Seven Questions We Would Have Asked at the Democratic Debate

Over 8 in 10 voters think prices charged for prescription drugs are unreasonable. What are your solutions for lowering prices at the counter and providing relief for millions of Americans who go through extreme measures to survive?

Talk was dominated by candidates’ support (or skepticism) of some version of universal health coverage, but some of the largest drivers of health care costs were mostly ignored: skyrocketing prescription drug prices and the high prices hospitals and physicians charge in the commercial sector.

With the exception of a few brief mentions of high insulin prices, the discussion about the high cost of prescription drugs never took off. In fact, former Vice President Joe Biden was the only candidate on stage to offer actual solutions to rein in drug prices, including price regulation for biologics (prior to these drugs getting market approval) and a proposal that would penalize drugmakers if their list prices rise faster than inflation (a provision in an ambitious drug pricing package, which recently advanced out of the Senate Finance Committee by a 19 – 9 vote).

But the inflated prices we pay in the private sector — everything from physician fees, tests, and other hospital services — are the core of the problem yet were ignored altogether. Instead, candidates were quick to blame insurance companies — not the high prices we pay in the private market — for our dysfunctional health care system. A more constructive discussion would have centered on actionable solutions to provide relief to families who are going bankrupt because our system has failed them. Sen. Kamala Harris said it best: The cost of doing nothing is too high. We ought to implement aggressive measures that tackle the lucrative pharmaceutical and hospital monopolies and encourage competition.

The health care costs discussion was instead driven by the need for universal health coverage (touted under the Medicare for All slogan) vs. expanded public coverage (public option). The main criticisms from candidates who strongly oppose a government-run, single payer system were cost and mass disruption. Medicare for All opponents honed in on the fact that more than 150 million people would be forced out of their private insurance — something Sen. Bernie Sanders says is necessary to stabilize the health care system.

The discussion around cost on night one was specifically about whether Sanders’ Medicare for All plan — which is backed by Sen. Elizabeth Warren — would raise taxes on the middle class. Medicare for All advocates answered that question by adding that total costs will go down under their plan. ​“Middle-class families are going to pay less out of pocket for their health care,” said Warren. ​“For middle-class families, costs — total costs — will go down.”

Future debates should not ignore the fact that prescription drug spending is rising and expected to grow faster than any other major health care goods or service over the next decade. If we don’t fix our dysfunctional systems, the American public will continue to bear the burden of drug spending through their wages, taxes, and out of pocket expenses — a burden the nation struggles to carry. 

What will you do to address the opioid crisis, which has killed more Americans than the Vietnam war?

This topic was ignored both nights — save for a mention in Sen. Amy Klobuchar’s closing statement Tuesday — despite the fact that the crisis is so severe and has reduced life expectancy in the country. 

National attention to this issue could be transformative, especially if candidates were to come out in support of medically proven forms of treatment and use their platform to dispel misconceptions about the disease. For the first time in three decades, the Centers for Disease Control and Prevention reported a decline in overdose deaths in 2018. Experts believe the decline is due in part to greater access to medications used to treat opioid use disorder, funded largely through $3.3 billion in opioid grants appropriated by the federal government. 

That money, which states have used to launch innovative outreach and treatment programs and help reverse trends in overdose deaths, is set to expire next year. Without a word from presidential contenders or Congress about reauthorization, and signs from President Trump that he considers this problem to be solved, states worry the nascent recovery could be put at risk.

“Public policy is still driven by the belief that opioid use disorder is a moral failing, and as a result just one in 10 people receive evidence-based treatment,” Julie Weigandt wrote in a piece dismantling misconceptions about opioid use. ​“We need to invest in programs that have been shown to save lives.” 

We know that states and counties are drivers of mass incarceration, but how can the federal government be a leader in criminal justice reform? 

Criminal justice issues were largely ignored on the first night, though there was some discussion on the second. Sen. Michael Bennet raised the issue of the school-to-prison pipeline. Biden discussed his criminal justice reform plan. Sen. Cory Booker attacked Biden for perpetuating ​“tough-on-crime” policies during his decades in the Senate. And Biden went after Harris for her record as a prosecutor and attorney general. Debate got heated, but nobody confronted the overarching problem that mass incarceration is driven more by state prisons and local jails than the federal system. 

Neither the White House nor Congress can explicitly control state-level incarceration. However, the federal government still has a significant role to play in ending mass incarceration.

First, federal prisons and jails still house roughly 10 percent of the 2.3 million people behind bars nationwide. Any effort to shrink the national jail and prison population will require the federal government to reduce its own numbers. There are a number of ways to approach this: reducing the number of people eligible for incarceration, reducing the length of prison sentences, and increasing the use of early release mechanisms. Even the president’s pardon power can have an impact in cutting the federal prison population.

Efforts at the federal level can also provide a model for states to follow. For example, Florida and North Carolina are debating their own state-level version of the federal ​“First Step Act” that was passed in November 2018 to help people transition out of prison.

Beyond improving its own system, the federal government has many tools to help nudge the states. At the front end of the system, incentive funding can encourage state-level decarceration and support mental health and drug treatment services, diversion programs, violence prevention projects, and other alternatives to incarceration. On the back end, federal programs relating to housing, education, and health care have often been denied to people convicted of crimes. Opening those programs to people behind bars or reentering society can play a role in preventing recidivism. 

The federal government can also help set best practices for all sorts of criminal justice policies, including how states run supervision programs, bail systems, and life within incarcerative facilities. Active oversight from the Department of Justice can ensure that state and local institutions are strictly adhering to the Constitution. And the federal government can give the states proper resources to treat drug addiction like a public health crisis instead of a criminal activity. 

Overall, candidates must confront the fact that incremental reforms will not be enough to truly roll back four decades of mass incarceration. Serious criminal justice reform means looking at large, structural challenges like overly punitive sentences, cash bail systems that punish the poor, and probation and parole systems that can act as tripwires to incarceration.

What criminal justice reforms would you prioritize as president? In other words, what areas do you think are most ripe for federal intervention and leadership, and what actions would you take to see results?

This is admittedly a subjective question, but there are plenty of areas where the states, local governments, and the private sector have built momentum, and the federal government could join in. 

For example, New York, New Jersey and Harris County, Texas have all recently ended cash bail systems that work to lock people up solely on the basis of their wealth. The federal government can help promote those successes in other counties and states. 

At the federal level, the First Step Act has already been passed, but it needs to be fully funded and expanded to a Second Step that reforms sentencing policies for more people. 

In the private sector, the National Collaborative on Gun Violence Research has announced that it has awarded $9.8 million to fund 13 major research projects and four doctoral dissertations on gun violence. This follows two decades of the federal government failing to fund research in the field. There is always an opportunity for the federal government to finally step back in and fund lifesaving research into gun safety and gun policy. 

Donald Trump was able to bring together unlikely allies to pass the First Step Act. If elected, are you willing to work with groups on the right to keep moving forward on criminal justice reform? 

We hope the answer to this question is a resounding: Yes. As our Co-Chair Laura Arnold discusses in the latest ​“Deep Dive with Laura Arnold” podcast, left-right coalitions can be catalysts of meaningful change during a time of unprecedented political polarization. Candidates must be willing to work with unlikely allies to promote good policy. 

Higher education debt is a problem in this country, but an even greater issue is college completion rates and support for nontraditional students. How will you make sure all students are successful?

While most discussion tends to center on canceling existing student debt, there are important issues that don’t get as much attention but have a huge impact on student outcomes, such accountability, predatory for-profit colleges, and the need for more support for nontraditional and low-income students. 

Mayor Pete Buttigieg said Tuesday he was targeted by advertising from predatory colleges as soon as his military deployment began. His is one of numerous stories about military veterans being exploited as for-profit schools, which make money from enrolling veterans, try to collect GI Bill money.

The targeting of veterans is one indication of a broader systemic problem. Not all for-profit colleges are predatory, but there is growing concern that too many students are graduating with a degree that isn’t worth anything, and that the federal government isn’t holding schools accountable. For decades the U.S. has sought to expand access for veterans and others to colleges and universities, pumping an estimated $130 billion in grants and loans into higher education each year. But remarkably, the federal government asks very little from schools in exchange for that funding, and there are few quality assurance measures in place to protect consumers. 

Changes in oversight could help protect the most vulnerable students. Greater access to data could also help individuals make better decisions about where to attend school and whether a certain program will pay off financially in the long run. And some research has shown that spending more per student has a bigger impact on outcomes than reducing tuition, meaning that scaling evidence-based programs shown to improve graduation rates could be just as important for student success as tackling affordability. 

Would you support investing in research on the causes of gun violence?

Gun violence is a tough issue: Talking about it can quickly become bitterly partisan. Many policy ideas for addressing gun violence are not based on research about what works — because so little of that research exists. This points to an urgent need to build the evidence base. 

Guns are the least-studied major cause of death in America. Research and data are necessary to inform effective policy, and yet federal funding has been near-nonexistent for decades. In the gap, private funding has tried to step in to fill the void. For example, Arnold Ventures partnered with RAND Corporation to form a new nonpartisan organization, the National Collaborative on Gun Violence Research, which just awarded $9.8 million to fund 17 research projects on gun violence. They were chosen by a 12-person advisory committee composed of a diverse group of leaders and will cover issues like domestic violence, suicide, and police-involved shootings. See all the awards here. 

However — and this is a critical point — private philanthropy can never come close to the breadth, depth, and scope of funding we hope to see from federal agencies. This pressing problem requires a large-scale investment by the nation’s largest research funder: the federal government.