In the first 2020 Democratic presidential debates in Miami, 20 Democratic presidential candidates took the stage.

“Polling shows healthcare to be the number one issue among voters,” says Julius Hobson, Jr., senior policy advisor, at Polsinelli, a firm with offices in Washington, D.C. “The Democratic debates illustrate most of the candidates understand the need to address the issue.”

All candidates are clearly left of center on health policy, says Jay Wolfson, DrPH, JD, associate vice president for health law, policy, and safety at the 

 at the University of South Florida. “There was not a single reference to personal responsibility, only the obligation of the government to provide.”

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 is defined differently across the panel, ranging from universal, single payer, no private insurance-"to expanding ACA elements to include option to buy into a Medicare policy, leaving the private market in place,” Wolfson says. “The candidates are out in front of Democratic primary voters who are not overwhelmingly in favor of Medicare for All,” Hobson says.

Pete Buttigieg. The mayor of South Bend, Indiana, “was most pragmatic about the impracticalities associated with eliminating private insurance and expecting the federal government to create a single payer, exclusive option,” Wolfson says. “He was also clearest about asking ‘how’ it will be paid for and managed.” 

The ‘who will pay and how to pay’ questions remain fundamentally unanswered. “Although [Senator Bernie] Sanders of Vermont is essentially calling for a political, social, and economic revolution-a structural and hard turn cultural change in the nation,” Wolfson says.

“For most of the other candidates, the most they have articulated is that they ‘have a plan,’ which for decades has been the excuse for not understanding the complex vicissitudes of what the U.S. healthcare system has become or how it works,” Wolfson says. “References to Canada, England, Germany, and France are irrelevant.”

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A single-payer option would ostensibly make the U.S. government the insurer and potential third-party administrator for all health benefits plans. “The U.S. does not currently do that for Medicare-it contracts through the commercial and managed care industries,” Wolfson says. “The U.S. does not and has never had the physical capacity and competence to become a universal health benefit management company.”

Former vice president Joe Biden’s ‘ACA’ as the solution response to U.S. Senator Kamala Harris’ story of a $5,000 deductible deterring a family from seeking emergency care was questionable, according to Wolfson. “The ACA, as designed and implemented, had and retains structural and actuarial flaws that created insurance policies that are often unusable because of the high cost sharing requirements referenced by Harris,” he says. “Congress has refused to fix any of that.” 

While all expressed positions on healthcare insurance, none addressed a key factor in healthcare-“there has been no discussion about healthcare access,” says Hobson. “What good is insurance if you live in a healthcare shortage area? Whether rural or urban, there are not enough healthcare providers.  The candidates need to address this problem.”

All candidates agreed to provide care for undocumented workers, within the construct of prevention and health promotion. “The bottom line remains the bottom line,” Wolfson says. “None of the candidates have a cogent, financially, and politically viable plan to ‘fix’ the broken parts. The partial expansion of Medicare comes the closest to being pragmatic-there remain the ‘who pays’ questions.” 

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What you need to know about the candidates’ views on healthcare.