California Sen. Kamala Harris has released a health care plan just in time for the second Democratic debate, offering a role for private insurance in a “Medicare for All” system and outlining new taxes to pay for it.

The plan comes after months of questions about whether she supports scrapping private insurance — and as former Vice President Joe Biden appears to be gearing up to attack her at the upcoming debate on her support for Medicare for All.

To review, Bernie Sanders’ single-payer health plan is called “Medicare for All,” and Kamala Harris is a cosponsor on that plan (along with several other presidential candidates, including N.J. Sen. Cory Booker, N.Y. Sen. Kirsten Gilibrand, and Massachusetts Sen. Elizabeth Warren). His plan would cover all Americans with a government-administered healthcare plan.

While Harris has cosponsored Sanders’ plan, she has also diverged from Sanders’ vision on the campaign trail, most notably on the role of private insurance.

Here are how some key elements of the Harris proposal match up.

Private insurance: Under Harris’ plan, private insurance would have a bigger role than under Sanders’ plan. Harris envisions a system like the current Medicare system, in which people can either purchase government-administrated Medicare plans or buy Medicare plans from private companies — an option known as Medicare Advantage.

That’s a big difference from Sanders’ plan, under which any insurance that duplicates the coverage provided by his Medicare for All system would be banned. As his version of Medicare for All is very expansive (covering dental and vision, for example, in addition to more basic medical care), that would mean a tiny role for private insurance.

Harris says there would still be room for employer-sponsored coverage under her plan. After a 10-year transition period (more on that below), employers could still offer insurance, according to her campaign. They would, however, have to get those plans certified as Medicare plans through the government to meet certain standards, including cost and quality of coverage.

New taxes: One key revenue-raiser Sanders has proposed for Medicare for All is what his plan calls a 4-percent “premium” on household income over $29,000. Harris’ plan would only impose that tax on households over $100,000, and would also raise even that threshold for households in “high-cost areas.”

To add to that revenue, Harris proposes taxes on financial transactions like stock and bond trades.

Transition time: Bernie Sanders’ plan calls for a four-year transition to his single-payer system. Harris would have a 10-year transition, and both would allow a public option, where Americans below age 65 could buy into the government’s Medicare program, in the first year.

This comes with costs and benefits — on the one hand, it’s a more extended time to make a big transition in how America does health care.

On the other hand, a 10-year phase-in window necessarily means counting on the transition to continue smoothly under the next president — whichever party he or she might come from.

Details: Sanders already has legislation introduced on Capitol Hill, whereas Harris has here released a broad outline of her plan. Key details — like, for example, more exact information on that what that 10-year transition would look like — still don’t exist. (That said, Sanders’ plan

Questions left to answer

One area that will most definitely get plenty of scrutiny is costs, both in the aggregate and individually. Among the unanswered questions in Harris’s plan: How much will the plan ultimately cost, and will those tax hikes cover it? And would this bring American health costs down overall? Harris says it would, but her initial plan did not offer detailed figures to explain how.

On top of that, individuals are going to want to know if their total health care costs — counting any premiums and taxes — under this plan would be greater or less than their current health care costs. And healthcare providers are similarly going to wonder how much they will be paid through the plan — one of the biggest questions surrounding Sanders’ Medicare for All plan.

And then there are the political questions Harris’ plan raises: Were she the nominee, would her plan — not exactly a single-payer plan — satisfy single-payer purists? Would it be too big of a change for people who favor a more moderate approach? And, of course: could it pass Congress?

Setting up the next debate

The new Harris plan at least partially answers one question that has been looming over her campaign for months: How much of a role should private insurance have? In January, in response to a question at a CNN town hall about private insurance, she said she wanted to “eliminate all of that.” But then, she later said she would favor some form of “supplemental” private insurance.

Similarly, in the last Democratic debate, she raised her hand to a question about whether she would support the elimination of private insurance, but then later said she thought the question referred to her own personal insurance.

This plan also places Harris in the spectrum of policy reforms that Democratic candidates have put forward. Her plan is less drastic (and with a less drastic timeline) than Sanders’ plan, but could mean much bigger changes than, for example, a public option plan like those that Biden, South Bend Mayor Pete Buttigieg, and former Texas Rep. Beto O’Rourke favor.

It also tees up a debate with Biden over how to pay for her plan. He had indirectly swiped at Harris over the idea of implementing Medicare for All without raising taxes on the middle class: “Come on! What is this, is this a fantasy world here?”

In their last debate match up, Harris attacked Biden harshly over his past opposition to federally mandated busing. The two will share the stage again on Wednesday night, the second night of this week’s debate. Biden has promised he’s “not going to be as polite” this time.

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Fresenius, one of the two largest dialysis providers in the U.S., has agreed to waive a $524,600.17 bill for a man who received 14 weeks of dialysis at a clinic in Montana.

NPR, Kaiser Health News, and CBS This Morning told Sovereign Valentine’s story this week, as part of the “Bill of the Month” series, a crowdsourced investigation that seeks to understand the exorbitant health care bills faced by ordinary Americans.

On Thursday, a representative from Fresenius told Sovereign’s wife, Dr. Jessica Valentine, that the company would waive their unpaid bill. Instead, they will be treated as in-network patients, and Fresenius will seek to negotiate with their insurer a rate higher than what the insurer has already paid. The Valentines are responsible only for their $5,000 deductible, which Sovereign, who goes by “Sov,” has already hit for the year. That leaves them with $0 left to pay on their in-network deductible.

“It’s a huge relief,” Sov said. “It allows me to put more energy back into just taking care of my health and not having stress hormones raging.” Sov said he hopes his experience will shed light on the problem of balance billing and help other patients in similar situations.

A 50-year-old personal trainer, Sov was diagnosed with kidney failure in January and sent for dialysis at a Fresenius clinic 70 miles from his home in rural Plains, Mont. A few days later, Sov and Jessica learned that the clinic was out-of-network and that they would be required to pay whatever their insurer didn’t cover.

The Valentines initially could not find an in-network option, and Sov needed dialysis three times a week to survive. After he underwent 14 weeks of dialysis with Fresenius, the couple received a bill for $540,841.90. Their insurer, Allegiance, paid $16,241.73, about twice what Medicare would have paid. Fresenius billed the couple the unpaid balance of $524,600.17 — an amount that is more than the typical cost of a kidney transplant.

Fresenius charged the Valentines $13,867.74 per dialysis session, or about 59 times the $235 Medicare pays for a dialysis session.

Fresenius spokesman Brad Puffer said that the Valentines should always have been treated as in-network patients because their insurer, Allegiance, is a subsidiary of Cigna, which has a contract with the dialysis company. Under this contract, Fresenius would have been paid a higher rate than what Allegiance paid. The Valentines, he said, were caught in the middle of a contract dispute between the companies.

“In the future, we pledge to better identify situations where we believe the insurer has incorrectly classified one of our facilities as being out of network,” Puffer said in a statement. “This will allow us to address the matter directly with the insurer in the first instance, without them placing the patient in the middle.”

Allegiance declined to comment for this story. Jessica Valentine questioned whether they may owe an out-of-network deductible and is waiting to hear what her insurer says about that.

Like her husband, Jessica is relieved that their bill seems to be resolved but worried that other people with bills like theirs might not be so lucky. She’s also grateful for all the attention their story has garnered. Montana Sen. Jon Tester’s office and their hospital’s insurance broker both offered to advocate for them. “And a nephrologist from Pennsylvania called me at work and expressed outrage and said she forwarded on our story to the medical director of Fresenius on our behalf,” Jessica wrote in an email.

Now that his bill has been resolved, Sov said he’ll be focusing on the next step in battling his kidney disease: a transplant. “I can just save my energy for that,” he said.

Bill of the Month is a crowdsourced investigation by NPR and Kaiser Health News that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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It’s one of the great achievements of oncology: with advances in treatment, cure rates for children with cancer in North America now exceed 80%, up from 10% in the 1960s.

Yet for kids across the developing world, the fruits of that progress remain largely out of reach. In low- and middle-income countries, restrictive access to affordable treatment, a shortage of cancer specialists and late diagnosis dooms more than 80% of pediatric patients to die of the same illnesses.

That’s one measure of what’s known as the “global cancer divide“— the vast and growing gap in access to quality cancer care between wealthy and poorer countries, and the suffering and death that occurs disproportionately in the latter.

Nowhere is that divide more pronounced than among children, and it’s driven in large part, experts say, by perceptions of pediatric cancer care as too costly and too complicated to deliver in low-resource settings. Those assumptions, they say, prevent policymakers from even considering pediatric oncology when setting national health priorities.

But one hospital in Rwanda is rewriting that narrative.

Built and operated by the Ministry of Health and the Boston-based charity Partners In Health, the Butaro Cancer Center of Excellence is unique in the region: a state-of-the-art medical facility providing the rural poor with access to comprehensive cancer care. And a new study shows that Butaro’s pediatric cancer patients can be cared for, and cured, at a fraction of the cost in high-income countries.

“There’s this myth that treating cancer is expensive,” says Christian Rusangwa, a Rwandan physician with Partners In Health who worked on the study. “And that’s because the data is almost all from high-income countries.”

Published in 2018 in the Journal of Global Oncology, the study showed that for patients at Butaro with nephroblastoma and Hodgkin lymphoma, two common childhood cancers, a full course of treatment, follow-up and social support runs as little as $1,490 and $1,140, respectively.

Much of the savings, the authors report, comes from the low cost of labor, which for the entire cancer center amounted to less than the average annual salary for one oncologist in the United States. They also cite strong partnerships with Harvard and the Dana-Farber Cancer Institute, whose Boston-based specialists volunteer their expertise on difficult patient cases via weekly video conferences with Butaro’s general practitioners.

“Most people don’t think about childhood cancer in terms of return on investment,” says Nickhill Bhakta, a pediatric oncologist with St. Jude Children’s Research Hospital in Memphis, which has put in place similar partnerships with institutions in Singapore and China. “But there’s a growing body of literature showing that, for governments, treatment is surprisingly cost-effective.”

Bhakta says some of the most compelling evidence for the cost-effectiveness of care in poor countries comes from Uganda, where in March, researchers reported remarkably low costs of treating Burkitt’s lymphoma, or BL. The most common childhood cancer in sub-Saharan Africa, BL is rapidly fatal, often within weeks. Yet when treated promptly, intensively and with supportive care, more than 90% of children survive the disease.

Worldwide, childhood cancers are relatively rare. But as Bhakta and colleagues reported in February in The Lancet Oncology, they’re a far bigger problem than previously believed. Close to half of all children with cancer go undiagnosed and untreated, they found, suggesting that the already low survival for these cancers in low- and middle-income countries “is probably even lower.”

“The naysayers will say, ‘we don’t have pediatric oncologists in Africa, how would we possibly address this problem?’ ” says Felicia Knaul, a professor of public health at the University of Miami. “And that’s why partnership models, like those supported by Dana Farber and St. Jude, are so important — they’ve shown that you can bridge that gap and have a tremendous impact.”

In 2009, Knaul, then director of the Harvard Global Equity Initiative, led a push to expand cancer care across the developing world, where a growing burden of disease had garnered little attention globally. “We challenge the public health community’s assumption that cancers will remain untreated in poor countries,” she and colleagues wrote in a 2010 “call to action” published in The Lancet, noting “similarly unfounded arguments” against the provision of HIV treatment.

In the early 2000s, more than 20 million people were living with HIV in sub-Saharan Africa, yet fewer than 50,000 had access to antiretroviral therapy. Though the life-saving drugs were, by then, widely available in the U.S., skeptics warned that treatment in Africa wouldn’t be cost-effective.

Prevention, they asserted, was the only feasible way forward. “The two most important interventions are monogamy and abstinence,” Andrew Natsios, then head of the U.S. Agency for International Development, told reporters in 2001. “The best thing to do is behave yourself.”

Two decades later, echoes of that attitude reverberate in the global cancer divide; even as cancer rates continue to climb across the developing world, low and middle-income countries account for just 5% of global spending on the disease.

Still, recent years have seen important gains.

In 2017, the World Health Assembly, the World Health Organization’s decision-making body, adopted a resolution on cancer that for the first time urged its member states to address childhood cancers. And in 2018, St. Jude and the WHO launched the Global Initiative on Childhood Cancer, a five-year, $15 million partnership aimed at aimed at ensuring that all children with cancer can access high-quality medicines. Their goal: to cure at least 60% of children with the six most common types of cancer by 2030.

“Here in the U.S., it was the suffering of children with acute leukemia that drove Sidney Farber to develop our first real chemotherapy drug,” said Meg O’Brien, vice president for global cancer treatment at the American Cancer Society. “I don’t think Dr. Farber or any of the tens of thousands of oncologists, nurses or scientists who have worked in cancer research or treatment in the years since would be content to see that what we consider one of our greatest triumphs in the battle against cancer has yet to reach children in low- and middle-income countries.”

Patrick Adams is a freelance journalist based in Atlanta, GA. Find him on Twitter at @jpatadams

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