradictory impulses— impulses mediated by an
inconsistent, unstable web of multiple representations , indicated by Lacan's “barring” of the Symbolic Other—the parlêtre has no
choice but to bump up against the unnatural void of its autonomy . The confrontation with this void is frequently avoided. The true
extent of one's autonomy is, due to its sometimes-frightening implications, just as often relegated to the shadows of the unconscious as those heteronomous factors secretly shaping conscious
thought and behavior.

The contradictions arising from the conflicts internal to the libidinal economy mark the precise places
where a freedom transcending mundane materiality has a chance briefly to flash into effective
existence; such points of breakdown in the deterministic nexus of the drives clear the space for the
sudden emergence of something other than the smooth continuation

of the default physical and sociopsychical “run of things.” Moreover, if the drives were fully functional—and,
hence, would not prompt a mobilization of a series of defensive distancing mechanisms struggling to transcend this threatening corpo-Real— humans would be

animalistic automatons, namely, creatures of nature. The pain of a malfunctioning, internally conflicted
libidinal economy is a discomfort signaling a capacity to be an autonomous subject . This is a pain even more essential
to human autonomy than what Kant identifies as the guilt-inducing burden of duty and its corresponding pangs of anxious, awe-inspiring respect. Whereas Kant treats the discomfort
associated with duty as a symptom-effect of a transcendental freedom inherent to rational beings, the reverse might (also) be the case: Such freedom is the symptom-effect of a discomfort
inherent to libidinal beings. Completely “curing” individuals of this discomfort, even if it were possible, would be tantamount to divesting them, whether they realize it or not, of an essential

As Lacan might phrase it, the split Trieb is the sinthome of subjectivity proper, the source of
feature of their dignity as subjects.

a suffering that, were it to be entirely eliminated, would entail the utter dissolution of subjectivity itself .
Humanity is free precisely insofar as its pleasures are far from perfection , insofar as its enjoyment is never
absolute .
 AT Empathy/Appropriation
No link to Beasley – we specifically tie our advocacy to a critique of neoliberal ideas of
individual rationality and free choice by putting everyone in the same boat and
imposing this risk on the government. Our critique of injustice avoids the fungibility of
empathy. Contextualizing vulnerability in the background of injustice spurs ethical
action
Michalinos Zembylas 13, Education @ Open (Cyprus), “The ‘Crisis of Pity” and the Radicalization of Solidarity: Toward Critical
Pedagogies of Compassion”, Educational Studies 49, p. 512-516

a politics of compassion that takes into consideration the possible dangers of compassion fatigue,
First of all, 

desensitization, and victimization has to begin from acknowledging common vulnerability and its

self-  human 

influence in inspiring meaningful actions that avoid presumptuous paternalism The (Porter 2006; Whitebrook 2002).

recognition of one’s own vulnerability can constitute a powerful point of departure for developing
compassion and solidarity with the other’s vulnerability (Butler 2004). As Butler asserts: “Each of us is constituted politically in part by virtue of the social vulnerability of our bodies. ... We cannot ... will away this vulnerability. We must

recognition of our
attend to it” (2004, p. 29). Butler’s description of the vulnerable body and self refers to the way we perform and are performed upon, and part of what we fear in the other is a projection of our own selves. Hence, Butler suggests that

own vulnerability opens up the potential for recognition of all humanity as vulnerable. Vulnerability
may be a more appropriate term than suffering
, therefore, because  the focus is not to ground the political applications of compassion,

merely on the alleviation of material suffering and hence a slide from compassion
to benevolence and sentimentality  (Porter 2006; Whitebrook 2002). Suggesting this epistemological shift of focus  does not imply ,

however,  that a narrative that focuses on the alleviation of material suffering  will necessarily result in
a slide into sentimentality political applications of compassion cannot be completely separated
. Undoubtedly, the 

from questions of material suffering . Thus, it needs to be acknowledged that although the move away from suffering may be theoretically useful, the shift to a narrative of common human vulnerability is not completely

The idea of common vulnerability enables us—teachers and students

unproblematic. 8 to explore in the classroom, for instance—

how we might move beyond dichotomies that single out the self or the other as victims, and therefore
deserving someone else’s pity. That is, the idea of common vulnerability puts in perspective the
as

notion of all of us as vulnerable, rather than the individual-other who needs our compassion. This notion

addresses concerns of students the who seem to be stuck in self-victimization claims and refuse to
, for example,

acknowledge that others also suffer . Although the idea of common vulnerability does not guarantee any departure from such claims, it opens space some

to problematize moralistic positioning . In addition, the notion of common vulnerability attacks a major emotional ideology grounded in the view that it is natural or normal to be fearful of the other, especially if it
involves racial differences. This is one of the most common and pernicious emotional ideologies underlying resistance (especially among White, middle-class students) to identifying with the other. However, if vulnerability concerns everyone and yet compassion is assigned differently (i.e.,

Through addressing
students think that some deserve compassion but others do not), then it is important to explore what it would take for students to begin imagining themselves as objects of lesser compassion in an unsuspected vulnerable moment.

this issue it is possible to respond to some of the desensitization concerns

in ways that do not reify stereotypes or promote essentialism,

outlined earlier, because the dichotomies between we and they will become meaningless and
unproductive. compassion serves to reinforce a strong connection between the personal and the
Second,

political and accentuates the interpersonal and the interrelational (Whitebrook 2002).  Empathetic
identification with the plight of others , then,  is not a sentimental recognition of potential sameness
—you are in pain and so am I, so we both suffer the same— but a realization of our own common
humanity, while acknowledging asymmetries of suffering , inequality, and injustice. A discourse of
vulnerability neither eschews questions of material suffering nor obscures issues of inequality on and injustice;

the contrary, it highlights both the symmetries and the asymmetries of vulnerability although the . That is,

experience of vulnerability may be universal, the discourse of common vulnerability raises more or less
important critical questions such as “vulnerable to what? to whom?” to dismiss the possibility of
sliding into a sentimental recognition of sameness—which is what a politics of compassion potential exactly ardently

seeks to avoid . Without this double realization—that is, we are all vulnerable but not in the same manner—our actions run the danger of being a form of charity and condescension toward those who are systematically and institutionally oppressed (Bunch 2002).

If properly recognized this realization can potentially address both the concern about the
in schools, double

desensitization of students and that of their self-victimization, because the distance between

spectator and sufferer will not be taken for granted any more, but rather its multiple complexities
will be acknowledged and interrogated the kind of compassion that is explored here requires a . In a sense then,

simultaneous identification and disidentification with the suffering of the other. The simultaneous
recognition of symmetry and asymmetry with the other removes the arrogance of claiming that we
know and feel their suffering. This emotional ambivalence of simultaneous identification and
pain and

disidentification is needed to focus attention on the other’s suffering,  but not becoming too identified
with it —a point raised earlier in Nelson’s (2004) reading of Arendt’s reporting on Eichmann’s trial. Students who already endure forms of suffering, of course, do not need a pedagogy to enlighten them how to disidentify with their own suffering. This does not imply, however,

awareness that others are vulnerable is important in the

that pedagogies that interrogate pity and encourage critical compassion are not for them; on the contrary, the critical , too,

struggle for action-oriented solidarity and the avoidance of egocentricity and cultural narcissism . Finally, the

third element of a politics of compassion is attentiveness to how the ethics of compassion questions injustice and inequality. 9 In particular, an important component of a politics of compassion that is critical and justice-oriented is how it deals with anger at injustice (Hoggett 2006). A
politics of compassion does not intentionally seek to cause anger, however, but rather encourages students and teachers to develop a critical analysis of anger, as it is likely that they will experience such feelings, when they begin questioning long-held assumptions and beliefs about other
people and social events (Zembylas 2007). Anger may call attention to demands for recognition, but also emphasize inequalities (Holmes 2004) and injustices at the civic level (Silber 2011). Anger at injustice can be a positive and powerful source of personal and political insight in
education (Lorde 1984), because it helps to move teachers and students out of a cycle of self-pity, blame, or guilt into a mode of action that somehow responds to injustice. For example, civic anger can be promoted in the classroom as a form of cultivating individual and collective political
consciousness and social resistance to injustices in the students’ community, although anger is not inevitably emancipatory. However, recognizing the positive power of anger and its link to the struggle against injustice in one’s own community is valuable, if teachers want to promote

The pedagogical challenge for critical pedagogues is how to encourage

options for action that may change the conditions of others’ vulnerability.

students to become active participants with a nuanced understanding of the emotional complexities
involved in histories of injustice and oppression .

Leong evidence doesn’t apply – it’s a critique of new materialisms, which is like object
oriented ontology – it’s not a K of active political engagement.