Emmarie Huetteman

Kaiser Health News

If you tuned in for the first five nights of the Democratic presidential debates, you might think “Medicare for All” and providing universal care are the only health care ideas Democrats have.

With less than four months to go before the Feb. 3 Iowa caucuses, proposals on issues like the opioid epidemic have attracted less attention.

That is because big-ticket policy ideas – like enrolling all U.S. residents into a Medicare-style program and eliminating private insurance – can help candidates stand out in the eyes of voters during a primary, said Robert Blendon, a professor of health policy and political analysis at Harvard University and director of the Harvard Opinion Research Program.

But Blendon said he has not seen polling suggesting voters have an appetite for another major health care debate. Voters are more concerned with how much they have to pay for medical care, like prescription drugs – “very practical, pocketbook issues,” he said.

“So it’s just my belief that whoever wins is going to have to switch back to pocketbook issues,” Blendon said of the eventual Democratic nominee.

The next Democratic presidential debate on Oct. 15 will give 12 of the candidates a fresh chance to talk about their ideas beyond sprawling health care reform. Let us walk you through a few proposals they have championed, plus what President Donald Trump is offering.

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Sanders’ plan to cancel medical debt

Sen. Bernie Sanders of Vermont rolled out a sweeping proposal last month to overhaul medical debt collection with a headline-catching promise: to wipe clean the roughly $81 billion Americans owe in past-due medical debt.

And the issue is ubiquitous since polls show voters are deeply concerned about their out-of-pocket costs. Raymond Kluender, an assistant professor at Harvard Business School who researches medical debt, said about 20% of households have medical bills in collections.

Kluender said Sanders’ plan targets debt that is rarely repaid anyway, noting that only about 8% of what is sent to collection agencies is ever repaid. Although some limited research suggests debt forgiveness may have mental health benefits, Kluender said, the effect Sanders’ move would have “is hard to know.”

Here are highlights of Sanders’ proposal:

Empower the federal government to negotiate, then pay off past-due medical bills that have been reported to the credit agencies. To calculate how much that debt is, the Sanders campaign points to a 2018 study that showed 1 in 6 Americans has a past-due medical bill on their credit report, with debt totaling about $81 billion.

Curb “abusive and harassing” debt collection tactics, including enforcing statutes of limitation that generally run from three to six years, depending on the state; limiting how often debt collectors can contact those who owe; requiring debt collectors to verify whether the information they have is accurate before attempting to collect; restricting the seizures of assets and garnishing of wages.

Task the Internal Revenue Service with examining nonprofit hospitals to ensure they meet the “charitable care standards” for facilities with nonprofit tax status.

Reform the bankruptcy court system to help those in debt.

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Biden’s plan to curb gun violence

Former Vice President Joe Biden announced a plan this month to reduce gun violence, an issue that has become a must for most Democratic voters.

In addition to outlining his proposal to ban the manufacture and sale of assault weapons and require universal background checks, Biden took the opportunity to talk about his legislative history on guns: In 1993, he helped pass the law that established the background check system, and in 1994, he helped secure the 10-year assault weapons ban that has since lapsed.

He also drew attention to his newer ideas to change the system, including a push toward transitioning to “smart guns.”

But Biden’s plan does not go as far as that of some of his opponents – including Sen. Cory Booker, D-N.J., who would require a license to own a firearm.

Here is what Biden has said he would do on gun control:

Ban the manufacture and sale of assault weapons and high-capacity magazines, and otherwise regulate and buy back existing weapons.

Require background checks for all sales, and close certain loopholes, including those that allow people with mental health issues and hate crime convictions to have firearms.

Reward states that set up firearm licensing programs, require owners to safely store their weapons and crackdown on “straw purchasers” who buy firearms for those who cannot pass a background check.

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Buttigieg’s plan to strengthen mental health care

Mayor Pete Buttigieg of South Bend, Indiana, introduced a wide-ranging, $300 billion proposal in August to improve treatment for mental health and substance abuse.

Few disagree on the need to increase access to mental health care in the United States, making the issue one that is unlikely to move voters on its own, Blendon said. But Buttigieg’s plan stands out for tripling the investments proposed by other Democratic candidates, including Massachusetts Sen. Elizabeth Warren.

True to his mayoral roots, Buttigieg adopts a locally driven approach. Among other strategies in his 19-page plan, he would give communities “most affected” by mental illness and addiction $10 billion annually for 10 years to address prevention and care.

His campaign claims the plan would enable about 10 million more people to access care over the first four years of the program. Here are some ways Buttigieg said he would do that:

Enforce mental health parity in coverage, including under Medicare and Medicaid.

Expand access to addiction treatments, including by deregulating buprenorphine, a medication-assisted treatment proven effective for opioid use disorder.

Reduce related incarceration, in part, by decriminalizing all drug possession and expunging past convictions.

Hold drug companies “accountable” for their role in the opioid epidemic, including by supporting state-level lawsuits.

“Combat the epidemic of social isolation and loneliness,” including through a national service program that would pair older and younger Americans.

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Warren’s plan to end the opioid crisis

Warren unveiled an aggressive plan to combat the nationwide opioid epidemic last spring, proposing to spread $100 billion across the country to help state, local and tribal governments respond to the crisis.

And unlike Buttigieg and his $300 billion mental health and addiction plan, Warren outlined how she would pay for it – with a tax on the richest 75,000 families.

“This crisis has been driven by greed, pure and simple,” she wrote in a Medium post detailing her plan.

Here is some of what her plan would do:

Prioritize and allocate money for public health departments, first responders and others in “front-line” communities.

Give states incentives to cover addiction services through state Medicaid programs.

Expand surveillance, research and access to treatment, including naloxone, the overdose reversal drug.

Trump’s efforts on medicare, public health and drug prices

Trump caused a stir this year when he declared the Republican Party would become “the party of health care” and suggested he was working on another proposal to replace the Affordable Care Act.

But he has said little on the subject since then, and a Washington Post report last month said the White House has abandoned that effort in favor of damage control should the 5th Circuit Court of Appeals strike down the Affordable Care Act.

Instead, the Trump administration has picked up on a series of often disparate health issues, including changes to how the government pays for care, investments in public health crises and steps intended to pressure drugmakers to lower prices.

One of Trump's latest moves came on Oct. 3, when he signed an executive order making a variety of changes to Medicare, including expanding the private Medicare Advantage plans available to seniors and changing the enrollment process. He took the opportunity to pan the progressive push toward a single-payer health care system as “socialist,” framing his changes as protections for seniors.

In addition to an ambitious plan to end HIV/AIDS introduced in February, the Trump administration unveiled a kidney care initiative in July that adjusts payment incentives to encourage preventive care, home dialysis and transplants. And last month, the administration said it was preparing to ban the sale of flavored e-cigarettes amid a public health scare over vaping and concerns about widespread use among teens.

And after promising to lower drug prices, Trump has struggled to make changes amid disagreements with the pharmaceutical industry and even fellow Republicans.

The administration has tasked the Department of Health and Human Services to work on other policies, including requiring hospitals to disclose prices and laying out a framework to allow, for the first time, the legal importation of prescription drugs from overseas.

Kaiser Health News (KHN) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.