Sand, Lahn call for increasing mental healthcare access, Medicaid oversight in debate

Both Democrat Rob Sand and Republican Zach Lahn said Tuesday in their final gubernatorial candidate debate that more work was needed to address mental healthcare and the impact of Medicaid privatization on healthcare providers, but the candidates offered different solutions to improving Iowa’s health system.

Tuesday’s debate, hosted by KCRG-TV9 and The Gazette in Cedar Rapids, was the third for Sand, Iowa’s current state auditor, and Lahn, a businessman with a farm in Belle Plaine. The candidates originally planned four debates but they were unable to reach an agreement on rescheduling a debate with “Iowa Press” on Iowa PBS that had originally been scheduled Oct. 21. Sand withdrew from the Iowa PBS debate following the death of his brother-in-law.

Though Sand did not mention his brother-in-law, Walter E. Lauridsen II, by name, the Democratic candidate said at the debate his family was one of many in the state who have struggled to find psychiatric services in Iowa for people in need. Lauridsen, the brother of Sand’s wife, died earlier in October in a traffic incident near Lucas. Sand said in a social media post sharing the news that “Walter lived with mental health complexities. While this is a difficult and painful time for all of us, we know he is now at peace.”

“If you’re one of the families that struggle to find a bed for people, we’re there with you,” Sand said during the debate. “We’ve struggled too. It’s a real problem in our state. We don’t have the availability that we need, and people suffer because of it needlessly.”

Sand also shared another personal story on mental health struggles, speaking about a 2025 incident when a man broke into Sand’s home in Des Moines while his family was away for Thanksgiving. Court records show the man was homeless at the time of arrest, and was later sentenced to two years probation after pleading guilty to burglary and two counts of interference causing injury. He was ordered to receive mental health treatment at an Iowa residential mental health facility, but was set to remain in custody until space was available.

Sand says he remembered having a conversation with the man’s sister after the crime.

“We reached out, and she was just happy to know that he was alive, because she hadn’t heard from him for three years,” Sand said. “This is a man who was living outdoors, saw a warm place. The problem is that we haven’t been paying enough attention to people who are struggling with mental health issues. And then sooner or later, their mental health issue becomes our problem, too, whether it’s because of crime or accidents or anything else. We’ve got to do a better job with this for everyone in this state, because it’s public safety, not just mental health.”

As of a 2023 report, Iowa had two available psychiatric beds per 100,000 individuals, ranking Iowa 51st among all states and Washington, D.C., in availability for state hospital beds available for adults with serious mental health issues.

Lahn says economic growth is key to improving mental healthcare

Lahn similarly said he believed Iowa needs to open additional mental health facilities, and said he believed “there are people that are in prisons in our state that need to be in mental health facilities — and actually, that’s hurting everybody involved.” However, he said the larger conversation on how to address this problem starts with growing Iowa’s economy.

“One thing I’ve learned in running for governor is clearly that we’re dealing with the allocation of scarce resources in the state,” Lahn said. “… I think as we look at, how do we improve access to this, we have to look at priorities that will help us grow as a state. But we cannot just continue to depend on, you know, funding from the federal government for things like this. We have to prioritize growth. If we don’t, we’re just gonna be continuing to put money at something that is not getting the return that we’d like it to have, and not serving the people, and not being able to open up more of these facilities to serve people that do have the mental health needs that need it.”

Sand calls for ending Medicaid privatization

But Sand argued there was a more direct fix for the issue — ending the privatization of Medicaid. Iowa Medicaid was privatized in 2016 under former Gov. Terry Branstad, but Sand said Iowa has seen the privatization of the public health coverage program fail over the past decade. He attributed shortages for mental healthcare and other healthcare to high rates of denied Medicaid coverage and reimbursements by the private managed care organizations (MCOs) that manage the state program. These denials lead to providers shutting down, he said, because they are not being paid.

In 2021, Sand released a report as state auditor which found the percentage of appeals in which judges overturned a reduction or denial of services increased 891% after Medicaid privatization. Sand said these denials not only lead to healthcare facilities closing, but raise healthcare costs across the board.

“It’s not just that people are closing down, because they can’t get paid — other healthcare practitioners have hired new full-time employees, where their entire job is to talk on the phone all day long with these MCOs, to argue about getting paid for the care they provided to people,” Sand said. “Who’s paying that person’s salary? We are. … Privatization of Medicaid in the state of Iowa has driven up costs. It is driven down the quality of care. It has led to mental healthcare practitioners closing their doors.”

Lahn said he understood there were problems with Iowa’s Medicaid system, and called for more oversight of MCOs. But he also said did not believe reversing privatization was the correct solution.

“I think there’s better oversight that we can have with this, but I do not believe the people of Iowa want the government running their healthcare,” Lahn said.

For government oversight, Lahn said he believed the government could take steps to ensure payments to healthcare providers are paid on time, and said the priority would be to pay large bills first.

“One of the issues that I hear from practitioners and hear from providers that sometimes that their largest bills get pushed down to the lower part of the bucket,” Lahn said.

He also said he believed MCOs should not be allowed to have “vertical integration,” meaning the companies involved cannot own healthcare facilities or pharmacies, as well as saying there should be a ban on the use of artificial intelligence when denying claims.

However, Lahn warned removing managed care oversight from Iowa Medicaid would remove “about $1 billion in federal funding” that currently goes to MCOs.

“I do believe there’s better oversight for this,” Lahn said. “I do believe there’s changes we can make to this, but I also believe that the private sector can handle these things better than the government can. But the government has a very distinct role to play in oversight in being the watchdog of these organizations, and I would like to increase that oversight over these organizations, to make sure they are providing the right type of care, they’re paying promptly, and people can have something they should be able to count on — which is just a good service from these companies.”

Agreement on Medicaid work requirements

Despite different opinions on privatization, both candidates said they generally support Medicaid work requirements, implemented on the federal level through the “One, Big Beautiful Bill” Act and similarly placed in Iowa law through a 2025 measure. Lahn said he fully supported work requirements and said he believed Medicaid expansion through the Affordable Care Act “didn’t close this loop” and allowed some able-bodied adults to receive benefits without seeking work.

“I think the people of Iowa just understand, look, if you’re an able-bodied adult, that can seek work, you should be seeking work,” Lahn said. “… But I think one other part of this that we need to make sure we’re focused on, too, is to make sure that only the citizens of the state that are eligible for these programs are getting these programs. I do not believe benefits should be going to illegal immigrants that are in the state.”

Lahn referenced a report from the Center for Immigration Studies, a D.C.-based research organization that advocates for reducing both legal and illegal immigration, which found 59% of “non-citizen households” used one or more public benefit program. Undocumented immigrants are largely banned from receiving any public benefits, but the report argued immigrants, including people in the country illegally, have received “welfare benefits on behalf of U.S.-born citizen children.”

“I think that there’s protections that we can put in place, technology that we can use to make sure that only the people who are eligible for these benefits are getting these benefits,” Lahn said. “And (for) the people who deserve these benefits, that we’re not creating endless bureaucratic paperwork for them, but we’re making it easy for them to be able to get the benefit that they deserve.”

Sand said he believed able-bodied individuals should work. “It’s not an option. If you want to have income, if you wanna have health insurance, that just makes sense,” he said.

He also said because Medicaid work requirements were a federal obligation, and “we are going to follow the law.”

However, Sand said he had concerns about people legitimately in need — who often are working — getting denied access to healthcare because of they were unable to file needed paperwork proving their work history in order to receive health coverage. He referenced a case that received national coverage when Arkansas implemented Medicaid work requirements. A man with a chronic obstructive pulmonary disorder, who was working 30 to 40 hours a week at a poultry plant, meeting the state work requirements, was unable to navigate the monthly reporting system. Because he was unable to report his work hours, he lost Medicaid coverage and could not afford his medication, leading to him losing his job — and eventually losing his life.

“I want able-bodied people to be working, but I want to make sure that what the government is doing is putting in a work requirement and not a paperwork requirement,” Sand said. “It should be simple. It should be straightforward. It should be something that very busy people who do not have a lot of free time on their hands can get done and get done quickly, and the government should take responsibility for making sure that that is happening.”