THE PROGNOSIS

This time it was Sen. Elizabeth Warren fielding attacks from all sides as the Democratic candidates vigorously debated Medicare-for-all in their fourth primary debate.

 Their differences over how to expand health coverage have been on display in all the previous debates, but last night the candidates especially tried to portray the Massachusetts senator who has been rising in the polls as cagey or extreme on the issue.

Despite the pressure, Warren again refused to say whether Medicare-for-all would result in higher taxes for the middle class or talk specifically about how it would eliminate employer-sponsored coverage for 160 million Americans. She notably vowed that her plan would not raise overall costs for the middle-class, and evaded the specific issue of taxes. 

“So my view on this, and what I have committed to, is costs will go down for hardworking, middle-class families,” Warren said. “I will not embrace a plan like Medicare for all who can afford it that will leave behind millions of people who cannot.”

New York Times's Margot Sanger-Katz: 

CNN's MJ Lee:

HuffPost's Amanda Terkel: 

South Bend, Indiana Mayor Pete Buttigieg slammed Warren for refusing to get specific about how she’d fund Medicare-for-all and for advocating a single, government plan everyone would have to enroll in.

“Your signature, Senator, is to have a plan for everything. Except this,” Buttigieg said. “No plan has been laid out to explain how a multi-trillion-dollar hole in this Medicare for all plan that Senator Warren is putting forward is supposed to get filled in.”

Politico's Elena Schneider: 

Even Sen. Bernie Sanders (I-Vt.) – the candidate Warren has most closely aligned with on Medicare-for-all – gave a subtle jab.

“I do think it’s appropriate to acknowledge taxes will go up,” Sanders said. “They will go up significantly for the wealthy.”

Sen. Amy Klobuchar (D-Minn.) suggested Warren wasn’t being “honest” in how she talks about the issue.

“At least Bernie's being honest here and saying how he's going to pay for this and that taxes are going to go up,” Klobuchar said. “And I'm sorry, Elizabeth, but you have not said that, and I think we owe it to the American people to tell them where we're going to send the invoice.”

Vox's Ezra Klein: 

PBS News Hour's Yamiche Alcindor: 

Compared to the first primary debate in June, the candidates by now have more clearly-defined positions on how to achieve universal health coverage. As in past debates, they were eager to differentiate themselves on exactly how they’d expand coverage to the uninsured and improve coverage for those who already have it.

Sen. Kamala Harris (D-Calif.) has proposed a version of Medicare-for-all that would involve private insurers administering it. Buttigieg wants to keep workplace coverage but let anyone buy into Medicare, in his “Medicare-for-all-who-want-it” plan. Former vice president Joe Biden has laid out how he’d provide a government-backed plan through the Affordable Care Act marketplaces.

Biden recited his now-familiar lines about expanding the ACA versus trying to overhaul the whole system. He also lobbed pointed attacks at Medicare-for-all, alleging it would raise taxes by about $5,000 a year for people making in between $50,000 and $75,000.

“On the single most important thing facing the American public, I think it's awfully important to be straightforward with them,” Biden said. “The plan is going to cost at least $30 trillion over 10 years. That is more on a yearly basis than the entire federal budget.”

Sanders and Warren, who are aligned on the most expansion version of Medicare-for-all, have faced tricky questions of how they’d pay for it and why they would need to do away with the private health insurance industry. 

Their most effective response has been to point to systemic and widely-acknowledged problems in the country’s health-care system. Last night, Warren returned again and again to the theme of bankruptcy stemming from medical bills (we recently wrote a Health 202 about this very problem), saying she has heard from people with multiple sclerosis, diabetes and cancer about the costs they incurred.

“They all had great health insurance right at the beginning,” Warren said. “But then they found out when they really needed it, when the costs went up, that the insurance company pulled the rug out from underneath them and they were left with nothing.”

Our Post colleague Robert Costa: 

Here are some other key health-related moments from the debate:

CANDIDATES AND THEIR HEALTH: Sanders, 78, said he was “healthy, I’m feeling great,” when asked how he can assure voters he's fit to tackle the presidency after his heart attack earlier this month. He plugged an upcoming campaign rally in New York -- where, as our Post colleagues Sean Sullivan and Dave Weigel scoop, Rep. Alexandria Ocasio-Cortez (D-N.Y.) plans to endorse the Vermont senator.

“I’ll be mounting a vigorous campaign all over this country," Sanders said. "That is how I can reassure the American people.” He thanked people who supported him during his recovery. “Let me take this moment to thank so many people from all over this country, including many of my colleagues up here for their love, for their prayers, and their well-wishes… I’m so happy to be back here with you this evening.”

Political strategist Caleb Hull:

New York Times political reporter Shane Goldmacher:

LA Times correspondent Matt Pearce:

Biden, 76, vowed to release his medical records ahead of the Iowa caucuses in February. And 70-year-old Warren, when asked about her age, said: "I say I will outwork, out-organize and outlast anyone and that includes Donald Trump or Mike Pence or whoever the Republicans get stuck with.”

ABORTION: Harris chimed in during the Medicare-for-all debate to point out a lack of questions about states passing new abortion restrictions.

 

When asked about how the candidates would stop laws restricting abortion, Harris said under her administration, the Justice Department would review whether laws comply with Roe v. Wade, otherwise they wouldn’t go into effect.

Sen. Cory Booker (D-N.J.) joined in: “We are seeing all over this country, women's reproductive rights under attack and... women should not be the only ones taking up this cause and this fight." Booker said he would create an Office of Reproductive Freedom, and called for codifying Roe v. Wade and repealing the Hyde Amendment, which bans the use of federal funds for abortions except in cases of life endangerment, rape or incest. 

Former Housing and Urban Development Secretary Julián Castro and Klobuchar also said they would codify Roe v. Wade. 

Warren reminded people that even when abortions were illegal, women still had access to the procedure if they could afford to travel to places where it was legal.

Rep.Tulsi Gabbard (D-Hawaii) said the need for “safe, legal and rare” abortions was one area she agreed with Hillary Clinton. She said there should be limits on third-trimester abortions “unless the life or severe health consequences of a woman are at risk.”

OPIOID CRISIS: Several candidates called for holding opioid executives accountable and sending them to prison for their role in the opioid crisis.

Harris said she thinks pharmaceutical executives should be locked up. “I do think of this as being a matter of justice and accountability because they are nothing more than some high-level dope dealers,” she said. “They should be held accountable. This is a matter of justice. And so as president of the United States, I would ensure that the United States Department of Justice understands that you want to deal with who is really a criminal.”

Castro said the executives “need to be held accountable not only financially but also with criminal penalties.” 

Business executive Andrew Yang cited Ohio as an epicenter of the crisis, saying there was a “point when there were more opioid prescriptions in the state of Ohio than humans in the state of Ohio.” Our fact-checker colleague Salvador Rizzo reports that statistic was accurate. “Ohio had a peak of 102.4 opioid prescriptions per 100 persons in 2010, according to the National Institute on Drug Abuse. Ohio’s rate has since declined. In 2017, it was 63.5 opioid prescriptions per 100 persons, but that was still higher than the U.S. average of 58.7,” Rizzo writes.

AHH, OOF and OUCH

AHH: Pete Buttigieg sharpened his aim at rivals Warren and Sanders with a new ad released ahead of last night's debate. 

The ad, titled “Makes More Sense,” cites Buttigieg’s health-care plan, contrasting it with the Medicare-for-all proposal touted by Sanders and Warren and framing the South Bend, Ind. mayor as more moderate on the issue. It features political analysts and television anchors talking about his plan.

“Bernie Sanders and Elizabeth Warren believe that we have to force ourselves into Medicare-for-all, where private insurance is abolished,” one commentator says. The ad adds Buttigieg is “trying to focus on choice, not infringing on people’s freedom to make that decision voluntarily.”

—"Buttigieg’s campaign said he was not leveling personal attacks, only highlighting his policy differences with others in the field," our Post colleague Amy B Wang reports. "But sometimes the attacks are fairly pointed. On health care, Buttigieg accuses Warren and Sanders of not trusting the American people to choose the right health care plans for themselves. Buttigieg’s plan would create a government-run 'public option' but would not abolish private insurance, allowing people to choose between the two."

The Health 202 wrote last month that Buttigieg’s “Medicare-for-all-who-want-it” plan appears to be a riff off the Sanders plan, but actually builds on the Affordable Care Act and looks more like a public option, comparable to the public option plan laid out by Biden.

OOF: A group of state attorneys general failed in a last-minute bid to delay the landmark opioid trial set to begin next week amid discussions about a settlement deal with the nation's three largest drug distributors.

The state AGs told U.S. District Court Judge Dan Aaron Polster they were trying to reach an $18 billion settlement with distributors McKesson Corp., Cardinal Health and AmerisourceBergen, our Post colleagues Lenny Bernstein, Scott Higham, Sari Horwitz and Aaron C. Davis report

Polster said during a hearing that jury selection will proceed today as scheduled. "The state attorneys general have filed their own lawsuits against the drug industry for saturating their states with highly addictive pain pills," our colleagues write. "... Lawyers representing the local communities said Tuesday night they are not part of the settlement talks with the distributors." 

The bellwether trial, meant to be a test case to determine how other lawsuits against the drug companies might play out, will begin in a Cleveland courtroom next week. There, jury selection will begin to pick the dozen people who will determine if the companies should be held responsible for the epidemic that has claimed more than 400,000 lives and left millions addicted. 

“Described as the most complex litigation ever, the trial will begin to sort out the welter of accusations over the crisis,” Lenny writes. “While six drug companies are defendants in the case, jurors also may hear blame cast widely on doctors, government agencies and perhaps even drug users themselves. The jury’s response will help decide who should bear the cost of one of this century’s worst public health crises.”

OUCH: More than 150 cases out of the more than 1,000 people who have been sickened by a vaping-related lung illness are teenagers under the age of 18.

The news has swept across social media platforms, as teenagers try to warn peers about the illness, sharing images of young patients in hospitals. Still, on those very platforms, others have mocked their classmates for quitting the use of e-cigarettes and vaping products and high school vape dealers have advertised their products.

“The posts offer a glimpse into the contradictory forces teens face: the draw of nicotine and marijuana, the pressure to fit in and be cool, the inclination to rebel — and now the potential that vaping, which has become central to adolescent culture in some places, could cause immediate and lethal harm,” our Post colleague Moriah Balingit reports. “…Interviews with pediatricians, public health officials and more than a dozen teenagers reveal that while many young people are trying to quit, others are resistant to the notion that vaping might be dangerous.”

Pediatricians are warning that even users who don’t acquire a lung injury could become addicted to the vaping products, as long-term effects are unknown. “But teens, like many adults, have cherry-picked information to justify continued use,” Moriah writes.

INDUSTRY RX

— There’s a dearth of women in top roles in the health-care industry, even as there are a lot of women who work in the industry overall. It has the highest share of women who work in entry-level roles, the Wall Street Journal’s Lauren Weber reports, citing data from LeanIn.Org and McKinsey & Co.

But women make up only 33 percent of the highest levels of the corporate ladder at a sample of 22 companies, and 75 percent of the employees at the lowest rungs of the ladder. That’s compared with men who make up 67 percent of the top leaders and 25 percent of entry-level workers.

The numbers are lower for women of color. Compared with white women, who make up 29 percent of top roles, women of color make up just 6 percent of C-suite positions.

— And here are a few more good reads: 

Fact Checker
Here's a roundup of eight claims from the fourth Democratic presidential debate of the 2020 campaign.
Glenn Kessler, Salvador Rizzo and Meg Kelly
Politics
The senator from Vermont wins the backing of the congresswoman from New York, a major coup and a potential blow to Sen. Elizabeth Warren of Massachusetts.
Sean Sullivan and David Weigel
A federal judge on Tuesday overturned ObamaCare protections for transgender patients, ruling that a 2016 policy violates the religious freedom of Christian providers.
The Hill

MEDICAL MISSIVES

Education
With seed money from GWU, Carleigh Berryman founded Viva Vita, which uses virtual-reality goggles for its treks.
Lauren Lumpkin
These players have developed fame and friendship through online gaming.
Hawken Miller
Education
A quarter of undergraduate women at the schools reported nonconsensual sexual contact.
Nick Anderson, Susan Svrluga and Scott Clement

STATE SCAN

Five towns have passed ordinances aiming to outlaw abortion. Critics say a legal challenge is likely.
Texas Tribune

DAYBOOK

Today

  • The Senate Special Committee on Aging holds a hearing on national, state, and local solutions to better support seniors.
  • The House Veterans’ Affairs Subcommittee on Oversight and Investigations holds a hearing on Assessing VA’s Systems for Protecting Veterans from Clinical Harm.

Coming Up

  • The Washington Post hosts its latest "Chasing Cancer" live event featuring influential cancer warriors, trailblazers and advocates from Silicon Valley on Thursday. 

SUGAR RUSH