Nowhere is access to affordable health care a bigger issue than in rural America and among many farmers, who often rely on off-farm jobs to buy insurance or pay thousands of dollars each year out of pocket.

The Democratic candidates’ solutions are to allow uninsured people to join Medicare, and/or expand Medicaid to virtually all low-income people, or simply replace private insurance entirely with Medicare for all. 

All the Democratic candidates pledge to stop what they say is Trump’s effort to sabotage the Affordable Care Act, which mandated individual coverage and coverage requirements and offered new subsidies for those with lower incomes.

The Trump administration, which is supporting a lawsuit to strike down the ACA, has been focused on trying to promote new private options but has little to show for its efforts so far. 

The Labor Department, for example, issued a rule to make it easier for unrelated people or businesses to develop health plan associations, which can have cheaper rates but reduced coverage, but the plan has been blocked by a federal court. 

Among the Democrats, Vermont Sen. Bernie Sanders and Massachusetts Sen. Elizabeth Warren have the most far-reaching proposals. Both would end private insurance, expand Medicare to every American and eliminate all deductibles and premiums. 

As for the rest of the Democratic candidates, their positions lean more toward the Medicare-X legislation developed by Colorado Sen. Michael Bennet, who had little support in presidential polls and dropped out of the race altogether on Tuesday night. Minnesota Sen. Amy Klobuchar, a presidential candidate who has been running sixth in national polls, is cosponsoring the bill.

The plan would expand the ACA income eligibility window by raising the tax credit ceiling beyond the current 400% of federal-poverty-line income, but also provide tax credits on premiums for those with higher income levels.

The subsidy plan would also cap the out-of-pocket cost of premiums so, for example, a family of four making $101,000 would pay no more than 9% of their income for premiums.

Bennet’s priority for expanded coverage would “start on the individual exchange … in rural areas where the market is failing too many people with only one or no insurers. Over the course of two years, Medicare-X expands to every county in the country and becomes available on the small business exchange.”

Rural areas must get expanded choices first, Bennet says, because “in 2019, 37% of counties, almost all of them in rural and small-town America … had only one insurer" on the exchanges.

Most fellow Democrats generally agree with Bennet’s ideas:

  • Extend ACA’s expansion of Medicaid to low-income households in the 14 states that haven’t so far chosen to accept that federal help. Reimbursement rates, which vary state to state and by medical service, would be phased up toward an average match of 90% of cost over five years.
  • Require the government to negotiate lower drug prices for Medicare patients and others, plus impose new rules restraining drug price increases. The latter is the goal of a bevy of bills by both parties in Congress, aimed especially to help seniors and low-income households. One bipartisan Senate bill would require drug manufacturers to send consumer rebates if they raised prices faster than inflation.
  • Force health care services to retarget their practices and billing toward health outcomes rather than fees to treat sick patients. Rural populations have the worst prevalence of chronic diseases, Bennet says, and that can be turned around “by restructuring incentives in the health care system.”
  • Make advancing telemedicine and remote patient monitoring a priority for federal investment, which would in turn require more universal rural broadband. 
  • Shore up the supply of primary care doctors, reversing a national shortage that is projected to swell toward 100,000 by 2030.  

“No networks, no premiums, no deductibles, no copays, no surprise bills,” Sanders says, and his plan would cover “dental, hearing, vision, and home- and community-based long-term care, mental health and substance abuse treatment, reproductive and maternity care, prescription drugs, and more.”

Warren has provided expert estimates of how much Medicare for all will cost over 10 years, $20.5 trillion, which would be offset by tax increases and cuts in health care spending.

Trump, meanwhile, pledged to repeal and replace Obamacare, but a Republican controlled Congress failed to do so in 2017 and 2018, and the president isn’t pursuing a replacement.

Trump also declared in 2016 he wouldn’t cut Medicare or Medicaid, but his administration has moved to do so in various ways, such as efforts since 2017 to cut Medicaid spending by converting to state block grants.

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On the other hand, Trump’s actions favorable to rural consumers include these:

  • At his urging, Congress rescinded the ACA tax penalty to individuals not buying health insurance.
  • In a budget passed in December, Trump got his desired repeal of another piece of ACA he disliked: the so-called Cadillac tax, which was a 40% excise tax on high-cost employer-sponsored health coverage.
  • Note, too, that the Food and Drug Administration, in its Drug Competition Action Plan, approved a record number of new generic drugs in 2017, a way of lowering drug prices by fostering competition.

Here is a look at some other themes Democratic candidates have been sounding on the campaign trail: 

Former Vice President Joe Biden says a full public Medicare option would deliver “more choice, reducing health care costs, and making our health care system less complex.”

Biden emphasizes cutting drug prices: allow consumers access to foreign markets for any drugs approved by the U.S. government; terminate pharmaceutical corporations’ tax break for advertisement spending; free up access to quality generics by better policing of big brand-name drug corporations’ tactics in delaying entrance of generics into the market.

Former New York Mayor Michael Bloomberg hasn’t offered a lot of details, but his discussion of the issue generally tracks the Democratic consensus. 

He appears to want consumer premiums to pay more of the total cost of an expanded public option than some others, and his priority for coverage is for “the uninsured, including low-income people who are in states that haven’t expanded Medicaid.”

Pete Buttigieg

Presidential candidate Pete Buttigieg

Pete Buttigieg, a former mayor of South Bend, Ind., wants to “dramatically reduce care shortages in rural areas by both training homegrown doctors and nurses and attracting health care workers from (the U.S. and abroad), with an emphasis on primary care, maternal care, mental health, and addiction providers,” according to his campaign.

He lists several ways to move in those directions: expanding school loan forgiveness programs to all health care sector employees, attracting more immigrant doctors by expanding the expanding the Conrad 30 medical practice waiver program, and implementing new models for rural health care such what he calls Rural Emergency Medical Centers.

Klobuchar says her priorities include expanding telehealth and rural health services and maintaining rural hospitals.

She emphasizes improving care for seniors and says “dental, vision, and hearing care should be covered as part of Medicare,” and such expansion must be “affordable for all seniors.” Also, seniors and their families “must have the resources they need to prepare for long-term care, including education about the types of services available,” she says. To help, she proposes a targeted federal income tax credit equal to 20% of the premium costs of qualified long-term care insurance.

Billionaire Tom Steyer agrees with other Democrats on extending ACA insurance to a broader swath of the population and extending Medicaid coverage. He says the government must make the pubic option so attractive that private insurers must improve coverage and reduce rates to compete with it. That will leave “people who receive coverage through their employer to opt into the public option if it better suits their needs.” 

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