with Paulina Firozi


Pete Buttigieg is quite liberal, even by the standards of his 2020 Democratic presidential primary rivals

But now that the South Bend, Ind. mayor is getting more specific about his health-care positions, he sounds a lot more like the race’s moderates than its progressives.

Buttigieg’s campaign will today release a plan for improving and expanding health care for Americans — primarily patients in rural areas — provided to The Health 202. While in the past, Buttigieg has expressed a vague preference for Medicare-for-all, he’s now calling for building on the Affordable Care Act marketplaces by making government subsidies to purchase health care more generous and injecting into the system a government-backed plan to compete with commercial carriers.

Adding a “public option,” or ability to buy a government-run health care plan, is precisely the incremental approach advocated by the race’s top moderate, former vice president Joe Biden. Buttigieg has an alternate phrase, calling it “Medicare-for-all-who-want-it.” But regardless of the framing, it puts the mayor squarely in the camp of Democrats who’d rather focus on getting coverage to the remaining uninsured Americans rather than overhauling it for everyone else.

“We cannot make progress toward universal health-care coverage unless we shore up the foundation laid by the ACA,” Buttigieg's campaign says in an 11-page document laying out his ideas.

It’s not that Buttigieg doesn’t eventually want Medicare-for-all. But he doesn’t think jumping to that system right away is a good idea. He looks at it this way: Starting with a public option would be a good way to see whether the government is able to offer a plan superior to commercial insurance.

“It’s a chance to test whether that is the case — you would see by what people opt into before you flip a switch,” Buttigieg told me yesterday.

When it comes to health policy, questions about who gets health coverage and where it comes from have dominated the Democratic primary debates so far. Of the race’s five top-polling candidates, Biden and Buttigieg prefer a public option and keeping the ACA, while Sens. Bernie Sanders (I-Vt.), Elizabeth Warren (D-Mass.) and Kamala Harris (D-Calif.) want a rapid shift to Medicare-for-all.

But Buttigieg — and many of his two dozen opponents — are pivoting to talk about health care through the lens of rural voters. These voters, many of them in the swing states of Iowa, Pennsylvania, Michigan and Wisconsin, are a key electorate if they have any hope of beating President Trump next year.

And there’s a lot of them out there. Rural Americans lag behind urban and suburban dwellers on nearly every measure of health and wellness. They have higher rates of chronic illness. They pay more for insurance with fewer options. They live further from doctors and hospitals. Their life expectancy has even fallen behind.

Buttigieg is proposing a number of measures to combat rural provider shortages, partly by boosting programs that encourage doctors to work in remote areas. His proposal also calls for investing in telehealth, boosting treatment for mental health and addiction treatment and creating a new Office of Health Equity and Justice at Health and Human Services, all with the aim of improving care for people living in rural places.

The proposal also lays out some specific ways to target maternal mortality rates, which are 60 percent higher than in cities, and strengthen existing programs for Native Americans and veterans.

“When Democrats are asked about rural America, they panic, talk about broadband and change the subject,” Buttigieg told me. “We need to be talking about the basic reasons why rural Americas are worried their kids and grandkids won’t be able to live in the communities they grew up in.”

Rural hospitals have been shuttering for years and could falter further if they lose commercially insured patients, a point that Medicare-for-all opponents have been pressing lately (I explained that issue in yesterday’s Health 202).

Buttigieg says he shares this concern, which is why he is proposing to raise Medicare rates, although he didn’t detail by how much (Medicare currently pays hospitals 87 cents on the dollar for their costs). His proposal also says states would be encouraged to increase their Medicaid payment rates.

Former Maryland health secretary Joshua Sharfstein, who weighed in on the Buttigieg outline, said he appreciates its holistic approach to health care that goes beyond just treating illness.

“This would get an ‘A’ in my book for that,” Sharfstein said. “He’s thinking about health care in terms of the communities they produce. It’s not enough to say we’re going to make sure all the hospitals stay open, we actually want to improve life expectancy and quality of life in rural areas.”

To readers: This is a special, abbreviated edition of the The Health 202. We'll be back with full coverage on Tuesdays, Wednesdays and Thursdays next week and through the remainder of August. Thanks for reading and have a great weekend.