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The General Agreement On Trade In Services: Implications For Health Policymakers (Health Affairs)

The General Agreement on Trade in Services (GATS), created under the auspices of the World Trade Organization, aims to regulate measures affecting international trade in services—including health services such as health insurance, hospital services, telemedicine, and acquisition of medical treatment abroad. The agreement has been the subject of great controversy, for it may affect the freedom with which countries can change the shape of their domestic health care systems. We explain the rationale behind the agreement and discuss its scope. We also address the major controversies surrounding the GATS and their implications for the U.S. health care system

The General Agreement On Trade In Services: Implications For Health Policymakers (Health Affairs)

The General Agreement on Trade in Services (GATS), created under the auspices of the World Trade Organization, aims to regulate measures affecting international trade in services—including health services such as health insurance, hospital services, telemedicine, and acquisition of medical treatment abroad. The agreement has been the subject of great controversy, for it may affect the freedom with which countries can change the shape of their domestic health care systems. We explain the rationale behind the agreement and discuss its scope. We also address the major controversies surrounding the GATS and their implications for the U.S. health care system

LOOTING:The Economic Underworld of Bankruptcy for Profit.

NBER Working Paper No. R1869 During the 1980s, a number of unusual financial crises occurred. In Chile, for example, the financial sector collapsed, leaving the government with responsibility for extensive foreign debts. In the United States, large numbers of government-insured savings and loans became insolvent - and the government picked up the tab. In Dallas, Texas, real estate prices and construction continued to boom even after vacancies had skyrocketed, and the suffered a dramatic collapse. Also in the United States, the junk bond market, which fueled the takeover wave, had a similar boom and bust. In this paper, we use simple theory and direct evidence to highlight a common thread that runs through these four episodes. The theory suggests that this common thread may be relevant to other cases in which countries took on excessive foreign debt, governments had to bail out insolvent financial institutions, real estate prices increased dramatically and then fell, or new financial markets experienced a boom and bust. We describe the evidence, however, only for the cases of financial crisis in Chile, the thrift crisis in the United States, Dallas real estate and thrifts, and junk bonds. Our theoretical analysis shows that an economic underground can come to life if firms have an incentive to go broke for profit at society's expense (to loot) instead of to go for broke (to gamble on success). Bankruptcy for profit will occur if poor accounting, lax regulation, or low penalties for abuse give owners an incentive to pay themselves more than their firms are worth and then default on their debt obligations.

The Scope of GATS and of Its Obligations by Bregt Natens, Jan Wouters

Bregt Natens, Jan Wouters - KU Leuven - Leuven Centre for Global Governance Studies Date Written: August 1, 2013 Abstract The GATS preamble already highlights the inevitable conflict between on the one hand achieving progressively higher levels of liberalization of trade in services in order to expand trade in services and promote growth, and on the other hand the right to introduce new regulation to meet national policy objectives. Hence, it was clear from the outset that the balance between trade liberalisation and domestic regulatory autonomy would be key in interpreting the constructively ambiguous GATS. The outcome of this exercise depends on three factors: the interpretation of (i) GATS’ overarching objectives, (ii) of the general scope of GATS and of the obligations arising from it (and the exceptions to them) and (iii) of the inherent individual flexibility of GATS. Whilst also touching on the first, this contribution mainly focuses on the second factor by addressing the scope of GATS, of its unconditional obligations, of obligations applying to sectors for which specific commitments have been scheduled and of obligations in GATS Annexes. Additionally, it provides an overview of the structure of GATS obligations. The third factor is mainly addressed throughout textboxes which provide an illustrative insight into how the European Union has used the inherent GATS flexibility to shape its obligations. Keywords: WTO, World Trade Organization, GATS, General Agreement on Trade in Services, services, scope, obligations, governmental authority exception

Adapting to a Highly Automated World

This is a very good paper that asks hard questions about what may happen in the near future as we get better and better at saving more and more labor. Its quite old but its very well done so it ages quite well, as a longtime amateur futurist I think more honest than many newer explorations of the same issues.

"Pre-Established" (status) and Financial Services Regulation in the GATS agreement

The status of whether a domestic law or regulation pre-existed the GATS agreement is an important status under WTO law. If an instrument or measure pre-existed the GATS it has far more lattitude to break GATS rules. This is why if we wait much longer, it may be very expensive, (based on the value of the lost business) perhaps nearly impossibly so, to establish a new "Medicare For All" (which does break GATS rules in a number of ways, for example, see Skala's paper) unless we immediately start the process of exiting and seeking carve outs from the GATS as far as this service sector. We should also start consulting experts so we can do that without destroying Medicare or Social Security's protection from GATS.

TISA Troubles

This study, co-published with the Rosa Luxemburg Foundation, examines the adverse impacts on public services and public interest regulation of the little-known Trade in Services Agreement (TiSA), quietly being negotiated in Geneva by a group of 23 governments, including Canada. Senior CCPA trade researcher Scott Sinclair argues that under the guise of expanding international trade in services, TiSA will make it much harder for governments to regulate vital services such as energy, water, banking, transport and online services. The agreement is also designed to pry open public services to commercial involvement. While this agenda may suit the commercial interests of the transnational corporations behind the secretive TiSA negotiations, it will not serve the broader public interest.

Higher social class predicts increased unethical behavior (PNAS)

Seven studies using experimental and naturalistic methods reveal that upper-class individuals behave more unethically than lower-class individuals. In studies 1 and 2, upper-class individuals were more likely to break the law while driving, relative to lower-class individuals. In follow-up laboratory studies, upper-class individuals were more likely to exhibit unethical decision-making tendencies (study 3), take valued goods from others (study 4), lie in a negotiation (study 5), cheat to increase their chances of winning a prize (study 6), and endorse unethical behavior at work (study 7) than were lower-class individuals. Mediator and moderator data demonstrated that upper-class individuals’ unethical tendencies are accounted for, in part, by their more favorable attitudes toward greed.

GATS Backgrounder from Public Citizen (2005)

“Governments are free in principle to pursue any national policy objectives provided the relevant measures are compatible with the GATS.” –WTO, Oct. 1999 “GATS provides guarantees over a much wider field of regulation and law than the GATT; the right of establishment and the obligation to treat foreign services suppliers fairly and objectively in all relevant areas of domestic regulation extend the reach of the Agreement into areas never before recognized as trade policy.” Good intro to/overview of GATS-

Maine CTPC Health Care Subcommittee Draft Report on GATS barriers to state health care reforms

This report was prepared for the state of Maine by trade experts from Georgetown University. It shows some of the hidden traps faced by states that attempt to make it possible for the working poor to afford better quality health care. This report is a must read for anybody interested in the United States health insurance situation. Note that we need to withdraw our country from these service sectors to be able to fix this problem. Note also that the situation could become much worse if additional trade agreements are signed, such as the "Friends of Services" negotiations going on in Geneva in 2006, which became TISA.

WTO - legal texts - Understanding on Commitments in Financial Services

"As of 2009, the 33 countries whose current schedules reference the Understanding include: Australia, Austria, Bulgaria, Canada, Czech Republic, Finland, Hungary, Iceland, Japan, Liechtenstein, New Zealand, Norway, Slovak Republic, Sweden, Switzerland, and the United States, as well as the European Communities members as of 1994 (Belgium, Denmark, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain and the United Kingdom.) The only developing nations that utilized the Understanding were Aruba, Netherland Antilles, Nigeria, Sri Lanka (for banking not insurance), and Turkey. Additionally, eight countries (Cyprus, Estonia, Latvia, Lithuania, Malta, Poland, Romania, and Slovenia) were in the process of revising their commitments to match the EC schedule" (from the commentary by Jane Kelsey on TISA Financial Services text) -- This document regulates government regulation of financial services like banking and insurance, including health insurance, greatly limiting what we can do. In particular it is thought to freeze new financial services regulations after its signing date, unless they were enumerated then. In the case of the US that date is February 26, 1998. If challenged in a WTO dispute proceeding a country that has violated a "standstill" may have to roll back its regulatory state to the level of regulation in effect on that date. A related concept, "ratchet" is also said to apply in WTO law - it denotes a one way capture of all deregulation in a committed sector making it a violation to re-regulate. See the definitions of "standstill", "rollback" and "ratchet" in trade parlance.

Interpretation of Article I, Section 3 (b) and (c) of GATS - PublicServicesScope

This is another article discussing the important "governmental authority exception" which defines the scope of GATS jurisdiction. (and what can be seen as a public service under GATS, the definition is very narrow- everything else is subject to all sorts of rules which bar government subsidization except if its 'minimally trade restrictive') - by Markus Krajewski

State Health Reform Flatlines

US states and the Federal government have tried the same things over and over again, and have repeatedly failed to make for-profit health insurance - especially nongroup insurance, affordable as more and more Americans fell theough the cracks. This paper details the history up to the mid 2000s. It shows how despite knowledge in high places that the strategies being used don't work, they continue to be recycled. (This is because the GATS and recent, even more ideologically extreme rules give them no choices that would work, and the ideology is a higher priority than people's lives.) Meanwhile 50-120 Americans die each day due to preventable factors amenable to improved healthcare or improved access to healthcare.

GATS and Women

"GATS is likely to have a disproportionately negative impact on women"

Model clauses for the exclusion of public services from trade and investment agreements ( EPSU & Markus Krajewski)

This paper discusses how trade agreements could be modified in the EU to protect their existing public services from trade and investment agreements which are designed to tear them apart and privatize public services against the people's will, behind their backs. _______ Unfortunately the EU examples given are much less applicable to the US because we are trying to do something which we ourselves devoted a great deal of energy into preventing by creating the WTO, other economic governance organizations and making all these conditions binding on ourselves especially, which seem generally to only allow the poorest (LDC) countries to set up new public services and monopolies. Also look up "LDC Services Waiver" for a related issue involving the jobs.

Ellen Gould discusses GATS on Talking Stick TV.

Video - Ellen Gould is a trade expert whose insight here is quite accurate. See what she tells us here about domestic regulations, technical standrds, licensing, medical standards, everything. Lots of info on what they want to do with healthcare. The WTO could sanction us if we wanted our doctors to meet higher standards than those in the developing countries. (around 25:00) The WTO also wants us to allow for profit offshoring of poor patients. Which would be subject to the same problems as the for profit system does now, except likely worse, with less accountability.

GATS and Financial Services Deregulation by Patricia Arnold

Medicare, Social Security and other governmentally subsidized financial services are put in grave danger by the GATS - This paper by a noted professor in accounting who has written a great deal of highly readable material on the WTO and its interaction with financial regulation is a short and concise intro to many of the major issues, particularly the threats GATS poses to Social Security and Medicare if those areas are allowed to compete with commercial banks or insurers. Caution is needed because millions could see huge changes in their only retirement benefits just as they were needed the most if Social Security and/or Medicare lose their protection from GATS rules, which is likely if current proposals are implemented,- see the Annex on Financial Services.

GATS and Public Service Systems

This is a must-read article as its by far the most concise and understandable explanation of the "governmental authority exception" an all important "two-pronged test" or definition, that defines the scope of what is allowed to be a public service and what is not, in the GATS agreement. In other words, what is subject to privatization rules, and what isn't. This definition is also borrowed or imported, in the computer programming sense, "as is" into hundreds of other trade agreements all around the globe. So this essay is extremely useful in understanding which healthcare or higher education proposals could work (and which ones would be subjected to a death of a thousand cuts, and couldn't) for example. The essay was originally written and published by the government of British Columbia province in Canada.

How the World Trade Organisation is shaping domestic policies in health care

David Price, Allyson M Pollock, Jean Shaoul, THE LANCET - Vol 354 - November 27,1999, pp. 1889-1891 "Multinational and transnational corporations, including the pharmaceutical, insurance, and service sectors, are lining up to capture the chunks of gross domestic product that governments currently spend on public services such as education and health. The long tradition of European welfare states based on solidarity through community risk-pooling and publicly accountable services is being dismantled. The US and European Union governments are aggressively backing this project in the interests of their business corporations. But the assault on our hospitals and schools and public-service infrastructure depends ultimately on a promise from one government to another to expand private markets. Such promises can be kept only if domestic opposition to privatisation is held in check. We need to constantly reassert the principles and values on which European health-care systems are based and resist the WTO agenda"

Trading Health Care Away? GATS, Public Services and Privatisation

"But talks have since begun to change one of the 28 agreements overseen by the WTO -- the General Agreement on Trade in Services or GATS. The US, EU, Japan and Canada are trying to revise GATS so that it could be used to overturn almost any legislation governing services from national to local level. And non-government organisations (NGOs) and trade unions are demanding that services in the public interest be clearly exempt from GATS. It details how public services may not in fact be excluded from GATS and explores the implications for public health care."

Patient Mobility Beyond Calais: Health Services Under WTO Law by Markus Krajewski

"The paper analyses the impact of WTO law on transnational patient mobility by transplanting the Watts case of the European Court of Justice into WTO law. The first part of the paper concerns the question whether medical or hospital treatment abroad concerns “trade in (health) services” in the meaning of the GATS. This part identifies the legal construction of this notion through the four modes of supply and also gives a short factual account of the scope and structure of trade in health services on a global level. The next part will ask more directly which measures fall into the scope of the GATS. In particular, it has to be determined whether the exclusion of services supplied in the exercise of governmental authority from the GATS influences the application of the agreement to health and medical services. Having determined under which circumstances the GATS applies to measures affecting the cross-border supply of health services, the subsequent part of the chapter discusses the substantive obligations of the GATS. After a short overview of the main principles of the GATS, the chapter will provide an in depth inquiry into the specific commitments in health services of the EU and other WTO Members, because only the exact analysis of the limitations and qualifications of these schedules allows us to clearly determine the impact of the GATS on the cross-border to provision of health services. In addition, the potential of the general exception clause of the GATS to justify regulations of health systems which violate GATS obligations needs to be ascertained. Lastly, the legal status of GATS in the EU legal order, in particular the contentious issue of direct effect, needs to be assessed, because only if the GATS is directly applicable would a patient who received medical treatment abroad be able to rely on the agreement to claim reimbursement of the costs of said treatment."

Putting Health First - Canadian Centre for Policy Alternatives

Canadian Health Care Reform, Trade Treaties and Foreign Policy - this essay describes the traps in the GATS agreement for Canadian health care, it also discusses 'carve outs' and why they are needed by Canada to protect their Medicare (public health care) from Trade Agreements that try to destroy, and privatize them. This death of a thousand cuts is caused by GATS, that is what's been done to the UK's NHS.

Public Citizen: Medicare and Social Security - SOS: Save our Services from the WTO

Bottom Line: If the Bush administration succeeds in even partially privatizing Social Security, under the WTO GATS agreement foreign corporations could end up with treaty rights to raid our tax dollars for profit and Americans could face shredded retirement and Medicare safety nets. For now, Social Security is probably safe from the GATS because the agreement exempts services that are exclusively a government monopoly and are not also offered on a commercial basis. But if Social Security is even partially privatized — as the Bush administration is advocating — and folks begin to invest some of their federal retirement funds in the stock market, then GATS would require some things that the privatizers don’t want to talk about. The agreements would: * permit foreign and offshore firms to compete for private Social Security accounts, thus preventing the most stringent regulation of these accounts and increasing the risks to retirees; * make it harder to fix Social Security after the privatization experiment predictably fails, because GATS requires that nations first compensate all of their trading partners for lost future economic opportunity if they “take back” the service from the private sector and make it public again. * Failure to compensate would result in punitive trade sanctions, which is why some say GATS makes privatization a one-way street.

Public Citizen: Comments on International Services Agreement ("TISA")

TISA is the US and Australia's proposed "mext generation" trade agreement to promote global outsourcing and offshoring of services. Its "everything in by default" approach makes it much more likely to be dangerous and its effects unpredictable. It would block Medicare for All and limit public services to only those which met very narrow exceptions or were essential to national security. It would create a lot of dishonesty in government because what politician would honestly say that a trade agreement tied their hands from delivering positive change, only allowing corporations to take more and more?

Public Citizen: Health Care Memo

"...However, many of today’s international trade agreements establish binding obligations constraining federal, state and local government policy and actions in numerous service sectors, including health services. These rules are not limited to trade in services across borders, but also constrain government regulation of foreign service sector firms operating within the United States. As a result, today’s “trade” pacts are delving deeply into domestic regulatory issues that have little or nothing to do with the traditional concept of trade between nations".

Public Citizen: "Presidential Candidates' Key Proposals on Healthcare and Climate Will Require WTO Modifications"(2008)

This essay's by Public citizen explains how the 2008 Presidential candidates proposals (just as today) all violated provisions of the GATS agreement and US 'commitments' and other trade rules and how those commitments were likely to conflict with the promises, making them impossible or very difficult to implement the longer we waited. The references are extremely useful. Highly recommended you read this if you are interested in healthcare in the US.

Public Citizen: Threats to Health Care Policy

"The WTO’s GATS delves into “areas never before recognized as trade policy"... "The GATS represents a 180-degree turn from the U.S. approach to health care policy − away from regulating industries for the benefit of the consumer, and towards regulating governments for the benefit of multinational firms and industries".

The recent Achmea case has received a lot of news coverage in Europe but almost none of it actually explains what the case was about. This PDF..

contains a factual summary (on page 13) which explains that the case was about the electoral victory in Slovakia of a candidate who ran on a platform of restoring single payer health care in the country, as well as limiting the profits of any health insurer, in the intirim period to 20% changes which which were immediately attacked in the first of two Investor vs. State arbitral lawsuits. Slovakia lost the first round. This case is also a good introduction to the sordid history of the IntraEUBITS.

Joint Declaration on the GATS agreement and Higher Education

Public higher education is under attack, globally. This attack begun in an WTO agreement called the General Agreement on Trade in Services, or 'GATS'. This is a statement on the GATS by the organizations that accredit literally thousands of universities in the US, Canada, and the EU, including the European University Association on whose web site it is hosted.

Services Trade and the Uruguay Round: An Issue Overview (December 5, 1995 CRS 95-1169)

"The General Agreement on Trade in Services (GATS), which went into effect on January 1, 1995, is a significant achievement, but only a first step on the road to liberalization of services barriers. For the first time, legally enforceable multilateral rules and principles for services trade are part of the international trading system. At the same time, the immediate elimination or reduction of barriers to services transactions was much less than desired by many. The GATS, however, includes provisions for future negotiations to liberalize trade. The Congress will have an important consultation role in these negotiations. If agreements are achieved, legislation may be necessary to implement them."

The Potential Impact of the World Trade Organization's General Agreement on Trade in Services on Health System Reform and Regulation in the United States. (2009)

In this 2009 paper, the late Nicholas Skala explained the "GATS" agreement, its implications for US healthcare reform (its many conflicts with many of the things that were done in the ACA and which are proposed for Medicare For All) and why we urgently need to get carve-outs in the WTO (and the WTO's implications for Social Security and Medicare). He even gave us a sample of a carve-out-Its urgent that we do this, soon. This paper is a must-read for anybody interested in US health care reform and the obstacles to it.

Lori Wallach discusses 'standstill' in this short video on Democracy Now

The Trade in Services Agreement extends the WTO GATS agreement and does so in a way that attempts to legitimize it retrospectively, it seems. It even uses the (1990s) dates from the GATS agreement. Could it really act as a standstill effective in the 1990s exposing later attempts at regulation to challenge and roll back? It seems as if that may be what is happening. (speculation on my part) Why?