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Photo Illustration: Sarah Grillo/Axios. Photos: Scott Eisen/Getty Images and Erik McGregor/LightRocket via Getty Images

Americans worry a lot about how to get and pay for good health care, but the 2020 presidential candidates are barely talking about what's at the root of these problems: Almost every incentive in the U.S. health care system is broken.

Why it matters: President Trump and most of the Democratic field are minimizing the hard conversations with voters about why health care eats up so much of each paycheck and what it would really take to change things.

  • Instead, the public debate focuses on ideas like how best to cover the uninsured and the relative virtue of health care “choice.”

The U.S. spent $3.6 trillion on health care last year, and almost every part of the system is pushing its costs up, not down.

Hospitals collect the biggest piece of the health care pie, at about $1 trillion per year.

  • Their incentive is to fill beds — to send as many bills as possible, for as much as possible.
  • Big hospital systems are buying up smaller ones, as well as physician practices, to reduce competition and charge higher prices.
  • And hospitals have resisted efforts to shift toward a system that pays for quality, rather than volume.

Drug companies, meanwhile, are the most profitable part of the health care industry.

  • Small biotech companies usually shoulder the risk of developing new drugs.
  • Big Pharma companies then buy those products, market them aggressively and develop a fortress of patents to keep competition at bay as long as possible.

The money bonanza is enticing some nontraditional players into the health care world.

Insurers do want to keep costs down — but many of their methods are deeply unpopular.

  • Making us pay more out of pocket and putting tighter restrictions on which doctors we can see create real and immediate headaches for patients.
  • That makes insurers the most convenient punching bag for politicians.

The frustrating reality: Democrats’ plans are engaging in the debate about possible solutions more than the candidates themselves.

  • It’s a tacit acknowledgment of two realities: That controlling the cost of care is imperative, and that talking about taking money away from doctors and hospitals is a big political risk.

What they’re saying: The top 2020 Democrats have actually released “insanely aggressive” cost control ideas, says Larry Levitt, executive vice president at the Kaiser Family Foundation. "But they don’t talk about that a lot.”

  • Medicare for All, the plan endorsed by Sens. Bernie Sanders and Elizabeth Warren, would sharply reduce spending on doctors and hospitals by eliminating private insurance and paying rates closer to Medicare's. Estimates range from about $380 billion to nearly $600 billion in savings each year.
  • Joe Biden and Pete Buttigieg have proposed an optional Medicare-like insurance plan, which anyone could buy into. It would pay providers less than private insurance, with the hopes of putting competitive pressure on private plans' rates.
  • The savings there would be smaller than Medicare for All's, but those plans are still significantly more ambitious than the Affordable Care Act or most of the proposals that came before it.

Yes, but: The health care industry has blanketed Iowa with ads, and is prepared to spend millions more, to defend the very profitable status quo.

  • The argument is simple: Reframe the big-picture debate about costs as a threat to your doctor or your hospital. It's an easy playbook that both parties, and the industry, know well. And it usually works.

The bottom line: “Voters want their health care costs reduced, but that doesn’t mean they would necessarily support what it would take to make that happen,” Levitt said.

Go deeper: Read the other stories in Axios' "What Matters 2020" series

Go deeper

House Judiciary Committee advances reparations bill in historic vote

Sheila Jackson Lee. Photo: Al Drago/Getty Images

The House Judiciary Committee voted 25 to 17 Wednesday to advance a bill that would create a commission to study reparations for Black Americans who are the descendants of slaves.

Why it matters: "No such bill has ever come this far during Congressional history of the United States," said Rep. Sheila Jackson Lee (D-Texas), who sponsored the bill, per the Washington Post.

Updated 4 hours ago - Politics & Policy

Officer Kim Potter arrested, charged with manslaughter in Daunte Wright's death

Kim Potter's booking photos. Photo: Hennepin County Sheriff's Office

Kim Potter, the former police officer charged with second-degree manslaughter in the fatal shooting of Daunte Wright, was released on a $100,000 bond on Wednesday, Hennepin County jail records show.

Why it matters: Sunday's shooting of the 20-year-old Black man in Brooklyn Center, Minnesota, just 10 miles from where George Floyd was killed by a Minneapolis police officer last year, has reinvigorated Black Lives Matter protests and led to three consecutive nights of unrest.

Updated 5 hours ago - Politics & Policy

Biden names Erika Moritsugu as senior AAPI liaison

Erika Moritsugu. Photo courtesy: National Partnership for Women & Families

President Biden has named Erika Moritsugu as deputy assistant to the president and Asian American and Pacific Islander senior liaison, the White House announced Wednesday.

Driving the news: The decision follows weeks of pressure from AAPI leaders to include more Asian American representation at the Cabinet level and in senior administration roles.