TCS Daily

Debatable Assumptions

By Arnold Kling - July 25, 2007 12:00 AM

"there will exist other better, yet more utopian, proposals...when we reject those 'better proposals,' we end up arguing that they are excessively utopian. Why are these reforms too utopian while ours are not?"
--Tyler Cowen

In public policy debates, it is common to claim that the other side has different goals. "They just want to screw the poor." "My opponent is a Communist." And so on.

However, it is possible to agree on goals but disagree on assumptions about what will achieve those goals. In fact, I think that it is reasonable to assume that political opponents disagree primarily in their assumptions rather than in their goals. In Tyler Cowen's terminology, our disagreements are about what is feasible rather than about what is desirable.

If my assumption is correct, then political debate would be more enlightening if we asked proponents to focus on their assumptions. When you say that your policy proposal would be an improvement, what are the key assumptions behind that statement?

Scoring the Assumptions

For example, suppose that someone proposes that health insurance should be made mandatory. Below are a set of assumptions that might be consistent with such a policy. In parentheses, I give a score that indicates my degree of belief in the assumption. The scale goes from 1 to 5, where 5 means that I strongly accept the assumption, and 1 means that I am highly skeptical of the assumption.

--People who do not buy health insurance will nonetheless obtain medical treatment. (5)

--When the uninsured are treated, the cost of their care necessarily falls on someone else. (2)

--People who are uninsured tend to fail to obtain preventive care. (5)

--The uninsured fail to obtain preventive care because they are uninsured. (2)

--This failure to obtain preventive care substantially raises costs in the long run. (2)

--The government can design a mandatory health insurance package that balances the needs of consumers, health care providers, and the providers of the insurance (which could be either private insurance companies or taxpayers or some combination). (2)

I do not believe that the cost of treating the uninsured necessarily falls on someone else. As one of my correspondents frequently points out, the taxpayers could provide funding for the treatment in the form of a loan rather than a gift, and the government could be quite aggressive about collecting any such outstanding loans.

One can argue that in practice we do fund the treatment of the uninsured through cost-shifting. It is only fair to compare mandatory health insurance with this reality, not to a hypothetical alternative. Point taken.

Many people are more convinced than I am that lack of health insurance causes major health problems, due to failure to obtain preventive care. There is an urban legend that 20,000 people die each year for lack of health insurance. The Institute of Medicine may be the original source for this claim, in which case it is based on superficial correlations, not on controlled studies that would be required in order to make a claim about, say, a new pharmaceutical. In careful comparisons of similar groups of people, it is rare to find significant differences in longevity based on levels of health care spending, which makes it unlikely that one can demonstrate a causal relationship between health insurance and longevity.

The famous RAND experiment found that decreasing insurance coverage reduced the use of preventive care, but without a significant overall adverse effect on health outcomes. Another analysis, by Amy Finkelstein, showed that Medicare increased health care utilization substantially, again with little noticeable impact on health outcomes.

I can believe that there is a significant group among the uninsured who take poorer care of their health than the rest of us. But I am not convinced that forcing those people to buy health insurance will make them take better care of themselves. It might even do the opposite.

My main area of skepticism about mandatory health insurance is the ability of government to design a health insurance package. In Massachusetts, for example, provider lobbies have a long history of dictating coverages that most consumers do not want. This is adversely affecting the Massachusetts health plan, where the premiums are likely to be double what was promised, if not higher.

The Assumptions Behind My Proposals

We can also examine the assumptions behind my own proposals on health care. For example, I have frequently recommended raising the age of eligibility for Medicare for people currently aged 50 and younger. The age might be 72, with gradual increases for younger workers as longevity continues to rise. I would state the assumptions behind this approach as follows.

--Within the next two decades, we will have to make major cuts in Medicare benefits in order to make the system sustainable. (5)

--Raising the age of eligibility now gives individuals the opportunity to make plans to provide saving and insurance to cover the reduction in Medicare coverage. (5)

--Many individuals actually would increase their use savings and purchases of private insurance rather than face devastating financial setbacks due to medical expenses between age 65 and 72. (3)

This exercise points out that the weakest assumption in my approach is that individuals would adapt to a higher age of eligibility and make appropriate long-term plans. Of course, any alternative approach to Medicare is also going to rest on some weak assumptions, such as an assumption that "cost control" will be effective.

The Corporate Setting

Inside corporations, government agencies, and other bureaucracies, acrimonious debates also break out. In these settings, I also would recommend assuming that everyone shares the same goals and framing the argument in terms of assumptions. When someone argues for a new marketing initiative or a particular systems development project, everyone should try to articulate the chain of assumptions that justify the proposal. Then have people score the assumptions. Scoring the assumptions is a way of taking the emotion out of disagreements. Divergence in scores will help to highlight the risks and uncertainties that surround the decision, so that perhaps people can find ways to test the critical assumptions before proceeding further.

The next time you hear someone make a proposal that you find outrageous, try getting at the assumptions behind it. See if you can identify which assumptions are 4's and 5's in terms of the advocate's confidence but 1's and 2's in terms of your own confidence. My guess is that this approach will lead to more constructive discussions and less personal antagonism.

Sometimes, assumptions simply are not compatible. If one person assumes that life begins at conception and someone else does not, there is not much room to resolve the issue through compromise or further study. Also, there may be situations where people really do disagree on goals, so that going over assumptions is futile. However, my bet would be that much more often differences in assumptions are at the heart of disagreement.

Arnold Kling is an adjunct scholar at the Cato Institute.


One key assumption
Arnold in your essay was this one:

"People who do not buy health insurance will nonetheless obtain medical treatment. (5)"

which you accept with high confidence.

Is there any evidence to support this contention, because think this one is key with respect to the public-private debate?

Why is it that the goal of GOVAGs' actions is
to benefit this or that group, or solve this or that problem, when this country started off by saying "and Governments are constituted among men to secure these Rights (to Life, Liberty and Pursuit of Happiness"?

How come we came to such a pass?

Why not bring the GOVAGs back to the Rights track from the "Confer this or that Benefit" track and/or "Solve this or that Problem" track?

Why is it that the word Right very rarely appears in the articles (or in the comments section)discussing GOVAGs actual and/or proposed and/or hypothetical actions?

Why and how has Right become a four-letter word not to be used in polite company?


An example:
Soon after I was separated from the service, I broke my leg in cycling accident. I hade no insurance. The ambulance came, I was admitted to the hospital, the surgeon reconstructed my lower leg, and I was released with a bill for just over ten thousand dollars. I immediately, worked my ass off to pay the debt. This took me about a year to accomplish and I did it with much gratitude and pride. At every step, someone volunteered to help me, rather than to leave me on the pavement with my foot turned out and backwards. As it turns out, I could have used VA benefits, but I didn't know about them and in retrospect, it was a very positive exercise for me to be self-responsible for my accidents and debts.

Another assumption re health insurance
Another assumption that supports the policy is that younger, healthier people tend not to carry health insurance. They don't think they "need" it.

To the extent they are right, their non-participation raises the per capita costs for the remaining insureds because they, who use less medical care, pay nothing rather than simply a smaller amount based on their age.

And, of course, if they are wrong and are injured or get unexpectedly sick, the assumptions listed in the main post kick in and care is provided to them anyway.

Assumption: Health care costs will always rise.
They will if they are subsidized.

Health outcomes
I can provide two such examples. Twice I came to require serious health care while not insured. The first time I convinced them I would pay, and in fact paid back the $40K they extended to me in care.

The second time I needed an operation-- still uninsured. This time they gave me $115K in treatment up front. I repaid them.

But those amounts, in terms of serious health care, are chicken feed. Let's say a family with low earnings who is poorly spoken (whereas I can have quite a silvery tongue when motivated by the imminence of my own demise) and has no health plan, has a member requiring $300K in work. It's not going to happen.

Such people have two choices. Either they go to the local television news channels with a heart rending appeal (this happens with a fair frequency) or the family member dies. Often they end up in Plan B-- lack of treatment leading to death.

Far more often, of course, is that they end up being treated in one of those rural clinics whose outcomes rank in the lowest ten percent. They may live, but for the rest of their span they're just not right.

insurance and preventative care
Arnold's assumption about the uninsured and seeking preventative care brought to mind a recent report by The United Health Group about consumers with high-deductible insurance plans (that qualify for Health Savings Accounts):

* CDHP [Consumer-Driven Health Plan] consumers more likely to make active and informed decisions about their own health and health care needs

* Increased use of preventive care services seen among CDHP members as compared to PPO enrollees"

- Brian T. Schwartz

low-risk people and insurance
I think there is a fallacy in suggesting that if low-risk people stay out of insurance pools that raises the cost for others.

Suppose that low-risk people are charged fair premiums that reflect their low risk. Then whether or not they stay in the pool does not matter.

The hidden assumption that you are making is that you assume that low-risk people subsidize high-risk people. That does not have to be the case. It could be that high-risk people are charged high premiums, and low-risk people are charged low premiums.

Making the assumption
Underlying the assumption is often another assumption: "He would do X. I could not do X unless I were a Communist/Profiteer/Slavetaker/Devil, therefore he must be a Communist/Profiteer/Slavetaker/Devil." This extends even to those disagreements (like abortion) where the goals are not common and cannot be reconciled.

Having a civilized disagreement requires getting over this assumption, or at least being explicit about it.

Ever ask why it cost so much?

Arnold Kling?
If this is you, why not address why the costs are so high?

Need to elect responsible members of Congress
"“They’ve been stalling,’’ said John W. Olver, D-Mass., chairman of the House Transportation-HUD Appropriations Subcommittee. “They are nihilists. They are jihadists.”"

MA is not known for its responsible members of Congress.

The reason health care costs so much more in the US than it does anywhere else is because it is organized around the profit principle. There is no regulatory mechanism within the government with a mandate to keep costs down. Not even Medicare-Medicaid.

To pretend to think otherwise would be to be wilfully oblivious.

Other nations keep costs down because they put a lid on profits. In their thinking (mine too) the public's health is a more important virtue than untrammeled capitalism.

people with disease and insurance

>"I think there is a fallacy in suggesting that if low-risk people stay out of insurance pools that raises the cost for others."

I would disagree. Low-risk people staying out of insurance pools means less money in the kitty to pay for claims. As claims go up, costs go up, the absence of low-risk people in the pool means the added costs go to everyone else in the pool, is spread over fewer people.

>"The hidden assumption that you are making is that you assume that low-risk people subsidize high-risk people. That does not have to be the case. It could be that high-risk people are charged high premiums, and low-risk people are charged low premiums."

Actually, I think the missing assumption is that of sick people. A person with a disease who takes medication continuously likely costs more than the premiums paid by that person. So the cost IS passed on to everyone else in the pool to cover the additional expense. Given the cost of pharmaceutical drugs, its easy for one sick person to take $2,000 a month in medications. Very few people could afford $2K a month in premiums, very few, if any, actually pay that much in premiums.

I support the idea of lower premiums for low-risk people and vice versa. You can talk about low-risk/high-risk all day long, but I think the most important factor is how many people are in the pool taking $1K, $2K, $3K worth of medication each month. They absolutely exist, and are more common than ever, adding that the price of drugs are going up on top of that, I think it is automatic that everyone in the pool will subsidize costs for high-risk people, or more accurately, people with disease. I don't know if anyone else has noticed, but that seems to be everyone over the age of 50 these days. I don't know anyone over 50 who isn't taking some kind of medication, may not cost a grand a month, but does it cost more than the cost of premiums? Thats what it comes down to.

I think low-risk people are needed in the pool to help defray claim costs for high-risk. Everyone in the insurance pool subsidizes each other, is how I think of it. Some are a net negative and some are a net positive in the pool. But insurance companies are still making money, gobs of money, so they have it figured out to an extent. Unfortunately, its profit they're driven by, not whats best for customers/patients.

I hope this explanation of an assumption highlights why its easy to be skeptical of pharma and insurance corporations. One drives up the price, the other responds by raising the price, people are in the middle getting squeezed. But people are to blame also for unhealthy habits, its certainly not solely the corporations' fault.

It's more than just profits
When you compare the US to other nations such as Canada or the UK or the Scandinavian countries, what you discover is that their total health care costs p/c are lower. It's true that all of these jurisdictions have sometimes significant waiting lists for certain kinds of care, sometimes even emergency care. To an extent, Michael Moore's Sicko missed a bit of the point. State-insured medicine in Canada doesn't provide better health care, it provides it at lower cost on a universal basis. However, it has a large private sector business in it, namely all of the medical practitioners who run their offices as small businesses (all of them). Second, Canada has a rule which the US government dislikes of requiring practitioners to prescribe the lowest cost version of any particular prescription, usually the generic copy of an innovator product. Third, there's no private insurance involved except as a top-up beyond the basic level of care provided by the government insurance. Where Canada falls flat compared to other jurisdictions, notably Sweden, is that it charges no user fees at all for state medical services.

In short, I'm suggesting that an outcome of state-insured medicine is a method of restricting total health care costs rather than providing better care for most in a private insured system. It's not because there's no profits in the system, it's that they are to some extent rationed by government budgets.

The net effect of all this is to provide overall lower GDP health care on a universal basis but results in lengthy waiting lists for more expensive services, such as organ transplants and joint replacements, that can be purchased in the US.

The result of this is that innovation in new technology tends to be lower. With a health care system dominated by direct user costs and fixed by government budgets, capital for new equipment such as MRI or PET tends to be scarce. Over time, this can result in higher inefficiency and increasing costs through things like increasingly outdated diagnostics.

So my conclusion is that Michael Moore may signficantly overstate the case and perpetuate a number of myths and errors, but one ironclad fact is true: the US pays more for healthcare on a per capita basis than any other nation in the OECD and has less than 100 per cent of its citizenry covered. Draw up a list: in one you have all those countries which ensure universal health care for all citizens consisting of all OECD and East Bloc nations, as well as all the highly industrialized nations in Asia. In the other list, those without universal health care, you have most of the Third World nations, and the US.

So it's simple, to which club do we wish to belong?

How much clear profit did your fees generate?
How much went to subsidize those who can't pay?

How much went to subsidize the inefficiency created by third party payments?

Ever get an itemized bill?

How much did you pay for a tissue?

learn the basics about risk
"Low-risk people staying out of insurance pools means less money in the kitty to pay for claims. "

This is just wrong. If it were true, then low-risk people would be subsidizing high-risk people.

In the mortgage market, there are various gradations of borrowers. The subprime borrowers pay higher interest rates. When they default, it's not the high-grade borrowers who subsidize them. It's the other subprime borrowers who don't default.

Similarly, in health insurance, in principle there should be pricing for risk. If you are high risk, you pay high premiums. You don't get subsidized by someone who is low risk.

In practice, risk sorting often does not happen. It is illegal in many states. In those states, the insurance company has to treat everyone as if they were high risk, and so premiums are very high.

Now, you could make it illegal for insurance companies to sort on the basis of risk, and you could also make health insurance mandatory. That way you force people who are young, don't smoke, etc., to subsidize high-risk people. That's not real insurance. That's government-engineered charity for high-risk people.

I know plenty of people over 50 who don't use meds...
Most of the people I know over 50 don't take prescription medications. Several people under 50 I know go to doctors for these medications to be prescribed to them. The trick is to avoid going to the doctor unless absolutely necessary so they aren't even tempted to prescribe meds to you. Most people I've known would be totally broke if they had to pay $1,000 or more per month on prescriptions! You don't see me buying 'health insurance' because I rarely if ever go to hospitals or doctors. I'll pay cash if I have a need for medical attention.(even if some goes to subsidize medical care for someone worse off financially than me) I would sooner vote for Hillary as to have to buy mandatory health insurance to subsidize 'preventive' care or meds.

Here's my vote
Feel free to disagree. I'll go with a universal system that limits payouts for services to a realistic schedule of fees-- one in which the premiums charged by the insuror equal the cost of total services to all customers.

Medical practitioners won't be making as much as they would under Medicare, for instance (current costs in that program are clearly not sustainable). So doctors not willing to go along with the game plan would be free to emigrate to Kinshasa, or the Caymans, or wherever the hell a free market in limitless health care still obtains.

I'll stay here.

Example of overpriced health care
I was injured in the mountains of Guatemala and went to an emergency room.

The bill was the equivalent of $100 ($75 for the x-ray and $25 for the doctor).

Initially, I thought I got a good deal, but was later told that I was overcharged that much because I was a "rich American."

Where is the incentive to innovate?
Why should any company invest in new MRI or artificial hearts or new drugs if they can't make any money?

How did Lasik surgery get better, faster and cheaper without subsidies?

There's hazards associated with looking 'rich' & being an American...
If you'd gone in there looking poor & Guatemalan you might have gotten a doctor for a dollar! What were the prices on other things like in Guatemala? Might make good retirement destination if you can lose that 'rich look' so they don't overcharge you on everything. Bet they don't charge locals the prices Americans are getting soaked for on meds either!

With respect to innovation
This has suffered under state insured systems in one principal area where they control drug costs. It's certainly not apparent that innovation in other areas has suffered. The principal profit area that has been eliminated by state insurance is private insurance, not the medical practitioners or their supplier companies.

So pharmaceuticals may be an issue. The question on the other side is, to what extent do intellectual property rights constitute a monopoly price structure?

The Real Problem... that medical insurance prevents there from being real competition in medical care. When we purchase automobile accident insurance, we are purchasing a policy to perform general repairs on an automobile, we are purchases protection from catostrophic accidents. Similarly, when we purchase homeowners insurance, we don't file a claim when the plaster cracks or the floors creak.

Why is medical insurance different? Why do we expect insurance to pay when we have to have a splinter removed from our toe?

The only places where medical care is DECREASING in costs is where the proceedure is elective, and thus not covered by insurance, i.e., Lasik, plastic surgery, etc. When there is real competition, and the consumer must pay out of pocket, guess what? Prices are held in check!

There are only two alternatives to reducing medical costs. Real competition (including the profit motive, beanie), or rationing with government price controls. I prefer the first, especially considering that if anybody thinks that the European or Canadian models are better, they are nuts.

Sure, we can have insurance for catstrophic events, and government subsidized care for the poor. Otherwise, I say that we should pay out of pocket. I guarantee that will REDUCE costs, AND improve care. That is what competition does: better products at a better price.


Are we talking risk, ideal or reality?
I agree with your comments ideally, but I'm confused by the shifting of focus.

>"This is just wrong. If it were true, then low-risk people would be subsidizing high-risk people."

Exactly, I'm saying it is true, low-risk does subsidize high-risk. You seem to confirm that to a degree later:

"In practice, risk sorting often does not happen. It is illegal in many states. In those states, the insurance company has to treat everyone as if they were high risk, and so premiums are very high."

Therefore, low-risk ARE subsidizing high-risk. Isn't that correct? The low-risk are paying premiums higher than necessary. At least in all my own experience in the work world, we all pay the same premium based on the plan we choose, regardless of risk.

Ideally, I mildly support the concept of risk sorting. But I also don't see how it totally removes the reality that low-risk will subsidize high-risk.

For example, unless the insurance company keeps strictly separate accounts and policies for high-risk vs. low-risk, so that money coming in from low-risk premiums is only used to pay low-risk claims, and vice versa, I don't see how everyone in the pool doesn't subsidize everyone else. Except of course, those who have claims that out-cost what they pay in premiums. Those people are subsidized by everyone else in the insurance pool, unless they're kept strictly separate.

It certainly seems possible insurance companies could do that, keep the accounts and policies strictly separate. So an increase in premiums for high-risk wouldn't affect premiums for low-risk, and vice versa. But does that happen anywhere? This is also a tad morally dubious. It groups the sick together and puts an extra burden on them, when they're already under extra stress because of an illness. And especially when a person transfers from low-risk to high-risk- they get sick and on top of that their premiums quadruple. And who decides who transfers? Do we really trust a company, in business to make a profit, to make a proper decision like that? I sure don't.

Which leads me to recognize a problem in this whole discussion- the focus on money. Given this environment, I understand why, but we're talking about health and well-being issues, when money is the main focus in such a discussion it automoatically subverts what should be the primary focus- peoples' health. Don't get me wrong, money is important in the equation, but it shouldn't be the top priority.

>"Now, you could make it illegal for insurance companies to sort on the basis of risk, and you could also make health insurance mandatory. That way you force people who are young, don't smoke, etc., to subsidize high-risk people. That's not real insurance. That's government-engineered charity for high-risk people."

I think you could do a combination that minimizes the subsidization. Someone gets screwed, thats the bottom line. You can screw everyone a little bit, it would include more subsidizing, but it would also mean everyone has insurance so if catastrophe hits they're covered, even if the healthy pay a little more than they should have to. Or you can screw the sick by a heavy margin, reduce or remove subsidizing, save the healthy some money and possibly leave them unprotected if they choose not to be covered.

Why doesn't anyone address the COSTS of medical care?
Parents whine and moan about the costs of higher education and rush out to find loans and grants to cover the costs.

Why are the costs of a university education rising so fast?

Same with health care. Why does it cost so much that it must be subsidized?

Lucky for you, so far
Why would you get defensive about being over 50 vs. under 50? Why even mention most people you know over 50 don't take prescriptions but several people you know under 50 do? Whats your point?

I agree- avoid going to the doctor if you can. Thats tough to avoid when diabetes, cancer, MS, alzheimers, etc., etc., etc. is attacking your body.

Most people I know as well would go broke paying $1,000 a month on medications. Thats why good insurance is such a huge benefit. You never know when disease will strike you. A thousand dollars a month on medication is easy to eclipse if you have a disease.

To each his own. You might be one of the very lucky, very few who never gets a disease or requires significant medical care in your lifetime. I toast your fortunes if so. But don't let it make you ignorant of reality in wider society. Or worse, heartless to the suffering of others.

The costs...
... for both situations rise faster than inflation due to the lack of a truly competitive market. College tuition is paid by grants, subsidized loans, scholarships, etc., and the schools are held captive by the tenure system. Similar, medical care is made noncompetitive due to insurance and government programs.

Make both of these truly competitive, and the costs will drop dramatically. I guarantee it!


What you paid
had to do with Guatemalan currency vs. United States currency, not "overpricing" in the U.S. (I am assuming that you're trying to demonstrate overcharging for medical care in the U.S., forgive me if I am wrong). That nation's currency and that nation's economy.

Even if they chose to "overcharge" you to get some of your wondrous American Dollars into their pockets while you still ended up with a great deal, the Guatemalan doctors can't very well charge U.S.-like prices for health care to people who would mostly not be able to pay the price. Not only would almost nobody in Guatemala be treated or healed, but additionally the doctors there would be without any practice at all in no time. Pricing has to roughly correspond to incomes. In the United States, we enjoy a superabundance of food at cheapo prices. But, the average Guatemalan, I will wager, would not be able to afford American prices for food, given the fact that as of 2005 the average Guatemalan was earning in Quetzals the equivalent of $5200 U.S.

Thanks to advances in medical technology being exported all around the world (with thanks most of all for that rightly going to the United States), routine broken bone care is common globally, and thus you didn't have too much to worry about with regards to the quality of the treatment regardless of the cheapo price.

God forbid if something truly catastrophic had happened to you down there.

No Subject
The people I know under 50 wouldn't need the prescriptions if they didn't go to the doctor so much. Doubtless they'd have me on more prescriptions than I could afford if went to the doctor & asked for them. Cheaper for me to stay on top of what I need to do to stay healthy so I won't get diabetes. Eat right things, get enough activity, that kind of stuff. If I put in the bank what the insurance company would charge to cover me it should be more than enough to cover an occasional hospital visit. Keeping up with your health issues on the internet can be very helpful, would recommend staying ahead of doctors on diseases affecting you for best health. I've noticed many prescription drugs have side effects worse than the condition they were meant to alleviate. That's another reason I avoid them whenever possible. Wish you well from whatever has been ailing you.

Assuming solutions
In the healthcare debate, the first assumption I encounter is that there are problems needing solutions. Within this first assumptions are several others, including the one that bothers me most - that the state can affect popular political solutions to the problems presented. I score my stance to this assumption as infinitessimally close to zero.

The reason for my stance is that in America, healthcare is a multi-faceted, complex, and rapidly advancing service that cannot be provided to every consumer on an equal basis. Yet for a state solution to be politically popular (and thus politically possible and sustainable), it must affect some measure of equality in access to healthcare.

Moreover, because medical advances must drain a deep pool of capital long before they become cheap enough for mass delivery, those who can´t provide some of the necessary advance capital can´t gain access to the medical advances at the time they become deliverable. Draining the pool of capital by extending immediate access rights to non-contributors will put the brakes on medical advances.

This fundamental problem can´t be overcome by offering the public fisc as the capital pool to fund medical advances or immediate access to them without causing severe economic harm and undercutting vital public services. Therefore, unequal access to cutting-edge healthcare is a built-in aspect that can´t be overcome, or "solved" by anyone, particularly the state.

Either live with a dynamic healthcare system characterized by unequal access and rapid advances or a stagnant healthcare system with equal access with few advances. This seems to me be the assumption-stripped choice America is presented with.

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