with Paulina Firozi

THE PROGNOSIS

If the fourth Democratic presidential debate goes anything like the last three, the candidates will spar vigorously tonight over how to get health coverage to more Americans.

But so far, in their fixation on how people obtain insurance, they’ve spent little time debating the skyrocketing costs for premiums, deductibles and medications that affect tens of millions of people who already have health plans.

That could be a missed opportunity. New research shows that Democratic-leaning voters actually want to hear more from the 2020 candidates about how to lower health-care costs for everyone — not just get coverage to those who don't have it. 

Kaiser Family Foundation poll released today.found majorities of such voters feel the candidates have spent too little time talking about health-care costs, surprise medical bills and reproductive health — and enough, or even too much, time discussing Medicare-for-all. 

Among the poll’s findings:

  • 58 percent of Democratic or Democratic-leaning voters said the candidates are spending too little time discussing women’s health care
  • 52 percent said they’re spending too little time on surprise medical bills
  • 50 percent said they’re spending too little time on how to lower the cost of health care
  • 47 percent said they’re spending too little time on the cost of prescription drugs

As 12 candidates take the stage at Otterbein University outside Columbus, Ohio, they’ll have yet another chance. Health care is an issue that got more airtime than any other topic (21 percent of all words spoken in all three debates combined, according to this Bloomberg analysis). Candidates have spent the first half-hour of each debate debating various iterations of Medicare-for-all versus the public option approach and whether to trash or keep employer-sponsored coverage (check out our past Health 202s here, here and here).

While the discussions have been unusually detailed for a televised debate — something that pleases your Health 202 author — the candidates have been criticized even by experts for having a relatively narrow focus despite a whole universe of ongoing and troublesome problems with how Americans access health care

“They are arguing endlessly about the subsidiary question of ‘how’ universal coverage would be achieved: with or without the availability of private employer-based insurance,” Andy Slavitt, who oversaw the Affordable Care Act under President Barack Obama, wrote in a recent USA Today op-ed.

“Americans need a bigger picture, and with President Donald Trump claiming that Democrats ‘want to take away your health care,’ they need a more accurate picture,” Slavitt wrote.

Discussions of Medicare-for-all and the public option are interesting and important, because they get at how to expand health coverage to the remaining 27 million Americans without it (although about half of them are already eligible for Medicaid or government subsidies to buy private plans).

But the polling reflects the ongoing struggle in the United States to make health insurance and prescription drugs affordable, problems Congress has said it wants to tackle this year. Both employer-sponsored plans, which cover 160 million Americans, and those available in the state-based marketplaces have suffered from rising premiums and increasingly steep deductibles.

Those problems won’t necessarily be solved even if universal health coverage is achieved. Even the 2010 ACA — the most sweeping health-care reform law in decades — didn’t bend the health-care cost curve even as it expanded coverage to about 20 million people.

So some health policy experts are arguing the candidates would do better to focus on the cost of health insurance and prescription drugs for consumers and suggest ways to mitigate those costs.

“I tend to think the affordability point is more important than the coverage one,” Bob Kocher, who worked on health policy issues at the National Economic Council under Obama, told me.

In his op-ed, Slavitt called on the Democratic candidates to lay out a vision for reforming health-care payments so they encourage better-quality care, improving lagging maternal health, combating opioid abuse and encouraging healthy behaviors that reduce the need for care.

Several of the candidates, including South Bend, Ind., Mayor Pete Buttigieg and Sens. Elizabeth Warren (D-Mass.) and Kamala Harris (D-Calif.) have laid out health-care proposals that go beyond just how to expand health coverage.

But whether the candidates go beyond their differences over Medicare-for-all in tonight’s debate remains to be seen.

AHH, OOF and OUCH

AHH: The debate could also bring questions about the health of the candidates themselves.

Two weeks after his heart attack, Sen. Bernie Sanders (I-Vt.) and his advisers know he'll have to prove he can be strong enough to take on President Trump in a general election. The campaign anticipates his heart attack will be addressed by the moderators, the New York Times’s Sydney Ember reports.

“His health issues have cast a degree of uncertainty over his campaign and left his aides rushing to reassure voters about his age and health, just as he was trying to improve his standing in a race that in recent weeks has become more of a two-person contest between Senator Elizabeth Warren and former Vice President Joseph R. Biden Jr.,” Sydney reports. “Aides have said they expect Mr. Sanders to come across as energetic as ever and have rebuffed questions about whether he can handle standing for so long onstage.”

— Meanwhile, as the health and age of the candidates have become a critical yet sometimes unspoken issue, Warren has seemingly taken chances to show off her fitness on the campaign trail, the Los Angeles Times’s Janet Hook reports.

“In the now-famous selfie-photo lines that are the capstone of her campaign rallies, Warren stays on her feet for hours greeting voters individually. Opening her rallies, she typically jogs to the podium,” she writes. “… Warren has largely escaped questioning about her age, but she will be standing next to the youngest of her rivals, 37-year-old Pete Buttigieg, the mayor of South Bend, Ind., who has campaigned on the need for generational change.”

OOF: Paul Farrell Jr. is a small-city lawyer taking on the nation’s biggest drug companies over the opioid crisis. His hometown in West Virginia has been at the center of the epidemic, and he’s now one of three attorneys leading the national legal challenge that’s set to begin Monday in federal court in Cleveland, our Washington Post colleague Joel Achenbach reports in this profile.

Farrell is “one of the backstage masterminds of the litigation, which now includes more than 2,600 communities,” Joel writes. “The plaintiffs argue that the nation’s biggest drug companies — manufacturers, distributors and retailers — recklessly peddled opioid painkillers and fueled a wave of addiction.”

He helped create a strategy around a state statute that says counties have the legal right to abate a public nuisance. Requiring abatement means the drug manufactures could be required to pay billions of dollars to help the communities ravaged by opioids.

“They broke it. So they need to fix it,” Farrell said of the pharmaceutical companies. “I want them to stop killing people. I want mothers to stop giving birth to babies addicted to opium. I want my friends and my friends’ children to stop overdosing. I want to stop going to funerals.”

OUCH: The federal government has allowed e-cigarette and vaping devices to boom as part of a mostly unregulated industry over the course of a decade, the New York Times’s Katie Thomas and Sheila Kaplan report.

“In dozens of interviews, federal officials and public health experts described a lost decade of inaction, blaming an intense lobbying effort by the e-cigarette and tobacco industries, fears of a political backlash in tobacco-friendly states, bureaucratic delays, and a late reprieve by an F.D.A. commissioner who had previously served on the board of a chain of vaping lounges,” they write.

In 2009, a pair of e-cigarette companies successfully sued the Food and Drug Administration for attempting to regulate the products as drugs — the agency instead had to treat them as tobacco products. In the last year of the Obama administration, officials rejected a plan to ban flavored e-cigarettes. In 2017, the agency under then-FDA Commissioner Scott Gottlieb delayed regulations that may have limited the e-cigarette products on the market.

Now, officials are grappling with an alarming spate of vaping-related lung illnesses that have been reported in nearly every state. “It has to get bad enough before you can actually get down to what needs to get done,” Robert M. Califf, a former FDA commissioner, told Katie and Sheila. “And I guess in a way this is an example.”

AGENCY ALERT

— Gottlieb tweeted that vaping products that contain THC, the main psychoactive component of marijuana, should be banned.

Officials say many of the people who have been sickened with the vaping-related illness reported using vaping products containing THC.

In an interview on CNBC, Gottlieb said that “no one should be vaping THC. Putting something into the lungs is inherently dangerous and we just shouldn’t allow the vaping of these concentrates.”

He also called for federal regulations of marijuana markets. Gottlieb said states can’t do the regulating themselves because they “don’t have the capacity to both police what’s being sold in their so-called legal dispensaries as well as shut down the black market … I think you’re going to need federal authorities in there to do that.”

He suggested the FDA and the Drug Enforcement Administration “could regulate what’s being sold for the potency, for the manufacturing, for the ingredients, for the claims that are being made.”

— In the same interview, Gottlieb also said he’s not sure vaping nicotine causes cancer in people, responding to a New York University study released last week that found e-cigarette vapor that has nicotine causes lung cancer in mice, CNBC’s Jessica Bursztynsky reports.

“I’m skeptical that nicotine causes cancer,” Gottlieb said in the interview. 

He said nicotine “might be a tumor promoter, [researchers] have said that there’s a potential that nicotine is a tumor promoter, but it doesn’t cause cancer.”

But he added that he would still believe that inhaling vapor from e-cigarettes would damage lungs. “You can’t inhale something into the lungs that way on a repeated basis and not cause some damage to the lung," he said. 

“Out of 40 mice exposed in the study to e-cigarette vapor with nicotine over 54 weeks, 22.5% developed lung cancer and 57.5% developed precancerous lesions on the bladder,” Jessica reports. “None of the 20 mice exposed to e-cigarette vaper without nicotine developed cancer over the four years they studied the mice, the researchers said.”

INDUSTRY RX

— Employers like Amazon are increasingly paying to have their employees travel to certain hospitals for care, shopping around for select services instead of relying on local providers.

The upside is competitive prices and better care, the Wall Street Journal’s Melanie Evans reports, despite the downside of extra costs for airfare, hotels and gas, as well as time away from home. At Amazon, 380,000 employees are eligible for a travel benefit - the company is paying for employees diagnosed with cancer to travel to Los Angeles to see top doctors at the City of Hope health system. (Amazon CEO Jeff Bezos owns The Washington Post.)

“Employer health plans, which cover roughly 153 million people in the U.S., struggle to command competitive prices and quality controls in some markets as health-care providers have consolidated and gained leverage in negotiations,” Melanie writes. “…By paying employees’ way to travel for medical care, Amazon hopes to increase workers’ choices and curb health spending by getting workers to top specialists and reducing the chance of the wrong diagnosis or treatment, said Dene Sparrman, the company’s director of global benefits.”

City of Hope didn’t say how many Amazon workers have traveled there since the program began in April.

— And here are a few more good reads: 

HEALTH ON THE HILL

TRUMP TEMPERATURE

MEDICAL MISSIVES

SECOND OPINION

DAYBOOK

Coming Up

  • The Senate Special Committee on Aging holds a hearing on national, state, and local solutions to better support seniors on Wednesday.
  • The House Veterans’ Affairs Subcommittee on Oversight and Investigations holds a hearing on Assessing VA’s Systems for Protecting Veterans from Clinical Harm on Wednesday.
  • The Washington Post hosts its latest "Chasing Cancer" live event featuring influential cancer warriors, trailblazers and advocates from Silicon Valley on Thursday. 

SUGAR RUSH