As Democratic presidential candidates debate their ideal health care system, blue states are making incremental — yet significant — changes to the existing one.

Why it matters: In the states where they have power, Democrats are creating a blueprint for how the ACA could evolve under Democratic control in Washington.

Where it stands: California recently passed the most ambitious expansions of the ACA to date.

• The ACA's premium subsidies are now available to middle-income people, and low-income undocumented children and young adults are eligible for the state Medicaid program.
• "This isn’t just the ACA warmed over. This is actually taking steps beyond it to make it better," said Peter Lee, executive director of Covered California, the state ACA exchange.

Other states have also made significant changes.

• Washington has created a state public option, and Colorado is creating a plan for one.
• Maryland now allows state residents to begin health insurance enrollment by checking a box on their state tax returns. Those who qualify for Medicaid would be automatically enrolled.

What's next: If a future Democratic president wanted something less ambitious than "Medicare for All," these reforms provide a starting point.

The other side: Republican-led states are surging ahead on their own reforms, like adding work requirements to Medicaid.

The bottom line: "Red states and blue states are moving in very different directions on health care, taking advantage of new flexibility on the one hand and combating efforts by the Trump administration on the other," said Larry Levitt of the Kaiser Family Foundation.

Go deeper:

• More Democrats are supporting public insurance programs
• Blue states dig in on the ACA

Last night's field of presidential candidates fought in 30-second soundbites over the merits of single payer Medicare for All versus a public option.

But none of the candidates moved beyond sparring over insurance reforms to address the underlying reason why people are having so much trouble affording their health care, which is that health care services keep getting more expensive.

• Although drug and insurance companies are Democrats' favorite punching bags, hospital care is the largest driver of U.S. health prices — yet hospitals are left out of Democrats' list of predatory health care companies.

Yes, but: You can't say that hospitals emerged unscathed from last night's debate. A key rationale for Medicare for All — or any public option — is that it lowers health care costs by paying lower rates for hospital and doctor services than private insurance does, which is why providers hate both plans.

Go deeper:

• Think drug costs are bad? Try hospital prices
• Hospital costs are high and all over the place
• Health care's big spending mismatch

Few things are more valuable in health care than data — specifically prescription data. Surescripts, a company that allows prescriptions to be filled electronically, controls a lot of that data and has every incentive to keep it gated, Axios’ Bob Herman reports.

Driving the news: Surescripts is asking the FBI to investigate allegations that one of its vendors illegally shared patients' medication histories with Amazon's online pharmacy, PillPack.

• It's a fight that highlights how difficult it has become for patients to share their own drug data and how incumbent players protect their turf.

How we got here: Surescripts contracted with a reseller called ReMy Health, which gave doctors and hospitals access to data on the drugs patients take or used to take.

Yes, but: Surescripts does not allow pharmacies to access medication history data. That means pharmacists, like those at PillPack, who want to verify someone's prescriptions have to spend the time contacting doctors instead of going directly to Surescripts.

• Here, Surescripts is alleging ReMy Health was sending that data to PillPack in violation of their contract and that PillPack was requesting data through providers who had never seen its patients.

The other side: ReMy Health did not respond to requests for comment. A PillPack spokesperson said the company's patients gave explicit consent to obtain medication histories.

The bottom line: Something as simple as making sure someone is taking the right medications isn't that simple when there are billions of dollars up for grabs.

Bloomberg has an excellent deep dive into allegations of price fixing for generic drugs and how a federal investigation into those alleged practices seems to have fizzled. My colleague Sam Baker breaks it down:

The evidence of collusion among leading generics firms is pretty strong, at least according to lawsuits filed by state officials.

• Sandoz, Mylan and Teva all raised their prices for competing versions of the same drug, roughly at the same time and ending up at the same price — which was as much as a 2,000% increase in some cases, according to Bloomberg.
• States’ lawsuits claim that executives from the 3 companies spoke by phone ahead of those price hikes, and the complaints allege that executives met often in person for the purpose of collusion.

The intrigue: The FBI raided Mylan’s headquarters in September 2016 — while CEO Heather Bresch was in Washington, D.C., preparing for a hearing about EpiPen price increases. But almost 3 years later, no federal charges have been filed against anyone from Sandoz, Mylan or Teva.

• The statute of limitations will run out next year for some of the alleged behavior, per Bloomberg.

The other side: There’s a good reason for the lack of charges, the companies argue: They’re innocent, and the FBI hasn’t found anything because there’s nothing to find.

Worthy of your time.

As the new owner of an Apple Watch, this was a letdown: Wearable activity trackers have "little benefit" on chronic disease health outcomes, according to a new American Journal of Medicine analysis.

• Only 1 of 6 studies found that people who wore the devices lost significant weight.
• No significant reduction was discovered in cholesterol or blood pressure.

The bottom line: The devices may motivate people to move more, but this increased movement didn't lead to major health outcome changes when they're used without input from a doctor or trainer, TODAY! writes.