Health Questions for Future Candidate Debates

Last week, the candidates for California Governor had a televised debate–and yet not a single question was on health care. The only mentions were Lt. Governor Newsom’s joke that some potholes are old enough to qualify for Medicare, and a follow-up question to Newsom on high speed rail about costs that added in the cost of single-payer.

As I tweeted, the lack of focus on health care was stunning. Medi-Cal is the biggest item in the and covers 14 million Californians–a third of the state, half of children, 2/3 of all nursing home residents. The main responsibilities of the state is to educate, medicate, and incarcerate: 50% of the budget is education, 33% in HHS, 10% public safety. That’s where the Governor has the most ability to have impact–both as a major purchaser (Medi-Cal, CALPERS, etc) and regulator (DMHC, DHCS, etc) of health care.

Wasn’t health care the #1 concern of voters in exit polls of last November’s elections? In the special elections so far? Wouldn’t that suggest that maybe a question or two? From a family’s budget, health care is often the second biggest cost after housing.

While single-payer/SB562 had been debated in previous gubernatorial debates, what of Medi-Cal? Covered CA?  the ? Trump’s plans? Rx costs? for health care price relief? the Assembly $1B health proposal unveiled Monday? Our package?

A few weeks ago, I was invited to moderate a debate on health care issues of leading candidates in California Congressional district 48. We prepared questions for these candidates about health care. While focused on federal issues, we hope future moderators use them as a guide and inspiration for the debates to come. This is by no means a comprehensive list, but rather a buffet of what could be asked–there’s no lack of good questions to ask about health care!

Stopping Attacks on the Affordable Care Act

  • Last May, the House of Representatives votes to pass the American Health Care Act, which sought to repeal the ACA, cut and cap the Medicaid program, forcing cuts to California’s health care system of over $20 billion/year, leave millions of Californians uninsured, and undermine key patient protections, including for those with pre-existing conditions. How would you have voted on the American Health Care Act?
  • One of the efforts by the current Congress was to “defund Planned Parenthood”—which actually doesn’t get any specific line items in the federal budget. Would you vote for the proposal to exclude Planned Parenthood as a provider of medical services in the Medicaid program?
  • The Trump Administration has signed an Executive Order to allow employers to claim a religious exemption on the mandate that if they provide coverage, that coverage must include contraception without cost-sharing. Should employers be able to dictate the health benefits of their workers?

Preventing the Sabotage of Our Health System

  • Others efforts at sabotage include that the Trump Administration is seeking is to promote “short term insurance” and “association health plans.” In both cases, these would be plans that do not have to abide by ACA consumer protections, and as such do not have to cover essential health benefits, could have annual or lifetime limits, and could deny based on pre-existing conditions? Would you vote to allow such plans to expand? Would you vote for a federal version of a state bill, SB910, would seek to ban these types of plans?
  • Another federal requirement is to ensure that insurers must spend a certain percentage of their premiums on patient care, rather than administration and profit. The Trump Administration wants to lower that percentage. Would you support that type of bill?  Would you support a federal version of a state bill to increase that “medical loss ratio” to 90%?
  • Another federal bill would establish re-insurance that redistributes money from insurers that end up with healthier patients to insurers who have a sicker populations, which has shown to help lower premiums. Reinsurance and similar programs were defunded by efforts of Sen. Marco Rubio who called them an “insurer bailout.” Senators Murray and Alexander were working on a proposal that would include reinsurance—would you support such a federal bill in concept?
  • The tax bill included a repeal of the Affordable Care Act’s individual mandate. As a result, the Congressional Budget Office and other analyses project that premiums will rise at least an additional 10% more than normal. Would you vote for a proposal to re-institute the tax payment for those who don’t by coverage?

Universal Coverage

  • Do you support the goal of quality, affordable health care for all Americans?
  • Do you support Sen. Sanders and/or Rep. Ellison’s bills for a Medicare for all-like, single-payer health care system?
  • If yes, why do you support it?
  • How would you go about advancing us to that goal?
  • Would you support steps to get to that goal? If so, which ones?
  • Under the ACA, California has brought it’s uninsured rate down from nearly 20% to less than 7%, the biggest reduction of all 50 states. Would you support steps to get from 7% to 0%, such as increasing subsidies in Covered California?
  • California is a high cost-of-living state. Would you provide addition assistance above 400% of the federal poverty level, where ACA subsidies run out, to prevent people from paying more than a percent of their income?
  • Would you support a public option? What does that mean to you?

Immigration

  • Who would be included? Would you expand coverage to include undocumented immigrants?
  • A few years ago, California has expanded its Medi-Cal program to cover all children, regardless of immigration status. Would you support expanding the Medicaid program federally so California gets a federal share for these children? Would you support expanding Medicaid for undocumented adults?
  • Should medical information be protected from use for any form of immigration enforcement?

Health Costs & Quality

  • How would you address the high cost of health care?
  • How would you address prescription drug costs?
    • Would you allow for re-importation of drug from other countries?
    • Would you allow Medicare to negotiate for prescription drug prices?
    • Would you limit meals/trips/gifts to doctors from drug companies?
    • Would you reduce the time that drug company hold an exclusive patent on a drug, if the drug was produced with public funding? If the drug is excessively priced?
  • How would you address prices by providers like hospital and doctors?
  • Health care costs are more expensive in American not because we use health care anymore, but because prices are just that much higher. How do you propose bringing down those prices?
    • Regulating health prices like public utilities?
    • Breaking up health care monopolies and oligopolies?
    • Reforms of the delivery system?
  • Would you support increasing the prevalence of high-deductible health plans so more patients have “skin in the game”?

Quality and Equity

  • How would you hold the industry accountable to improve quality? What policies would you put in place? What tools would you use?
  • People of color have worse health outcomes in our health system, even when you hold for income, education, and other factors. How would you address racial and ethnic disparities in our health system?
  • Are there specific population-based solutions that you would endorse? (This could include specific efforts for people with certain conditions, children, seniors, racial/ethnic groups, LGBTQ people, immigrants, people with disabilities, etc.)

Insurance Regulation

  • Several major insurers proposed to merge in the last few years–but some of those mergers fell apart, in part due to anti-trust review. Aetna-CVS has proposed to merger. What limits would you put on health industry mergers? What criteria would you use?
  • Would you require insurers who participate in Medicaid to be in the exchanges, or vice-versa?
  • Would other regulations or oversight would you put on health insurers?

Medi-Cal

  • What changes would you seek in Medicaid (known as Medi-Cal in California), which currently covers 13.5 million Californians, including a third of the state, half of our children, and two-thirds of our nursing home residents?
  • How would you, in Medi-Cal, increase access? improve quality? Reduce disparities and improve equity?
  • Last June, the House of Representatives voted on a budget blueprint that would have cut and capped Medicaid, ratcheting down Medicaid by tens of billions of dollars a year over a decade. Would you have voted for that budget blueprint?

Medicare

  • The budget also included severe cuts of $400B in Medicare. Would you support such cuts to Medicare?
  • Would you support shifting Medicare to a privatized, voucher system?
  • How would you ensure Medicare’s viability into the future?
  • Would you support lowering or raising the age for Medicare eligibility?

Budget

  • The budget also included cuts to a range of social services, that impact health, from food stamps to housing support to nutrition programs.
  • One of the reasons that other countries spend less on health care is because they spend more human services and the social safety-net. What investments would you make in the safety-net?

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