THE PROGNOSIS

Democrats running for president have largely avoided answering this sticky question: Would they ditch the private insurance that tens of millions of Americans rely on, as they try to achieve their goal of universal health coverage?

Most of the candidates at last night’s presidential debate wouldn’t go there. But Sen. Elizabeth Warren (D-Mass.), the top-polling contender on the stage, did. 

She and New York Mayor Bill DeBlasio were the only candidates of the 10 present to raise their hands when moderator Lester Holt asked who would get rid of private coverage in favor of a government-run plan.

“Yes, I’m with Bernie on Medicare-for-all,” Warren said, referring to Sen. Bernie Sanders’s trademark health-care plan. “There are a lot of politicians who say, oh, it's just not possible, we just can't do it, have a lot of political reasons for this. What they're really telling you is they just won't fight for it. Well, health care is a basic human right, and I will fight for basic human rights.”

Our colleague Dave Weigel: 

Differences over the future of private health insurance, which covers around 180 million Americans, fueled some of the most spirited exchanges on the first Democratic primary debate last night. The topic was one of several where the Democrats were pressured to respond to ideas considered too liberal just a few elections ago, showing the party’s move to the political left, my colleague Jeff Stein notes.

Sanders wasn’t on the stage – he and former vice president Joe Biden will be among 10 more candidates in a second debate tonight. But his Medicare-for-all proposal and its dramatic overhaul of the United States health-care system helped illuminate a key point of difference between candidates last night. Some criticized the potential negative effects on patients and hospitals. Others charged that private insurance is so poor it needs to be replaced with something better.

“Why are you defending private insurance to begin with?” De Blasio asked Beto O’Rourke, interrupting the former congressman from Texas. O’Rourke was answering Holt’s question of whether he’d replace private insurance.

“No, I think the choice is fundamental to our ability to get everybody cared for,” O’Rourke responded.

“Wait, wait, wait, Congressman O'Rourke,” De Blasio retorted. “Private insurance is not working for tens of millions of Americans when you talk about the co-pays, the deductibles, the premiums, the out of pocket expenses. It's not working. How can you defend a system that's not working?”

“That's right,” O’Rourke responded. “So for those for whom it's not working, they can choose Medicare.”

Six of the candidates have either signed onto Medicare-for-all or said they support some version of it. But four of those – Sen. Cory Booker (D-N.J.), former Housing and Urban Development secretary Julian Castro, Rep. Tulsi Gabbard (D-Hawaii) and Washington Gov. Jay Inslee – weren’t willing to publicly embrace its perhaps most politically risky proposal of replacing all private coverage with a single, government-run plan.

Booker and Gabbard both said they think Medicare-for-all is the best way to achieve universal health coverage while seeming to leave the door open to retaining commercial health coverage, too. Inslee touted his state’s recent creation of a public option to compete with private plans (Health 202 wrote about that here).

Other candidates on stage, who say they prefer to simply expand Medicare or Medicaid, chose to jab at the idea of Medicare-for-all. Former Rep. John Delaney and Sen. Amy Klobuchar (D-Minn.) gave the most explicit criticisms, saying if it were carried out as Sanders envisions, people would lose plans they like and hospitals would shutter.

“I am just simply concerned about kicking half of America off of their health insurance in four years, which is exactly what this bill says,” Klobuchar said.

Our colleague Yasmeen Abutaleb: 

Our colleague Aaron Blake: 

Delaney said Democrats should be “the party that keeps what’s working and fixes what’s broken” considering “100 million Americans say they like their private health insurance.”

“We should give everyone in this country health care as a basic human right for free, full stop,” he said. “But we should also give them the option to buy private insurance. Why do we have to stand for taking away something from people?”

Delaney also took a dip into one of the chief criticisms levied by Medicare-for-all opponents, including basically the entire health care industry: That it would result in much lower payments for health-care providers, causing even worse doctor and hospital shortages and ultimately making it harder for people to get care.

He called it “bad policy” to require hospitals Medicare rates – which are lower than those paid by private insurance – for every patient, predicting that would force hospitals to eventually close.

“If you go to every hospital in this country and you ask them one question…how would it have been for you last year if every one of your bills were paid at the Medicare rates?” Delaney said. “Every single hospital administrator said they would close.”

“And the Medicare-for-all bill requires payments to stay at current Medicare rates,” he added. “So to some extent, we’re supporting a bill that will have every hospital closing.”

Here are a few of the other notable health care-related moments from the first night of the first debate: 

ABORTION:  There seemed to be more agreement on the debate stage among the candidates on the issue of abortion coverage than there was on health insurance more generally.

Klobuchar had one of the biggest applause lines of the night with a zinger in response to Inslee who said he was the “only candidate here who has passed a law protecting a woman's reproductive rights in health insurance and the only candidate who passed a public option.” Klobuchar shot back: “I just want to say there are three women up here who fought very hard for a woman's right to choose.”

Julián Castro said his health-insurance plan would cover abortions. He also called for “reproductive justice.” "What that means is just because a woman — or, let’s not forget someone in the trans community, a trans female — is poor doesn’t mean they shouldn’t have the right to exercise the right to choose. And so I absolutely would cover the right to have an abortion.”

Warren called for codifying Roe V. Wade: “It's not enough for us to expect the courts to protect us,” she said. “Forty-seven years ago, Roe v. Wade was decided, and we've all looked to the courts all that time, as state after state has undermined Roe, has put in exceptions, has come right up to the edge of taking away protections... We now have an America where most people support Roe v. Wade. We need to make that a federal law.”

New York Times's Margot Sanger-Katz: 

Kaiser Health News's Julie Rovner: 

OPIOID CRISIS: Just two candidates – Booker and O’Rourke – specifically addressed the opioid crisis. Booker said drug companies should “absolutely be held criminally liable, because they are liable and responsible… It is time that we have a national urgency to deal with this problem and make the solutions that are working to actually be the law of our land and make the pharmaceutical companies that are responsible help to pay for that.” O’Rourke called out opioid manufacturer Purdue Pharma by name, saying their “connection to the opioid crisis and the overdose deaths that we're seeing throughout this country, they've been able to act with complete impunity and pay no consequences, not a single night in jail…. Unless there's accountability and justice, this crisis will continue." 

Fact Check: Our Post colleague and fact-checker Glenn Kessler writes that in terms of financial punishment, O’Rourke’s remark was incorrect. “Purdue Pharma, the maker of OxyContin, in March paid a $270 million civil settlement in Oklahoma and faces lawsuits around the country. In 2007, three executives were spared prison time and sentenced to probation after agreeing to plead guilty to charges that they misled federal regulators about the addiction risks of the drug,” he reports.

GUN CONTROL: Moderator Chuck Todd pressed the candidates on their gun law positions, beginning a series of questions on the issue by citing the 2017 mass shooting at Marjory Stoneman Douglas High School in Parkland, Fla. Klobuchar praised the survivors of the shooting for their activism around gun control. “They started literally a national shift,” she said. “When kids talked to their parents and their grandparents, they say I don’t understand why we can’t put these sensible things in place, they listen. And if we get bested by a bunch of 17-year-olds, it's the best thing that ever happened.”

Warren called for more research on gun policies and said gun violence is a “national health emergency in this country, and we need to treat it like one.” “So what can we do?... We can do universal background checks, we can ban the weapons of war, but we can also double down on the research and find out what really works."  

“For millions of Americans, this is not a policy issue, this is an urgency,” Booker said. “For those that have not been directly affected, they’re tired of living in a country where their kids go to school to learn about reading, writing and arithmetic and how to deal with an active shooter.” He pushed for requiring licenses for all gun owners.  

Rep. Tim Ryan (D-Ohio) said it was also important to address the “trauma that our kids have,” calling for mental health counselors in all schools. “We need trauma-based care in every school. We need social and emotional learning in every school,” he said. “If our kids are so traumatized that they're getting a gun and going into our schools, we're doing something wrong, too, and we need reform around trauma-based care.”

Parkland shooting survivor David Hogg, who co-founded gun control advocacy group Never Again MSD: 

AHH, OOF and OUCH

AHH: A federal appeals court inserted a new obstacle in the ongoing case over the fate of the Affordable Care Act. The U.S. Court of Appeals for the 5th Circuit, set to start hearing oral arguments on the ACA's constitutionality on July 9, requested additional information about to whether the House and more than a dozen Democratic states have the proper standing to appeal a lower-court decision that struck down the law.

"Some legal experts said the request did not bode well for the future of President Barack Obama’s signature domestic policy achievement," our Post colleague Yasmeen Abutaleb reports. "...Others said the court might simply be ensuring that the House and Democratic states’ standing is valid and would be upheld by the Supreme Court in the likely event of an appeal." 

If neither the states nor the House can prove they have proper standing to appeal the decision, that could mean the lower court ruling stands.

“If the Fifth Circuit upholds the lower court ruling — which would almost certainly put it back in front of the Supreme Court — it would create a political and logistical mess for the Trump administration and Congress, which has no alternative to the sprawling health law,” Yasmeen writes. “Republicans repeatedly failed to repeal and replace Obamacare while they controlled both the House and the Senate in 2017 and have little appetite to revisit health reform.”

Nicholas Bagley, a professor of law at the University of Michigan Law School called it an “ominous sign.”

Bagley added it’s not entirely clear what that would mean for the case:

Jonathan Adler, a law professor at Case Western Reserve University School of Law, told Yasmeen there are "perfectly normal, understandable reasons why courts would ask these sorts of questions," but added "the order does add a little bit of uncertainty in this litigation." 

OOF: A Centers for Disease Control and Prevention advisory panel is now saying some people up to age 45 could benefit from getting the the HPV vaccine. 

As of now, the HPV vaccine is recommended for preteen boys and girls, with catch-up vaccinations recommended for people through age 26, our Post colleague Lindsey Bever reports. But after a two-day meeting of the federal public health advisory panel, the committee voted 10-to-4 to “recommend HPV vaccination for women and men ages 27 to 45 who are not adequately vaccinated." 

The Food and Drug Administration last year expanded its approval of the vaccine – which was developed to prevent HPV-related cancer usually transmitted through oral, anal or vaginal sex – for individuals ages 27 to 45. "According to the CDC, most sexually active people will contract HPV at some point," Lindsey writes. "Some people may never know they have it, and the active infection may be short-lived because, in most cases, the body’s immune system suppresses the virus. Still, the virus can lead to many types of cancer, including cervical, anal, vaginal and penile as well as cancer of the throat." 

OUCH: Drug overdose-related deaths may be set to decrease for the first time in decades, according to provisional data from the CDC.

Although deaths from 2018 across the United States are still being tallied, the provisional data indicates the number of deaths will drop for the first time since 1990. The data “predict there were nearly 69,100 drug deaths in the 12-month period ending last November, down from almost 72,300 predicted deaths for 12 months ending November 2017,” the Wall Street Journal’s Jon Kamp reports.

Health officials still caution the drug epidemic is far from over. “The death rate remains swollen by powerful synthetic opioids like fentanyl,” Jon writes.

Access to the opioid-overdose antidote naloxone may have contributed to some decline in overdose deaths. But meanwhile, opioids are still driving death rates higher in numerous states.

HEALTH ON THE HILL

— The Senate yesterday approved its own $4.6 billion emergency spending bill that’s meant to provide care for the thousands of migrants entering the United States at the border.

The measure passed on a 84-to-8 vote amid fresh concerns about the conditions for children and families at migrant shelters as well as shock over a widely circulated photo of a father and daughter who drowned trying to cross a river into Texas. 

The Senate’s version includes $2.88 billion for the Department of Health and Human Service’s Office of Refugee Resettlement, which could run out of money before July, our Post colleagues Erica Werner and Mike DeBonis report.

The legislation "threatened to get hung up in disputes over a different version of the bill passed by the House with mostly Democratic votes, even as leaders in both chambers insisted they would not head home for Congress’s Fourth of July recess before sending a final bill to President Trump," our colleagues adds. 

— Before last night's debate, some Democratic presidential candidates visited a children's migrant shelter in Florida as national attention has swelled around the conditions at such facilities. 

"Homestead is not one of the shelters that has made headlines for unsafe conditions, but it has been a popular backdrop for opposition to the Trump administration’s widely criticized family separation policies," our Post colleagues David Weigel, Colby Itkowitz and Chelsea Janes report.

— The Senate Health, Education, Labor and Pensions Committee voted to advance a healthcare package sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) meant to lower costs for patients on a 20-to-3 vote.

Modern Healthcare's Susannah Luthi reports there was one change to the proposed ban on surprise medical bills, with potential for more changes before the measure comes to the full chamber for a vote in the coming weeks.

“As it stands, the provision on surprise medical bills would cap out-of-network physician or hospital charges at a rate already negotiated by insurers. An amendment to that provision came from Sen. Bill Cassidy (R-La.) and would make insurers post all the physician and hospital options in their networks so patients could see their choices of doctor before deciding on a plan,” Susannah writes. “But Cassidy and other colleagues—who were driving forces behind an arbitration model to settle any payment disputes between physicians, hospitals and insurers—made it clear they will keep working to move the bill toward a more provider-friendly form as hospital and physician groups continue to strongly oppose the benchmark rate cap.”

— The panel also approved as part of the package a bipartisan bill that would raise the legal age to purchase tobacco to 21, a measure co-sponsored by Senate Majority Leader Mitch McConnell (R-Ky.) and Sen. Tim Kaine (D-Va.).

“I’m grateful to my colleagues for advancing our legislation to help curb the spike of youth tobacco use,” McConnell said in a statement, as our Post colleagues Felicia Sonmez and Jenna Portnoy report. “Because children are extremely vulnerable to becoming addicted to nicotine and suffering its lifelong consequences, we must do everything we can to keep these products out of their hands.”

— And here are a few more good reads from The Post and beyond: 

The Fix
Winners: Warren, Castro, and the Spanish language. Losers: O'Rourke, and having a plan.
Aaron Blake
Politics
Former HUD secretary Julián Castro challenged his rivals to repeal the law that makes crossing the border illegally a federal crime.
Nick Miroff
AGENCY ALERT
Immigration
The officers, who have been directed to implement the program, say it is “fundamentally contrary to the moral fabric of our Nation and our international and domestic legal obligations.”
Maria Sacchetti
World
A man and his 23-month old daughter, migrants from El Salvador, were swept away in the river waters in Brownsville, Tex., on Sunday. A graphic photo of them shocked the world.
Reis Thebault, Luis Velarde and Abigail Hauslohner
A look inside the Border Patrol station at Clint, Tex., where visiting lawyers said they saw migrant children being held in filthy conditions.
New York Times
"Many infants and children are losing weight because of the quality and quantity of food being provided," a doctor who inspected a Border Patrol facility said.
BuzzFeed News
Politics
The Department of Veterans Affairs moved to fire a whistleblowing psychologist one day before her House testimony.
Joe Davidson
MEDICAL MISSIVES
Politics
"If one person's life is saved from seeing it, or their families seeing it," Rep. Susan Wild said, “I will have accomplished what I wanted to accomplish.”
Kayla Epstein
National
Christopher W. Cox resigned after allegations that he participated in an extortion scheme, which he denies.
Katie Zezima and Beth Reinhard
STATE SCAN
Health
“You ain’t getting it,” one lawmaker responded when told the federal government believes it is “entitled” to a portion of the windfall.
Lenny Bernstein
Business
The nation’s first such ban occurs in the city where market-leading e-cig maker Juul Labs is based.
Rachel Siegel
BATON ROUGE, La. (AP) — For years, Louisiana offered hepatitis C treatment to only the most severe cases in its Medicaid program and prisons, unable to afford broader access to the extremely...
Associated Press
INDUSTRY RX
Amazon.com Inc. is adding another option for customers to get packages from the online retailer: picking them up at Rite Aid drugstores.
Wall Street Journal
DAYBOOK

Coming Up

  • The Bipartisan Policy Center hosts an event: “Good Health is Good Business” on Friday.
  • The American Enterprise Institute holds an event on cannabis legalization on Friday.
SUGAR RUSH

Here are some of the issues covered during the first debate of the 2020 presidential election: 

The best one-liners from night one of the first Democratic debate: