It’s primary season and health care is on the ballot. With Tuesday, May 8 fast approaching, I wanted to offer some thoughts on the positions taken by each of Ohio’s gubernatorial candidates specifically in the area of health policy.

Given the uncertainty of the partisan composition of the U.S. Congress after the coming mid-term elections, the fate of the Affordable Care Act (ACA) is still unknown. It appears that Congressional Republicans may even be making a play to attempt to repeal the ACA before the midterm election in November.

While federal politics are uncertain, the positions taken by the major candidates for Ohio governor comprise something of a roadmap of directions that the state—and to some extent the nation—may take. A lot is at stake in this election for health care.

The Republicans

Mary Taylor

Lieutenant Governor Mary Taylor pulls no punches in the health care space. The issue is listed first on her campaign web site, which boldly declares that “Obamacare has been a disaster for the people of Ohio.”

Taylor’s stalwart opposition to all things ACA is probably the voter’s best shorthand for understanding her vision for the state. Her web site notes that “As Insurance Director, Mary Taylor led the charge against Obamacare and an Ohio-based exchange.” She opposes Medicaid expansion, which provides health care access to more than 700,000 Ohioans. She believes in loosening rules around employer responsibilities for providing health insurance. And she claims that the ACA has reduced competition on private markets by requiring all plans to meet a certain baseline of services–the ACA’s “essential health” provisions established by the medical professionals with which the ACA’s architects consulted.

The problem is that Taylor’s critique of the ACA is largely circular. As Director of the Ohio Department of Insurance, Taylor was well-positioned to help improve the competitiveness of Ohio’s health care exchanges. She could have held Ohio insurers to account, for example, by failing to rubber stamp large rate increases. Instead of setting about working with insurers to find ways to meet Ohioans’ needs, she used her position to stoke flames and increase anxiety and uncertainty on insurance markets. Somewhat perversely, aspects of the ACA that Taylor believes to be a disaster were made worse by her failure to carry out her duties as Ohio’s chief insurance regulator. Her plans, if she is to be elected governor, are straight out of the Trump-Ryan playbook, as she proposes to gut the ACA’s anti-discrimination protections and coverage guarantees in the name of increased market competition.

Plus or minus a few proposals (encouraging primary care-only practices, for example, or increasing access to Health Savings Accounts), the Taylor plan is essentially to return to the status ex ante position that existed pre-ACA, with promises that market competition and increased policy flexibility on the state level will meet Ohioans’ health care needs. She doesn’t explain how this policy vision will serve the almost millions of Ohioans who received health care access for the first time through the ACA exchanges or the Medicaid expansion. Their fate hinges, again, largely on a turn to market competition that is purchased by deregulating health care and trusting the insurance industry to police itself.

Mike DeWine

Attorney General Mike DeWine, who polls tell us is the presumptive front runner, is a curious case of health policy nebulousness. Unlike all of the other candidates, DeWine’s web site does not have an issues tab. Instead, it highlights only one issue: Ohio’s opioid crisis. (The point of this round-up is not to focus on opioids alone, so I will not treat DeWine’s attempt to focus on this one issue as though it stands-in for a robust health policy vision, which he doesn’t seem to have. All candidates support some kind of swift action on the opioids issue, though they differ in scope and tone.)

DeWine seems to have staked his campaign purely on his biography and his tenure as Attorney General. None of these accomplishments fall in the health care space. One thing that is worth mentioning is that on the campaign trail and in debates, DeWine has refused to answer even the most basic questions about health care. More to the point, where Mary Taylor is a stalwart opponent of the ACA, DeWine has refused to give a clear and answer on whether he supports the Medicaid expansion that brought health care access to almost a quarter-million Ohioans. This exchange between Taylor and DeWine at a recent debate pretty much sums it up:

TAYLOR: I think that the question is pretty clear. Mike DeWine will you end the Medicaid expansion? Yes or no?
DEWINE: It will not exist, Mary. Of course…
TAYLOR: Yes or no. Will you end the Medicaid expansion?
DEWINE: Mary, it will not exist as we know it today. It can’t, and it was your administration that took it. And…
TAYLOR: John Kasich
DEWINE: That was all John? You had nothing to do that, huh?
TAYLOR: You served as Lt. Governor. Do you understand the responsibility of the Lt. Governor?
DEWINE: Alright, alright. I just wanted.. it’s fine.
TAYLOR: It’s one of all of the offices you’ve served.
DEWINE: I served as Lt. Governor and I did a lot of things, Mary. A lot of things that made a big difference.
TAYLOR: You still won’t answer the question.
DEWINE: I don’t think you have. You can’t list three or four things that you’ve done.
TAYLOR: Will you end the Medicaid expansion?

Since the exchange ends with the moderator moving to the next question, we can add:

DEWINE: [Crickets]

It is, of course, patently absurd that DeWine, a seasoned Ohio politician who has played a prominent role in the Kasich administration, would need to further study the Medicaid expansion to take a position on it. Or that he wouldn’t already have a position on it. Rather, he is trying to carve out a non-committal space between Taylor and the Democrats, likely because he is aware that the Medicaid expansion increasingly has bipartisan support, especially within the context of the opioid crisis that he touts as his key issue. This has allowed Taylor to appeal to the hard Right while DeWine attempts to make a play for Kasich Republicans and Independents. But the play, however, is based less on an embrace of centrist health policy positions than it is intentional confusion on where the candidate himself stands.

The Democrats

Dennis Kucinich

Long known as a progressive, from his time as Cleveland mayor to his time in the U.S House of Representatives, Dennis Kucinich makes good on his reputation by advocating for single-payer, national health care and a robust approach to health–and not just health care, as it is often understood. The problem is that Kucinich is vague in terms of the actual mechanics of his otherwise admirable vision. His web site promises only that he will “convene all parties to bring forward a comprehensive plan, to provide every Ohioan with access to affordable, low-cost, basic medical, mental health, dental, and prescription drug care, with a new emphasis on regenerative health care, disease prevention, diet and complementary therapies.” On the state level, Kucinich has expressed support for the Ohio Health Security Act, a state-level single-payer plan that remains sitting in the legislature, awaiting further action.

Kucinich emphasizes single-payer’s ability to “reduce the health care burden of business and industry” and notes that such an approach “will save businesses money, create a healthier work force and protect families from economic ruin when illness strikes.” Passing a single-payer health care plan in Ohio would, of course, require the Democrats not only to gain control of the governor’s office, but the legislature as well. In this regard, a vote for Kucinich based on his health care plan is a play for a longer vision, beyond the current state of American and Ohio health politics and policymaking. What is unclear is whether or how a Governor Kucinich would defend gains made under the ACA. It will be hard, after all, to defend a bill that he has called an embrace of “predatory capitalism” with much credibility.

Perhaps most attractive about Kucinich’s approach is his emphasis on a broad approach to health, including nutrition education and food desert reduction, wellness and prevention, environmental health, stress management, and beyond. Regardless of whether or not single payer is realizable in the short term, it would undoubtedly be a benefit to our state to have a governor who understands that the social determinants of health play a significant role in health outcomes, and that improving the social determinants requires holding companies accountable. At the same time, Kucinich’s comments recently that vaccine science is not settled are extremely troublesome, especially considering that Ohio already lags much of the nation in immunization rates. We can’t have politicians – especially public health-minded politicians – muddying the waters.

Joe Schiavoni

State Senator Joe Schiavoni, serving the Youngstown-Mahoning Valley area since 2009, has received less attention than the other Democrats, but has put forth a number of policy ideas for advancing health care in Ohio. While he has sought to distinguish himself as a fighter for the working class who will take on the Ohio establishment (literally, as his ads have emphasized his background as a boxer), Schiavoni mostly emphasizes traditional Democratic priorities in health care, such as defending Medicaid expansion and the ACA generally, as well as defending Planned Parenthood, making health care for women and children a priority, and protecting the poor. Like Kucinich’s messaging, Schiavoni evokes community-level interventions to make in-roads into Ohio’s longstanding short-comings in public health. Schiavoni specifically identifies working “with local communities” to address Ohio’s shameful infant mortality rates. As with Kucinich’s platform, it is nice to see a politician nod explicitly and often to public health, beyond health insurance and medical care.

Richard Cordray

The campaign web site for Richard Cordray, former Ohio Attorney General and Director of the Consumer Financial Protection Bureau, appointed by President Obama, emphasizes Cordray’s reputation for taking on large companies engaged in scrupulous practices. Like Schiavoni’s, Cordrary’s health care plan constitutes a continuation of and defense of the Obama legacy, which makes him the standard bearer of his former boss’s legacy. Cordray’s running mate, former congresswoman, Betty Sutton, who Obama also appointed to his administration, had previously also run (before dropping out to become Cordray’s running mate) on a strong ACA-continuation platform. Cordray’s web site touts Sutton’s co-sponsorship of the Children’s Health Insurance Program (CHIP) and efforts to curb discrimination by health insurers.

As the campaign’s health care platform notes, however, though the ACA was a start, “more still needs to be done.” Beyond defending the ACA from Trump administration repeal efforts, Cordray’s web site identifies an expansion of CHIP as a core priority, noting that that an unacceptably large number of children in Ohio still lack basic health care access. As part of a commitment to women and children they also promise (as Schiavoni and Kucinich do as well) to resist attacks on Planned Parenthood funding, support policies to increase contraceptive access, and reinvest in programs to increase pre-natal and neonatal health, with the ultimate aim of reducing Ohio’s atrocious infant mortality rates. Cordray promises to repair damage done by the Kasich-Taylor administration to Ohio’s health insurance markets by working with insurers to incentivize more competition and options in Ohio’s rural counties.

The campaign’s web site also notes the basic fact that the Republican-controlled Ohio legislature has made known its intention to chip away at Medicaid by erecting enrollment barriers, and may seek to freeze enrollment or even end the expansion altogether. To this extent, Cordray, if not always the most exciting candidate, has touted what he sees as his comparative electability. To be sure, controlling the veto pen may prove to be the most important role the next Ohio governor plays with regard to health policy. The only question is whether what is expected to be a “Blue Wave” nationally can peel off even a few Ohio legislative seats to undo the current veto-proof majority Ohio Republicans enjoy.

All Together Now: The Choice Facing Ohioans

We have five quite different pictures here from the viable Republican and Democratic gubernatorial candidates.* To be sure, there are a number of other policy issues that many Ohio voters will be considering, including positions on guns and the economy. In the area of health care, however, the choice can be summed up as follows:

– Dennis Kucinich’s progressive bona fides lay in his promise to pursue a single-payer health care system. Since single-payer is undoubtedly a steep climb to actualize, however, we can assume that Kucinich will fight to restore state support for many of the ACA’s gains. We can assume that he will play an important role in resisting Trump administration efforts to further erode the ACA. But Kucinich’s criticisms of the ACA leave one wondering to what extent he will invest in such work. At a minimum we would expect him to wield the governor’s veto pen on issues such as Medicaid work requirements and repealing the Medicaid expansion, since those do not concern the private markets that Kucinich regards as “predatory.”

– Both Richard Cordray and Joe Schiavoni have made protecting the gains made under the ACA, including the Medicaid expansion, a centerpiece of their campaign. While they both offer smaller (though still important) policy proposals that would advance health care in Ohio, especially around stabilizing markets and funding services and supports, both represent strong defenses of the Obama administration’s policy gains. A vote for either Cordray and Schiavoni is therefore a more modest vote (when compared to Kucinich) for state-level resistance to future Republican repeal efforts. Of course, as Schiavoni’s hometown paper, The Youngstown Vindicator, has noted, Schiavoni has a fraction of the financial resources that Cordray has. If defending Obama-era gains is the goal, the politically seasoned Cordray is the better bet against the very-politically-seasoned and institutionally-entrenched DeWine or Taylor.

– Mary Taylor will continue her almost decades-long project of undermining the ACA. Virtually everything she offers in the health policy space constitutes a rollback to pre-ACA status ante, with little to say about how to help those who will undoubtedly–because they have in the past–fall through the cracks of market forces, or who are offered sub-standard plans by their employers, or are poor or disabled. One can assume that Ohio un- and underinsurance rates will swell under a Taylor administration.

– Like the other candidates, Mike DeWine will do something about the opioid crisis. Unlike the other candidates, we are not sure what he will do exactly in health care beyond opioids. While we assume that he will ultimately come out against the Medicaid expansion, he will not say it–yet. We can assume that DeWine will do everything that Taylor says she will do. The difference is that, unlike DeWine, Taylor has the guts to tell us what those things are. She gets points for that, I think.