Student Example

Yusuf Ciftci wrote this persuasive research essay in Caitlin Hymans’ ENGL 200 class. It won first place in the 2021 Expository Program Writing Awards. Ciftci’s audience is legislative leadership in states that have not expanded to Medicaid.

Healthcare Equity and Social Justice 

The ideals of the American Revolution were founded on the concept of unalienable rights, described as “life, liberty, and the pursuit of happiness” in the Declaration of Independence. The inclusion of an endowed right to life is rather interesting. What constitutes the right to life? How can the government ensure a right to life among constituents? These difficult questions have dominated political discourse surrounding American healthcare since the early 20th century. In recent decades, rising healthcare costs, barriers to healthcare access, and deteriorating health outcomes among the general population have threatened this fundamental right to life. In response, legislative reforms have focused on mending inequalities within the American healthcare system. Most notably, the Affordable Care Act (ACA), colloquially known as Obamacare, significantly altered the structure of American healthcare in the past decade. A critical, yet controversial, component of the ACA focused on increasing healthcare coverage through Medicaid expansion, the premier federal safety net for socioeconomically disadvantaged individuals.

To explore why some legislators oppose Medicaid expansion, I will initially analyze the short- term fiscal impact of Medicaid expansion, barriers to healthcare delivery, and limitations on patient autonomy. Following this analysis, I will explore research on health outcomes, long- term health expenditures, and healthcare delivery reforms in Medicaid to understand the positive impacts of expansionary policies.

Many legislators who oppose Medicaid expansion are concerned about inefficiencies in Medicaid, directing attention to high tax rates and excessive spending throughout the years to maintain the program. Bryce Ward, a researcher on health economics with a Ph.D. from Harvard University, states that the median cost of Medicaid expansion for each state is approximately $100 million each year. Moreover, the federal government only covers the cost of expansion for the first three years of implementation, followed by incremental increases in state responsibility for the cost of expansion in successive years (2020). The substantial cost of Medicaid expansion, at $100 million each year, is concerning for legislators who are tasked with allocating limited funds to improve their communities. As a result, legislators may view opposing such large amounts of government spending as an appealing prospect to garner support among constituents.

Additionally, some are worried about the fiscal burden of Medicaid expansion on states after the three-year grace period. Given legislative term limits and recurrent election cycles, there is limited political incentive to undertake such a burdensome expansion in the view of some policymakers. Instead, legislators may focus on policies that are more likely to provide tangible short-term benefits to their communities. Rising tax rates introduce another dimension of complexity on the issue of Medicaid expansion. Ward (2020) states that “several states have explicitly raised taxes and fees to cover their share of Medicaid expansion.” Therefore, legislators who value limited government interference may be unwilling to adopt government- subsidized healthcare coverage and leverage their opposition to high tax-rates for constituent support. The fiscal impact of Medicaid expansion is a challenge that must be addressed if the ACA is to succeed in its goal of increasing access to healthcare.

Opponents of Medicaid expansion are also worried that expanding Medicaid may not improve short-term health outcomes because of barriers to healthcare delivery. Gordon et al. (2018), a group of health policy professors in leading medical schools across the nation, explored this endogenous relationship between healthcare delivery and health outcomes. According to their study, relatively low Medicaid reimbursement rates and the “administrative burden of navigating a state-run insurance program” led to historically low provider participation rates in 2018. Physicians are confronted with several barriers that prevent them from providing care for those in need. These include both bureaucratic restrictions on scope of practice and insurance companies requiring prior authorization for treatments. Moreover, providers interviewed as part of the study explicitly stated that inadequate investment placed a strain on providers and was not feasible in the short-term (Gordon et al., 2018). Thus, legislators may believe that Medicaid expansion negatively impacts healthcare workers who are reluctant to undertake the additional administrative burden of Medicaid expansion without adequate compensation.

On the other hand, such policies introduce an additional barrier to healthcare delivery and reinforce detrimental health outcomes among at-risk communities. One pediatrician specifically addressed barriers to mental healthcare, stating that “They [patients] have very poor access…[to] mental health services. The mental health services they do have, on paper don’t seem to solve the problems” (Gordon et al., 2018). Barriers to healthcare delivery place an undue burden on physicians, ultimately reflecting on patients in the form of disparate health outcomes. Presumably, a majority of legislators are concerned with public service and improving the lives of their constituents. As a result, some legislators may be hesitant to endorse Medicaid expansion without fundamental changes in healthcare delivery.

Finally, some legislative opponents of Medicaid expansion argue that the policy limits patient autonomy, the intrinsic right of patients to decide on medical care. In 2012, the Supreme Court reached a landmark decision ruling that critical parts of the ACA, including the Medicaid expansion mandate, were constitutional (National Federation of Independent Business v. Sebelius, 2012). However, on the question of whether Congress exceeded its power in withdrawing federal funds for states refusing to expand Medicaid, the Supreme Court ruled that “the Medicaid expansion provisions were unconstitutionally coercive as written.” Therefore, the federal government exceeded its power in leveraging federal funds to incentivize Medicaid expansion. This apparent overreach of power by the federal government may be worrying for some legislators who oppose Medicaid expansion. Among policymakers who value individual autonomy, the prospect of the federal government dictating medical care and coercing individuals to enroll in government-subsidized health coverage is likely to elicit strong opposition. As a result, legislators may appeal to constituents by publicly opposing “coercive” Medicaid expansion mandates and appearing to advocate for the common citizen in the face of government overreach.

I understand why some legislators may oppose Medicaid expansion as a mandate of the ACA because of its fiscal burden on constituents, inefficient healthcare delivery, and constraints on patient autonomy. However, I respectfully disagree with these arguments for several reasons. I believe that Medicaid expansion will decrease long-term healthcare costs, incentivize the development of efficient healthcare delivery models, and ultimately increase patient autonomy by resulting in a healthier population.

Medicaid expansion will lead to improved long-term health outcomes, effectively reducing healthcare costs and compensating for short-term costs. In his article “The Long-term Health Impacts of Medicaid and CHIP,” Owen Thompson, a professor of health economics, longitudinally tracked health outcomes among children benefitting from Medicaid coverage. The study suggests that “an additional year of public health insurance eligibility during childhood… substantially reduces health limitations, chronic conditions and asthma prevalence while improving self-rated health” (2017). The results indicate that healthcare coverage in early childhood translates to improved health outcomes and lower rates of chronic illness in adulthood. Essentially, Medicaid expansion serves to improve the health and lives of children. These long-term impacts may serve as an incentive for legislators who value intrinsic concepts like “the American Dream” and equality of opportunity. Essentially, children will have the opportunity to succeed and contribute to society as healthy individuals without experiencing burdensome health disparities. By endorsing Medicaid expansion, legislators will position themselves as advocates for future generations and demonstrate their investment in the long- term success of the communities they represent, an appealing prospect for any policymaker across the country.

Conversely, improved long-term health outcomes will reduce the fiscal burden of disease on individuals and the healthcare system, lowering healthcare costs as a result. The Centers for Disease Control, the leading public health institute in the nation, reports that treatment costs for individuals with chronic conditions constitute roughly 90% of all healthcare expenditures in the United States. Moreover, approximately 42% of the general population is diagnosed with a chronic condition (Buttorff, Ruder, and Bauman, 2017). Given that the United States spends $3.5 trillion on healthcare each year, chronic conditions represent a tremendous financial burden on patients, providers, and taxpayers alike. Additionally, the annual cost of Medicaid expansion is estimated at 100 million each year, a significantly smaller amount compared to the healthcare cost of treating chronic illness (Ward, 2020). As established by Thompson (2017), Medicaid expansion is correlated with improved long-term health outcomes and reduced rates of chronic disease. Therefore, reduced healthcare expenditures to treat chronic illness in the long-term will offset the short-term fiscal impact of Medicaid expansion on constituents. Once again, endorsing Medicaid expansion allows legislators to entrench themselves as advocates concerned with long-term success in communities they represent. Moreover, legislators concerned about the fiscal impact of Medicaid may view the long-term payoffs in the form of improved health outcomes and reduced expenditures as appealing factors.

Medicaid expansion has also benefited from flexibility at the state level, where different states have implemented various programs to improve Medicaid. States are commonly referred to as laboratories of democracy, as they often practice innovative or controversial programs before such policies are implemented on a federal level. Medicaid expansion is no exception to this trend. The State Innovation Models Initiative, sponsored by the Centers for Medicare and Medicaid Services (CMS), offers grants for states to implement innovative healthcare delivery models. For example, Maine and Minnesota have utilized these grants to implement the Patient-Centered Medical Homes (PCMH) primary care model for Medicaid recipients. This innovative healthcare delivery model coordinates patient care among providers, including primary care physicians, specialty providers, and long-term care specialists, among others (Van Vleet and Paradise, 2014).

Moreover, the PCMH model incorporates community and personalized wellness coaching into healthcare. According to a longitudinal study on the effect of PCMH on health outcomes, researchers found that patients receiving care under this coordinated care model had lower mortality rates, decreased rates of chronic illness, and lower numbers of visits to the emergency room (Jackson et al., 2013). These key indicators of long-term patient health outcomes may be encouraging for legislators who desire to improve the lives of their constituents and communities. Considering that the PCMH is one aspect of flexibility in healthcare delivery, there exists tremendous potential to implement other innovative models of healthcare delivery and improve healthcare outcomes across the nation through Medicaid expansion.

Another key provision of Medicaid integrates social determinants of health (SDOH) into healthcare, ultimately leading to reduced healthcare disparities and increased patient autonomy. The SDOH are commonly defined as socioeconomic and environmental factors that influence individual health. These include income, education, housing, and transportation (Alderwick and Gottlieb, 2019). According to a study by Braveman and Gottlieb (2014), socioeconomic status “follows a stepwise gradient pattern, with health improving incrementally as social position rises.” Moreover, this same study reported that “the number of U.S. deaths in 2000 attributable to low education, racial segregation, and low social support was comparable with the number of deaths attributable to myocardial infarction, cerebrovascular disease, and lung cancer, respectively.” The SDOH are a significant systemic barrier to healthcare access and negatively impact health outcomes among individuals.

Furthermore, these determinants limit patient autonomy, as patients are forced to choose between healthcare and essential expenses like food and rent. Thus, individuals are not afforded the right to choose medical care for themselves simply because they are unable to access healthcare. Provisions of Medicaid expansion integrate programs targeting SDOH inequalities with healthcare delivery, demonstrating tremendous potential to alleviate these systemic barriers to patient autonomy. This is an appealing prospect for legislators who value patient autonomy and desire to portray themselves as advocates of limited government interference.

Like many issues that impose significant challenges on the status quo, Medicaid expansion remains a controversial issue among legislators across the nation. There are legitimate concerns with the fiscal impact of Medicaid expansion, inefficient models of healthcare delivery, and possible limitations on patient autonomy among legislators who oppose Medicaid expansion. Nonetheless, I believe that the beneficial impacts of Medicaid expansion warrant its consideration as a tool to reduce healthcare disparities in the American healthcare system. Expansionary policies can achieve this goal by decreasing long-term health expenditures, incentivizing flexibility to develop efficient healthcare delivery models, and ultimately increasing patient autonomy. These outcomes represent important progress toward achieving the Declaration of Independence’s ideals of “right to life, liberty, and the pursuit of happiness.”

References

Alderwick, H., & Gottlieb, L. M. (2019). Meanings and misunderstandings: A social determinants of health lexicon for health care systems. The Milbank Quarterly, 97(2), 407.

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports (Washington, D.C.: 1974), 129 Suppl 2(Suppl 2), 19–31. https://doi.org/10.1177/00333549141291S206.

Buttorff, C., Ruder, T., and Bauman, M. (2017). Multiple chronic conditions in the United States, pp. 1-33. Santa Monica, CA: Rand.

Crumley, D., Lloyd, J., Pucciarello, M., & Stapelfeld, B. (2018). Addressing social determinants of health via Medicaid managed care contracts and section 1115 demonstrations. Center for Health Care Strategies. https://www. chcs. org/media/Addressing-SDOH-Medicaid- Contracts-1115-Demonstrations-121118. pdf.

Gordon, S. H., Gadbois, E. A., Shield, R. R., Vivier, P. M., Ndumele, C. D., & Trivedi, A. N. (2018). Qualitative perspectives of primary care providers who treat Medicaid managed care patients. BMC Health Services Research, 18(1), 728.

Health and Economic Costs of Chronic Diseases. (2020, September 15). Retrieved November 05, 2020, from https://www.cdc.gov/chronicdisease/about/costs/index.htm

Jackson, G. L., Powers, B. J., Chatterjee, R., Prvu Bettger, J., Kemper, A. R., Hasselblad, V., … & Gray, R. (2013). The patient-centered medical home: a systematic review. Annals of Internal Medicine, 158(3), 169-178.

Nat. Fedn. of Indep. Business v. Sebelius, 132 S. Ct. 2566, 567 U.S. 519, 183 L. Ed. 2d 450 (2012). Thompson, O. (2017). The long-term health impacts of Medicaid and CHIP. Journal of Health Economics, 51, 26-40.

Van Vleet, A., & Paradise, J. (2014). The state innovation models (SIM) program: an overview. Kaiser Family Foundation.

Ward, B. (2020). The impact of Medicaid expansion on states’ budgets. The Commonwealth Fund.

Student Example

MacKenzie Gwinner wrote this persuasive research essay in Jonathan Blake’s ENGL 200 class. Gwinner’s resistant readers are police officers.

Should the U.S. Use Needle Exchange Programs?

Needle Exchange Programs, also known as Syringe Exchange Programs, provide free syringes to people without a prescription. These are mostly used by people who use intravenous drugs. Many Needle Exchange Programs (NEPs) also provide access to and information about medical professionals and rehabilitation facilities and require one needle turned in for every needle given. Needle Exchange Programs are a controversial topic in America. Critics cite moral and safety concerns. Many people see Needle Exchange Programs as promoting drug abuse, increasing criminal activity, and creating unsafe communities. Law enforcement in particular may see these programs as contradictory to their job and the “War on Drugs.” Proponents point out the role of NEPs in decreasing the spread of HIV/AIDS, preventing improper disposal of dirty needles, and connecting people to medical personnel. For whatever reason that people are opposed to or in favor of NEPs, the bottom line appears to be safety and health.

One of the main reasons that people oppose Needle Exchange Programs is the concern that they support and encourage drug abuse. Danny Jones, Mayor of Charleston, West Virginia, in an article published in The New York Times, opposes NEPs and had the program in this town shut down, “citing…what he saw as a weekly influx of people using drugs” (Katz). Jones is not the only public official rallying against these programs. Miami police chief Javier Ortiz believes that the program enables people who abuse drugs and labels drug abuse as acceptable behavior (Wright). The police are on the frontlines of the issue with Needle Exchange Programs. Not only is their support necessary to create an effective program, they are also placed in danger when interacting with people who are addicted to drugs from needle stick injuries.

A second concern against Needle Exchange Programs is that they will increase the prevalence of improperly discarded needles, which would increase the danger of a needle stick accident. Miami police chief Ortiz spoke out against NEPs after one of his officers was pricked with a used needle while making an arrest (Wright). The immediate concern for that officer is if that needle was infected, he has a chance of contracting HIV. The concern for safety does not only apply to police officers; adults and children in the community can be put at risk if they come into contact with an infected needle. This is one of the reasons that Mayor Jones shut down the NEP in his town: a five-year-old girl received a needle stick injury while using a McDonald’s restroom (Katz). These accidents have the potential to result in devastating outcomes and are a major safety concern for areas with a high population of people who abuse drugs. Needle stick accidents are not the only concern community members and officials have about needles.

An unexpected consequence of Needle Exchange Programs was the creation of a community- funded black market for syringes, where people pick up dirty syringes to exchange for clean ones which they sell (Jacobs). Reselling syringes is illegal; however, it is easy because the needles are free and obtained in a legal way. This consequence is another reason that people may oppose Needle Exchange Programs, particularly those in law enforcement. In areas with NEPs, needle possession is not considered illegal. This fact makes their job more difficult since they must be caught selling the needles to arrest them; moreover, law enforcement may see an uptick in crime related to Needle Exchange Programs.

It is important to recognize that the moral concerns about encouraging drug use, as well as the safety concerns of needle-stick accidents and increased crime rates are valid. However, Needle Exchange Programs are used because they have benefits as well. While critics and proponents of NEPs disagree on whether or not they should be used, both groups are concerned with the safety and health of their communities.

HIV/AIDS is a major public health and safety concern, and decreasing its prevalence is one area that both critics and proponents of Needle Exchange Programs support. Over 1.1 million people in the United States are living with HIV, and in 2014 over 6,500 people died from the disease (HIV.gov). Decreasing the prevalence of HIV is important to protect people who are not infected and make it less likely that they will contract the disease in the future, no matter how it is transmitted.

According to the Center for Disease Control and Prevention, Needle Exchange Programs have been associated with a 70% decrease in new HIV cases among people who inject intravenous drugs as well as a decrease in persons at risk for HIV (CDC). This is one of the main reasons that NEPs are used in the first place. The current Surgeon General of the United States, Dr. Jerome Adams, advocates for these programs and convinced then-Governor of Indiana Mike Pence to legalize Needle Exchange Programs in 2015 (Forman). They were legalized in Indiana following what was called a public health emergency, where cases of HIV rose from 26 to 158 in only 8 months (Forman). Needle Exchange Programs discourage the reuse and sharing of needles, which is how they decrease the prevalence of HIV. The benefits of Needle Exchange Programs are not limited to disease prevention amongst intravenous drug users, but cause other positive outcomes.

A scientific study in Baltimore, Maryland completed in 1997 concluded that Needle Exchange Programs have not been found to increase the amount of improperly disposed of needles (Doherty et al., “Discarded Needles”). When that study was followed up two years later, the researchers found that the number of improperly disposed of needles had decreased in the areas surrounding NEPs and were unchanged in areas far from the site (Doherty et al., “Effect”). Consequently, fewer syringes are on the ground in areas with Needle Exchange Programs, which would also decrease the likelihood of someone accidentally being stuck by a needle. A study done in 1992 in Connecticut found that needle stick injuries among police officers were decreased once the possession of syringes without a prescription was decriminalized (Groseclose et al.). Needle Exchange Programs can increase the safety of a community by decreasing the amount of syringes discarded on the streets and decreasing the amount of injuries received by police officers due to those syringes. In addition to the decrease in accidents, Needle Exchange Programs can also help decrease the amount of people using intravenous drugs.

Needle Exchange Programs are credited with helping people who have addictions enter rehabilitation facilities. A 2000 study in Seattle found that people who used NEPs were more likely to reduce or stop their drug abuse and five times as likely to enter treatment compared to people with drug addictions that had never used a NEP (Hagan et al.). People with addictions are still members of the community, and they also need to be protected. The face-to-face interactions with health care professionals and referrals to rehabilitation facilities can help them conquer their addiction and return to being a functional member of the community. This approach helps to reduce criminal activity and increase the safety in communities.

There has been research on the effect of Needle Exchange Programs on crime levels. A study of arrests made in Baltimore in areas where there were and were not NEPs revealed that there were not more arrests made near NEPs than far away (Marx et al.). This finding helps to dissuade the fear that Needle Exchange Programs will increase the rate of criminal activity. There is also evidence that shows NEPs do not encourage drug use. The Foundation for AIDS Research released a fact sheet that cites studies demonstrating that NEPs do not cause people to begin using drugs or those who already use to increase their frequency of drug abuse (amfAR). The current research shows that the presence of Needle Exchange Programs in a community do not increase crime or drug abuse. Thus, it is unlikely that police officers would make more arrests and could still spend the same amount of time on other aspects of community protection.

After researching the positive and negative outcomes of Needle Exchange Programs, I believe that these programs are an important tool that should be used in the United States due to their ability to decrease the prevalence of HIV, decrease the number of improperly disposed needles and accidents caused by them, and to help people with drug addictions enter a treatment facility; in addition to these benefits, little evidence supports a correlation between NEPS and increased level of crime or drug abuse. It is important to still remember that not every community will have the same outcome. There may be instances where NEPs are producing the opposite result. I believe that in these cases, rather than ending the program, it would be worthwhile to discover why the program is failing and to take steps to remedy it. The controversy surrounding Needle Exchange Programs is centered around the issue of safety and health, and how that can be improved in communities. With the proper resources, Needle Exchange Programs have the ability to increase the safety of law enforcement, people with addictions, and community members as a whole.

Works Cited

amfAR. “Fact Sheet: Public Safety, Law Enforcement, and Syringe Exchange.” The Foundations for AIDS Research, 2011, www.amfar.org/uploadedFiles/_amfarorg/Around_the_World/ TREAT_Asia/factsheetJan2010.pdf.

Centers for Disease Control and Prevention. “Access to Clean Syringes.” Office of the Associate Director for Policy, 2016, www.cdc.gov/policy/hst/hi5/cleansyringes/index.html.

Doherty, M., Garfein, R., Vlahov, D., Junge, B., Rathouz, Pr., Galai, N., Anthony, J., and P. Beilenson. “Discarded Needles Do Not Increase Soon After the Opening of a Needle Exchange Program.” American Journal of Epidemiology, 1997, vol. 145, no. 3, 730-736.

Doherty, M., Junge, B., Rathouz, P., Garfein, R., Riley, E., and D. Vlahov. “The Effect of a Needle Exchange Program on Numbers of Discarded Needles: A 2-year Follow-up.” American Journal of Public Health, 2000, vol. 90, no. 6, 936-939.

Forman, Emily. “Trump’s Surgeon General Pick Built Reputation Fighting HIV And Opioids in Indiana.” NPR: Public Health, 2017, www.npr.org/sections/health- shots/2017/07/05/535618770/surgeon-general-nominee-championed-policies-to-curb-  indiana-s-opioid-epidemic.

Groseclose, SL., Weinstein, B., Jones, TS., Valleroy, LA., Fehrs, LJ., and WJ Kassler. “Impact of Increased Legal Access to Needles and Syringes on Practices of Injecting-drug Users and Police Officers—Connecticut, 1992-1993.” Journal of Acquired Immune Deficiency Syndrome, 1995, vol. 10, no. 1, 82-89.

Student Example

Emily Schwein wrote this persuasive research essay in Brenda Martin’s ENGL 200 class. The intended audience are politicians and others who would be against exempting feminine products from taxation.

Go with the Flow

 One quality that many find valuable in leadership is relatability. It provides one with a sense of security knowing that their leaders have had similar life experiences as them and have their best interest in mind. Some argue that this is not the case for women in the US today. Women have been a part of Congress since 1917, and the number has gradually increased as the years go by.

In Kansas Legislature, 26% of the seats are filled by women, leaving 74% to men (Shorman). Some would say that this is harmful to women because those who haven’t experienced all that comes with being a woman are making decisions that have an impact on their health and well- being. Menstruation has been a constant in women’s lives, but only just recently have women spoken up about the tax that comes along with it in Kansas.

When nature calls, should women have to literally pay the price?

Those who believe that feminine hygiene products should be taxed have reasonable claims. They bring up something that is difficult to define: necessity. To some, necessity could mean a certain brand, absorbency, or ingredients, and to others, it could mean the cheapest version that would get them by. Like many issues in the US, the tax on tampons also falls in the grey area because as simple as it sounds, “[I]t is surprisingly hard to define the place where toiletries end, and medication begins” (Barro). For example, in Illinois, the Department of Revenue has to verify that “medicated lip balm is not medication, and neither is dandruff shampoo” (Barro). How can you tax exempt something on the basis of a subjective topic? This is a valid argument because it is impossible to have women from all walks of life come to a consensus on what they deem a necessity.

Another logical concern of those who believe that feminine hygiene products should be taxed has to do with budgetary concerns. Because sales tax varies from state-to-state and each state has a different budget, it is difficult to make feminine hygiene products tax exempt everywhere. For example, “[I]n California, it is estimated that exempting tampons and pads from tax will reduce revenue by $20 million a year and in Utah, by $1 million” (Durkin). Money is a valid reason for wanting to keep the tax on tampons. Not only would Kansas lose money from removing the tax on feminine hygiene products, but it would also “open the flood gates for toilet paper or soap” to be tax exempt as well (Durkin). If the tax on feminine hygiene products were to be removed, the lost money would have to be made up somewhere and Kansas citizens will be paying either way.

I hear and understand that necessity is subjective to the individual and that exempting feminine hygiene products from sales tax would financially burden Kansas, but I have to disagree with the taxation. I believe that this discussion should be centered around the human life on the other side of the cash register. Regardless of the subjectivity of necessity, all people who experience menstruation can’t just ignore it. The argument about money makes it even clearer to me why feminine hygiene products should be tax exempt: because it shouldn’t be about money. Feminine hygiene products are an unquestionable necessity, and decisions regarding them should be made by those who have experienced menstruation.

Menstruation is natural and unavoidable, but the government doesn’t treat it as such. Various states exempt necessity items from sales tax, but “the majority of states impose a general sales tax on tampons, pads, reusable menstrual cups, and other menstrual hygiene products,” meaning they deem feminine hygiene products as a luxury item (Bennett). While I understand that the line between necessity and luxury items can be blurred, I still believe that tampons should be treated as an unquestionable necessity. According to Maslow’s Hierarchy of Needs, one’s physiological and safety needs must be met before any other progress in life can be made. For example, when girls reach the age of menstruation, school attendance begins to drops because according to the Department of Education Deputy Chancellor Elizabeth Rose, “[H]aving access to feminine care products is essential to ensuring that girls have the support they need to focus on learning and feel comfortable during class” (“Free Feminine Hygiene”). Imagine sitting in class and being expected to pay attention while constantly worried about getting blood on your seat. This is a reality for many young girls whose parents can’t afford feminine hygiene products. Tampons are not a luxury; they are a necessity not only for comfort but for the health of women. Women all across the world who either aren’t provided with or can’t afford feminine hygiene products are forced to “use rags or soil their clothes because they don’t have the access to appropriate hygiene products” (Rabin). Even when they do have access to tampons or sanitary napkins, it’s not enough to last through their entire cycle. Women “on average have their period every 28 days, for 4.5 days and [are] advised to change [their] tampon or pad every four to eight hours.” When this four to eight-hour requirement is not met, women could contract toxic shock syndrome, “an infection causes by bacteria associated with tampon use,” and become very ill or even die (Durkin). Feminine hygiene products aren’t just necessary for comfort, but for health and well-being as well; therefore, they should not be taxed.

Furthermore, while women are involved in Congress, they are far outweighed by their male counterparts. Only 26% of Kansas Legislature consists of females (Shorman). This fact is an issue when it comes to laws being passed that effect the reproductive and overall health of women. Men haven’t experienced all that comes with being a woman and shouldn’t be put in a position that impacts their well-being. When asked about the tax put on tampons, many men, including former President Barack Obama, respond with the following: “I have no idea why states would tax these as luxury items. I suspect it’s because men were making the laws when these were passed” (Sahadi). Obama’s statement solidifies many women’s frustration. Men simply have never experienced a period and shouldn’t be making decisions that impact those who do. These taxation laws were made during a time when women didn’t have as much of a voice in Congress, so why should they continue to reign true without the opinion of women?

As a menstruating woman, I am intrigued and want to learn about the monetary concerns and the experiences of other women. While I understand that necessity is difficult to establish and that taxes are seemingly set in stone by mostly male legislatures, I believe that feminine hygiene products should be tax exempt in Kansas. The concerns of the opposing side are valid and deal with logistical issues, but I believe that it is more important to care for other human lives than it is to put a label on necessity and profit from an unavoidable bodily function.

Works Cited

Barro, Josh. “The Latest Sales Tax Controversy: Tampons.” The New York Times, 7 Jan. 2016, www.nytimes.com/2016/01/07/upshot/the-latest-sales-tax-controversy-tampons.html.

Bennett, Jennifer. “The Tampon Tax: Sales Tax, Menstrual Hygiene Products and Necessary Exemptions.” Hein Online, 183-215, 7 Nov. 2019, www.heinonline.org/HOL/.

Durkin, Abigail. “Profitable Menstruation: How the Cost of Feminine Hygiene Products is a Battle Against Reproductive Justice.” Georgetown University Law Center, vol. 1, no. 18, 22 Mar.

Student Example

Libby Couture wrote this persuasive research argument in Mary Cook’s ENGL 200. Note how Couture uses her own academic major – architecture – to motivate her issue. Couture’s audience are architects who prefer to demolish structures instead of repurposing them.

Adaptive Reuse in Architecture

 Within architecture there are many smaller niches to focus on. One such niche is adaptive reuse, which has grown in popularity over the past few decades. Due to the changing needs of society and, consequently, the changing goals of architecture, the term “adaptive reuse” has also been redefined. Today, adaptive reuse is defined as “the act of modifying a building to accommodate uses that are different from those originally intended” (Rayman 140). Further, adaptive reuse achieves such results by changing the “capacity, function and performance” of the building through a “process of upgrading and enhancing […] while retaining most of the original building” (De Silva 1). Although there is still some ambiguity in regard to how much of the original building must be kept and to what extent the purpose changes, this definition provides us with a much better understanding of adaptive reuse and its intentions, processes, and results.

Early in the history of architecture, adaptive reuse was not as prevalent due to the amount of untouched, accessible land to build on. However, as areas became more populated and open land increasingly difficult to come by, new building sites often came with preexisting structures on them. From here the architects, builders, engineers, and anyone else involved in the project had two decisions: demolish the preexisting structure and build from the ground up or incorporate the building into the new design with the idea of repurposing the structure. This latter idea is known as adaptive reuse.

The advantages and disadvantages of demolishing or repurposing buildings should both be viewed through the lens of the architect and the values they wish to uphold. While there are many differing and more specific values architects hold, there are a few overarching themes as mentioned by the American Institute for Architects (AIA), which is a leading organization for architects in the United States. One of the most important values is that of equity and human rights, which is demonstrated through the “accessibility to the built environment for all” (“Where Architects Stand”). In addition to equity, it is the goal of architects to strengthen the community by building relationships with community members, providing an opportunity for cultural expression, and working to solve problems by bringing about social change. AIA also mentions that environmental sustainability and protection from climate change are ways architects can and should approach projects (“Where Architects Stand”). These various goals and values of designers are taken into consideration in the design of a building and are one way to measure the success of a completed design. In analysis of adaptive reuse, it is important to consider these goals, especially in relation to the benefits and drawbacks. Evaluating adaptive reuse in the context of values that architectural designers hold helps gain a better understanding of how this approach lines up with the larger goals of architecture.

Some architectural designers don’t see the benefit in adaptive reuse because it can be considered a little more constraining in the way to design, contradicting the value for more freedom and control over the building. Because adaptive reuse starts with a preexisting structure, there are some limitations to what can be changed due to structural integrity and feasibility of moving or removing components. The inability to move certain walls, columns, or floor slabs can lead to more restricted floor plans and sections. Additionally, material choice is sometimes limited as the materials of the old structure must be considered, rather than having the ability to develop a material pallet from scratch (De Silva 3). This, among other factors, influences the aesthetic of the building and limits the design options for the architect. Because of these obstacles an architect might encounter during an adaptive reuse project, using this approach might become less ideal and can contribute to the decision to demolish a building, rather than repurpose it. The aforementioned claims are extremely valid points to be made and should definitely be considered in analysis of this architectural method. However, we can also consider these values in a different light and rethink how they can be successfully applied to adaptive reuse. Although there are many different ways to evaluate the effectiveness and success of a design, three factors will be examined: economics, the environment, and the surrounding culture. Many individuals believe that adaptive reuse comes at a high cost, especially for the firms and individuals carrying the project out. Such high of costs are due to remediation, maintenance, and renovation, which are all important to address in the repurposing of an old building.

Sufficient measures must be taken at a cost to ensure a stable and well-maintained structure as to keep all users safe and healthy (De Silva 3). While these costs do add up, there are many other costs architects and builders must factor in when building from the ground up. Two main costs include demolition and extensive material costs, both of which are minimized when using adaptive reuse. Additionally, many of the high costs associated with finding skilled individuals to restore structures are lowered when adaptive reuse takes place at larger scales and when the economic activity in an area increases (Stas 30). Ultimately, the savings for developers outweigh the costs associated with adaptive reuse. In order to fully analyze the economic impacts of adaptive reuse, multiple perspectives must be taken into consideration. By repurposing buildings, more space becomes available for business to occupy and the area becomes much more desirable for economic activity to occur. As such, there are extensive opportunities for economic growth in the community including new jobs, higher incomes, increased tax revenues, and higher property values (Stas 38). Also, many areas see an increase in heritage tourism, often bringing in millions of dollars annually to various communities (Stas 30). Adaptive reuse provides many economic benefits for the individuals involved in the design and construction process as well as for the public and local community following installment.

Aside from the economic benefits, there are numerous reasons to apply adaptive reuse to projects because of its environmentally sustainable nature. There are three main factors contributing to the environmental sustainability of adaptive reuse: material use and waste, land conservation, and energy consumption. Because adaptive reuse preserves as much of the building as possible, including structure, infill, and even ornament, there is a considerate reduction of material production and waste. Not only are less materials required to complete the project because some can be reused, but less materials are also sent to the landfill upon demolishing a structure (De Silva 2). By reusing materials and not requiring as much new material, adaptive reuse is advantageous in minimizing waste and limiting use of valuable resources. Even in the case of building from the ground up without demolishing structures, a new plot of land is necessary to build. When adaptive reuse is implemented however, land can be reused and is conserved, proving to be environmentally equitable (De Silva 3). Another aspect to consider in environmental sustainability is energy consumption. In the case of demolishing and rebuilding a new structure, extensive amounts of energy are needed for the demolition and construction.

Because demolition and construction are minimal in adaptive reuse, the associated energy use is also minimized, making this method more environmentally sustainable (De Silva 2). In a world that needs to solve climate change and protect the environment, architects must reflect these ideals in the projects and designs they make. Adaptive reuse provides architects with the opportunity to address the value of environmental sustainability and should therefore be a more prominent design solution.

One misconception about adaptive reuse is its inability to move communities forward and allow for growth; instead, many believe that it focuses too much on the old. Because of this preconceived idea, building from the ground up is seen to be more culturally advantageous.

Contrary to this belief, adaptive reuse can be extremely beneficial in terms of the cultural impact it has on the surrounding community. Adaptive reuse allows for the recognition of cultural heritage and provides decaying areas with an opportunity to be revived. Because adaptive reuse preserves old structures, the process “allows for these buildings to remain historically relevant in a modern context” (Smallwood). The older architectural styles display the area’s history and authenticity and begin to tell a story of its past. However, rather than having an overwhelming number of historical structures, adaptive reuse allows for the integration of contemporary architecture. This balance between historic and modern creates a unique atmosphere and environment, reviving the local area and making it a much more attractive destination. Such changes provide a new sense of place and are integral in the societal and cultural advantages of adaptive reuse.

As land and structures are becoming more valuable, adaptive reuse should become more of a focus for architects because it benefits both the society and architectural designer. Adaptive reuse is economically beneficial, environmentally sustainable, and culturally rewarding. Adaptive reuse provides architects with an amazing opportunity to integrate the foundational values into a design and make an even greater impact on the community they are serving. Because of the increasing number of buildings and decreasing amount of open land, adaptive reuse will only continue to grow in popularity. These changing conditions result in a need to change the way we find solutions. As architects, whose jobs are to solve problems and strengthen communities, implementing adaptive reuse is one step towards being successful and making a difference. Practicing adaptive reuse demonstrates the architect’s ability to adjust to the changing demands from society and shows care of economic, environmental, and cultural sustainability, benefitting the architect, developers, and local community. Adaptive reuse’s advantageous nature makes it an excellent candidate for future projects and should be a design method that architects highly value.

Works Cited

De Silva, Dilantha, and Kanchana Perera. Barriers and Challenges of Adaptive Reuse of Buildings.Department of Building Economics, University of Moratuwa, 2016.

Rayman, Mohamed, et al. “Adaptive Reuse: A Review and Analysis of its Relationship to the 3 Es of Sustainability.” Facilities, vol. 35, no. 3, 2017, pp. 138-154. ProQuest, https://er.lib.k- state.edu/login?url=https://www-proquest-com.er.lib.k-state.edu/docview/ 1879964587?accountid=11789, doi:http://dx.doi.org.er.lib.k-state.edu/10.1108/F-12- 2014-0108.

Smallwood, Christopher. “The Role of Adaptive (Re)use.” PMI® Global Congress 2012—North America, Vancouver, British Columbia, Canada. Newtown Square, PA: Project Management Institute, 2012.

Stas, Nart. The Economics of Adaptive Reuse of Old Buildings: A Financial Feasibility Study & Analysis. UWSpace, 2007. http://hdl.handle.net/10012/2707.

“Where Architects Stand: A Statement of Our Values.” The American Institute of Architects, www.aia.org/resources/50766-where-architects-stand-a-statement-of-our-va.

Student Example: Persuasive Research Open Letter

Sarah Inskeep wrote this persuasive research open letter in Rachel Schaller’s ENGL 200 class. As you’ll see, K-State’s President Myers is the intended audience.

Sustainability & K-State: A Letter to President Myers

 May 22, 2020

Dear President Myers,

To begin, as a student, I would like to thank you for your steadfast leadership and encouragement through the uncertainty and changes brought about by the COVID-19 pandemic. I am immensely grateful for the efforts that have been made both to support students during these difficult times and to continue providing education and opportunities.

This spring, I graduated with a major in physics and a minor in conflict analysis and trauma studies. I am proud to be a part of the K-State family and am passionate about our role in bettering our community and our world. Being a part of two quite different academic programs has made clear to me the diversity of K-State’s strengths and inspired me to get involved with the review process of the 2025 Visionary Plan.

I understand that, at present, planning groups are focused on three strategic initiatives: innovation in education; global food, health, and biosecurity; and becoming a cyber land-grant university (2025 Visionary Plan). I am also aware that additional areas of emphasis—data science, research, and resilience—were proposed by the College of Arts and Sciences (Sustainability Meetings). I am excited about these initiatives and am eager to see what the planning groups develop. I am writing, however, to propose that the overall Visionary Plan could be strengthened and that present financial and enrollment challenges could better be addressed by drawing these initiatives together with a common purpose that is aligned with K-State’s mission, vision, and values: addressing climate change.

Sustainability, I know, was addressed by the 2025 Sustainability Strategic Action (2025 SSAP) in the original 2025 Visionary Plan and is a common element in 2025 Refresh. I believe we should instead make it a defining element—something explicitly and intentionally integrated into each strategic initiative as well as into the mission and vision of the university—not because the other goals are unimportant, but because it is what brings them together. Global food, health, and biosecurity are inextricably tied to climate change, as detailed in the IPCC’s Global Warming of 1.5 ºC, in reports from the US Department of Defense, and in research presented by K-State faculty. There is a need, both locally and globally, for a better understanding of how to mitigate and adapt to changes in our food and health systems due to climate change. As the first land grant school in the nation with expertise in many fields, close ties to agricultural communities, and a dedication to maintaining dialogue on difficult topics, we are perfectly equipped to take the lead in developing that understanding. Then, through innovation in teaching and strengthening our presence as a cyber land-grant, we could also ensure it is available to all who need it. Doing so would create a brand for K-State, making us known as a place that develops holistic solutions to the most complex and pressing problems.

That K-State is uniquely equipped to take on the challenges of climate change is not a new idea. The team that created the 2025 SSAP shared it, too. Since last fall, I have been a part of a new team of students, faculty, and staff from across the university voluntarily working to review that plan. From that work, I understand the primary concerns of administration at present are related to enrollment and to finances. As a student, I have worked with state and national organizations through the conflict studies program and do not at all intend to downplay the significance or complexity of those issues. They are not, however, issues that inhibit us from moving forward with the 2025 SSAP. On the contrary, I believe they are issues that may be remedied by moving forward with it. Reducing energy use and improving efficiency is becoming increasingly cost- effective, especially in places like Kansas where we have plenty of wind and, according to NOAA, more sunny days per year than Florida. Though solar and wind projects may have an intimidating price tag, they often have short payback periods and save money after that. Furthermore, they provide a living laboratory for students to work in and learn from, giving them concrete experience in the growing renewable energy sector.

Big projects aside, much of the plan requires no additional investment because we already have the personnel and expertise we need on campus. Just as our campaign for diversity and inclusion has largely emerged from existing faculty and staff, a campaign for sustainability could be created through collaboration among those who are already a part of the K-State family. Scientists like Jesse Nippert, director of the National Science Foundation’s Konza Prairie Long Term Ecological Research Network, have been researching the effects of a changing climate on native prairie plants and food crops. Agronomists like Chuck Rice, Noble Prize Laureate for his work with the Intergovernmental Panel on Climate Change, have been studying how we can mitigate agricultural emissions and adapt our agricultural systems to changing environments. The National Science Foundation also chose K-State for a National Research Traineeship to support collaborative research on water conservation and renewable energy generation by faculty and graduate students in agronomy, engineering, anthropology, and sociology. There are numerous other projects also already underway, from an interdisciplinary environmental sciences major, to pollution prevention and biodiesel development, to natural landscaping and studies in sustainable design. Why not take advantage of this emerging theme?

In last fall’s survey for the 2025 Refresh process, respondents were asked about the changes made to the university’s visionary goal. One respondent wrote that the problem with the previous goal was that it “provided no vision to rally around” and that it “reflected a lack of understanding of KSU’s potential to help Kansas and the world.” The respondent was supportive of the new goal but suggested more specificity. Becoming a Top 50 Research University may not be within our reach, but we don’t need it to be to succeed. “KSU can’t do everything, but it could do some things very well, if only we commit to areas that we can impact (food security, prosperity in rural communities, stewardship of natural resources),” they wrote. “The current proposal would be more powerful if it acknowledged the particular scope over which KSU could be held accountable” (2025 Visionary Plan).

This response is well worth consideration. Increasingly, young people identify climate change as the challenge of our times and are searching for ways to make a difference. According to recent Gallup polls, 70% of people age 18-34 are “worried a great deal/fair amount” by climate change (Reinhart). These groups of people are looking for ways to contribute, to learn how they can help create a brighter future, and we have the resources and the expertise to provide a world-class education regarding these issues in a way no other school can. If we commit to sustainability, to addressing climate change, we will attract those young people and thereby realize our vision of preparing “each generation to advance society and enrich the world for those who follow” (2025 Visionary Plan).

As for the concern, presented to me by faculty and administration, that overtly addressing climate change would be taking too political a stance: it’s true that climate change has become a politicized issue, but it is first and foremost a scientific one. With a careful approach we could help remind society that this is the case. Time and again, we at K-State have made clear our commitment to maintaining dialogue and opportunities for free speech about typically divisive topics. Our reputation on this can aid us in depoliticizing climate change for the betterment of all. At present, because climate change is seen as an issue associated with a certain political party, the problem is not taken seriously by many and there is a severe lack of innovation in figuring out what can be done to address it. The same dilemma is playing out with COVID-19. As a result, 93,800 people have died in the United States as of May 21, and each day there are 1,000-2,000 more deaths. With crises like these, we must change the perspective so that people of different ideologies can agree on the scientific basis of the problem and engage in constructive dialogue about solutions. This is exactly the kind of “Republic of Science” approach upheld by one of our lead donors, Charles Koch. Through it, creative tension allows for much swifter progress. K-State can play a leading role in creating this change in perspective. We are only one school, but we are nestled in the heartland of the United States, and our family is made up of brilliant people from around the world. Our actions and our words ripple out into our community, to our state, to other land-grant schools, and on from there. We may not be able to see those more distant effects, but that does not mean we should ignore them.

As our seal reminds us, we can only rule by obeying nature’s laws. As stewards of the land, air, and water, we have made a commitment to doing so—to protecting our future, to ensuring the health and prosperity of communities at home and across the globe. It is both our legacy and our responsibility to uphold that commitment, even when it is not easy, even when doing so requires facing problems more complex than any we have known before. Already the health and prosperity of communities and ecosystems around the world are declining, but through research and creativity, through harnessing the power of innovative learning and discovery, we may yet find answers to today’s questions and solve the problems of tomorrow. That is why we should move forward with the 2025 Sustainability Strategic Action Plan and make sustainability an overarching part of our mission and vision as a university.

Student Example: Persuasive Research Open Letter

Lilly Holthus wrote this persuasive research open letter in Wendy Matlock’s ENGL 200 class.

Living with Physician-Assisted Suicide

November 6, 2020

Dear Government Officials of Kansas:

I am coming to you as a student from Kansas State University who is passionate about healthcare and bettering the lives of others. As a student who is studying integrative physiology, I have an understanding of the type of care that is provided to patients, and I am further interested in broadening the minds of the Kansas legislature about providing more options to a specific group of patients: the terminally ill.

Physician-assisted suicide is the act of a doctor prescribing a lethal drug to a terminally ill patient. The patient then administers the drug by dissolving it in a glass of water and then drinking it, placing the drug in their feeding tube, or taking the drug intravenously (Gather). The act of physician-assisted suicide was first legalized in the United States in the state of Oregon in 1997. This law, also known as the Death with Dignity Act, states that a terminally ill patient who has less than six months to live can request self-administering drugs (Plaisted). Physician- assisted suicide is now legal in more states including Washington, Vermont, California, Colorado, Montana, and the District of Columbia (Legault). Despite physician-assisted suicide already being legalized in these states, it is a highly debated topic amongst others, weighing ethics and the rights of terminally ill patients to the type of care they receive. Because of the importance of this upcoming topic in the state of Kansas, it is necessary to discuss and view the impact that it could have on the future of healthcare.

Some are worried that if physician-assisted suicide becomes normalized for terminally ill patients, it has the potential to devalue the patient and put the patient at risk. A common belief of physician-assisted suicide is that it devalues the patient’s life because it is a suggestion to end their life just because of an illness. It is also believed that because a patient is already in a vulnerable state due to the high degree of their illness, they are more prone to fall victim to suggestions such as physician-assisted suicide (Goligher). These fears and concerns are relevant to the fact that taking one’s life is a serious matter, but statistics have shown that this option is specifically designed for the mentally capable, terminally ill patients. Data that was taken from Oregon between 1998 and 2015 and Washington between 2009 and 2015, show that only 0.4% of deaths in the two states were a result of physician-assisted suicide. 75% of those physician- assisted suicides were made by cancer patients who had less than six months to live. The remaining 15% had a neurodegenerative disease (Emanuel). These statistics tell us that patients’ lives are not being devalued, nor are they being put at risk. Because of the predicted time-period a patient has left, they are fully aware that death is coming for them and choosing to participate in speeding the process up does not devalue their life. We can also see that these patients are not being subjected to vulnerability as they account for so little of deaths in total, and the decision is completely autonomous.

Although a patient has the right to determine their care, many see that a physician’s job is to improve the well-being of an ill patient, and physician-assisted suicide contradicts that goal. An article in CMHJ stated that physician-assisted suicide is detrimental to the trust in the doctor- patient relationship (Smith). This is because patients or family members viewed the situation as the physician not trying to save the patient. One article also indicated that “the physician’s most basic tasks and considerations are to ‘always bear in mind the obligation to respect human life’ and ‘the health and well-being of the patient’” (Goligher). While it is true that it is a physician’s job to provide the patient with the utmost care, 85% of patients were able to trust a physician who participated in assisted suicide just as much as a physician who had not (Smith). This goes to show that having the option of physician-assisted suicide provided does not damage the relationship. Although it is not a physician’s choice to determine whether a patient receives physician-assisted suicide, a 2014 survey showed that 54% of physicians in the United States supported physician-assisted suicide and their patient’s decision to partake in the process (Emanuel). Even with the high amount of support from physicians, they are not obligated or required to participate to take part in the process or give permission (Smith). This proves that it does not contradict a physician’s goal of improving their patient’s well-being because they are supporting their patients in the type of treatment that they choose to receive.

Due to the seriousness of deciding to end one’s life because of terminal suffering, patients are required to go through a series of interviews and psychological evaluations to determine if they are in the right mind frame to make the decision. A patient must first prove that they have less than six months to live with at least two physicians’ predictions (Smith). They must also show that they can make an autonomous decision. This means they must be able to make a choice, understand their illness and the treatment they are currently receiving, appreciate that they have been affected and are receiving treatment, and finally be able to rationalize and process the information and look at the consequences or other alternative treatments (Gather). The patient must then request the lethal drug on multiple accounts with consent from a physician, receive an opinion from a second physician, participate in a psychiatric evaluation, and wait 15 days between the physician’s consent and the actual administration of the drug (Smith). Because of the strict protocol, we can assure that a patient is only being influenced by their own opinion. This process ensures a patient genuinely wants to go through with physician- assisted suicide and determines that they have the mental capacity to willingly accept the outcome of physician-assisted suicide.

Because of the suffering that a terminal illness entails, physician-assisted suicide allows a patient to pass with dignity and autonomy. As mentioned before, physician-assisted suicide was first passed as a law called the Death with Dignity Act, and many other states have followed in suit. Lawmakers first decided on this name because their goal was to provide terminally ill patients with an option that allowed them to speed up the slow dying process, and instead die with dignity and meaning (Smith). This leads to a complete, autonomous choice of the patient to make this decision. Many patients who know they are dying prefer to make that last decision confidently before they lose control of their own body (Plaisted). There are even some religions, such as the United Methodist, who believe that God has granted them “the right of personal choice and that this authority must extend to matters of life and death” (Thobaben 1997), and express that they should be able to exercise this ability within physician-assisted suicide (Burdette). Autonomy is a moral right that we as humans have, and we should respect any autonomous decision that a patient makes including their choice to participate in physician- assisted suicide. Although it is currently not legalized in the state of Kansas, this shows that we are stripping terminally ill patients of an option that could relieve them of their misery and allow the control to be in their hands.

As someone who is passionate about caring for others and wants to provide the best options for patients, I believe that it is important for the state of Kansas to consider moving forward with the rising option of physician-assisted suicide and at least allow the terminally ill a second choice. Many of us are aware and respect that human life is valuable and important, but if a terminally ill patient is suffering and is aware that a slow, and painful death is upon them, should we not give them the right to autonomously decide to end their pain? One defender of physician-assisted suicide and the Death with Dignity Acts stated, “Aiding an autonomous person at his or her request to bring about death is, from this perspective, a way of showing respect for the person’s autonomous choices. Similarly, denying the person access to other individuals who are willing and qualified to comply with the request shows a fundamental disrespect for the person’s autonomy” (Plaisted). With this in mind, I ask of you to acknowledge and respect that patients have the right to determine the care they receive, and we should consider allowing terminally ill patients to exercise this right through the option of physician- assisted suicide.

Let us make a difference in a patient’s suffering.

Sincerely,

Lilly Holthus

Kansas State University

Integrative Physiology | Pre-Occupational Therapy

Works Cited

Burdette, Amy M., and Terrence D. Hill, and Benjamin E. Moulton. “Religion and Attitudes Toward Physician-Assisted Suicide and Terminal Palliative Care.” Journal for the Scientific Study of Religion, vol. 44, no. 1, 1 March 2005, pp. 79-93. EBSCOhost, http://web.b.ebscohost.com.er.lib.k-state.edu.. Accessed 1 Nov. 2020.

Emanuel, Ezekiel J., Bregje D. Onwuteaka-Philipsen, and John W. Urwin, et al. “Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe.” Jama Network, vol. 316, no. 1, American Medical Association, 5 July 2016, pp. 79-90, https://jamanetwork-com.er.lib.k-state.edu/journals/jama/fullarticle/2532018.Accessed 23 Oct. 2020.

Finlay, I. G., and R. George. “Legal Physician-Assisted Suicide in Oregon and the Netherlands: Evidence Concerning the Impact on Patients in Vulnerable Groups-another Perspective on Oregon’s Data.” Journal of Medical Ethics, vol. 37, no. 3, March 2011, pp. 171. ProQuest, https://er.lib.k-state.edu/login?url=https://www-proquest-com.er.lib.k-state.edu. Accessed 1 Nov. 2020.

Gather, Jakov, and Jochen Vollman. “Physician-Assisted Suicide of Patients with Dementia. A Medical Ethical Analysis with a Special Focus on Patient Autonomy.” International Journal of Law and Psychiatry, vol. 35, no. 5-6, Elsevier, Sept.-Dec. 2013, pp. 444-53. ScienceDirect, https://www-sciencedirect-com.er.lib.k state.edu/science/article/pii/S0 160252713000708. Accessed 26 Oct. 2020.

The Kroger-Albertsons Proposed Merger: How Should the Federal Trade Commission Rule?

Tyler Tiede

Tyler Tiede wrote this persuasive research essay in Cindy Debes’s ENGL 200 class. It won first place in the 2023 Expository Writing Program Essay Awards. Tiede wrote for a resistant audience who believes the merger between Kroger and Albertsons violates antitrust laws and subsequently leads to a monopoly of the grocery industry.

Writing for the HuffPost, Al Franken, a former Democratic United States Senator from Minnesota, said, “Antitrust law isn’t about protecting competing businesses from each other, it’s about protecting competition itself on behalf of the public.” I agree with Senator Franken and believe the best way to achieve this objective is through robust market competition.

Consumers benefit when they have more choice of where to purchase regardless of the product or service sought. However, governments should use caution when enforcing antitrust laws to ensure that their regulatory actions do not unintentionally reduce competition. The Federal Trade Commission (FTC), the agency charged with enforcing antitrust laws, including the Sherman Antitrust and Clayton Acts, is being called on to evaluate the merger proposed on October 14, 2022, by two major grocery retailers, Kroger and Albertsons Companies, Inc. As Nathaniel Meyersohn, consumer reporter for CNN Business, said, “If approved by regulators, the nearly $25 billion deal would be one of the biggest in U.S. retail history,” causing many consumer protection experts across the country to sound the alarm. “Antitrust advocates say the merger would force out the competition and concentrate power among the largest chains, driving up prices” (Meyersohn).

Sarah Miller, Executive Director of the American Economic Liberties Project, is among those calling for regulators to intervene. Millers says, “There is no reason to allow two of the biggest supermarket chains in the country to merge—especially with food prices already soaring,” and many Americans agree with her (“Kroger-Albertsons Merger”). Miller believes the FTC should block this proposed merger due to the volatility of the grocery market and the critical role these stores have on the public’s ability to purchase food at affordable prices. Miller and many others find the merger especially concerning since it would combine two of the largest companies in the grocery industry and split sixty percent of all sales between just five corporations (“Kroger- Albertsons Merger”). In Miller’s professional opinion, “This merger is a cut and dry case of monopoly power, and enforcers should block it” (“Kroger-Albertsons Merger”). Miller’s position is based on the premise that allowing Kroger and Albertsons to merge will reduce market competition, create a monopoly, and result in all retailers increasing prices. She is also disturbed by the trend of grocery retailers seeking to consolidate in recent years, noting that previous mergers in the industry have “been mismanaged by antitrust enforcers.”

Many people share Miller’s concerns, and for a good reason, because, throughout history, this country has experienced instances when monopolies harmed consumers due to the lack of competition and innovation. Andrew Beattie, a former managing editor at Investopedia, an online financial information platform, says a monopoly reduces competition and “tends to lead to higher prices and inferior products” (Beattie). There is no question the merger of Kroger and Albertsons will form a major conglomerate in the retail grocery industry. The companies acknowledge their combined forces will allow them to “deliver fresh and affordable food to approximately 85 million households with a premier omnichannel experience” operating in 48 states and the District of Columbia (“Kroger and Albertsons”). While the proposed merger will certainly bolster Kroger-Albertsons’ size and market reach, we must ask ourselves whether it meets the enforcement standards of forming a monopoly and whether this newly formed entity will help or harm consumers.

I recognize the importance of antitrust regulation to ensure fair and adequate competition in any market. I agree that a lack of industry competition allows companies to sit back and raise prices on everyday items because there is little to no motivation to lower them. Most importantly, I understand the views of those who oppose the merger, like Stacy Mitchell of the Institute for Local Self-Reliance, who argues, “Americans don’t need another mega-grocer. Kroger and Albertsons together would control 20% of grocery sales in the U.S.” (Redman). That said, I respectfully disagree with those who oppose the proposed merger of Kroger and Albertsons because I do not believe the transaction meets the regulatory standards of a monopoly, will not impede competitiveness, and therefore does not violate antitrust laws. By evaluating how the merger may benefit consumers, the grocery market’s current segmentation, and these companies’ ability to remain viable competitors in a changing retail landscape, I will demonstrate how this transaction may prove beneficial to consumers and should be approved by government regulators.

It is crucial to consider how the merger may improve supply chain challenges and how the companies’ increased purchasing power after the merger may benefit consumers. Supply chain issues have impacted virtually every industry since the onset of the COVID-19 pandemic in 2020. The ability for Kroger and Albertsons to leverage a combined “66 distribution centers and 52 manufacturing plants” means the combined entity can “optimize its supply chain to deliver the freshest products from field to table to more customers more quickly” (“Kroger and Albertsons”). The merger provides the companies the ability “to better negotiate supply chain relationships, and to invest in technology to run a more efficient (distribution) operation” (Cheng).

In addition to getting products on the store shelves more effectively, the combined market share would allow these companies greater purchasing power, which in turn would help control prices. Reuters, a respected source for business news, reports, “Kroger and Albertsons would together have an edge over negotiations on product prices with suppliers, including consumer goods companies, at a time when prices of groceries and essentials are soaring in the country” (Venugopal). In their announcement, Kroger set forth a plan to lower prices by “reinvest[ing] approximately half a billion dollars of cost savings from synergies (realized from the merger) to reduce prices for customers” (“Kroger and Albertsons”). Allowing Kroger and Albertsons to merge will introduce a significant competitor to Walmart and Sam’s Club, Costco, and Amazon, incentivizing them to keep prices low for consumers. Many people think the merger will cause Kroger-Albertsons and the other retailers to increase prices. Considering the companies’ combined purchasing power and desire to become a retail leader in the industry, I believe the transaction may help drive down prices, which would be highly beneficial to consumers especially given this period of sustained inflation.

As noted above, many are concerned that the proposed merger of Kroger and Albertsons will create a monopoly and want the FTC to block the transaction as a violation of antitrust laws. Jeff Wells with The Grocery Dive, an online publication dedicated to analyzing trends affecting the grocery industry, opined that the FTC’s decision on the proposed merger would be determined based on how they define the market and how the companies deal with divestitures. I argue these retailers are not setting out to form a monopoly but merging to gain the leverage needed to remain competitive in a changing market. The market has seen a sizable shift toward big-box stores like Walmart, Costco, Sam’s Club, and Target, and the emergence of new online grocery options like Amazon. Therefore, the root of the debate on whether the merger of Kroger and Albertsons violates antitrust laws will rest on how the FTC defines the market and if they agree efficiencies can be achieved through the merger that will enhance competition. Daniel Rubinfeld, a law professor at New York University and a former deputy assistant attorney general for antitrust with the Department of Justice, explains the significance of how the FTC segments the market. If the FTC sees Kroger and Albertsons as “the first- and second-largest supermarket chains in the U.S.,” then Rubinfeld believes the merger will undoubtedly be halted for creating a monopoly because “it would effectively mean those two companies have cornered the market” (Wells). Rubinfeld acknowledged, “If this were 20 years ago when I was still working in the government, I would expect the FTC would try to block this deal” (Wells). However, defining the competition narrowly to include only supermarkets does not fully capture the diverse nature of today’s grocery retail options. For this reason, I contend that regulators should consider how the market has expanded over the past two decades when evaluating the legality of this merger.

While that industry landscape of twenty years ago may have dictated that a merger of Kroger and Albertsons would create a monopoly, companies have evolved and adapted to meet customers’ needs. The grocery industry has seen significant expansion in recent decades that has shifted how consumers purchase food. The grocery market segment can no longer be seen to include only conventional supermarket chains. Therefore, the view of what constitutes the grocery market must evolve to account for the expansion of big-box and online retailers. The Wall Street Journal sets forth projections of estimated food sales in the United States among the top ten retailers in the grocery industry. In their projection, Kroger has the second largest market share at 9 percent of sales, while Albertsons is the fourth largest with 5 percent of sales (Kang). Assuming the merger is approved, and the combined Kroger-Albertsons company maintains its current market share of 14 percent, which is unlikely given the divestiture “of between 100 and 375 stores, which the companies have agreed to identify” as part of this transaction, the percentage of sales would still be far less than the largest market share holder, Walmart, with 22 percent of all sales (Kang). Simeon Gutman, an equity analyst for Morgan Stanley, noted, “The inclusion of Walmart as a competitor could be a key swing factor” regarding the retail food market (Wells). While some may argue that this merger would place too much market control with too few organizations, the data do not support that position.

Even if we assume Kroger-Albertsons retain a market share of 13 percent following the merger, given generously by the Wall Street Journal, the top five companies would barely hold a majority of the market share. If we examine the existing nine companies and add the next largest supplier, the top ten companies would only hold 59 percent of all food sales in the United States. These projections do not include new grocers that have recently come on the scene, including natural grocers, which alter how consumers procure their groceries (Kang). As one analyzes all the data, this transaction looks less like two major grocers attempting to create a monopoly and more like two medium-sized retailers trying to gain efficiencies to remain competitive and viable in an ever-changing market.

Despite the many well-founded concerns expressed by consumers and market experts who believe the merger of Kroger and Albertsons will reduce competition, this proposed merger may allow these companies to remain viable in a changing grocery retail environment. Without a merger, consumers may lose one or both retailers from the market, thus reducing competition overall. Today’s grocery store looks much different than ten to fifteen years ago. These differences are due to the expansion of groceries in big-box stores, new alternative stores, online grocery shopping, and several other innovations, including drive-thru pickup, contactless delivery, self-checkout stations, and loyalty shopper programs to name just a few. Also, the growing popularity of German-based Aldi and Trader Joe’s has further impacted how consumers shop for groceries. While these stores offer fewer options and alternative brands, many consumers favor these retailers to purchase food at lower prices and find the smaller store size easier to navigate than searching through the thousands of products on shelves at conventional supermarkets. Many consumers purchase from Costco and Sam’s Club to buy items in bulk, saving them from frequenting the grocery store as often and, at times, saving them money on a per unit purchase basis. Finally, alternate stores like Dollar Tree, Dollar General, and Family Dollar have come onto the grocery scene, offering both freezer and shelf- stable foods at affordable prices. These retail alternatives, combined with the impact Amazon has had in online grocery sales, have significantly altered where people buy food.

Understanding grocery store innovations and the expanding marketplace is crucial to see why Kroger and Albertsons must merge to remain competitive and viable. The traditional supermarket is no longer conducive to evolving consumer demands, and retailers who fail to adapt may soon become extinct and forced to go out of business. If that happens, we will find fewer retailers and place more of the market share in the hands of Walmart, Sam’s Club, and Costco, losing vastly more than the competition many feared.

Regulators responsible for evaluating the proposed merger of Kroger and Albertsons have an important task before them. Every household in America purchases groceries, so this regulatory decision will affect much of the population. Given that groceries are a staple and a sizable portion of people’s earnings are allocated for food, this decision will significantly impact individuals’ budgets and the overall economy of the United States. The goal for regulators is to ensure the ongoing competitiveness of the grocery market. The initial reaction of consumers, consumer advocates, business experts, and regulators may be to view the proposed merger as creating a monopoly. These individuals should analyze changes in the grocery industry, relevant market data, and input from industry experts to determine whether the Kroger-Albertsons merger will impede competitiveness or instead benefit consumers. I believe the merger will allow these companies to better compete with large-scale retailers and help them to survive this changing retail environment. The merger may not only keep one or both companies from going out of business but allow them to thrive while keeping prices affordable and enhancing the customer experience, which positively affects market competitiveness. Therefore, the FTC should allow the merger to occur because the transaction does not meet the regulatory standards of a monopoly, will not impede competitiveness, and does not violate antitrust laws.