Health care, and how to pay for it, is one of the biggest topics of debate this election season. More than half the state’s hospitals are operating in the red, according to the Iowa Hospital Association, while the Kaiser Family Foundation found Iowans’ per capita spending on healthcare is sharply increasing.
Democratic presidential candidate healthcare proposals throw around terms like "Medicare for All" and "public option," but they can be sorted into roughly two categories.
On one side there’s Vermont Sen. Bernie Sanders and Massachusetts Sen. Elizabeth Warren. They’re proposing a single-payer plan, dubbed “Medicare for All.” This plan would eliminate the private insurance industry and put everyone on a government plan like Medicare, which right now is mostly for people over 65. This, they argue, would save a lot on administrative costs.
"The function of the current healthcare system is not to provide quality care for all in a cost effective way. The function of the current system is to make billions of dollars in profits for the insurance companies and the drug companies," Sanders said at a CNN town hall earlier this year.
In the other category are candidates like South Bend Mayor Pete Buttigieg. He has a plan called Medicare
for All Who Want It. This would also extend Medicare to the general public, known as a "public option," but it would also keep the private insurance industry so people have a choice.
I just don’t think it’s a good idea to command Americans to adopt Medicare for All whether they want it or not. Under my plan, if you prefer to keep your private insurance, you can. I just think ours will be better," Buttigieg said on CNN last month.
Other candidates who have plans in this vein include Minnesota Sen. Amy Klobuchar, former Texas Rep. Beto O’Rourke, and former Vice President Joe Biden, who's also pushing to expand Affordable Care Act subsidies.
Many of the candidates with a public option plan also want to expand subsidies under the Affordable Care Act like Joe Biden, who was vice president when the Affordable Care Act passed. He's been the most vocal about this issue and wants to expand tax credits to lower premiums and says deductibles will be capped at $1,000 a year.
He argues his plan is more practical, and cost effective, compared to “Medicare for All."
"I think we should be in a position of taking a look at what costs are. My plan for health care costs a lot of money. It costs $740 billion. It doesn’t cost $30 trillion, $3.4 trillion a year, it turns out, is twice what the entire federal budget is," Biden said during the debate last month.
California Sen. Kamala Harris is proposing a 10-year transition period to a "Medicare for All" system, but it would allow private insurers to offer Medicare plans that adhere to strict government requirements.
So far, Iowans have mixed feelings about these plans and who they want to support.
At a mental health forum at Drake University in Des Moines, Indianola resident Esther Kauffeld-Hoffa says she likes Warren and her Medicare for all proposal.
"I think the costs will actually go down," she said. "People are starting to not be able to afford their health care that they get through work. It's gotten so expensive."
But Cedar Rapids resident Synona Culbertson says she’s leaning towards candidates who have plans that provide a public option.
"I think people that have private insurance that like their private insurance should be able to keep that," she said.
According to an Iowa poll out last month by the Des Moines Register, 41 percent of likely caucus-goers support Medicare for all, while 24 percent think it’s a bad policy.
Barb Kniff-McCulla, the owner of a small construction company in Pella said she's opposed to any plan that expands Medicare. That’s because she’s afraid it could mean an increase her payroll taxes to fund it. This has been proposed by some candidates like Sanders.
"I think our costs would go through the roof, they would skyrocket. And how are we going to pay for this?" she said.
That’s why Kniff-McCulla said she’s voting for President Donald Trump. Trump opposes the Democrats' proposals to expand public insurance and ran on a promise to dismantle the Affordable Care Act, something he hasn’t been able to do yet.
Jim Atty, the CEO of the Waverly Health Center 20 miles north of Waterloo, said he’s also worried about plans that would expand Medicare. Iowa has one of the lowest Medicare reimbursement rates in the country and that’s already putting a lot of financial pressure on rural hospitals like his, he said.
"We can't really afford more uninsured and underinsured in the state. And a big part of that is is you look at just the erosion of services," he said.
Atty’s referring to the rural hospitals that have cut services like birthing units to balance their budgets.
Peter Damiano, the Director of the University of Iowa Policy Center, agrees that reimbursement rates are a problem under candidates’ current proposals.
"If reimbursement rates don't change under a Medicare for all, it could further stress, rural hospitals and, and all hospitals, if all of their patients are now being reimbursed at that same level," he said.
But Damiano said the thing voters need to remember is that candidates’ plans still lack many critical details -- like that will happen with reimbursement rates. That makes it hard to know what impact they’ll really have.
And Damiano said if a Democrat does make it into the White House, any proposed plan will need to pass through Congress.
Natalie Krebs is IPR's health reporter. Funding for her work is provided by the Mid-Iowa Health Foundation.