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DES MOINES — Hillary Clinton and Bernie Sanders both devote a good chunk of their stump speeches to the problem of rising prescription drug prices — but their solutions are vastly different.

For Clinton, the answer is to treat drug costs as the next big challenge to be tackled with policy tweaks that build on the successes of the Affordable Care Act.

For Sanders, drug costs are the reason for a complete overhaul that transitions to a whole new system: single-payer health care.


The future of American health care has become a defining battle between Clinton and Sanders, one of the biggest fights that Iowa voters will help settle in Monday’s caucuses. Sanders believes a Canadian-style single-payer system — where the government pays for everyone’s medical care instead of private insurance companies — is the best way to bring drug prices under control.

But as Clinton has been telling everyone who will listen, she doesn’t see any future in trying to overturn the entire health care system, or have any hope that it will actually happen anytime soon. Her answer: Get drug prices under control with the system we already have.


Talking to union members here, Sanders recounted a trip he took in the late 1990s while he represented Vermont in the US House, when he loaded women with breast cancer onto a bus and drove them to Montreal. There they found the same drugs available for one-tenth the price they were paying in the United States, he said.

“We should not have to get medicine from Canada. The pharmaceutical industry has got to stop ripping us off,” Sanders said. “It seems to me that the time is now for us to say loudly and clearly that in the United States of America, health care is a right for all people, and we are going to pass a Medicare-for-all, single-payer bill.”

Many in the crowd stood up to cheer. But, as Sanders himself acknowledges on the campaign trail, it’s a point of sharp disagreement within the Democratic Party.

By contrast, Clinton uses drug prices as a prime example of how she would “build on the progress” of the Affordable Care Act. She makes a point to distinguish that from Sanders’ single-payer proposal, which she portrays as too divisive to succeed.

“Let’s hold onto the progress we’ve made, but I want to make it better. We need to get the costs down. Out-of-pocket costs are too high. Prescription drug costs are too high,” Clinton told supporters packed into a bowling alley in Adel, Iowa, on Wednesday to claps and nods. “So we need to go after the problems to make sure the Affordable Care Act is truly affordable.”

She then segued into her critique of Sanders’s plan.

“Senator Sanders and I share the same goal. We both want universal coverage,” she said. “He has a different idea, and I fear it would lead to gridlock, not action. It would throw us into a contentious national debate that would not let us move forward, and I don’t think the people in Iowa can wait.”

Clinton cited a favored anecdote about a woman who saw the price for a drug she had taken for decades skyrocket from $200 to $14,000 a month. She argued for the need to go after “predatory pricing,” to allow Medicare to negotiate directly with drug makers, and to eliminate tax breaks for drug advertising — three pillars of her prescription drug plan.

Sanders has a more narrowly tailored drug-price plan, too, one that he has introduced as legislation in the Senate. On the stump, though, he doesn’t talk about that at all. Instead, he fires up crowds with the more sweeping solution: “Medicare for all.”

It is a disagreement that illuminates not only Clinton’s and Sanders’s differences on health care, but, in the eyes of many voters across Iowa who gathered to hear them speak last week, the contrast between them as candidates.

For Jean Ross, co-president of National Nurses United, which has members campaigning for Sanders across Iowa in a red passenger bus that says “Medicare for all” on the side, the gap between the Vermont senator and Clinton on single-payer health care explained everything about her outlook on the race.

“We’ll make it happen, just give us a leader. That’s Bernie. It’s sadly not Hillary,” Ross said, adding that, with her union’s 90 percent female membership, she would love “to find a female Bernie.”

“But Hillary is no female Bernie,” she said.

Dave Butcher, 72, who was gathering signatures for Sanders outside the Grinnell College gym where the senator spoke last Monday, felt the same.

“We’re going to be incremental to death. Nothing is going to change,” he said when asked about the internal Democratic debate on health care. “We’ve got to go for the change.”

But not everybody rallying for Sanders was so optimistic.

“I don’t think that’ll fly in the United States,” said Lisa Case, who attended the Grinnell town hall. Some polling has found majority support for single-payer, but Republicans will likely retain control of at least one chamber of Congress no matter who wins the White House.

Among Clinton supporters, many said that they would love to see single-payer in the United States — but, like their candidate, they didn’t think it was feasible.

Sanders “may be on the right path, but we’re not ready for that,” said Vicky Brenner, 56, who attended Clinton’s rally in Adel. “I think a lot of what he says, a lot of people agree with, but it’s not viable.”

In Cedar Falls, Iowa, on Tuesday before Clinton spoke, Tim Rediske, 63, summed it up simply: “Single-payer would be great, but it’s not going to happen.”

The issue came down to which candidate voters believed could actually achieve what they were pitching from the stump. Those boosting Sanders seemed to believe, like their candidate, that mobilization — a “political revolution,” as the senator likes to say — would be enough to turn the debate in their favor.

“I’ve got all the respect in the world for the Clintons,” Scott Hayek, one of the union members at the Des Moines rally, said. But Sanders, he continued, has “a track record of kind of bucking the system, and that really hits home.”

That same quality, however, was a weakness of Sanders for those leaning toward Clinton. The former secretary of state emphasizes her perseverance on the stump, while warning against high-minded ideas that are impossible to put into action.

“I don’t know that [Sanders] has the strength to get people to work with him,” said Susan Baker, who does building maintenance at the University of Northern Iowa, where the Cedar Falls event was held. “I think she’s a little bit stronger.”