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  The Do No Harm Affirmative Case:
    Case Overview and Strategy
I. Case Overview

Here is the structure of the case:

America's mental care system is not functioning properly because:
  • We are giving too little care to people who need it; and
  • We are giving too much care to people who don't need it.
Why is this happening? Partly because:
  • Too many people who are mentally ill do not have insurance coverage for mental health services.
  • Too many people who have coverage have the wrong kind of coverage.
Why is that? In part because of government policies that:
  • Encourage employer-provided insurance rather than individually owned insurance.
  • Encourage third-party insurance rather than individual self-insurance.
  • Encourage government insurance rather than private insurance.

By approaching the issue in this way, Affirmative teams will be able to present a case that (a) identifies all of the major ways in which government policies create distortions, (b) establishes that these distortions have adverse unintended consequences for mental health patients and (c) provides for the correction of those distortions (and therefore the alleviation of the harms they inflict). Note: The distortions we identify are distortions that are bad in their own right (independent of mental health) and have adverse consequences for the health care system as a whole. However, it turns out that the consequences are especially bad for those with mental health problems.

II. Case Strategy

Just as doctors are supposed to follow the Hippocratic Oath's injunction to "first do no harm," so policy makers should ensure that they are not inadvertently contributing to the very problems they are trying to solve. There is systematic discrimination against the mentally ill throughout our health care system. But this is not the result of natural market forces. Instead, it is caused by unwise government policies. The solution to the problem is reforms whose goal is "do no harm."

The Do No Harm Affirmative case lends itself to a two-pronged strategy:

1. In the First Affirmative Constructive, the Affirmative team should establish a strong link between Inherency (the problems of current policies) and Harms (the consequences of those policies). Specifically, Affirmative teams should concentrate on the following results of bad policies:

A. Because of the bias toward employer-provision:
  • People with mental health problems are less likely to be insured.
  • Those who are insured are less likely to have coverage for mental health.
  • Those who have coverage for mental health are likely to have coverage that is incomplete and inferior to coverage for other health problems.
  • Those who have coverage for mental health are more likely to lose their coverage because of a change in job status.

B. Because of the bias toward third-party provision, people with mental health problems are likely to have the wrong kind of insurance - relying too much on third-party payment and too little on self-insurance through accounts that patients own and control.

C. Because of the bias toward government provision, many enrolled in such programs as Medicare, Medicaid and S-CHIP are likely to have mental health coverage that is inferior to coverage in the private sector.

2. When presenting the Affirmative plan in the Second Affirmative Constructive, the Affirmative team should link the components of the plan to the causes of the Harms. Specifically, the Affirmative plan should be presented as a method of solving for three government policy failures:
  • Bias toward employer-provision
  • Bias toward third-party provision
  • Bias toward government provision
Specifically, it should propose to remove government as a cause of problems by:
  • Removing the bias toward employer-provided insurance by giving people just as much incentive to acquire individually owned, personal and portable insurance.
  • Removing the bias toward third-party insurance by giving people just as much incentive to self-insure through Medical Savings Accounts.
  • Removing the bias toward government insurance programs by giving all enrollees the opportunity to enroll in private insurance plans instead.

These "solutions" will not solve all our problems. But they will keep government from being a cause of systematic discrimination against people who suffer from mental illness.

How this Case Differs from Most Common Affirmative Cases

Technique. The case developed here is a shotgun approach. Many affirmative approaches will focus on problems at the surface of the health care system. This case seeks to identify the underlying causes of those surface problems and correct those problems at their root. While this is a generalist approach to the topic, the case contains a common theme that unites all the issues: the removal of government policies that are making our problems worse.

Advantages. The primary strength of this approach is that it allows the affirmative team to argue from the position of a vision of the health care system that is comprehensive, integrated and non-contradictory. For a general description (that has no particular reference to mental health) see John C. Goodman's . There are risks in not taking this approach. The reason: the health care system is very complex. Fiddling with one part of it invariably causes reverberations in other parts of it. So affirmative teams are likely to get drawn into defending an overall vision of what the health care system should look like, whether they like it or not.

Example: Take an affirmative case that advocates mental health parity (requiring that mental illness and physical illness be treated equally in health insurance plans). Won't such a mandate raise the cost of insurance? Yes. Won't that cause more people to be uninsured? Yes. Won't that cause more people to rely on free care programs or enroll in government insurance programs? Yes. Won't that raise costs to taxpayers? Yes. Won't that cause employers and insurers to revise their policies to cut back on other benefits? Yes. Won't that cause employers to screen potential employees more carefully to weed out ones with (potentially costly) mental health problems? Yes.

In short, what begins as an apparently very narrow case has the potential to draw the affirmative into defending a vision about what to do about the problem of health care costs, the uninsured, employer provision, group versus individual insurance, the roll of public programs etc.

Disadvantages. This case requires the affirmative team to have a broad, comprehensive understanding of health economics. The reason: this case is based on explaining economic incentives and why they need to be changed. Further, it is a comprehensive approach to incentives, covering virtually every aspect of the health care system.

Variations. As an alternative to the case presented here, affirmative teams may want to consider developing a more narrow approach. In general, the "Do No Harm" case could be broken down into three or four separate cases. The NCPA will develop these over the next few months.

Status. This case is preliminary. The NCPA will revise and improve over the next few months.

 
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